Doença de lesões mínimas : a propósito de um caso clínico

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

Articulatory imprecision in dysarthria following childhood cerebellar tumor: A perceptual and acoustic investigation of three male participants

Articulatory imprecision has been documented as a key perceptual feature of the dysarthria associated with childhood cerebellar tumor (CCT). As yet the underlying acoustic and physiological characteristics of motor speech production that contribute to this perceptual feature have not been identified. The aim of the current study was to describe perceptual and acoustic characteristics of consonant production in three children with dysarthria associated with CCT The results indicated that in all three cases the timing of articulatory movements during stop consonant production differed from that measured in a control group of same-age peers. The impact of cerebellar lesions in adulthood on articulatory gestures is used as a reference for discussing the findings of the current study with similarities evident. Also discussed are future research directions for examining the underlying acoustic or physiological basis for articulatory imprecision in children with dysarthria associated with CCT.

The effect of corneal thickness and corneal curvature on pneumatonometer measurements

Purpose. The purpose of this study was to investigate the influence of corneal topography and thickness on intraocular pressure (IOP) and pulse amplitude (PA) as measured using the Ocular Blood Flow Analyzer (OBFA) pneumatonometer (Paradigm Medical Industries, Utah, USA). Methods. 47 university students volunteered for this cross-sectional study: mean age 20.4 yrs, range 18 to 28 yrs; 23 male, 24 female. Only the measurements from the right eye of each participant were used. Central corneal thickness and mean corneal radius were measured using Scheimpflug biometry and corneal topographic imaging respectively. IOP and PA measurements were made with the OBFA pneumatonometer. Axial length was measured using A-scan ultrasound, due to its known correlation with these corneal parameters. Stepwise multiple regression analysis was used to identify those components that contributed significant variance to the independent variables of IOP and PA. Results. The mean IOP and PA measurements were 13.1 (SD 3.3) mmHg and 3.0 (SD 1.2) mmHg respectively. IOP measurements made with the OBFA pneumatonometer correlated significantly with central corneal thickness (r = +0.374, p = 0.010), such that a 10 mm change in CCT was equivalent to a 0.30 mmHg change in measured IOP. PA measurements correlated significantly with axial length (part correlate = -0.651, p < 0.001) and mean corneal radius (part correlate = +0.459, p < 0.001) but not corneal thickness. Conclusions. IOP measurements taken with the OBFA pneumatonometer are correlated with corneal thickness, but not axial length or corneal curvature. Conversely, PA measurements are unaffected by corneal thickness, but correlated with axial length and corneal radius. These parameters should be taken into consideration when interpreting IOP and PA measurements made with the OBFA pneumatonometer.

Accuracy of Goldmann, ocular response analyser, Pascal and TonoPen XL tonometry in keratoconic and normal eyes

Aim: The aim of this study was to evaluate the practicality and accuracy of tonometers used in routine clinical practice for established keratoconus (KC). Methods: This was a prospective study of 118 normal and 76 keratoconic eyes where intraocular pressure (IOP) was measured in random order using the Goldman applanation tonometer (GAT), Pascal dynamic contour tonometer (DCT), Reichert ocular response analyser (ORA) and TonoPen XL tonometer. Corneal hysteresis (CH) and corneal resistance factor (CRF), as calculated by the ORA, were recorded. Central corneal thickness (CCT) was measured using an ultrasound pachymeter. Results: The difference in IOP values between instruments was highly significant in both study groups (p<0.001). All other IOP measures were significantly higher than those for GAT, except for the Goldmann-correlated IOP (average of the two applanation pressure points) (IOPg) as measured by ORA in the control group and the CH-corrected IOP (corneal-compensated IOP value) (IOPcc) measures in the KC group. CCT, CH and CRF were significantly less in the KC group (p<0.001). Apart from the DCT, all techniques tended to measure IOP higher in eyes with thicker corneas. Conclusion: The DCT and the ORA are currently the most appropriate tonometers to use in KC for the measurement of IOPcc. Corneal factors such as CH and CRT may be of more importance than CCT in causing inaccuracies in applanation tonometry techniques.

Conflicts and online community social capital:the influence of conflict management practices

Conflicts are part and parcel of online community dynamics (De Valck 2007; Harrison and Jenkins 1996; Kozinets 2001) – from flames about publishing inappropriate content (De Zwart and Lindsay 2009) to battles to win high status positions (Campbell, Fletcher and Greenhill 2009) and stigmatization of illegitimate insiders (Tikkanen, Hietanen, Henttonen, and Rokka 2009) up to bashing and smearing campaigns (Bocij 2002). As the concept of community presumes unity, marketers may be inclined to suppress any dissonance in their online brand communities thinking that it may hurt brand image or community attractiveness. However, Fournier and Lee (2009) advise marketers to embrace the conflicts that make communities thrive. As tensions and conflict cannot be avoided this seems logical advice. Nevertheless, are all tensions and conflicts created equally? Are some not more constructive (or destructive) than others? Thus, should all tensions and conflicts really be embraced, and what can be done to channel tensions and conflicts such that they do not become destructive? These questions form the starting point of this paper.

The relationship between measurement method and corneal structure on apparent intraocular pressure in glaucoma and ocular hypertension

Purpose: To analyse the relationship between measured intraocular pressure (IOP) and central corneal thickness (CCT), corneal hysteresis (CH) and corneal resistance factor (CRF) in ocular hypertension (OHT), primary open-angle (POAG) and normal tension glaucoma (NTG) eyes using multiple tonometry devices. Methods: Right eyes of patients diagnosed with OHT (n=47), normal tension glaucoma (n=17) and POAG (n=50) were assessed, IOP was measured in random order with four devices: Goldmann applanation tonometry (GAT); Pascal(R) dynamic contour tonometer (DCT); Reichert(R) ocular response analyser (ORA); and Tono-Pen(R) XL. CCT was then measured using a hand-held ultrasonic pachymeter. CH and CRF were derived from the air pressure to corneal reflectance relationship of the ORA data. Results: Compared to the GAT, the Tonopen and ORA Goldmann equivalent (IOPg) and corneal compensated (IOPcc) measured higher IOP readings (F=19.351, p<0.001), particularly in NTG (F=12.604, p<0.001). DCT was closest to Goldmann IOP and had the lowest variance. CCT was significantly different (F=8.305, p<0.001) between the 3 conditions as was CH (F=6.854, p=0.002) and CRF (F=19.653, p<0.001). IOPcc measures were not affected by CCT. The DCT was generally not affected by corneal biomechanical factors. Conclusion: This study suggests that as the true pressure of the eye cannot be determined non-invasively, measurements from any tonometer should be interpreted with care, particularly when alterations in the corneal tissue are suspected.

Corneal pachymetry in normal and keratoconic eyes:Orbscan II versus ultrasound

Purpose: To compare corneal thickness measurements using Orbscan II (OII) and ultrasonic (US) pachymetry in normal and in keratoconic eyes. Setting: Eye Department, Heartlands and Solihull NHS Trust, Birmingham, United Kingdom. Methods: Central corneal thickness (CCT) was measured by means of OII and US pachymetry in 1 eye of 72 normal subjects and 36 keratoconus patients. The apical corneal thickness (ACT) in keratoconus patients was also evaluated using each method. The mean of the difference, standard deviation (SD), and 95% limits of agreement (LoA = mean ± 2 SD), with and without applying the default linear correction factor (LCF), were determined for each sample. The Student t test was used to identify significant differences between methods, and the correlation between methods was determined using the Pearson bivariate correlation. Bland-Altman analysis was performed to confirm that the results of the 2 instruments were clinically comparable. Results: In normal eyes, the mean difference (± 95% LoA) in CCT was 1.04 μm ± 68.52 (SD) (P>.05; r = 0.71) when the LCF was used and 46.73 ± 75.40 μm (P = .0001; r = 0.71) without the LCF. In keratoconus patients, the mean difference (± 95% LoA) in CCT between methods was 42.46 ± 66.56 μm (P<.0001: r = 0.85) with the LCF, and 2.51 ± 73.00 μm (P>.05: r = 0.85) without the LCF. The mean difference (± 95% LoA) in ACT for this group was 49.24 ± 60.88 μm (P<.0001: r = 0.89) with the LCF and 12.71 ± 68.14 μm (P = .0077; r = 0.89) when the LCF was not used. Conclusions: This study suggests that OII and US pachymetry provide similar readings for CCT in normal subjects when an LCF is used. In keratoconus patients, OII provides a valid clinical tool for the noninvasive assessment of CCT when the LCF is not applied. © 2004 ASCRS and ESCRS.

Internal quantum efficiency and tunable colour temperature in monolithic white InGaN/GaN LED

Internal Quantum Efficiency (IQE) of two-colour monolithic white light emitting diode (LED) was measured by temperature dependant electro-luminescence (TDEL) and analysed with modified rate equation based on ABC model. External, internal and injection efficiencies of blue and green quantum wells were analysed separately. Monolithic white LED contained one green InGaN QW and two blue QWs being separated by GaN barrier. This paper reports also the tunable behaviour of correlated colour temperature (CCT) in pulsed operation mode and effect of self-heating on device performance. © 2014 SPIE.

Colour management of InGaN/GaN based monolithic two-wavelength LEDs

The recent advancement in the growth technology of InGaN/GaN has decently positioned InGaN based white LEDs to leap into the area of general or daily lighting. Monolithic white LEDs with multiple QWs were previously demonstrated by Damilano et al. [1] in 2001. However, there are several challenges yet to be overcome for InGaN based monolithic white LEDs to establish themselves as an alternative to other day-to-day lighting sources [2,3]. Alongside the key characteristics of luminous efficacy and EQE, colour rendering index (CRI) and correlated colour temperature (CCT) are important characteristics for these structures [2,4]. Investigated monolithic white structures were similar to that described in [5] and contained blue and green InGaN multiple QWs without short-period superlattice between them and emitting at 440 nm and 530 nm, respectively. The electroluminescence (EL) measurements were done in the CW and pulse current modes. An integration sphere (Labsphere “CDS 600” spectrometer) and a pulse generator (Agilent 8114A) were used to perform the measurements. The CCT and Green/Blue radiant flux ratio were investigated at extended operation currents from 100mA to 2A using current pulses from 100ns to 100μs with a duty cycle varying from 1% to 95%. The strong dependence of the CCT on the duty cycle value, with the CCT value decreasing by more than three times at high duty cycle values (shown at the 300 mA pulse operation current) was demonstrated (Fig. 1). The pulse width variation seems to have a negligible effect on the CCT (Fig. 1). To account for the joule heating, a duty cycle more than 1% was considered as an overheated mode. For the 1% duty cycle it was demonstrated that the CCT was tuneable in three times by modulating input current and pulse width (Fig. 2). It has also been demonstrated that there is a possibility of keeping luminous flux independent of pulse width variation for a constant value of current pulse (Fig. 3).

Short-term stability in refractive status despite large fluctuations in glucose levels in diabetes mellitus type 1 and 2

Purpose: This work investigates how short-term changes in blood glucose concentration affect the refractive components of the diabetic eye in patients with long-term Type 1 and Type 2 diabetes. Methods: Blood glucose concentration, refractive error components (mean spherical equivalent MSE, J0, J45), central corneal thickness (CCT), anterior chamber depth (ACD), crystalline lens thickness (LT), axial length (AL) and ocular aberrations were monitored at two-hourly intervals over a 12-hour period in: 20 T1DM patients (mean age ± SD) 38±14 years, baseline HbA1c 8.6±1.9%; 21 T2DM patients (mean age ± SD) 56±11 years, HbA1c 7.5±1.8%; and in 20 control subjects (mean age ± SD) 49±23 years, HbA1c 5.5±0.5%. The refractive and biometric results were compared with the corresponding changes in blood glucose concentration. Results: Blood glucose concentration at different times was found to vary significantly within (p<0.0005) and between groups (p<0.0005). However, the refractive error components and ocular aberrations were not found to alter significantly over the day in either the diabetic patients or the control subjects (p>0.05). Minor changes of marginal statistical or optical significance were observed in some biometric parameters. Similarly there were some marginally significant differences between the baseline biometric parameters of well-controlled and poorly-controlled diabetic subjects. Conclusion: This work suggests that normal, short-term fluctuations (of up to about 6 mM/l on a timescale of a few hours) in the blood glucose levels of diabetics are not usually associated with acute changes in refractive error or ocular wavefront aberrations. It is therefore possible that factors other than refractive error fluctuations are sometimes responsible for the transient visual problems often reported by diabetic patients. © 2012 Huntjens et al.

Gravity collapse structures in the Central Precordillera fold-andthrust belt, Argentina

Several landforms found in the fold-and-thrust belt area of Central Precordillera, Pre-Andes of Argentina, which were often associated with tectonic efforts, are in fact related to non-tectonic processes or gravitational superficial structures. These second-order structures, interpreted as gravitational collapse structures, have developed in the western flank of sierras de La Dehesa and Talacasto. These include rock-slides, rock falls, wrinkle folds, slip sheets and flaps, among others; which together constitute a monoclinal fold dipping between 30º and 60º to the west. Gravity collapse structures are parallel to the regional strike of the Sierra de la Dehesa and are placed in Ordovician limestones and dolomites. Their sloping towards the west, the presence of bed planes, fractures and joints; and the lithology (limestone interbedded with incompetent argillaceous banks) would have favored their occurrence. Movement of the detached structures has been controlled by lithology characteristics, as well as by bedding and joints. Detachment and initial transport of gravity collapse structures and rockslides in the western flank of the Sierra de la Dehesa were tightly controlled by three structural elements: 1) sliding surfaces developed on parallel bedded strata when dipping >30° in the slope direction; 2) Joint’s sets constitute lateral and transverse traction cracks which release extensional stresses and 3) Discontinuities fragmenting sliding surfaces.  Some other factors that could be characterized as local (lithology, structure and topography) and as regional (high seismic activity and possibly wetter conditions during the postglacial period) were determining in favoring the steady loss of the western mountain side in the easternmost foothills of Central Precordillera.

Surgical Options After Fontan Failure

OBJECTIVE: The objective of this European multicenter study was to report surgical outcomes of Fontan takedown, Fontan conversion and heart transplantation (HTX) for failing Fontan patients in terms of all-cause mortality and (re-)HTX. METHODS: A retrospective international study was conducted by the European Congenital Heart Surgeons Association among 22 member centres. Outcome of surgery to address failing Fontan was collected in 225 patients among which were patients with Fontan takedown (n=38; 17%), Fontan conversion (n=137; 61%) or HTX (n=50; 22%). RESULTS: The most prevalent indication for failing Fontan surgery was arrhythmia (43.6%), but indications differed across the surgical groups (p<0.001). Fontan takedown was mostly performed in the early postoperative phase after Fontan completion, while Fontan conversion and HTX were mainly treatment options for late failure. Early (30 days) mortality was high for Fontan takedown (ie, 26%). Median follow-up was 5.9 years (range 0-23.7 years). The combined end point mortality/HTX was reached in 44.7% of the Fontan takedown patients, in 26.3% of the Fontan conversion patients and in 34.0% of the HTX patients, respectively (log rank p=0.08). Survival analysis showed no difference between Fontan conversion and HTX (p=0.13), but their ventricular function differed significantly. In patients who underwent Fontan conversion or HTX ventricular systolic dysfunction appeared to be the strongest predictor of mortality or (re-)HTX. Patients with valveless atriopulmonary connection (APC) take more advantage of Fontan conversion than patients with a valve-containing APC (p=0.04). CONCLUSIONS: Takedown surgery for failing Fontan is mostly performed in the early postoperative phase, with a high risk of mortality. There is no difference in survival after Fontan conversion or HTX.

Mitral Valve Surgery for Rheumatic Lesions in Young Patients

BACKGROUND: The appropriateness of rheumatic mitral valve repair remains controversial due to the risks of recurrent mitral dysfunction and need for reoperation. The aims of this study were to determine the overall short- and long-term outcomes of pediatric rheumatic mitral valve surgery in our center. METHODS: Single-center, observational, retrospective study that analyzed the results of rheumatic mitral valve surgery in young patients, consecutively operated by the same team, between 1999 and 2014. RESULTS: We included 116 patients (mean age = 12.6 ± 3.5 years), of which 66 (57%) were females. A total of 116 primary surgical interventions and 22 reoperations were performed. Primary valve repair was possible in 86 (74%) patients and valve replacement occurred in 30 (26%). Sixty percent of the patients were followed up beyond three months after surgery (median follow-up time = 9.2 months [minimum = 10 days; maximum = 15 years]). Long-term clinical outcomes were favorable, with most patients in New York Heart Association functional class I (89.6%) and in sinus rhythm (85%). Freedom from reoperation for primary valve repair at six months, five years, and ten years was 96.4% ± 0.25%, 72% ± 0.72%, and 44.7% ± 1.34%, respectively. Freedom from reoperation for primary valve replacement at six months, five years, and ten years was 100%, 91.7% ± 0.86%, and 91.7% ± 0.86%, respectively. Mitral stenosis as the primary lesion dictated early reintervention. CONCLUSIONS: Despite the greater rate of reoperation, especially when the primary lesion was mitral stenosis, rheumatic mitral valve repair provides similar clinical outcomes as compared with replacement, with the advantage of avoiding anticoagulation.

Potencial antifúngico, antioxidante e inibidor da produção de aflatoxina por extratos fenólicos de Chlorella sp. e Spirulina platensis

A contaminação fúngica acarreta alterações na qualidade nutricional e no valor econômico de produtos alimentícios podendo causar danos patológicos em plantas, animais e humanos. A identificação da atividade antioxidante, antifúngica e antimicotoxinas, em extratos de microalgas com propriedade de inibir a multiplicação de fungos e subseqüente produção de micotoxinas abre a perspectiva de empregar substâncias mais eficientes e com maior ação específica contra estes microorganismos. Entre os compostos com propriedades inibidoras de radicais livres, de crescimento fúngico e produção de micotoxinas, destacam-se os compostos fenólicos, que podem inibir a atividade metabólica microbiana, dificultando a atividade de enzimas. Neste estudo foram avaliados o poder de inibição de multiplicação fúngica de Rhizopus oryzae e Aspergillus flavus pelos extratos fenólicos de Chlorella sp. e Spirulina platensis, bem como sua atividade antioxidante, e a atividade antimicotoxinas da última microalga contra Aspergillus flavus. O conteúdo de fenóis totais foi em média 1000 µgfenóis/g Spirulina platensis e 600 µgfenóis/g Chlorella sp., sendo que o acido gálico e o cafeíco foram identificados como compostos majoritários na Spirulina platensis. As determinações de glicosamina (parede celular) e ergosterol (membrana celular) mostraram-se bons indicativos do desenvolvimento microbiano permitindo uma boa estimativa da inibição dele. O extrato fenólico de Spirulina platensis apresentou capacidade de inibir cerca de 50% a formação da parede e da membrana celular para ambos os fungos estudados e de 100% a produção de aflatoxina B1 até o 10º dia de cultivo do Aspergillus flavus. Além disso, o extrato metanólico de Spirulina platensis inativou 53,5% o DPPH reativo, limitou o escurecimento enzimático ocasionado pela peroxidase em 55% e inibiu a peroxidação lipídica em 46% após 14 dias de armazenamento sob luz. Estes resultados mostram que a ação antifúngica, antimicotoxinas e antioxidante está naturalmente presente em alguns tecidos microbianos e que encontrar a forma de extraí-los e aplicá-los como conservantes alimentícios é muito promissor para substituição aos antifúngicos e outros conservantes químicos.

Obtenção e caracterização de queratinase de bacillus sp. P45 a partir de coprodutos e aplicação na produção de queijos cremosos enriquecidos com chia e quinoa

As proteases constituem 60-65% do mercado global das enzimas industriais e são utilizadas na indústria de alimentos no processo de amaciamento de carne, na síntese de peptídeos, preparo de fórmulas infantis, panificação, cervejarias, produtos farmacêuticos, diagnósticos médicos, como aditivos na indústria de detergentes e na indústria têxtil no processo de depilação e transformação do couro. Proteases específicas produzidas por micro-organismos queratinolíticos são chamadas de queratinases e distinguem-se de outras proteases pela maior capacidade de degradação de substratos compactos e insolúveis como a queratina. Atualmente, processos que apontem o uso total das matérias-primas e que não resultem em impactos negativos ao meio ambiente tem ganhado destaque. Dentro desta temática, destacam-se a reutilização da farinha de penas residual durante o cultivo do Bacillus sp. P45 para produção de proteases e a biomassa residual de levedura, ambas com elevados teores de proteínas, podendo ser utilizadas no cultivo do Bacillus sp. P45 para obtenção de proteases. O objetivo deste trabalho foi obter a enzima queratinase purificada em grandes quantidades, sua caracterização, bem como a sua aplicação em processos de coagulação enzimática do leite para o desenvolvimento de um queijo cremoso enriquecido com farinha de chia e quinoa. Além disso, aplicar diferentes coprodutos para produção de enzimas proteolíticas e queratinolíticas. A presente tese foi dividida em quatro artigos: no primeiro foi realizado a obtenção da queratinase purificada em maiores quantidades e a determinação dos parâmetros de estabilidade térmica e a influência de componentes químicos na atividade enzimática. A obtenção da enzima em maiores quantidades alcançou fatores de purificação de 2,6, 6,7 e 4,0 vezes, paras 1º SAB, 2º SAB e diafiltração, respectivamente. A recuperação enzimática alcançou valores de 75,3% para o 1º SAB, 75,1% no 2º sistema e 84,3% na diafiltração. A temperatura de 55ºC e o pH 7,5 foram determinados como ótimos para atividade da enzima queratinase. O valor da energia de desativação (Ed) médio foi de 118,0 kJ/mol e os valores de z e D variaram de 13,6 a 18,8ºC, e 6,9 a 237,3 min, respectivamente. Além disso a adição de sais (CaCl2, CaO, C8H5KO4 e MgSO4) elevou a atividade da enzima na presença destes compostos. O segundo artigo apresenta a aplicação da queratinase como coagulante de leite bovino e sua aplicação na obtenção de queijo cremoso enriquecido com chia e quinoa. A enzima mostrou atividade de coagulação semelhante ao coagulante comercial, na concentração de 30mg/mL. A enzima purificada foi empregada de forma eficiente na fabricação do queijo cremoso, que apresentou valores de pH de 5,3 e acidez de 0,06 a 0,1 mol/L, com elevação durante os 25 dias de armazenamento. O terceiro artigo apresenta o perfil do queijo cremoso enriquecido com farinha de chia e quinoa, o qual apresentou alto índice de retenção de água (>99,0%) e baixos valores de sinérese (<0,72%). Elevados teores de fibras foi verificado (3,0 a 5,0%), sugerindo seu consumo como fonte de fibras. As análises microbiológicas foram de acordo com a legislação vigente. Na análise sensorial foi verificado altos valores de suavidade ao paladar e verificado maiores valores de consistência e untabilidade nas amostras com maiores concentrações de nata e quinoa. O quarto artigo traz a extração de β-galactosidase por ultrassom e o uso da biomassa residual da levedura, bem como o uso de farinha de penas residuais como substrato para obtenção de proteases. O ultrassom foi eficiente para ruptura celular e extração de β-galactosidase, apresentando alta atividade (35,0 U/mL) e rendimento (876,0 U/g de biomassa). A maior atividade proteolítica (1300 U/mL em 32 h) e queratinolítica (89,2 U/mL) verificadas ocorreram utilizando-se a biomassa e a farinha de penas residuais, respectivamente. Maior produtividade proteolítica (40,8 U/mL/h) foi verificado no meio utilizando biomassa residual como substrato. Já a maior produtividade queratinolítica (2,8 U/mL/h) foi alcançada utilizando farinha de penas reutilizada.