El empleo de la vegetación en el tratamiento funcional y paisajístico de taludes de carretera: investigación sobre el comportamiento de determinadas especies

La tarea de implantar una cubierta vegetal en taludes de carretera implica la consideración de una serie de factores que se presentan en estos lugares con matices específicos y configuran, aisladamente o en su conjunto, una situación distinta de la que habitualmente se presenta a la hora de sembrar o de plantar de forma común. Efectivamente, la pendiente, la temperatura del suelo, la compacidad del suelo, el contenido y distribución de humedad, la cantidad de materia orgánica, suelen definir un medio sumamente inadecuado para el desarrollo de la vegetación. De hecho, la colonización natural no se produce, o se lleva a cabo a un ritmo muy lento, en los taludes del tipo que se origina habitualmente junto a las grandes carreteras. Por otro lado, el establecimiento de una cubierta vegetal permanente parece ser el mejor procedimiento para conseguir la fijación y estabilización de taludes. En ponderación conjunta de los aspectos funcionales, económicos, estéticos y de conservación del medio natural, ofrece ventajas indudables sobre cualquier otro método; ventajas que persisten, en muchas ocasiones, aún limitando la consideración por separado a uno cualquiera de los cuatro aspectos. El problema objeto de este estudio, queda así centrado en la superación de la contradicción enunciada. Es claro que la solución puede conseguirse a base de "grandes remedios", como sería la modificación radical del "medio talud", viable técnicamente pero inviable económicamente en tal grado que no merece se le preste mayor atención que esta simple mención. La solución ha de buscarse, no obstante, por ese mismo camino, pero quitando a la modificación la nota de radical. El empleo de materiales que actúan como "mulch", estabilizador o acondicionador, y de técnicas tales como la hidrosiembra, ha supuesto un avance importante en el planteamiento técnico-económico del problema- Los materiales y técnicas aludidas proporcionan un medio menos hostil, en el que la vegetación puede debatirse ya con mejores perspectivas. La situación, en este hipotético ahora, podría dibujarse en dos trazos fundamentales: 1) El talud, tratado por cualquiera de los procedimientos conocidos, sigue siendo un medio artificial. Por lo tanto, al estudio de las condiciones climáticas, de las propiedades - del suelo y de la vegetación espontánea, ha de concedérsele importancia mucho menor de la acostumbrada en los estudios que contemplan un medio natural o poco modificado. 2) La finalidad perseguida es fijar los taludes de forma rápida y permanente. Importa, pues, decisivamente el efecto inicial de control de la erosión; y en segundo lugar dejar la puerta abierta para que los procesos naturales incidan sobre lo operado artificialmente, para irlo sustituyendo paulatinamente. En cualquier caso, y como prolongación de lo ya señalado acerca del peso a conceder al entorno natural, puede afirmarse que, más que los elementos definitorios de las comunidades naturales, son las componentes operativas de las especies empleadas las que determinan la viabilidad global de la acción emprendida. Se trata, pues, de buscar una comunidad funcional, cuyos componentes básicos apuntarían hacia el cumplimiento en el espacio y en el tiempo de una serie de funciones; entre ellas, es primordial el control de la erosión, que exige efectos extensos, inmediatos y permanentes. Los primeros capítulos del trabajo se dedican a la descripción de los aspectos particulares que el mecanismo erosivo presenta en los taludes de carreteras y de los factores que influyen en el establecimiento de la cubierta vegetal. En el capítulo 4 se sientan las bases que han de conducir a la elección de especies, y se enumeran los requisitos que éstas han de reunir. A continuación, se describe el medio en que se ha llevado a cabo la parte experimental: 30 taludes de la Autopista Barcelona-Gerona, en el tramo comprendido entre San Celoni y el Aeropuerto de Gerona, y las actuaciones realizadas sobre ellos, que son de dos tipos: 1) Cubrimiento de la superficie del talud, previo o simultáneo a la siembra, con uno de los siguientes materiales: - Tierra vegetal acopiada durante la explanación de la carretera. - Mulch de fibra larga, constituido por paja de cereal trabada con bitumen. - Mulch de fibra corta con un estabilizador de suelos, a base de alginatos. 2) Siembra con mezcla de semillas elegida entre seis previamente definidas. El estudio de los factores del medio, permite aceptar la homogeneidad previa a las actuaciones, y concretar el estudio del comportamiento de las especies en su respuesta a unos pocos elementos diferenciales: Intrínsecos al talud Desmonte o terraplén Exposición (solana o umbría) Pendiente Extrínsecos al talud Tipo de tratamiento recibido Composición de la siembra. Por último, en el Capitulo 4 se procede a la elección de especies a sembrar, mediante sucesivas aproximaciones a partir de la flora autóctona, disponibilidad de la se milla y consideraciones funcionales. La dosificación de las mezclas se verifica en base al Índice de concurrencia, con matizaciones derivadas de exposición y tipo de tratamiento. Las dificultades que se encuentran para conseguir el establecimiento en taludes artificiales de las especies habitualmente empleadas como pratenses, notoriamente relevantes en las zonas áridas, donde se suma a ellas la falta continuada de humedad durante largos períodos, han animado a investigar el comportamiento de algunas especies poco conocidas. Para ello, se llevaron a cabo ensayos de germinación en situaciones adversas, similares a las de los taludes. A continuación se describen las especies estudiadas, con referencia esquemática a su ecología y a los rasgos funcionales que han conducido a su elección. La inventariación de los resultados obtenidos en los taludes se realizó mediante un muestreo sistemático; el análisis de la información proporcionada se verificó en varias etapas. Un primer análisis consistió en explayar los resultados medios correspondientes a grupos de taludes, definidos según elementos diferenciales comunes, y a los diferentes conceptos del inventario (presencia en muestra, superficie cubierta y número de plantas). Este primer análisis permite definir la respuesta de las especies a las distintas actuaciones artificiales. El comportamiento de cada especie se aborda mediante la elaboración de cuatro índices, de los cuales sólo se retienen finalmente dos. Los Índices evidencian qué especies han dado los mejores resultados y qué otras han dado los peores; resta un tercer grupo, definido con menor precisión, que seguirá siendo analizado en las etapas posteriores del análisis. El estudio de las posibles correlaciones entre las especies, pone de manifiesto una baja estructuración de los datos, como por otra parte cabía esperar en una etapa preliminar de desarrollo, pero también evidencia ciertas constantes y paralelismos o divergencias en los comportamientos. El capítulo final contempla la posibilidad de distribuciones irregulares a lo largo de la altura de los taludes, como probablemente se darían si no existiesen actuaciones artificiales.

Análisis de la marcha: evaluación de un exoesqueleto aplicado a la marcha asistida

La marcha humana es el mecanismo de locomoción por el cual el cuerpo humano se traslada en línea recta gracias a una serie de movimientos coordinados de la pelvis y de las articulaciones del miembro inferior. Frecuentemente se encuentra influenciada por factores biomecánicos, anatómicos o patologías del sistema neuromusculoesquelético que modifican la forma de caminar de cada individuo. La lesión de médula espinal es una de las patologías que afectan el desarrollo normal de los patrones de la marcha por alteración de la movilidad, de la sensibilidad o del sistema nervioso autónomo. Aunque la lesión medular afecta otras funciones, además de la pérdida de función motora y sensorial, la recuperación de la capacidad de caminar es la mayor prioridad identificada por los pacientes durante la rehabilitación. Por ello, el desarrollo de dispositivos que faciliten la rehabilitación o compensación de la marcha es uno de los principales objetivos de diferentes grupos de investigación y empresas. En el contexto del proyecto Hybrid Technological Platform for Rehabilitation, Functional Compensation and Training of Gait in Spinal Cord Injury Patients se ha desarrollado un dispositivo que combina una órtesis activa (exoesqueleto) y un andador motorizado. Este sistema, como otros dispositivos, tiene el movimiento humano como estándar de referencia, no obstante no se evalúa de manera habitual, cómo es el patrón de la marcha reproducido y su similitud o diferencias con la marcha humana, o las modificaciones o adaptaciones en la interacción con el cuerpo del paciente. El presente estudio trata de examinar las características de la marcha normal en diversos grupos de población, y las diferencias con el patrón de marcha lenta. Finalmente, se pretende evaluar qué modificaciones y adaptaciones sufre el patrón de marcha lenta teórico al ser reproducido por el exoesqueleto. La presente investigación consiste en un estudio cuantitativo transversal desarrollado en dos etapas: estudio 1 y estudio 2. En el estudio 1 se analizó el patrón de la marcha a velocidad libremente seleccionada (normal) y el patrón de la marcha a velocidad lenta (0.25m/s) en 62 sujetos distribuidos en grupos considerando el sexo y los percentiles 25, 50 y 75 de estatura de la población española. Durante el estudio 2 se analizó el patrón de la marcha lenta reproducido por el dispositivo Hybrid a diferentes porcentajes de peso corporal (30%, 50% y 70%) en diez sujetos seleccionados aleatoriamente de la muestra del estudio 1. En ambos estudios se obtuvieron variables espacio-temporales y cinemáticas mediante un sistema de captura de movimiento con 6 cámaras distribuidas a lo largo de un pasillo de marcha. Se calcularon las medias, las desviaciones estándar y el 95% de intervalo de confianza, y el nivel alfa de significación se estableció en α=0.05 para todas las pruebas estadísticas. Las principales diferencias en el patrón normal de la marcha se encontraron en los parámetros cinemáticos de hombres y mujeres, aunque también se presentaron diferencias entre los grupos en función de la estatura. Las mujeres mostraron mayor flexión de cadera y rodilla, y mayor extensión de tobillo que los hombres durante el ciclo normal, aunque la basculación lateral de la pelvis, mayor en las mujeres, y el desplazamiento lateral del centro de gravedad, mayor en los hombres, fueron los parámetros identificados como principales discriminantes entre sexos. La disminución de la velocidad de la marcha mostró similares adaptaciones y modificaciones en hombres y en mujeres, presentándose un aumento de la fase de apoyo y una disminución de la fase de oscilación, un retraso de los máximos y mínimos de flexoextensión de cadera, rodilla y tobillo, y una disminución del rango articular en las tres articulaciones. Asimismo, la basculación lateral de la pelvis y el movimiento vertical del centro de gravedad disminuyeron, mientras que el movimiento lateral del centro de gravedad y el ancho de paso aumentaron. Durante la evaluación del patrón de la marcha reproducido por el exoesqueleto se observó que las tres articulaciones del miembro inferior disminuían el rango de movimiento por la falta de fuerza de los motores para contrarrestar el peso corporal, incluso con un 70% de descarga de peso. Además, la transferencia de peso se encontró limitada por la falta de movimiento de la pelvis en el plano frontal y se sustituyó por un aumento de la inclinación del tronco y, por tanto, del movimiento lateral del centro de gravedad. Este hecho, junto al aumento del desplazamiento vertical del centro de gravedad, hizo del patrón de la marcha reproducido por el exoesqueleto un movimiento poco eficiente. En conclusión, se establecen patrones de marcha normal diferenciados por sexos, siendo la basculación lateral de la pelvis y el movimiento lateral del centro de gravedad los parámetros discriminantes más característicos entre sexos. Comparando la marcha a velocidad libremente seleccionada y la velocidad lenta, se concluye que ambos sexos utilizan estrategias similares para adaptar el patrón de la marcha a una velocidad lenta y se mantienen las características diferenciadoras entre hombres y mujeres. En relación a la evaluación del dispositivo Hybrid, se deduce que la falta de movimiento lateral de la pelvis condiciona la transferencia de peso y el aumento del rango de movimiento del centro de gravedad y, en consecuencia, tiene como resultado un patrón de la marcha poco eficiente. Este patrón no resultaría indicado para los procesos de rehabilitación o recuperación de la marcha, aunque podría considerarse adecuado para la compensación funcional de la bipedestación y la locomoción. ABSTRACT The human walking is a means of moving body forward using a repetitious and coordinated sequence of pelvis and lower limb motions. It is frequently influenced by biomechanical and anatomical factors or by musculoskeletal pathologies which modify the way of walking. The spinal injury is one of those pathologies which affect the normal pattern of walking, due to the alteration of the mobility, the sensory or the autonomic nervous system. Although the spinal injury affects many other body functions, apart from the motor and sensory ones, the main priority for patients is to recover the ability of walking. Consequently, the main objective of many research groups and private companies is the development of rehabilitation and compensation devices for walking. In this context, the Hybrid Technological Platform for Rehabilitation, Functional Compensation and Training of Gait in Spinal Cord Injury Patients project has developed a device which integrates an exoskeleton and a motorized smart walker. This system, as other similar devices, has the human movement as standard reference. Nevertheless, these devices are not usually evaluated on the way they reproduce the normal human pattern or on the modifications and in the interactions with the patient’s body. The aim of the present study is to examine the normal walking characteristics, to analyze the differences between self-selected and low speed walking patterns, and to evaluate the modifications and adaptations of walking pattern when it is reproduced by the exoskeleton. The present research is a quantitative cross-sectional study carried out in two phases: study 1 and study 2. During the study 1, the self-selected and the low speed (0.25m/s) walking patterns were analyzed in sixty-two people distributed in groups, according to sex and 25th, 50th and 75th percentiles of height for Spanish population. The study 2 analyzed the low speed walking pattern reproduced by the Hybrid system in three conditions: 30%, 50% and 70% of body weight support. To do this, ten subjects were randomly selected and analyzed from the people of study 1. An optoelectronic system with six cameras was used to obtain spatial, temporal and kinematic parameters in both studies. Means, standard deviations and 95% confidence intervals of the study were calculated. The alpha level of significance was set at α=0.05 for all statistical tests. The main differences in normal gait pattern were found in kinematic parameters between men and women. The hip and the knee were more flexed and the ankle plantar flexion was higher in women than in men during normal gait cycle. Although the greater pelvic obliquity of women and the higher lateral movement of center of gravity of men were the most relevant discriminators between male and female gait patterns. Comparing self-selected and low speed walking patterns, both sexes showed similar adaptations and modifications. At low speed walking, men and women increased the stance phase ratio and decreased the swing phase ratio. The maximum and minimum peak flexion of hip, knee and ankle appeared after and the range of motion of them decreased during low speed walking. Furthermore, the pelvic obliquity and the vertical movement of the center of gravity decreased, whereas the lateral movement of center of gravity and step width increased. Evaluating the gait pattern reproduced by the exoskeleton, a decrease of lower limb range of motion was observed. This was probably due to the lack of strength of the engines, which were not able to control the body weight, even with the 70% supported. Moreover, the weight transfer from one limb to the contralateral side was restricted due to the lack of pelvis obliquity. This movement deficiency was replaced by the lateral torso sway and, consequently, the increase of lateral movement of the center of gravity. This fact, as well as the increase of the vertical displacement of the center of gravity, made inefficient the gait pattern reproduced by the exoskeleton. In conclusion, different gait patterns of both sexes have been determined, being pelvis obliquity and lateral movement of center of gravity the most relevant discriminators between male and female gait patterns. Comparing self-selected and low speed walking patterns, it was concluded that both sexes use similar strategies for adapting the gait pattern to a low speed, and therefore, the differentiating characteristics of normal gait are maintained. Regarding the Hybrid system evaluation, it was determined that the gait pattern reproduced by the exoskeleton is inefficient. This was due to the lack of pelvis obliquity and the increase of the center of gravity displacement. Consequently, whereas the walking pattern reproduced by the exoskeleton would not be appropriated for the rehabilitation process, it could be considered suitable for functional compensation of walking and standing.

NMR studies of muscle glycogen synthesis in insulin-resistant offspring of parents with non-insulin-dependent diabetes mellitus immediately after glycogen-depleting exercise.

To examine the impact of insulin resistance on the insulin-dependent and insulin-independent portions of muscle glycogen synthesis during recovery from exercise, we studied eight young, lean, normoglycemic insulin-resistant (IR) offspring of individuals with non-insulin-dependent diabetes mellitus and eight age-weight matched control (CON) subjects after plantar flexion exercise that lowered muscle glycogen to approximately 25% of resting concentration. After approximately 20 min of exercise, intramuscular glucose 6-phosphate and glycogen were simultaneously monitored with 31P and 13C NMR spectroscopies. The postexercise rate of glycogen resynthesis was nonlinear. Glycogen synthesis rates during the initial insulin independent portion (0-1 hr of recovery) were similar in the two groups (IR, 15.5 +/- 1.3 mM/hr and CON, 15.8 +/- 1.7 mM/hr); however, over the next 4 hr, insulin-dependent glycogen synthesis was significantly reduced in the IR group [IR, 0.1 +/- 0.5 mM/hr and CON, 2.9 +/- 0.2 mM/hr; (P < or = 0.001)]. After exercise there was an initial rise in glucose 6-phosphate concentrations that returned to baseline after the first hour of recovery in both groups. In summary, we found that following muscle glycogen-depleting exercise, IR offspring of parents with non-insulin-dependent diabetes mellitus had (i) normal rates of muscle glycogen synthesis during the insulin-independent phase of recovery from exercise and (ii) severely diminished rates of muscle glycogen synthesis during the subsequent recovery period (2-5 hr), which has previously been shown to be insulin-dependent in normal CON subjects. These data provide evidence that exercise and insulin stimulate muscle glycogen synthesis in humans by different mechanisms and that in the IR subjects the early response to stimulation by exercise is normal.

Biochemical characterization and DNA binding properties of the MocR family member GabR, a PLP-dependent transcription factor

GabR è un fattore di trascrizione chimerico appartenente alla famiglia dei MocR/GabR, costituito da un dominio N-terminale elica-giro-elica di legame al DNA e un dominio effettore e/o di oligomerizzazione al C-terminale. I due domini sono connessi da un linker flessibile di 29 aminoacidi. Il dominio C-terminale è strutturalmente omologo agli enzimi aminotransferasici fold-type I, i quali, utilizzando il piridossal-5’-fosfato (PLP) come cofattore, sono direttamente coinvolti nel metabolismo degli aminoacidi. L’interazione contemporanea di PLP e acido γ-aminobutirrico (GABA) a GabR fa sì che questa promuova la trascrizione di due geni, gabT e gabD, implicati nel metabolismo del GABA. GabR cristallizza come un omodimero con una configurazione testa-coda. Il legame con la regione promotrice gabTD avviene attraverso il riconoscimento specifico di due sequenze dirette e ripetute (ATACCA), separate da uno spacer di 34 bp. In questo studio sono state indagate le proprietà biochimiche, strutturali e di legame al DNA della proteina GabR di Bacillus subtilis. L’analisi spettroscopica dimostra che GabR interagisce con il PLP formando l’aldimina interna, mentre in presenza di GABA si ottiene l’aldimina esterna. L’interazione fra il promotore gabTD e le forme holo e apo di GabR è stata monitorata mediante Microscopia a Forza atomica (AFM). In queste due condizioni di legame è stata stimata una Kd di circa 40 ηM. La presenza di GABA invece, determinava un incremento di circa due volte della Kd, variazioni strutturali nei complessi GabR-DNA e una riduzione del compattamento del DNA alla proteina, indipendentemente dalla sequenza del promotore in esame. Al fine di valutare il ruolo delle caratteristiche topologiche del promotore, sono state inserite cinque e dieci bp all’interno della regione spacer che separa le due sequenze ripetute dirette riconosciute da GabR. I significativi cambiamenti topologici riscontrati nel frammento aggiunto di cinque bp si riflettono anche sulla forte riduzione dell’affinità di legame verso la proteina. Al contrario, l’inserzione di 10 bp provoca solamente l’allontanamento delle sequenze ripetute dirette. L’assenza quindi di cambiamenti significativi nella topologia di questo promotore fa sì che l’affinità di legame per GabR rimanga pressoché inalterata rispetto al promotore non mutato. L’analisi del potenziale elettrostatico superficiale di GabR mostra la presenza di una fascia carica positivamente che si estende lungo un’intera faccia della proteina. Per verificare l’importanza di questa caratteristica di GabR nel meccanismo di interazione al DNA, sono stati preparati ed indagati i mutanti R129Q e K362-366Q, in cui la carica positiva superficiale risultava indebolita. L’affinità di legame dei mutanti di GabR per il DNA era inferiore rispetto alla proteina non mutata, in particolar modo nel mutante K362-366Q. Le evidenze acquisite suggeriscono che la curvatura intrinseca del promotore ed il corretto orientamento delle sequenze sulla doppia elica, più della distanza che le separa, siano critici per sostenere l’interazione con GabR. Oltre a questo, la superficie positiva di GabR è richiesta per accomodare la curvatura del DNA sul corpo della proteina. Alla luce di questo, l’interazione GabR-gabTD è un esempio di come il riconoscimento specifico di sequenze, la topologia del DNA e le caratteristiche strutturali della proteina siano contemporaneamente necessarie per sostenere un’interazione proteina-DNA stabile.

Contribuição da consulta de enfermagem na adesão ao tratamento do diabetes mellitus na estratégia saúde da família do município de Ribeirão Preto, SP

Trata-se de estudo de intervenção tipo antes e depois, no qual o sujeito é seu próprio controle, fator que permite identificar os efeitos na adesão ao tratamento e controle dos níveis glicêmicos. Teve como objetivo avaliar a contribuição da consulta de enfermagem na adesão ao tratamento do diabetes mellitus tipo 2, em uma Unidade Saúde da Família, de acordo com o \"Protocolo de atendimento as pessoas com diabetes mellitus,\" em Ribeirão Preto, SP. A coleta de dados foi realizada no período de setembro de 2014 a janeiro de 2015. O trabalho foi aprovado pelo Comitê de Ética em Pesquisa da Escola de Enfermagem de Ribeirão Preto, SP, sob Parecer nº 648.970. Participaram 31 pessoas com diabetes mellitus, por meio de três consultas de enfermagem, na unidade de saúde e no domicílio, com intervalo de um mês entre as três consultas de todos os participantes. Foi utilizado um roteiro contendo variáveis sociodemográficos e clínicas e o teste de Medida de Adesão ao Tratamento. Para a análise da adesão, durante e após a intervenção, utilizou-se a estatística descritiva e o teste de Mann- Whitney; para a comparação do antes e após a intervenção, utilizou-se o teste de Wilcoxon; para análise de correlação com as variáveis numéricas, o coeficiente de correlação de Spearman e o teste Q de Cochran, para a comparação dos exames nos momentos anterior, durante e posterior à intervenção. Os resultados mostraram que os participantes tinham entre 33 e 79 anos, sendo 58,1% do sexo feminino; 71% tinham companheiro; renda familiar de 1 a 3 salários-mínimos (83,9%); 80,6% referiram ser profissionalmente inativos (aposentados, pensionistas ou do lar); média de 5,68 anos de estudo e predomínio de menos de 8 anos de estudo (67,7%). Em relação aos valores da pressão arterial sistêmica constatou hipertensão arterial sistêmica grau I em 25,8% das pessoas com diabetes mellitus, 90,3% com índice de massa corporal apresentando excesso de peso, quanto à circunferência abdominal, 32,2% dos homens estavam com valores maiores que 102 cm e 45,2% das mulheres com valores acima de 88 cm. A avaliação dos pés, com uso do monofilamento Semmes-Weinstein de 10g, apresentou 9,7% das pessoas com diabetes mellitus com pé em risco para ulceração e diminuição ou ausência de sensibilidade tátil pressórica protetora dos pés. O tempo de diagnóstico do diabetes mellitus tipo 2 variou entre 1 a 39 anos, predominando as comorbidades hipertensão arterial (83,9%), dislipidemia (58,1%) e obesidade (41,8%). Quanto aos exames laboratoriais, observa-se que, em 64,5% da população estudada, os níveis da glicemia de jejum estavam acima de 100 mg/dL , ocorrendo pequena redução para 61,3% nos casos de pessoas com diabetes mellitus durante a intervenção e se manteve após. No que se refere à glicemia pós-prandial, os casos das pessoas com diabetes mellitus com valores iguais ou acima de 160 mg/dL, antes da intervenção era de 45,2% e durante e após a intervenção caiu para 38,7%. Em contrapartida, aumentou o número de pessoas com diabetes mellitus durante e após a intervenção, com valores da glicemia pós-prandial abaixo de 160 mg/dL, de 54,8% para 61,3%. E, em relação à hemoglobina glicada, foi observado que em 61,3% das pessoas com diabetes mellitus os valores antes da intervenção eram iguais ou acima de 7%. Durante a intervenção, caiu para 19,3% e após a intervenção o número de pessoas com diabetes mellitus, com a hemoglobina glicada igual ou superior a 7%, chegou a 38,7%. Quanto aos valores abaixo de 7%, observou-se aumento de 38,7% antes da intervenção para 80,6 e 61,3% respectivamente, durante e após a intervenção, com diferença estatisticamente significante (p< 0,001). As pessoas com diabetes mellitus desse estudo, apresentaram 83,87% de adesão ao tratamento antes da intervenção, e esses escores subiram para 96,78% após a intervenção, fato corroborado pelo teste de Wilcoxon que mostrou escores estatisticamente significantes (p<0,001), entre antes e após a intervenção. Esse estudo contribui para ressaltar a importância do enfermeiro, enquanto integrante da equipe multiprofissional, seguindo as orientações do \"Protocolo de atendimento ao indivíduo com diabetes\", tanto no atendimento individual quanto em grupo, reorganizando o processo de trabalho, contribuindo para maior adesão ao tratamento e controle dos níveis glicêmicos, ao minimizar a fragmentação e assegurar a continuidade na assistência, por meio de abordagem integral ao diabético

Three-Dimensional kinetic adaptations of gait throughout pregnancy and postpartum

Biomechanical adaptations that occur during pregnancy can lead to changes on gait pattern. Nevertheless, these adaptations of gait are still not fully understood. The purpose was to determine the effect of pregnancy on the biomechanical pattern of walking, regarding the kinetic parameters. A three-dimensional analysis was performed in eleven participants. The kinetic parameters in the joints of the lower limb during gait were compared at the end of the first, second, and third trimesters of pregnancy and in the postpartum period, in healthy pregnant women. The main results showed a reduction in the normalized vertical reaction forces, throughout pregnancy, particularly the third peak. Pregnant women showed, during most of the stance phase, medial reaction forces as a motor response to promote the body stability. Bilateral changes were observed in hip joint, with a decrease in the participation of the hip extensors and in the eccentric contraction of hip flexors. In ankle joint a decrease in the participation of ankle plantar flexors was found. In conclusion, the overall results point to biomechanical adjustments that showed a decrease of the mechanical load of women throughout pregnancy, with exception for few unilateral changes of hip joint moments.

Second St. Gallen European Organisation for Research and Treatment of Cancer Gastrointestinal Cancer Conference: consensus recommendations on controversial issues in the primary treatment of rectal cancer

Primary treatment of rectal cancer was the focus of the second St. Gallen European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Cancer Conference. In the context of the conference, a multidisciplinary international expert panel discussed and voted on controversial issues which could not be easily answered using published evidence. Main topics included optimal pretherapeutic imaging, indication and type of neoadjuvant treatment, and the treatment strategies in advanced tumours. Here we report the key recommendations and summarise the related evidence. The treatment strategy for localised rectal cancer varies from local excision in early tumours to neoadjuvant radiochemotherapy (RCT) in combination with extended surgery in locally advanced disease. Optimal pretherapeutic staging is a key to any treatment decision. The panel recommended magnetic resonance imaging (MRI) or MRI + endoscopic ultrasonography (EUS) as mandatory staging modalities, except for early T1 cancers with an option for local excision, where EUS in addition to MRI was considered to be most important because of its superior near-field resolution. Primary surgery with total mesorectal excision was recommended by most panellists for some early tumours with limited risk of recurrence (i.e. cT1-2 or cT3a N0 with clear mesorectal fascia on MRI and clearly above the levator muscles), whereas all other stages were considered for multimodal treatment. The consensus panel recommended long-course RCT over short-course radiotherapy for most clinical situations where neoadjuvant treatment is indicated, with the exception of T3a/b N0 tumours where short-course radiotherapy or even no neoadjuvant therapy were regarded to be an option. In patients with potentially resectable tumours and synchronous liver metastases, most panel members did not see an indication to start with classical fluoropyrimidine-based RCT but rather favoured preoperative short-course radiotherapy with systemic combination chemotherapy or alternatively a liver-first resection approach in resectable metastases, which both allow optimal systemic therapy for the metastatic disease. In general, proper patient selection and discussion in an experienced multidisciplinary team was considered as crucial component of care.

Ultrasound Mapping of Nerve Stimulator Response during Sciatic Nerve Blockade and Relation to Postoperative Pain Scores

1.1 Background and Purpose: Ultrasound guided sciatic nerve blockade has rapid onset but at 24 hours pain is greater than nerve stimulator techniques. Injection of the nerve branches or trunk and sub-sheath blockade increase success and reduce onset times but risk injury. This study mapped needle coordinates for sciatic nerve blockade with nerve stimulation and its relation to postoperative pain scores. 1.2 Method: Angle and distance of the needle tip and infusion catheter from the popliteal sciatic nerve at which stimulated plantar flexion occurred were measured. Pain scores at postanesthesia unit discharge and 24 hours were recorded. 1.3 Results: 81% of opioid naïve patients reported immediate analgesia and 20.8% at 24 hours. In opioid tolerant patients 56.8% reported immediate analgesia and 9.1% at 24 hours. Plantar flexion was observed with the needle in the posterior medial quadrant near the sciatic nerve. Opioid tolerant patients reported adequate analgesia when the needle was located more medially and proximally to the sciatic nerve. 1.4 Conclusion: Stimulated plantar flexion is isolated to a narrow angular range in the posterior medial quadrant adjacent to the sciatic nerve. Opioid tolerant patients report adequate analgesia if the needle and catheter are more medial and proximal to the nerve surface.

Regional morphology of the transversus abdominis and obliquus internus and externus abdominis muscles

Background. The mechanisms by which the abdominal muscles move and control the lumbosacral spine are not clearly understood. Descriptions of abdominal morphology are also conflicting and the regional anatomy of these muscles has not been comprehensively examined. The aim of this study was to investigate the morphology of regions of transversus abdominis and obliquus internus and externus abdominis. Methods. Anterior and posterolateral abdominal walls were dissected bilaterally in 26 embalmed human cadavers. The orientation, thickness and length of the upper, middle and lower fascicles of transversus abdominis and obliquus internus abdominis, and the upper and middle fascicles of obliquus externus abdominis were measured. Findings. Differences in fascicle orientation, thickness and length were documented between the abdominal muscles and between regions of each muscle. The fascicles of transversus abdominis were horizontal in the upper region, with increasing inferomedial orientation in the middle and lower regions. The upper and middle fascicles of obliquus internus abdominis were oriented superomedially and the lower fascicles inferomedially. The mean vertical dimension of transversus abdominis that attaches to the lumbar spine via the thoracolumbar fascia was 5.2 (SD 2.1) cm. Intramuscular septa were observed between regions of transversus abdominis, and obliquus internus abdominis could be separated into two distinct layers in the lower and middle regions. Interpretation. This study provides quantitative data of morphological differences between regions of the abdominal muscles, which suggest variation in function between muscle regions. Precise understanding of abdominal muscle anatomy is required for incorporation of these muscles into biomechanical models. Furthermore, regional variation in their morphology may reflect differences in function. (C) 2004 Elsevier Ltd. All rights reserved.

The impact of neurodynamic testing on the perception of experimentally induced muscle pain

Neurodynamic tests such as the straight leg raising (SLR) and slump test are frequently used for assessment of mechanosensitivity of neural tissues. However, there is ongoing debate in the literature regarding the contributions of neural and non-neural tissues to the elicited symptoms because many structures are affected by these tests. Sensitizing manoeuvres are limb or spinal movements added to neurodynamic tests, which aim to identify the origin of the symptoms by preferentially loading or unloading neural structures. A prerequisite for the use of sensitizing manoeuvres to identify neural involvement is that the addition of sensitizing manoeuvres has no impact on pain perception when the origin of the pain is non-neural. In this study, experimental muscle pain was induced by injection of hypertonic saline in tibialis anterior or soleus in 25 asymptomatic, naive volunteers. A first experiment investigated the impact of hip adduction, abduction, medial and lateral rotation in the SLR position. In a second experiment, the different stages of the slump test were examined. The intensity and area of experimentally induced muscle pain did not increase when sensitizing manoeuvres were added to the SLR or throughout the successive stages of the slump test. The findings of this study lend support to the validity of the use of sensitizing manoeuvres during neurodynamic testing. (C) 2004 Elsevier Ltd. All rights reserved.

DHPLC analysis of patients with nevoid basal cell carcinoma syndrome reveals novel PTCH missense mutations in the serol-sensing domain

Nevoid Basal Cell Carcinoma Syndrome (NBCCS) is an autosomal dominant disorder characterised by multiple basal cell carcinomas, palmar and plantar pitting, odontogenic keratocysts of the jaws and bilamellar calcification of the falx. Mutations in the PTCH gene are responsible for NBCCS but most studies have found mutations in less than half of the cases tested. We used denaturing high performance liquid chromatography (DHPLC) to screen for PTCH mutations in 28 NBCCS cases, most of whom had been previously evaluated by single stranded conformation polymorphism analysis but found to be negative. Protein truncating (n = 10) and missense or indel (n = 4) mutations were found in 14/28 (50%) cases and one additional case carried an unclassified variant, c.2777G>C. Thirteen of the variants were novel. The mutation frequency was similar in inherited and de novo cases. Three of the missense and indel mutations were in the sterol-sensing domain, and one was in the sixth transmembrane domain.