Unstable bicondylar tibial plateau fractures: a clinical investigation

OBJECTIVE: To evaluate fracture patterns in bicondylar tibial plateau fractures and their impact on treatment strategy. DESIGN: Prospective data analysis with documentation of initial injury and treatment strategy, computed tomography scans, conventional x-rays, long-term evaluation of radiographs, and functional assessments. SETTING: Level 1 regional trauma center. PATIENTS: Prospective data acquisition of 14 consecutive patients (10 male and 4 female) with a bicondylar tibial plateau fracture (AO Type C). INTERVENTION: Application of a stepwise reconstruction strategy of the tibial plateau starting with the reposition and fixation of the posteromedial split fragment using a 3.5 buttress plate, followed by reposition and grafting of the lateral compartment and lateral fixation with a 3.5 plate in 90 degree to the medial fixation device. MAIN OUTCOME MEASUREMENTS: All patients were evaluated with full-length standing film, standardized x-rays, Lysholm score for functional assessment, and patient's self-appraisal. RESULTS: Most of the complex bicondylar fractures follow a regular pattern in that the medial compartment is split in a mediolateral direction with a posteromedial main fragment, combined with various amounts of multifragmental lateral compartment depression. The technique introduced allows for accurate and stable reduction and fixation of this fracture type. The final Lysholm knee score showed an average of 83.5 points (range: 64.5-92). CONCLUSIONS: Complex bicondylar tibial plateau fractures follow a regular pattern, which is not represented in existing 2-dimensional fracture classifications. A 2-incision technique starting with the reduction of the posteromedial edge results in accurate fracture reduction with low complication rates and excellent knee function.

The cement prosthesis-like spacer: an intermediate halt on the road to healing.

BACKGROUND Periprosthetic infections remain a devastating problem in the field of joint arthroplasty. In the following study, the results of a two-stage treatment protocol for chronic periprosthetic infections using an intraoperatively molded cement prosthesis-like spacer (CPLS) are presented. METHODS Seventy-five patients with chronically infected knee prosthesis received a two-stage revision procedure with the newly developed CPLS between June 2006 and June 2011. Based on the microorganism involved, patients were grouped into either easy to treat (ETT) or difficult to treat (DTT) and treated accordingly. Range of motion (ROM) and the knee society score (KSS) were utilized for functional assessment. RESULTS Mean duration of the CPLS implant in the DTT group was 3.6 months (range 3-5 months) and in the ETT group 1.3 months (range 0.7-2.5 months). Reinfection rates of the final prosthesis were 9.6% in the ETT and 8.3% in the DTT group with no significant difference between both groups regarding ROM or KSS (P = 0.87, 0.64, resp.). CONCLUSION The results show that ETT patients do not necessitate the same treatment protocol as DTT patients to achieve the same goal, emphasizing the need to differentiate between therapeutic regimes. We also highlight the feasibility of CLPS in two-stage protocols.

Epoetin and Darbepoetin for Managing Anemia in Patients Undergoing Cancer Treatment: Comparative Effectiveness Update

Objectives: To update the 2006 systematic review of the comparative benefits and harms of erythropoiesis-stimulating agent (ESA) strategies and non-ESA strategies to manage anemia in patients undergoing chemotherapy and/or radiation for malignancy (excluding myelodysplastic syndrome and acute leukemia), including the impact of alternative thresholds for initiating treatment and optimal duration of therapy. Data sources: Literature searches were updated in electronic databases (n=3), conference proceedings (n=3), and Food and Drug Administration transcripts. Multiple sources (n=13) were searched for potential gray literature. A primary source for current survival evidence was a recently published individual patient data meta-analysis. In that meta-analysis, patient data were obtained from investigators for studies enrolling more than 50 patients per arm. Because those data constitute the most currently available data for this update, as well as the source for on-study (active treatment) mortality data, we limited inclusion in the current report to studies enrolling more than 50 patients per arm to avoid potential differential endpoint ascertainment in smaller studies. Review methods: Title and abstract screening was performed by one or two (to resolve uncertainty) reviewers; potentially included publications were reviewed in full text. Two or three (to resolve disagreements) reviewers assessed trial quality. Results were independently verified and pooled for outcomes of interest. The balance of benefits and harms was examined in a decision model. Results: We evaluated evidence from 5 trials directly comparing darbepoetin with epoetin, 41 trials comparing epoetin with control, and 8 trials comparing darbepoetin with control; 5 trials evaluated early versus late (delay until Hb ≤9 to 11 g/dL) treatment. Trials varied according to duration, tumor types, cancer therapy, trial quality, iron supplementation, baseline hemoglobin, ESA dosing frequency (and therefore amount per dose), and dose escalation. ESAs decreased the risk of transfusion (pooled relative risk [RR], 0.58; 95% confidence interval [CI], 0.53 to 0.64; I2 = 51%; 38 trials) without evidence of meaningful difference between epoetin and darbepoetin. Thromboembolic event rates were higher in ESA-treated patients (pooled RR, 1.51; 95% CI, 1.30 to 1.74; I2 = 0%; 37 trials) without difference between epoetin and darbepoetin. In 14 trials reporting the Functional Assessment of Cancer Therapy (FACT)-Fatigue subscale, the most common patient-reported outcome, scores decreased by −0.6 in control arms (95% CI, −6.4 to 5.2; I2 = 0%) and increased by 2.1 in ESA arms (95% CI, −3.9 to 8.1; I2 = 0%). There were fewer thromboembolic and on-study mortality adverse events when ESA treatment was delayed until baseline Hb was less than 10 g/dL, in keeping with current treatment practice, but the difference in effect from early treatment was not significant, and the evidence was limited and insufficient for conclusions. No evidence informed optimal duration of therapy. Mortality was increased during the on-study period (pooled hazard ratio [HR], 1.17; 95% CI, 1.04 to 1.31; I2 = 0%; 37 trials). There was one additional death for every 59 treated patients when the control arm on-study mortality was 10 percent and one additional death for every 588 treated patients when the control-arm on-study mortality was 1 percent. A cohort decision model yielded a consistent result—greater loss of life-years when control arm on-study mortality was higher. There was no discernible increase in mortality with ESA use over the longest available followup (pooled HR, 1.04; 95% CI, 0.99 to 1.10; I2 = 38%; 44 trials), but many trials did not include an overall survival endpoint and potential time-dependent confounding was not considered. Conclusions: Results of this update were consistent with the 2006 review. ESAs reduced the need for transfusions and increased the risk of thromboembolism. FACT-Fatigue scores were better with ESA use but the magnitude was less than the minimal clinically important difference. An increase in mortality accompanied the use of ESAs. An important unanswered question is whether dosing practices and overall ESA exposure might influence harms.

Effects of erythropoiesis-stimulating agents on fatigue- and anaemia-related symptoms in cancer patients: systematic review and meta-analyses of published and unpublished data.

Background:Erythropoiesis-stimulating agents (ESAs) reduce the need for red blood cell transfusions; however, they increase the risk of thromboembolic events and mortality. The impact of ESAs on quality of life (QoL) is controversial and led to different recommendations of medical societies and authorities in the USA and Europe. We aimed to critically evaluate and quantify the effects of ESAs on QoL in cancer patients.Methods:We included data from randomised controlled trials (RCTs) on the effects of ESAs on QoL in cancer patients. Randomised controlled trials were identified by searching electronic data bases and other sources up to January 2011. To reduce publication and outcome reporting biases, we included unreported results from clinical study reports. We conducted meta-analyses on fatigue- and anaemia-related symptoms measured with the Functional Assessment of Cancer Therapy-Fatigue (FACT-F) and FACT-Anaemia (FACT-An) subscales (primary outcomes) or other validated instruments.Results:We identified 58 eligible RCTs. Clinical study reports were available for 27% (4 out of 15) of the investigator-initiated trials and 95% (41 out of 43) of the industry-initiated trials. We excluded 21 RTCs as we could not use their QoL data for meta-analyses, either because of incomplete reporting (17 RCTs) or because of premature closure of the trial (4 RCTs). We included 37 RCTs with 10 581 patients; 21 RCTs were placebo controlled. Chemotherapy was given in 27 of the 37 RCTs. The median baseline haemoglobin (Hb) level was 10.1 g dl(-1); in 8 studies ESAs were stopped at Hb levels below 13 g dl(-1) and in 27 above 13 g dl(-1). For FACT-F, the mean difference (MD) was 2.41 (95% confidence interval (95% CI) 1.39-3.43; P<0.0001; 23 studies, n=6108) in all cancer patients and 2.81 (95% CI 1.73-3.90; P<0.0001; 19 RCTs, n=4697) in patients receiving chemotherapy, which was below the threshold (⩾3) for a clinically important difference (CID). Erythropoiesis-stimulating agents had a positive effect on anaemia-related symptoms (MD 4.09; 95% CI 2.37-5.80; P=0.001; 14 studies, n=2765) in all cancer patients and 4.50 (95% CI 2.55-6.45; P<0.0001; 11 RCTs, n=2436) in patients receiving chemotherapy, which was above the threshold (⩾4) for a CID. Of note, this effect persisted when we restricted the analysis to placebo-controlled RCTs in patients receiving chemotherapy. There was some evidence that the MDs for FACT-F were above the threshold for a CID in RCTs including cancer patients receiving chemotherapy with Hb levels below 12 g dl(-1) at baseline and in RCTs stopping ESAs at Hb levels above 13 g dl(-1). However, these findings for FACT-F were not confirmed when we restricted the analysis to placebo-controlled RCTs in patients receiving chemotherapy.Conclusions:In cancer patients, particularly those receiving chemotherapy, we found that ESAs provide a small but clinically important improvement in anaemia-related symptoms (FACT-An). For fatigue-related symptoms (FACT-F), the overall effect did not reach the threshold for a CID.British Journal of Cancer advance online publication, 17 April 2014; doi:10.1038/bjc.2014.171 www.bjcancer.com.

Genetic and microbial factors modulating the ubiquitin proteasome system in inflammatory bowel disease

OBJECTIVE: Altered microbiota composition, changes in immune responses and impaired intestinal barrier functions are observed in IBD. Most of these features are controlled by proteases and their inhibitors to maintain gut homeostasis. Unrestrained or excessive proteolysis can lead to pathological gastrointestinal conditions. The aim was to validate the identified protease IBD candidates from a previously performed systematic review through a genetic association study and functional follow-up. DESIGN: We performed a genetic association study in a large multicentre cohort of patients with Crohn's disease (CD) and UC from five European IBD referral centres in a total of 2320 CD patients, 2112 UC patients and 1796 healthy controls. Subsequently, we did an extensive functional assessment of the candidate genes to explore their causality in IBD pathogenesis. RESULTS: Ten single nucleotide polymorphisms (SNPs) in four genes were significantly associated with CD: CYLD, USP40, APEH and USP3. CYLD was the most significant gene with the intronically located rs12324931 the strongest associated SNP (pFDR=1.74e-17, OR=2.24 (1.83 to 2.74)). Five SNPs in four genes were significantly associated with UC: USP40, APEH, DAG1 and USP3. CYLD, as well as some of the other associated genes, is part of the ubiquitin proteasome system (UPS). We therefore determined if the IBD-associated adherent-invasive Escherichia coli (AIEC) can modulate the UPS functioning. Infection of intestinal epithelial cells with the AIEC LF82 reference strain modulated the UPS turnover by reducing poly-ubiquitin conjugate accumulation, increasing 26S proteasome activities and decreasing protein levels of the NF-κB regulator CYLD. This resulted in IκB-α degradation and NF-κB activation. This activity was very important for the pathogenicity of AIEC since decreased CYLD resulted in increased ability of AIEC LF82 to replicate intracellularly. CONCLUSIONS: Our results reveal the UPS, and CYLD specifically, as an important contributor to IBD pathogenesis, which is favoured by both genetic and microbial factors.

Evaluating minimal important differences for the FACT-Melanoma quality of life questionnaire

Objectives. Minimal Important Differences (MIDs) establish benchmarks for interpreting mean differences in clinical trials involving quality of life outcomes and inform discussions of clinically meaningful change in patient status. As such, the purpose of this study was to assess MIDs for the Functional Assessment of Cancer Therapy–Melanoma (FACT-M). ^ Methods. A prospective validation study of the FACT-M was performed with 273 patients with stage I to IV melanoma. FACT-M, Karnofsky Performance Status (KPS), and Eastern Cooperative Oncology Group Performance Status (ECOG-PS) scores were obtained at baseline and 3 months following enrollment. Anchor- and distribution-based methods were used to assess MIDs, and the correspondence between MID ranges derived from each method was evaluated. ^ Results. This study indicates that an approximate range for MIDs of the FACT-M subscales is between 5 to 8 points for the Trial Outcome Index, 4 to 5 points for the Melanoma Combined Subscale, 2 to 4 points for the Melanoma Subscale, and 1 to 2 points for the Melanoma Surgery Subscale. Each method produced similar but not identical ranges of MIDs. ^ Conclusions. The properties of the anchor instrument employed to derive MIDs directly affect resulting MID ranges and point values. When MIDs are offered as supportive evidence of a clinically meaningful change, the anchor instrument used to derive thresholds should be clearly stated along with evidence supporting the choice of anchor instrument as the most appropriate for the domain of interest. In this analysis, the KPS was a more appropriate measure than the ECOG-PS for assessing MIDs. ^

Use of echocardiography reveals reestablishment of ventricular pumping efficiency and partial ventricular wall motion recovery upon ventricular cryoinjury in the zebrafish

AIMS While zebrafish embryos are amenable to in vivo imaging, allowing the study of morphogenetic processes during development, intravital imaging of adults is hampered by their small size and loss of transparency. The use of adult zebrafish as a vertebrate model of cardiac disease and regeneration is increasing at high speed. It is therefore of great importance to establish appropriate and robust methods to measure cardiac function parameters. METHODS AND RESULTS Here we describe the use of 2D-echocardiography to study the fractional volume shortening and segmental wall motion of the ventricle. Our data show that 2D-echocardiography can be used to evaluate cardiac injury and also to study recovery of cardiac function. Interestingly, our results show that while global systolic function recovered following cardiac cryoinjury, ventricular wall motion was only partially restored. CONCLUSION Cryoinjury leads to long-lasting impairment of cardiac contraction, partially mimicking the consequences of myocardial infarction in humans. Functional assessment of heart regeneration by echocardiography allows a deeper understanding of the mechanisms of cardiac regeneration and has the advantage of being easily transferable to other cardiovascular zebrafish disease models.

Modelado de sistemas de inteligencia ambiental para el entrenamiento de las cualidades físicas

En un ejercicio no extenuante la frecuencia cardíaca (FC) guarda una relación lineal con el consumo máximo de oxígeno (V O2max) y se suele usar como uno de los parámetros de referencia para cuantificar la capacidad del sistema cardiovascular. Normalmente la frecuencia cardíaca puede remplazar el porcentaje de V O2max en las prescripciones básicas de ejercicio para la mejora de la resistencia aeróbica. Para obtener los mejores resultados en la mejora de la resistencia aeróbica, el entrenamiento de los individuos se debe hacer a una frecuencia cardíaca suficientemente alta, para que el trabajo sea de predominio dinámico con la fosforilación oxidativa como fuente energética primaria, pero no tan elevada que pueda suponer un riesgo de infarto de miocardio para el sujeto que se está entrenando. Los programas de entrenamiento de base mínima y de base óptima, con ejercicios de estiramientos para prevenir lesiones, son algunos de los programas más adecuados para el entrenamiento de la resistencia aeróbica porque maximizan los beneficios y minimizan los riesgos para el sistema cardiovascular durante las sesiones de entrenamiento. En esta tesis, se ha definido un modelo funcional para sistemas de inteligencia ambiental capaz de monitorizar, evaluar y entrenar las cualidades físicas que ha sido validado cuando la cualidad física es la resistencia aeróbica. El modelo se ha implementado en una aplicación Android utilizando la camiseta inteligente “GOW running” de la empresa Weartech. El sistema se ha comparado en el Laboratorio de Fisiología del Esfuerzo (LFE) de la Universidad Politécnica de Madrid (UPM) durante la realización de pruebas de esfuerzo. Además se ha evaluado un sistema de guiado con voz para los entrenamientos de base mínima y de base óptima. También el desarrollo del software ha sido validado. Con el uso de cuestionarios sobre las experiencias de los usuarios utilizando la aplicación se ha evaluado el atractivo de la misma. Por otro lado se ha definido una nueva metodología y nuevos tipos de cuestionarios diseñados para evaluar la utilidad que los usuarios asignan al uso de un sistema de guiado por voz. Los resultados obtenidos confirman la validez del modelo. Se ha obtenido una alta concordancia entre las medidas de FC hecha por la aplicación Android y el LFE. También ha resultado que los métodos de estimación del VO2max de los dos sistemas pueden ser intercambiables. Todos los usuarios que utilizaron el sistema de guiado por voz para entrenamientos de 10 base mínima y de base óptimas de la resistencia aeróbica consiguieron llevar a cabo las sesiones de entrenamientos con un 95% de éxito considerando unos márgenes de error de un 10% de la frecuencia cardíaca máxima teórica. La aplicación fue atractiva para los usuarios y hubo también una aceptación del sistema de guiado por voz. Se ha obtenido una evaluación psicológica positiva de la satisfacción de los usuarios que interactuaron con el sistema. En conclusión, se ha demostrado que es posible desarrollar sistemas de Inteligencia Ambiental en dispositivos móviles para la mejora de la salud. El modelo definido en la tesis es el primero modelo funcional teórico de referencia para el desarrollo de este tipo de aplicaciones. Posteriores estudios se realizarán con el objetivo de extender dicho modelo para las demás cualidades físicas que suponen modelos fisiológicos más complejos como por ejemplo la flexibilidad. Abstract In a non-strenuous exercise, the heart rate (HR) shows a linear relationship with the maximum volume of oxygen consumption (V O2max) and serves as an indicator of performance of the cardiovascular system. The heart rate replaces the %V O2max in exercise program prescription to improve aerobic endurance. In order to achieve an optimal effect during endurance training, the athlete needs to work out at a heart rate high enough to trigger the aerobic metabolism, while avoiding the high heart rates that bring along significant risks of myocardial infarction. The minimal and optimal base training programs, followed by stretching exercises to prevent injuries, are adequate programs to maximize benefits and minimize health risks for the cardiovascular system during single session training. In this thesis, we have defined an ambient intelligence system functional model that monitors, evaluates and trains physical qualities, and it has been validated for aerobic endurance. It is based on the Android System and the “GOW Running” smart shirt. The system has been evaluated during functional assessment stress testing of aerobic endurance in the Stress Physiology Laboratory (SPL) of the Technical University of Madrid (UPM). Furthermore, a voice system, designed to guide the user through minimal and optimal base training programs, has been evaluated. Also the software development has been evaluated. By means of user experience questionnaires, we have rated the attractiveness of the android application. Moreover, we have defined a methodology and a new kind of questionnaires in order to assess the user experience with the audio exercise guide system. The results obtained confirm the model. We have a high similarity between HR measurements made of our system and the one used by SPL. We have also a high correlation between the VO2max estimations of our system and the SPL system. All users, that tried the voice guidance system for minimal and optimal base training programs, were able to perform the 95% of the training session with an error lower than the 10% of theoretical maximum heart rate. The application appeared attractive to the users, and it has also been proven that the voice guidance system was useful. As result we obtained a positive evaluation of the users' satisfaction while they interacted with the system. In conclusion, it has been demonstrated that is possible to develop mobile Ambient Intelligence applications for the improvement of healthy lifestyle. AmIRTEM model is the first theoretical reference functional model for the design of this kind of applications. Further studies will be realized in order to extend the AmIRTEM model to other physical qualities whose physiological models are more complex than the aerobic endurance.

Dysfunctional profile for patients in physical neurorehabilitation of upper limb

This paper proposes a first approach to Objective Motor Assessment (OMA) methodology. Also, it introduces the Dysfunctional profile (DP) concept. DP consists of a data matrix characterizing the Upper Limb (UL) physical alterations of a patient with Acquired Brain Injury (ABI) during the rehabilitation process. This research is based on the comparison methology of UL movement between subjects with ABI and healthy subjects as part of OMA. The purpose of this comparison is to classify subjects according to their motor control and subsequently issue a functional assessment of the movement. For this purpose Artificial Neural Networks (ANN) have been used to classify patients. Different network structures are tested. The obtained classification accuracy was 95.65%. This result allows the use of ANNs as a viable option for dysfunctional assessment. This work can be considered a pilot study for further research to corroborate these results.

Definición e implementación de métricas objetivas para la evaluación funcional del miembro superior: aplicación a población con lesión medular cervical

En personas que padecen una Lesión Medular cervical, la función de los miembros superiores se ve afectada en mayor o menor medida, dependiendo fundamentalmente del nivel de la lesión y de la severidad de la misma. El déficit en la función del miembro superior hace que la autonomía e independencia de las personas se vea reducida en la ejecución de Actividades de la Vida Diaria. En el entorno clínico, la valoración de la función del miembro superior se realiza principalmente con escalas clínicas. Algunas de ellas valoran el nivel de dependencia o independencia en la ejecución de Actividades de la Vida Diaria, como, por ejemplo, el índice de Barthel y la escala FIM (Medida de la Independencia Funcional). Otras escalas, como Jebsen-Taylor Hand Function, miden la función del miembro superior valorando la destreza y la habilidad en la ejecución de determinadas tareas funcionales. Estas escalas son generales, es decir, se pueden aplicar a distintas poblaciones de sujetos y a la presencia de distintas patologías. Sin embargo, existen otras escalas desarrolladas específicamente para valorar una patología concreta, con el objetivo de hacer las evaluaciones funcionales más sensibles a cambios. Un ejemplo es la escala Spinal Cord Independence Measure (SCIM), desarrollada para valorar Lesión Medular. Las escalas clínicas son instrumentos de medida estandarizados, válidos para su uso en el entorno clínico porque se han validado en muestras grandes de pacientes. No obstante, suelen poseer una elevada componente de subjetividad que depende principalmente de la persona que puntúa el test. Otro aspecto a tener en cuenta, es que la sensibilidad de las escalas es alta, fundamentalmente, a cambios groseros en el estado de salud o en la función del miembro superior, de forma que cambios sutiles en el sujeto pueden no ser detectados. Además, en ocasiones, poseen saturaciones en el sistema de puntuación, de forma que mejorías que se puedan producir por encima de un determinado umbral no son detectadas. En definitiva, estas limitaciones hacen que las escalas clínicas no sean suficientes, por sí mismas, para evaluar estrategias motoras del miembro superior durante la ejecución de movimientos funcionales, siendo necesaria la búsqueda de instrumentos de medida que aporten objetividad, complementen las valoraciones y, al mismo tiempo, intenten solventar las limitaciones que poseen las escalas. Los estudios biomecánicos son ejemplos de métodos objetivos, en los que diversas tecnologías se pueden utilizar para recoger información de los sujetos. Una concreción de estos estudios son los estudios cinemáticos. Mediante tecnología optoelectrónica, inercial o electromagnética, estos estudios proporcionan información objetiva acerca del movimiento realizado por los sujetos, durante la ejecución de tareas concretas. Estos sistemas de medida proporcionan grandes cantidades de datos que carecen de una interpretación inmediata. Estos datos necesariamente deben ser tratados y reducidos a un conjunto de variables que, a priori, posean una interpretación más sencilla para ser utilizados en la práctica clínica. Estas han sido las principales motivaciones de esta investigación. El objetivo principal fue proponer un conjunto de índices cinemáticos que, de forma objetiva, valoren la función del miembro superior; y validar los índices propuestos en poblaciones con Lesión Medular, para su uso como instrumentos de valoración en el entorno clínico. Esta tesis se enmarca dentro de un proyecto de investigación: HYPER (Hybrid Neuroprosthetic and Neurorobotic Devices for Functional Compensation and Rehabilitation of Motor Disorders, referencia CSD2009-00067 CONSOLIDER INGENIO 2010). Dentro de este proyecto se lleva a cabo investigación en el desarrollo de modelos, para determinar los requisitos biomecánicos y los patrones de movimiento de los miembros superiores en sujetos sanos y personas con lesión medular. Además, se realiza investigación en la propuesta de nuevos instrumentos de evaluación funcional en el campo de la rehabilitación de los miembros superiores. ABSTRACT In people who have suffered a cervical Spinal Cord Injury, upper limbs function is affected to a greater or lesser extent, depending primarily on the level of the injury and the severity of it. The deficit in the upper limb function reduces the autonomy and independence of persons in the execution of Activities of Daily Living. In the clinical setting, assessment of upper limb function is mainly performed based on clinical scales. Some value the level of dependence or independence in performing activities of daily living, such as the Barthel Index and the FIM scale (Functional Independence Measure). Other scales, such as the Jebsen-Taylor Hand Function, measure upper limb function in terms of the skill and ability to perform specific functional tasks. These scales are general, so can be applied to different populations of subjects and the presence of different pathologies. However, there are other scales developed for a specific injury, in order to make the functional assessments more sensitive to changes. An example is the Spinal Cord Independence Measure (SCIM), developed for people with Spinal Cord Injury. The clinical scales are standardized instruments measure, valid for use in the clinical setting because they have been validated in large patient samples. However, they usually have a high level of subjectivity which mainly depends on the person who scores the test. Another aspect to take into account is the high sensitivity of the scales mainly to gross changes in the health status or upper limb function, so that subtle changes in the subject may not be detected. Moreover, sometimes, have saturations in the scoring system, so that improvements which may occur above a certain threshold are not detected. For these reasons, clinical scales are not enough, by themselves, to assess motor strategies used during movements. So, it’s necessary to find measure instruments that provide objectivity, supplement the assessments and, at the same time, solving the limitations that scales have. Biomechanical studies are examples of objective methods, in which several technologies can be used to collect information from the subjects. One kind of these studies is the kinematic movement analysis. By means of optoelectronics, inertial and electromagnetic technology, these studies provide objective information about the movement performed by the subjects during the execution of specific tasks. These systems provide large quantities of data without easy and intuitive interpretation. These data must necessarily be treated and reduced to a set of variables that, a priori, having a simpler interpretation for their use in the clinical practice. These were the main motivations of this research. The main objective was to propose a set of kinematic indices, or metrics that, objectively, assess the upper limb function and validate the proposed rates in populations with Spinal Cord Injury, for use as assessment tools in the clinical setting. This dissertation is framed within a research project: HYPER (Neurorobotic Devices for Functional Compensation and Rehabilitation of Motor Disorders, grant CSD2009- 00067 CONSOLIDER INGENIO 2010). Within this research project, research is conducted in relation to the biomechanical models development for determining the biomechanical requirements and movement patterns of the upper limb in healthy and people with Spinal Cord Injury. Moreover, research is conducted with respect to the proposed of new functional assessment instruments in the field of upper limb rehabilitation.

O idoso e sua participação - aspectos da vida urbana componentes da cidade amiga do idoso

Esta investigação teve por objetivo analisar a participação de idosos em direção à promoção da saúde considerando a articulação com oito aspectos da vida urbana do projeto cidade amiga do idoso (espaços abertos e prédios, transporte, moradia, participação social, respeito e inclusão social, participação cívica e emprego, comunicação e informação, e apoio comunitário e serviços de saúde) do bairro Vila Tibério, município de Ribeirão Preto, estado de São Paulo, Brasil. Trata-se de pesquisa descritiva de abordagem qualitativa sustentada pelos conceitos e princípios da promoção da saúde, a partir da perspectiva da participação social e do estabelecimento de ambientes saudáveis, motivo do alinhamento com os aspectos da vida urbana do Projeto Cidade Amiga do Idoso. A pesquisa atendeu aos preceitos éticos, sendo sua realização aprovada por Comitê de Ética em Pesquisa. A captação do empírico se deu por meio da realização de grupos focais com base no Protocolo de Vancouver, desenvolvido pelo Government of British Columbia, somando 32 idosos e 6 representantes de prestadores de serviços em 5 grupos focais. Adicionalmente, foi aplicado instrumento de avaliação funcional para verificar condição de independência ou dependência dos 32 idosos, sendo feita avaliação qualitativa da capacidade autorreferida pelos idosos, segundo a escala utilizada. Realizou-se análise de conteúdo na vertente temática para o material dos grupos, com a identificação de três temas: território: lugar de vida e cidadania, formação de redes de suporte social ao idoso e participação dos idosos na vida do bairro. A violência, o abandono presentes no território, em especial nos espaços coletivos, trazem preocupação e medo aos idosos, pois dificultam a livre circulação no território. Por outro lado, há no bairro certa tradição e possibilidade de serem construídas relações de amizade e apoio, que permitem ao idoso sentir-se acolhido, sendo enfatizado que as relações de amizade e mesmo as institucionalizadas, como por exemplo, o trabalho dos agentes comunitários de saúde, são necessárias às relações de convivência e sustentação na vida dos idosos. É trazida a importância dos jornais do bairro e de seu papel como elemento constitutivo da rede apoio na área de comunicação e informação dentro do território. A vinculação ao mundo do trabalho, com atividades remuneradas, ainda é uma forma que os idosos encontram de se manterem próximos aos amigos e participantes da vida em comunidade. Há dificuldade em ampliar a participação dos idosos por diferentes motivos que vão desde a dificuldade de mobilidade dentro do bairro, acesso à informação sobre as atividades disponíveis, ausência de canais mais ágeis de comunicação, baixa adesão aos processos de participação social no campo da saúde e assistência social, trabalho dos idosos como cuidadores de outros idosos familiares ou de netos. Situações que dificultam maior adesão aos processos de participação social, embora seja assinalada a importância destes processos para a melhoria do bairro. O conjunto dos resultados aponta que os idosos apresentam muitas dificuldades para ampliar sua participação nos processos coletivos no bairro, que por vezes se mostra hostil em suas condições a este grupo. Por outro lado se fazem presentes potencialidades, nas brechas e sugestões que indicam a possibilidade para se situarem no processo de construção da Promoção da Saúde no território em que estão inseridos, utilizando de suas características, perfis de vida e atuação para agir com autonomia e constituírem-se como protagonistas dos processos e de ações no território. Com a ciência dos limites, credita-se a esta investigação a possibilidade de que os elementos aqui discutidos possam oferecer subsídios para que as políticas voltadas ao envelhecimento saudável nos âmbitos da saúde, segurança, educação, assistência social, dentre outras possam se repensadas ou reestruturadas

Qualidade de vida relacionada à saúde e uso de tecnologia de comunicação alternativa por pessoas com câncer de cabeça e pescoço

O tratamento do câncer de cabeça e pescoço e a dificuldade de comunicação decorrente da laringectomia interferem de maneira significativa na qualidade de vida das pessoas acometidas, principalmente quanto aos aspectos funcionais, psicológicos e sociais. Este estudo teve como o objetivo avaliar a qualidade de vida relacionada à saúde (QVRS) de pessoas com câncer de cabeça e pescoço. Trata-se de um estudo exploratório com metodologia quantitativa, do tipo transversal. A coleta de dados foi realizada no período de maio a setembro de 2015, com 100 pessoas com câncer de cabeça e pescoço, divididas em dois grupos: G1: pessoas laringectomizadas, G2: pessoas não laringectomizadas. Para isto, foi utilizado um aplicativo de comunicação alternativa instalado em tablet e foram aplicados o Critério de Classificação Econômica Brasil (CCEB) e a escala Functional Assessment Cancer Therapy (FACT-H&N). Para a análise dos dados foram utilizados o teste exato de Fisher, teste de Kruskal-Wallis, Ancova e estatística descritiva. Como resultados observou-se a prevalência de pessoas do sexo masculino, com faixa etária entre 59 e 74 anos , casadas, aposentadas não ativas, com baixa escolaridade e baixo nível socioeconômico. Os sujeitos participantes de ambos os grupos avaliaram sua qualidade de vida global, de um modo geral, como satisfatória sendo que as funções mais acometidas foram: bem estar emocional e bem estar funcional. Quanto às comparações dos escores finais da escala, observa-se que os participantes do G1 apresentaram melhor QVRS do que os do G2 no escore FACT-G total score, o G1 apresentou melhor QVRS do que o G2, enquanto no FACT-H&N Total score e TOI o G2 apresentou resultados ligeiramente melhores, porém sem significância estatística. Quanto ao uso do LIVOX, todos os participantes que apresentaram alguma dificuldade no seu uso tinham mais de 58 anos e se declararam aposentados não ativos (p=0,04). Conclui-se que é importante o oferecimento, tanto no pré quanto no pós operatório, de cuidados que possam avaliar e melhorar a qualidade de vida relacionada à saúde das pessoas com câncer de cabeça e pescoço

Repercussões cardiovasculares no adulto : pós reparação de tetralogia de Fallot

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Sistemas duplos renais : revisão sistemática

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Programme Prevent-Teach-Reinforce : une intervention comportementale pour diminuer les comportements problématiques en milieu scolaire

Cet article a pour but de décrire le programme d’intervention Prevent-Teach-Reinforce (PTR; Dunlap et al., 2010) en mettant l’accent sur les théories béhaviorales sous-jacentes qui ont servi à son développement. Le PTR est un programme visant la diminution des comportements problématiques chez les enfants et les adolescents en milieu scolaire qui est basé sur l’évaluation fonctionnelle pour développer une intervention individualisée et intensive. Nous effectuons une analyse critique afin de proposer un protocole de validation scientifique puisque le programme n’a fait l’objet que d’une seule évaluation randomisée. Les implications pour la pratique clinique sont aussi discutées en mettant l’accent sur le rôle du psychologue dans l’implantation de ce programme.