804 resultados para Transversal skills
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Dissertao apresentada para obteno do grau de Mestre em Engenharia Civil, Perfil de Construo, pela Faculdade de Cincias e Tecnologias da Universidade Nova de Lisboa
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INTRODUO: Estudos prvios, com tcnicas de imagem, documentam de forma consistente a existncia de alteraes da substncia branca cerebral relacionadas com o envelhecimento (ASBRE). Tais alteraes podero ter um papel importante no declnio funcional do idoso, reflectindose sobretudo no desempenho motor e cognitivo, com repercusso evidente na prtica clnica. Apesar disso, a caracterizao em definitivo dos fentipos clnicos e da evoluo das ASBRE continua por esclarecer, possivelmente pelas dificuldades metodolgicas de que se reveste o seu estudo, incluindo: a adequao das baterias neuropsicolgicas, a utilizao de amostras de doentes com diferentes graus de severidade e de envolvimento regional, as limitaes das diferentes escalas e a sensibilidade dos diferentes mtodos de imagem. A Ressonncia Magntica (RM) de difuso tem revelado grande sensibilidade para as alteraes isqumicas, admitindose que poder permitir uma melhor caracterizao das ASBRE e deste modo possibilitar uma correlao mais precisa com as variveis cognitivas e motoras, permitindo avaliar ainda a substncia branca aparentemente normal (SBAN). OBJECTIVOS: Descrever a evoluo imagiolgica das ASBRE no intervalo de um ano e analisar a sua expresso clnica e impacto funcional; identificar factores preditivos de progresso das ASBRE e de declnio funcional associado. Descrever a expresso clnica e perfil evolutivo dos doentes com ASBRE com envolvimento preferencial da regio parietooccipital; comparar este grupo de doentes com os doentes com ASBRE, sem envolvimento preferencial desta regio. Medir os coeficientes de difuso aparente (CDA), utilizando regies de interesse (RDI), em diferentes localizaes da substncia branca, incluindo substncia branca lesada e SBAN, descrever sua evoluo temporal no intervalo de um ano e determinar suas correlaes clnicas e imagiolgicas. MTODOS: Utilizando uma amostra de convenincia, foram estudados 30 doentes, com mais de 65 anos, sem incapacidade funcional ou com incapacidade mnima, avaliada pela escala de actividades instrumentais da vida diria (IADL), apresentando ASBRE em TC. Foi utilizado um protocolo exaustivo de avaliao clnica (com particular destaque para as funes motoras e cognitivas) e imagiolgica, em dois momentos de avaliao separados por um ano de intervalo (t0 e t1). As ASBRE foram avaliadas com escalas visuais, escala ARWMC e escala de Fazekas, e os doentes foram estudados em funo do grau de severidade (ligeiro versus moderado a grave na escala de Fazekas) e de um envolvimento preferencial posterior (definido como 2 ou mais pontos na escala ARWMC na regio parietooccipital por comparao com a regio frontal). Os CDA foram avaliados mediante estudo de RDI, na substncia branca frontal lesada (SBFL) e SBAN frontal, parietooccipital e dos pednculos cerebelosos. Para verificar diferenas na ordem de distribuio das variveis foi usado o teste de MannWhitney e para comparao de propores, o teste exacto de Fisher. Na comparao entre a avaliao em t0 e t1 foi usado o teste Wilcoxon Signed Ranks na comparao da distribuio da ordem das variveis e o teste McNemar na anlise de frequncias. Na anlise correlacional foram utilizados os testes de T para variveis emparelhadas e as correlaes entre estas foram efectuadas com o coeficiente de correlao de Spearman ou de Pearson. O trabalho foi aprovado pela Comisso de tica do hospital onde foi realizado e todos os doentes includos assinaram um consentimento informado. RESULTADOS: A idade mdia da populao estudada foi 72,5 anos (17 doentes eram do sexo masculino). No final de um ano, 1 doente tinha falecido e 3 doentes no completaram a avaliao imagiolgica. Registouse uma progresso significativa das ASBRE segundo a escala ARWMC (t0: 8,37 / t1: 9,65 ; p<0,001). Na anlise funcional, motora e cognitiva, no houve um agravamento significativo. Avaliando os doentes em t0 e t1 segundo o grau de severidade das ASBRE, o grupo com atingimento moderado a grave (ASBRE2) comparado com o grupo com atingimento ligeiro (ASBRE1) apresentava: maior extenso de leso da substncia branca (ARWMC t0: 11,9 / 4,8 ; p<0.001 ; t1: 14,0 / 5,9 ; p<0,001); tendncia a pior desempenho funcional (IADL t0: 90,7 / 99,2 ; p=0,023; t1: 86,4 / 96,7 ; p=n.s.) e motor (SPPB t0: 9,8 / 10,3 ; p=n.s. ; t1: 9,5 / 10,5 ; p=0,058); tendncia a maior compromisso do humor (Escala Cornell t0: 6,7 / 3,5 ; p=0,037; t1: 6,2 / 4,5 ; p=n.s.). Analisando a evoluo, de t0 para t1, de cada um dos grupos (ASBRE2 e ASBRE1) registouse: aumento da extenso da leso da substncia branca em ambos (ASBRE2: 12,0 / 14,0;z=2,687 ; p=0,007; ASBR1: 4,8 / 5,9 ; z=2,724 ; p=0,006); variao no significativa funcional e motora; tendncia ao agravamento em ambos na prova de Cancelamento de dgitos (ASBRE2: 17,5 / 17,4 ; p=n.s. ; ASBRE1: 19,9 / 16,9 ; z=2,096 ; p=0,036);tendncia melhoria em ambos no MMS (ASBRE2: 25,7 / 27,5 ; z=2,155 ; p=0,031; ASBRE1: 27,5 / 28,2 ; p=n.s). Avaliando os doentes em t0 e t1 em funo do padro de distribuio das ASBRE, os doentes com um envolvimento preferencial posterior (ASBREP) comparados com os restantes (ASBREnP), apresentavam: maior extenso da leso (ARWMC t0: 10,8 / 6,9 ; p=0,025; t1: 12,9 / 7,6 ; p=0,011); diferenas no significativas no desempenho motor; tendncia a melhor desempenho na prova dos Labirintos (t0: 8,1 / 11,8 ; p=0,06; t1: 8,7 / 9,5 ; p=n.s.) e Cancelamento de dgitos (t0: 20,9 / 17,4 ; p=0,045; t1: 18,5 / 16,3 ; p=n.s.); tendncia a maior compromisso depressivo na GDS (t0: 5,0 / 3,68 ; p=n.s. ; t1: 5,7 / 3,3 p=0,033). Analisando o perfil evolutivo de t0 para t1, registouse: aumento da extenso da leso nos dois grupos (ASBREP: 10,8 / 12,9 ; z=2,555 ; P=0,011; ASBREnP: 6,4 / 7,6 ; z=2,877 ; p=0,04); variao em sentidos diferentes com melhoria funcional no grupo ASBREP (91,0 / 95,5 ; z=0,926 ; p=0,036) e agravamento no grupo ASBREnP (96,7 / 89,8 ; z=2,032 ; p=0,042); variao sem sentidos diferentes, com agravamento significativo no grupo ASBREnP no item estao de p do SPPB (ASBREP 3,8/3,9 p=n.s.; ASBREnP 3,9/3,6; z=2,236 ; p=0,025); tendncia melhoria nos dois grupos no MMS (ASBREP: 27,2 / 28,2 ; p=n.s.; ASBREnP: 26,3 / 27,7 ; z=2,413 ; p=0,016) e tendncia em sentidos diferentes no Trail Making, com eventual melhoria no grupo ASBREP (113,9 / 91,6 ; p=n.s.) e agravamento no grupo ASBREnP (113,7 / 152,0 ; z=2,155 ; p=0,031). Na anlise da imagem, utilizando a escala ARWMC e o estudo dos CDA, na avaliao transversal na incluso, a comparao entre as pontuaes mdias da escala ARWML nas diferentes regies mostrava diferenas significativas (F=39,54 , p<0,0001). A anlise comparativa posthoc de Bonferroni mostrou valores significativamente mais altos para as regies frontais e parietooccipitais (p<0,0001). Os valores mdios dos CDA eram significativamente diferentes entre regies (F=44,56; p<0,0001), sendo mais altos na SBFL (p<0,0001). No existia diferena significativa entre os valores registados na SBAN nas regies frontais e parietooccipitais. As pontuaes regionais da escala ARWMC e os valores mdios dos CDA correlacionavamse todos de forma positiva. A pontuao da escala ARWMC na regio frontal correlacionavase significativamente com os valores do CDA da SBFL (r=0,467 ; p=0,012). Existia tendncia para uma correlao positiva entre as pontuaes da escala ARWMC na regio frontal e os valores mdios dos CDA na SBAN frontal (r=0,276 ; p=0,155). As pontuaes da escala ARWMC e os CDA correlacionavamse de forma positiva com a idade e com a tenso arterial (TA). Foram encontradas correlaes significativas entre: idade e SBAN frontal (r=0,440 ; p=0,019); TA diastlica e SBFL (r=0,386 ; p=0,034); TA sistlica e SBAN Parietooccipital (r=0,407 ; P=0,032). Na avaliao motora e cognitiva, dado elevado nmero de variveis, foi efectuada uma anlise de factor principal. Registouse uma tendncia global negativa na correlao entre as pontuaes da escala visual na regio frontal, os valores dos CDA, e o desempenho motor e cognitivo. Na anlise evolutiva, (n=19), registouse variao significativa dos CDA, com aumento na SBFL (Direita: z=2,875 ; p=0,004 ; Esquerda: z=2,113 ; p=0,035) e diminuio na SBAN dos pednculos cerebelosos (Direita: z=2,094 ; p=0,036 ; Esquerda: z=1,989 ; p=0,047). Foi observada uma correlao negativa entre a variao do CDA na SBAN dos pednculos cerebelosos e na SBFL contralateral (SBAN pednculo cerebeloso Esquerdo / SBFL Direita: r=0,133 ; p=n.s.; SBAN pednculo cerebeloso Direito / SBFL Esquerda: r=0,561 ; p=0,012). Os valores dos CDA direita correlacionavamse de forma positiva com a velocidade da marcha (r=0,562 ; p=0,012). CONCLUSES: A progresso das ASBRE pode ser observada com uma escala visual detalhada no intervalo de um ano. Contudo, o eventual agravamento da incapacidade funcional, motora e cognitiva, no parece ser aprecivel em igual intervalo de tempo. A maior severidade das ASBRE associase a uma tendncia para um maior compromisso funcional, motor e possivelmente do humor. A questo da progresso em escalas simplificadas, de um estdio ligeiro para um estdio moderado a grave, no elucidada pelos resultados do presente trabalho. Os doentes com um envolvimento preferencial da regio parietooccipital podero constituir um subgrupo distinto que, apesar de ter maior extenso de leso, parece ter um melhor desempenho motor e cognitivo. O perfil evolutivo destes doentes parece igualmente ser distinto, no se observando a tendncia ao agravamento funcional, motor e cognitivo (sobretudo em provas de funo executiva) que se encontra nos restantes doentes. A anlise transversal na incluso, utilizando uma escala visual e o estudo dos CDA, sugere que a severidade das ASBRE se correlaciona com o compromisso motor e cognitivo, bem como com a idade e com a TA. Uma maior vulnerabilidade da substncia branca frontal leso vascular parece ter um papel importante no compromisso motor e na disfuno executiva, (essencialmente custa do compromisso da ateno), possivelmente associada desconexo dos circuitos frontosubcorticais. A anlise dos CDA sugere que isso vlido igualmente para a SBAN e sublinha que, as imagens de RM convencional podero no traduzir a verdadeira extenso da leso e consequentemente do compromisso motor e cognitivo. A relao entre a progresso da doena vascular em leses frontais constitudas e a reduo do CDA no pednculo cerebeloso contralateral poder estar associada a um pior desempenho motor. A disrupo dos circuitos frontocerebelosos, determinando hipometabolismo e diminuio da perfuso no cerebelo, poder ser responsvel pela diminuio do CDA no cerebelo. ABSTRACT INTRODUCTION: Previous studies, with new imaging techniques, have consistently documented the presence of agerelated white matter lesions (ARWML), emphasizing their role in agerelated functional decline, mainly related to motor and cognitive impairment, and inherent consequences in clinical practice. However clinical significance of ARWML remains to be elucidated, probably on account of methodological difficulties such as: specific neuropsychological batteries, utilization of samples with different degrees of severity and regional involvement, utilization of different imaging scales and different sensitivity of imaging techniques. Recently, Diffusion Weighted Magnetic Ressonance imaging (DWI) has shown a higher sensitivity to ischemic lesions, suggesting it might be superior for characterization of ARWML, allowing more precise correlation with motor and cognitive variables, and evaluating also normal appearing white matter (NAWM). OBJECTIVES: To describe imagiologic evolution of ARWML within one year interval and to analyse its clinical and functional significance. To identify predictors of ARWML progression and associated functional impairment. To describe clinical characteristics and evolution profile of patients with predominantly posterior lesions; to compare this group of patients with patients without predominantly posterior lesions. To study average Apparent Diffusion Coeficcients (ADC) in different white matter regions using regions of interest (ROI); to analyse their evolution profile and to determine their clinical and imagiologic correlations. METHODS: A sample of 30 patients older than 65 years, without functional impairment or with minimal impairment, according to the Instrumental Activities of Daily Lliving scale, with ARWML on CT scan, were studied in a crosssectional design. An extensive clinical(with detailed motor and cognitive evaluation) and imagiologic protocol was applied in two oneyear interval separate moments (t0 and t1). ARWML were studied using visual scales, ARWMC and Fazekass scale, and patients were studied according to degree of severity (Fazekas scale mild versus moderate / severe) and preferential involvement of the posterior region (defined as 2 or more points in the ARWMC scale in the parietooccipital region compared with frontal region). Evaluation of ADC was performed using ROI in frontal lesioned white matter (FLWM) and NAWM (frontal, parietooccipital and cerebellar regions). To study differences in the distribution of variables the MannWhitney test was used and to compare proportions the exact Fisher Test was used. To compare temporal evolution profile between t0 and t1, the Wilcoxon Signed ranks Test was used to analyse the distribution of variables and the Mc Nemar Test to analyse frequencies. Correlation analysis was performed using Spearman or Pearson tests. The study was approved by the local Ethics Committee and all patients signed an informed consent. RESULTS: Mean age was 72.5 years (17 patients were male). By the end of the study, one patient was dead and 3 patients did not undergo brain imaging. There was a higher extent of ARWML evaluated with the ARWMC scale (t0: 8.37 / t1: 9.65 ; p<0.001). Functional, motor and cognitive performance did not progress significantly. Evaluating patients in t0 and t1 according to the degree of severity (Fazekas scale), the moderate / severe group of patients (WML2), compared with the mild group (WML1), showed: higher extent of lesion (ARWMC scale t0: 11.9 / 4.8 ; p<0.001 ; t1: 14.0 / 5.9 ; p<0.001); tendency to worse functional (IADL t0: 90.7 / 99.2 ; p=0.023; t1: 86.4 / 96.7 ; p=n.s.) and motor (SPPB t0: 9.8 / 10.3 ; p=n.s. ; t1: 9.5 / 10.5 ; p=0.058) performance; tendency to higher depressive scores (Cornell Scale t0: 6.7 / 3.5 ; p=0.037; t1: 6.2 / 4.5; p=n.s.). Analysing the evolution profile from t0 to t1 of each group (WML2 and WML1), there was a higher extent of lesion (ARWMC scale) in both (WML2: 12.0 / 14.0; z=2.687 ; p=0.007; WML1: 4.8 / 5.9 ; z=2.724 ; p=0.006); nonsignificant variation in functional and motor performances; tendency to worse performance on the Digit Cancelling (WML2: 17.5 / 17.4 ; p=n.s. ; WML1: 19.9 / 16.9 ; z=2.096 ; p=0,036) and to better performance on the MMS (WML2: 25.7 / 27.5 ; z=2.155 ; p=0.031; WML1: 27.5/ 28.2 ; p=n.s). Evaluating patients in t0 and t1 according to the regional distribution of ARWML, patients with predominantly posterior lesions (WMLP) compared with the rest of the group (WMLnP), showed: higher extent of lesion (ARWMC scale t0: 10.8 / 6.9 ; p=0.025; t1:12.9 / 7.6 ; p=0.011); non significant differences on motor evaluation; tendency to a better performance on Maze (t0: 8.1 / 11.8 ; p=0.06; t1: 8.7 / 9.5 ; p=n.s.) and Digit cancelling (t0: 20.9 / 17.4 ; p=0.045; t1: 18.5 / 16.3 ; p=n.s.) tests;tendency to higher scores on GDS (t0: 5.0 / 3.68 ; p=n.s. ; t1: 5.7 / 3.3 p=0.033). Analysing the evolution profile from t0 to t1 of each group (WMLP and WMLnP), there was: higher extent of lesion (ARWMC scale) in both groups (WMLP: 10.8 / 12.9 ;z=2,555 ; P=0,011; WMLnP: 6.4 / 7.6 ; z=2.877; p=0.04); variation in different directions with better functional performance in the group WMLP (91.0 / 95.5 ;z=0.926 ; p=0.036) and worse in WMLnP (96.7 / 89.8 ; z=2.032 ; p=0.042); variation in different directions with worse motor performance in one SPPB item (total stands) in the group WMLnP (WMLP 3.8/3.9 p=n.s.; ASBREnP 3.9/3.6; z=2.236 ; p=0.025);tendency to improvement in both groups in MMS (WMLP: 27.2 / 28.2 ; p=n.s.; WMLnP:26.3 / 27.7 ; z=2.413 ; p=0.016); tendency to a variation in different directions in the Trail Making Test, with possible improvement in the group WMLP (113.9 / 91.6 ;p=n.s.) and worsening in the group WMLnP (113.7 / 152.0 ; z=2.155 ; p=0.031). Imaging analysis in the inclusion, using the ARWMC scale and ADC evaluation, showed significant differences in different regions (F=39.54, p<0.0001). Comparative posthoc Bonferroni analysis showed significantly higher scores in the frontal and parietooccipital regions (p<0.0001. ADC values were significantly different between regions (F=44.56; p<0.0001), being higher in FLWM (p<00001). There was no significant difference between ADC in NAWM in frontal and parietooccipital regions. ARWMC scores and ADC values correlated positively. Significant correlations were found between frontal ARWMC score and FLWM ADC values (r=0.467 ; p=0.012). ARWMC scores and ADC values correlated positively with age and blood pressure. Significant correlations were: age and frontal NAWM (r=0.440 ; p=0.019); Diastolic blood pressure and FLWM (r=0.386 ; p=0.034); sistolic blood pressure and parietooccipital NAWM (r=0.407 ; P=0.032). Due to the higher number of motor and cognitive variables a preliminary study was done, using principal component analysis. A global tendency to a negative correlation was found between ARWMC scores, ADC values and motor and cognitive performances. Evolutive analysis of ADC (n=19), showed a significant variation, with higher values in t1 in FLWM (Right: z=2.875 ; p=0.004 ; Left: z=2.113 ; p=0.035) and lower values in t1 in cerebellar NAWM (Right: z=2.094 ; p=0.036 ; Left: z=1.989 ; p=0.047). A negative correlation was found between ADC variation in cerebellar NAWM and contralateral FLWM (Left cerebellar NAWM / Right FLWM: r=0.133 ; p=n.s.; Right cerebellar NAWM/ Left FLWM: r=0.561 ; p=0.012). ADC values on the right correlated positively with walking speed (r=0,562 ; p=0,012). CONCLUSIONS: Progression of ARWML can be documented with a detailed visual scale in a one year interval. However, functional, motor and cognitive impairment, do not seem to progress significantly within the same period. A higher severity of ARWML is associated with a tendency to a worse functional and motor performance (and possibly to higher scores in depression scales). The issue of progression in a simplified visual scale from a mild to a moderate / severe degree of ARWML is not further elucidated. Patients with predominantly posterior lesions may be a subset of ARWML patients, with a different profile, that despite higher extent of lesion, seem to fair better than the rest of the group, namely with better performance on motor and cognitive tests. Evolution profile of this subset of patients also seems to be different, without a clearcut tendency to worsening functional, motor and cognitive (particularly for executive function tests) performance that is observed in the rest of the group. Imaging analysis, with a visual scale and ADC evaluation, suggests that severity of ARWML correlates negatively with cognitive and motor performance and positively with age and blood pressure. A higher vulnerability of frontal white matter to vascular disease seems to play an important role in motor and cognitive dysfunction, mainly determined by impairment of attention skills associated with frontalsubcortical disconnection. DWI results, suggest that this may also be true for NAWM, underlining that conventional MR images may not represent the true extent of cognitive decline. The relation between vascular disease progression inside frontal lesions and ADC reduction in contralateral cerebellar peduncles, may be associated with a worse motor performance. Disruption of frontocerebellar cicuits, with associated regional hypometabolism, may be responsible for the reduction of cerebellar ADC.
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Dissertao para obteno do Grau de Mestre em Engenharia Civil Perfil de Construo
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Dissertao para obteno do Grau de Mestre em Engenharia Civil - Perfil de Construo
