Treatment outcome in individuals with chronic pain: is the Pain Stages of Change Questionnaire (PSOCQ) a useful tool? Jenny StrongCorresponding Author Contact Information, E-mail The Corresponding Author, a, Kym Westburya, Glen Smithb, Ian McKenziec and William Ryan

The efficacy of psychological treatments emphasising a self-management approach to chronic pain has been demonstrated by substantial empirical research. Nevertheless, high drop-out and relapse rates and low or unsuccessful engagement in self-management pain rehabilitation programs have prompted the suggestion that people vary in their readiness to adopt a self-management approach to their pain. The Pain Stages of Change Questionnaire (PSOCQ) was developed to assess a patient's readiness to adopt a self-management approach to their chronic pain. Preliminary evidence has supported the PSOCQ's psychometric properties. The current study was designed to further examine the psychometric properties of the PSOCQ, including its reliability, factorial structure and predictive validity. A total of 107 patients with an average age of 36.2 years (SD = 10.63) attending a multi-disciplinary pain management program completed the PSOCQ, the Pain Self-Efficacy Questionnaire (PSEQ) and the West Haven-Yale Multidimensional Pain Inventory (WHYMPI) pre-admission and at discharge from the program. Initial data analysis found inadequate internal consistencies of the precontemplation and action scales of the PSOCQ and a high correlation (r = 0.66, P < 0.01) between the action and maintenance scales. Principal component analysis supported a two-factor structure: 'Contemplation' and 'Engagement'. Subsequent analyses revealed that the PSEQ was a better predictor of treatment outcome than the PSOCQ scales. Discussion centres upon the utility of the PSOCQ in a clinical pain setting in light of the above findings, and a need for further research. (C) 2002 International Association for the Study of Pain. Published by Elsevier Science B.V. All rights reserved.

The relation between the transversus abdominis muscles, sacroilac joint mechanics, and low back pain

Study Design. Two abdominal muscle patterns were tested in the same group of individuals, and their effects were compared in relation to sacroiliac joint laxity. One pattern was contraction of the transversus abdominis, Independently of the other abdominals; the other was a bracing action that used all the lateral abdominal muscles. Objectives. To demonstrate the biomechanical effect of the exercise for the transversus abdominis known to be effective in low back pain. Summary of Background Data. Drawing in the abdominal wall is a specific exercise for the transversus abdominis muscle (in cocontraction with the multifidus), which is used in the treatment of back pain. Clinical effectiveness has been demonstrated to be a reduction of 3-year recurrence from 75% to 35%. To the authors' best knowledge, there is not yet in vivo proof of the biomechanical effect of this specific exercise. This study of a biomechanical model on the mechanics of the sacroiliac joint, however, predicted a significant effect of transversus abdominis muscle force. Methods. Thirteen healthy individuals who could perform the test patterns were included. Sacroiliac joint laxity values were recorded with study participants in the prone position during the two abdominal muscle patterns. The values were recorded by means of Doppler Imaging of vibrations. Simultaneous electromyographic recordings and ultrasound imaging were used to verify the two muscle patterns. Results. The range of sacroiliac joint laxity values observed in this study was comparable with levels found in earlier studies of healthy individuals. These values decreased significantly in all individuals during both muscle patterns (P < 0.001). The independent transversus abdominis contraction decreased sacroiliac joint laxity (or rather increased sacroiliac joint stiffness) to a significantly greater degree than the general abdominal exercise pat-tern (P < 0.0260). Conclusions. Contraction of the transversus abdominis significantly decreases the laxity of the sacroiliac joint. This decrease in laxity is larger than that caused by a bracing action using all the lateral abdominal muscles. These findings are in line with the authors' biomechanical model predictions and support the use of independent transversus abdominis contractions for the treatment of low back pain.

Adjustment of homeless adolescents to a crisis shelter: Application of a stress and coping model

The present study examined the utility of a stress and coping model of adaptation to a homeless shelter among homeless adolescents. Seventy-eight homeless adolescents were interviewed and completed self-administered scales at Time 1 (day of shelter entry) and Time 2 (day of discharge). The mean duration of stay at the shelter was 7.23 days (SD = 7.01). Predictors included appraisal (threat and self-efficacy), coping resources, and coping strategies (productive, nonproductive, and reference to others coping). Adjustment outcomes were Time I measures of global distress, physical health, clinician-and youthworker- rated social adjustment, and externalizing behavior and Time 2 youthworker-rated social adjustment and goal achievement. Results of hierarchical regression analyses indicated that after controlling for the effects of relevant background variables (number of other shelters visited, sexual, emotional, and physical abuse), measures of coping resources, appraisal, and coping strategies evidenced distinct relations with measures of adjustment in ways consistent with the model's predictions with few exceptions. In cross-sectional analyses better Time I adjustment was related to reports of higher levels of coping resources, self-efficacy beliefs, and productive coping strategies, and reports of lower levels of threat appraisal and nonproductive coping strategies. Prospective analyses showed a link between reports of higher levels of reference to others coping strategies and greater goal achievement and, unexpectedly, an association between lower self-efficacy beliefs and better Time 2 youthworker-rated social adjustment. Hence, whereas prospective analyses provide only limited support for the use of a stress and coping model in explaining the adjustment of homeless adolescents to a crisis shelter, cross-sectional findings provide stronger support.

Development of a generic crop model template in the cropping system model APSIM

The Agricultural Production Systems slMulator, APSIM, is a cropping system modelling environment that simulates the dynamics of soil-plant-management interactions within a single crop or a cropping system. Adaptation of previously developed crop models has resulted in multiple crop modules in APSIM, which have low scientific transparency and code efficiency. A generic crop model template (GCROP) has been developed to capture unifying physiological principles across crops (plant types) and to provide modular and efficient code for crop modelling. It comprises a standard crop interface to the APSIM engine, a generic crop model structure, a crop process library, and well-structured crop parameter files. The process library contains the major science underpinning the crop models and incorporates generic routines based on physiological principles for growth and development processes that are common across crops. It allows APSIM to simulate different crops using the same set of computer code. The generic model structure and parameter files provide an easy way to test, modify, exchange and compare modelling approaches at process level without necessitating changes in the code. The standard interface generalises the model inputs and outputs, and utilises a standard protocol to communicate with other APSIM modules through the APSIM engine. The crop template serves as a convenient means to test new insights and compare approaches to component modelling, while maintaining a focus on predictive capability. This paper describes and discusses the scientific basis, the design, implementation and future development of the crop template in APSIM. On this basis, we argue that the combination of good software engineering with sound crop science can enhance the rate of advance in crop modelling. Crown Copyright (C) 2002 Published by Elsevier Science B.V. All rights reserved.

Description of stable pain in rheumatoid arthritis: A 6 year study

Objective. To study pain quality and variability in patients with rheumatoid arthritis (RA). Methods. Pain, disease activity, and functional status Were assessed 3 times over 6 years in an initial cohort of 120 clinic patients with chronic pain from RA. A pain visual analog scale and the McGill Pain Questionnaire (MPQ) were used to record pain intensity and quality. RA disease activity and function were measured. Results. There was no statistically significant difference in any measure over the 3 assessments. RA pain intensity was moderate. The MPQ showed that sensory components of the pain were described in terms of pressure and constriction. Pain related affect was described with adjectives suggesting positive psychological adaptation to pain. Conclusion. The. results indicate a general profile of no change in pain sensation, affect, and emotional quality in clinic monitored patients with ongoing RA and ongoing, moderate levels of disease activity and function. The MPQ provides qualitative detail to patient's report of pain severity that could be a useful addition to longterm documentation of RA outcome. Regular MPQ documentation of current pain in outpatients could indicate whether any significant change in pain levels is reflected in altered word selection that reflects physiological or psychological change, and could assist clinicians to select the most appropriate form of therapy for RA pain.

Studies in search of a suitable experimental insect model for xenodiagnosis of hosts with Chagas' disease: 3 - On the interaction of vector species and parasite strain in the reaction of bugs to infection by Trypanosoma cruzi

The reaction of nine vector species of Chagas' disease to infection by seven different Trypanosoma cruzi strains; Berenice, Y, FL, CL, S. Felipe, Colombiana and Gávea, are examined and compared. On the basis of the insects' ability to establish and maintain the infection, vector species could be divided into two distinct groups which differ in their reaction to an acute infection by T. cruzi. While the proportion of positive bugs was found to be low in Triatoma infestans and Triatoma dimidiata it was high, ranging from 96.9% to 100% in the group of wild (Rhodnius neglectus, Triatoma rubrovaria)and essentially sylvatic vectors in process of adaptation to human dwellings, maintained under control following successful insecticidal elimination of Triatoma infestans (Panstrongylus megistus, Triatoma sordida and Triatoma pseudomaculata). An intermediate position is held by Triatoma brasiliensis and Rhodnius prolixus. This latter has been found to interchange between domestic and sylvatic environments. The most important finding is the strikingly good reaction between each species of the sylvatic bugs and practically all T. cruzi strains herein studied, thus indicating that the factors responsible for the excellent reaction of P.megistus to infection by Y strain, as previously reported also come into operation in the reaction of the same vector species to acute infections by five of the remaining T.cruzi strains. Comparison or data reported by other investigators with those herein described form the basis of the discussion of Dipetalogaster maximus as regards its superiority as a xenodiagnostic agent.

The immediate effects of atlanto-occipital joint manipulation and suboccipital muscle inhibition technique on active mouth opening and pressure pain sensitivity over latent myofascial trigger points in the masticatory muscles

DESIGN: A randomized controlled trial.OB JECTIVE: To investigate the immediate effects on pressure pain thresholds over latent trigger points (TrPs) in the masseter and temporalis muscles and active mouth opening following atlanto-occipital joint thrust manipulation or a soft tissue manual intervention targeted to the suboccipital muscles. BACKGROUND : Previous studies have described hypoalgesic effects of neck manipulative interventions over TrPs in the cervical musculature. There is a lack of studies analyzing these mechanisms over TrPs of muscles innervated by the trigeminal nerve. METHODS: One hundred twenty-two volunteers, 31 men and 91 women, between the ages of 18 and 30 years, with latent TrPs in the masseter muscle, were randomly divided into 3 groups: a manipulative group who received an atlanto-occipital joint thrust, a soft tissue group who received an inhibition technique over the suboccipital muscles, and a control group who did not receive an intervention. Pressure pain thresholds over latent TrPs in the masseter and temporalis muscles, and active mouth opening were assessed pretreatment and 2 minutes posttreatment by a blinded assessor. Mixed-model analyses of variance (ANOVA) were used to examine the effects of interventions on each outcome, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction. RESULTS: The 2-by-3 mixed-model ANOVA revealed a significant group-by-time interaction for changes in pressure pain thresholds over masseter (P<.01) and temporalis (P =.003) muscle latent TrPs and also for active mouth opening (P<.001) in favor of the manipulative and soft tissue groups. Between-group effect sizes were small. CONCLUSIONS: The application of an atlanto-occipital thrust manipulation or soft tissue technique targeted to the suboccipital muscles led to an immediate increase in pressure pain thresholds over latent TrPs in the masseter and temporalis muscles and an increase in maximum active mouth opening. Nevertheless, the effects of both interventions were small and future studies are required to elucidate the clinical relevance of these changes. LEVEL OF EVIDENCE : Therapy, level 1b. J Orthop Sports Phys Ther 2010;40(5):310-317. doi:10.2519/jospt.2010.3257. KEYWORDSDS: cervical manipulation, muscle trigger points, neck, TMJ, upper cervical.

Contributo para a validação da versão portuguesa da Quebec Back Pain Disability Scale : fiabilidade e poder de resposta em utentes com dor lombar crónica

RESUMO: Um dos principais resultados das intervenções de Fisioterapia dirigidas a utentes com Dor Lombar Crónica (DLC) é reduzir a incapacidade funcional. A Quebec Back Pain Disability Scale (QBPDS) é um instrumento amplamente aceite a nível internacional na medição do nível de incapacidade funcional reportada pelos indivíduos com DLC. O objetivo deste estudo é dar um contributo para a adaptação cultural da versão portuguesa da QBPDS (QBPDS-VP) e investigar o poder de resposta e interpretabilidade da escala. Metodologia: Realizou-se um estudo metodológico, multicentro, baseado num coorte prospetivo de 132 utentes com DLC. Os utentes foram recrutados a partir da lista de espera de 16 serviços de Medicina Física e de Reabilitação/Fisioterapia de várias áreas geográficas de Portugal. A QBPDS- VP foi administrada 3 vezes, em 3 momentos de recolha de dados distintos: T0 - momento inicial (utentes em lista de espera); T1 - 1 semana de intervalo (início dos tratamentos de Fisioterapia); e T2 - 6 semanas de intervalo (pós-intervenção de Fisioterapia). Os dados recolhidos em T0 foram utilizados para a análise fatorial e para o estudo da consistência interna (n=132); os dados da amostra emparelhada de T0 e T1 (n=132) para a fiabilidade teste-reteste; e os dados da amostra emparelhada de T0 e T2 (n=120) para a análise do poder de resposta e interpretabilidade. A âncora externa utilizada foi a perceção global de mudança, neste caso a PGIC- VP, que foi respondida em T1 e T2. O nível de significância para o qual os valores se consideraram satisfatórios foi de p≤ 0,05. O tratamento dos dados foi realizado no software IBM SPSS Statistics (versão 20). Resultados: A QBPDS- VP é uma escala unidimensional, que revela uma excelente consistência interna (α de Cronbach= 0,95) e uma fiabilidade teste-reteste satisfatória (CCI= 0,696; IC 95%: 0,581–0,783). Esta escala demonstrou um poder de resposta moderado, quando aplicada em utentes com DLC ( = 0,426 e AAC= 0,741; IC 95%: 0,645 – 0,837). A Diferença Mínima Detetável (DMD) estimada foi de 19 pontos e as estimativas da Diferença Mínima Clinicamente Importante (DMCI) variaram entre 7 (pelo método curva ROC) e 8 pontos (pelo método “diferença média de pontuação”). A estimativa pela curva ROC deriva do ponto ótimo de corte de 6,5 pontos, com Área Abaixo da Curva (AAC)= 0,741, sensibilidade de 72%, e especificidade de 71%. Uma análise complementar da curva ROC baseada nas diferenças de pontuações da QBPDS, expressa em percentagem, revelou um ponto ótimo de corte de - 24% (AAC= 0,737, sensibilidade de 71%, e especificidade de 71%). Para pontuações iniciais da QBPDS- VP mais altas (≥34 pontos), foi encontrado um ponto ótimo de corte de 10,5 pontos (AAC= 0,738, sensibilidade de 73%, e especificidade de 67%). Conclusão: A QBPDS-VP demonstrou bons níveis de fiabilidade e poder de resposta, recomendando-se o seu uso na medição e avaliação da incapacidade funcional de utentes com DLC. A DMD estimada, de 19 pontos, determinou uma amplitude válida da QBPDS-VP de 19 a 81 pontos. Este estudo propõe estimativas de DMCI da QBPDS- VP numa aplicação específica da escala (em utentes com DLC que são referidos para a intervenção de Fisioterapia). A pontuação inicial da QBPDS- VP deve ser considerada na interpretação de mudanças de pontuação, após a intervenção de Fisioterapia.------------ ABSTRACT: One of the main results of physiotherapy interventions for patients with Chronic Low Back Pain (CLBP) is decrease the functional disability. The Quebec Back Pain Disability Scale (QBPDS) is an instrument widely accepted internationally, in measuring the level of disability reported by individuals with CLBP. The purpose of this study is to contribute to the cultural adaptation of the Portuguese version of QBPDS (QBPDS - PV) and investigate the Responsiveness and Interpretability of QBPDS-PV. Methodology: This was a methodological and multicenter study, based on a sample of 132 subjects with CLBP. The patients were recruited from the waiting lists of 16 medicine rehabilitation service, in many Portugal districts. The Quebec Back Pain Disability Scale was administered in three different moments: T0 – baseline (patients in the waiting list); T1- one week after T0 (the beginning of treatment); and T2 – six weeks after T1 (the posttreatment). The data collected at T0 were used for factor analysis and to study the internal consistency (n = 132); paired sample data of T0 and T1 (n=132) were used for test-retest reliability, and sample data paired for T0 and T2 (n=120) used for responsiveness and interpretability analysis. The external anchor was the global perception of change, measured by the Portuguese version of Patient’s Global Impression of Change (PGIC) Scale. The minimal level of significance established was p ≤ 0,05. Data analysis was performed using the IBM SPSS Statistics software (version 20). Results: The QBPDS-PV is a unidimensional scale, demonstrates an excellent internal consistency (Cronbach's α=0.95) and satisfactory test-retest reliability (ICC= 0.696, 95% CI: 0.581–0.783). The scale revealed moderate responsiveness when applied to patients with CLBP ( = 0.426 and AUC= 0.741, 95% CI: 0.645 - 0.837). The Smallest Detectable Change (SDC) was 19 points, whereas the Minimal Clinically Important Change (MCIC) ranged between 7 (ROC curve method) and 8 points (by the "mean difference score"). The estimate was derived from the ROC curve by an optimal cutoff point of 6.5 points, with Area Under the Curve (AUC)= 0.741, sensitivity 72%, and specificity of 71%. A complementary analysis of the ROC curve based on differences in QBPDS scores from baseline, expressed in percentage, revealed an optimal cutoff point of -24% (AUC= 0.737, sensitivity of 71%, and specificity of 71%). For the highest initial scores of QBPDS-PV (≥ 34 points) was found an optimal cutoff of 10.5 points (AUC= 0.738, sensitivity of 73%, and specificity 67%). Conclusion: The QBPDS-PV demonstrated good levels of reliability and responsiveness, being recommended its use in the measurement and evaluation of disability of patients with CLBP. The SDC of 19 points determined the QBPDS‟ scale width of 19 to 81. This study proposes MCIC values for QBPDS –PV for this specific setting (in CLBP patients who are referred for physiotherapy intervention). The QBPDS –PV baseline score have to be taken into account while interpreting the score change after physiotherapy intervention.

NEGOSEIO: framework for the sustainability of model-oriented enterprise interoperability

Dissertation to obtain the degree of Doctor of Philosophy in Electrical and Computer Engineering(Industrial Information Systems)

Adaptação cultural e contributo para a validação da escala petterns of activity measura - pain (POAM-P)

RESUMO: A dor lombar crónica (DLC) é uma das condições clínicas mais comuns e com elevados custos socioeconómicos no mundo ocidental. Estudos recentes indicam que os utentes com DLC apresentam diferentes padrões de atividade que influenciam os níveis de incapacidade funcional. Contudo, a evidência acerca destas associações é, ainda, limitada e inconclusiva. Em Portugal, não existe, do nosso conhecimento, nenhuma escala validada para a população portuguesa que meça estes padrões de atividade em utentes com DLC. Objetivos: Adaptar culturalmente a escala Patterns of Activity Measure – Pain (POAM-P) para a população portuguesa com dor lombar crónica inespecífica (DLCI) e contribuir para a sua validação. Metodologia: A versão original (inglesa) do POAM-P foi traduzida e adaptada para a língua portuguesa (POAM-P-VP) através de uma equipa multidisciplinar que incluiu tradutores, retrotradutores (cegos e independentes), peritos de diferentes áreas e utentes com DLCI, de acordo com as recomendações de linhas orientadoras atuais para este processo. A análise factorial e das propriedades psicométricas da POAM-P-VP contou com uma amostra de 132 utentes. A consistência interna foi analisada através do coeficiente alpha de Cronbach (α) e para a análise da fiabilidade teste-reteste recorreu-se ao coeficiente de correlação intraclasse (ICC:2,1). A análise da validade de construto convergente e discriminativa das componentes da POAM-P-VP foi conseguida através da aplicação da versão portuguesa da escala Tampa Scale of Kinesiophobia (TSK-13-VP), e recorrendo ao cálculo do coeficiente de Spearman. Todos os cálculos estatísticos foram realizados no software IBM SPSS Statistics (versão 20). Resultados: A análise factorial permitiu identificar três componentes da POAM-P-VP (evitamento, persistência excessiva e persistência consistente com a dor), sendo estruturalmente diferentes das subescalas do POAM-P original. Estas componentes apresentaram uma consistência interna boa a elevada. As componentes 1 e 2 apresentaram uma fiabilidade teste-reteste moderada a excelente, e a componente 3 uma fiabilidade teste-reteste pobre, limitando o seu poder de uso na prática clínica e em investigação. Relativamente à validade de construto, nenhuma das hipóteses estabelecidas no estudo apriori foram verificadas, não podendo aferir acerca da relação dos padrões de atividade com a cinesiofobia, medida pelo TSK-13-VP. Porém, a componente de evitamento da POAM-P-VP parece medir conteúdos partilhados com a TSK-13-VP (rs = 0.15, p<0.048). Conclusão: A adaptação e contributo para a validação da versão portuguesa da escala POAM-P constituiu um ponto de partida para a existência de um instrumento de medição de padrões de atividade de utentes portugueses com DLC, requerendo mais estudos para a sua validação. Apesar de algumas limitações, considera-se que este estudo é de grande importância para os fisioterapeutas e investigadores que buscam um maior conhecimento e efetividade das abordagens de intervenção em utentes com dor lombar crónica.-------------- ABSTRACT: Chronic low back pain (CLBP) is one of the most common clinical conditions as well as one with high economical costs within western countries. Recent studies have shown that patients with LBP present different patterns of activity which influence their levels of functional capacity. However, evidence on these associations is still limited and inconclusive. To our knowledge, there is in Portugal no valid scale for measuring these patterns of activity in CLBP patients. Purpose: Culturally adapt the Patterns of Activity Measure – Pain (POAM-P) scale to the Portuguese population with non-specific chronic low back pain (NSLBP) and contribute to its validation. Method: The original English version of POAM-P was blindly and independently translated, back translated and adapted to the Portuguese language (POAM-P-VP) by a multidisciplinary team of translators, experts from different fields, and patients with NSLBP, according to established guidelines for this process. Factorial and psychometric properties’ analysis of POAM-P-VP comprised a sample of 132 patients. The internal consistency was analyzed based on Cronbach's alpha-coefficient (α) and for test-retest reliability analysis the Intraclass Correlation Coefficient (ICC) was used. The analysis of convergent and discriminant construct validity of POAM-P-VP components was achieved through the use of the Portuguese version of the Tampa Scale of Kinesiophobia (TSK-13-VP), using the Spearman coefficient calculation. All statistical calculations were performed using IBM SPSS Statistics software (v.20). Results: The factor analysis allowed for the identification of three components of POAM-P-VP (avoidance, excessive persistence and pain-contingent persistence), structurally different from the original POAM-P subscales. These components demonstrated a good to high level of internal consistency. Components 1 and 2 demonstrated moderate to excellent test-retest reliability, whereas component 3 presented low test-retest reliability thus limiting its clinical and investigative use. With regard to construct validity, none of the previously established hypothesis was verified, therefore not making it possible to assess the relation between activity patterns and kinesiophobia, measured by TSK-13-VP. However, the avoidance component of POAM-P-VP seems to share measurable contents with TSK-13-VP (rs = 0.15, p<0.048). Conclusion: The adaptation and contribution to the validation of the Portuguese version of POAM-P scale, sets a starting point to the existence of a useful instrument for measuring activity patterns in Portuguese CLBP patients, requiring further studies towards its validation. Despite some limitations, this study is considered of high importance to physiotherapists as well as investigators in search of deeper knowledge and effective practical approaches on chronic low back pain patients.

Efeitos da laqueação proximal dos vasos curtos e da fundoplicatura total sobre a microcirculação do fundo gástrico : estudo microvascular em cobaias

RESUMO: A operação de Nissen, por laparoscopia, é considerada a cirurgia antirefluxo mais adequada por ser a que melhor replica a fisiologia normal da válvula gastresofágica na maioria dos doentes com sintomas típicos de doença do refluxo gastresofágico (DRGE). São critérios técnicos o encerramento seguro dos pilares do diafragma e a criação de fundoplicatura completa (360 graus), curta (inferior a dois centímetros), lassa e sem tensão – desiderando para o qual a laqueação proximal dos vasos curtos gástricos é crucial. Realizei a operação de Nissen, por laparoscopia, em sessenta mulheres e quarenta homens com DRGE, sem mortalidade operatória, no Serviço de Cirurgia 6 do Hospital dos Capuchos, CHLC, EPE. Os cem doentes apresentavam média etária de 46 anos e queixas, com tempo de evolução entre 1 e 43 anos, de pirose (90%), regurgitação (80%), azia (73%), epigastralgias (54%). A endoscopia alta revelou esofagite de grau Savary-Miller 0-I (62%), II (23%), III (8%), IV (7%); hérnia de deslizamento (71%), hérnia paraesofágica (8%), sem hérnia (21%); a pHmetria de 24h diagnosticou padrão misto (38%), levantado (20%), deitado (20%), inconclusiva (22%) e a manometria diagnosticou EEI hipotónico (35%), peristálise esofágica normal (88%), hipomotilidade ligeira (5%) e foi omissa (7%). Hérnia hiatal, esofagite grave, ineficácia do controlo sintomático com inibidor da bomba de protões e desejo de descontinuidade terapêutica constituíram as indicações para tratamento cirúrgico. Por celioscopia, efetuei laqueação dos vasos curtos gástricos (70%), cruroplastia e fundoplicatura total (seda 2/0), curta (dimensão média 1,5-2 cm), lassa, sem tensão e sem calibração intraoperatória do esófago. A fundoplicatura de Nissen laparoscópica mostrou-se segura e eficaz no tratamento da DRGE. A sua idoneidade foi ainda comprovada pela normalização da pHmetria de 24 horas e da manometria pós-operatórias, com significado estatístico, num grupo de catorze voluntários assintomáticos. Em catamnese com recuo médio 30,7 meses 94% dos indivíduos persistem assintomáticos. Interrogando-me acerca das repercussões desta operação sobre a microcirculação do fundo gástrico coloquei, como premissa, a possibilidade de na operação de Nissen a laqueação dos vasos curtos poder induzir modificação no diâmetro arteriolar da parede do fundo gástrico. Para pesquisar a influência da laqueação dos vasos curtos gástricos e da fundoplicatura total sobre o calibre arteriolar da parede do estômago no cárdia, no fundo e na região dos vasos curtos gástricos, idealizei um Projeto de investigação experimental em cobaias. O Projeto foi desenvolvido no Centro de Investigação do Departamento de Anatomia da FCM-UNL. Para a sua realização obtive autorização da Comissão Científica e Pedagógica da FCM-UNL, requeri a acreditação como investigador à Direção Geral de Veterinária e, por recorrer à utilização de animais, submeti-o à Comissão de Ética da FCM-UNL, que o aprovou por unanimidade. Para limitar o número de animais utilizados ao mínimo necessário, calculei, por método estatístico, a quantidade de cobaias necessárias. Subdividindo-as num grupo de ensaio (GE), onde realizei a operação de Nissen, e num grupo de controlo (GC), onde apenas procedi a tração gástrica, defini e apliquei protocolos de anestesia, de cirurgia e de eutanásia, segundo os princípios dos 3R – Replacement, Reduction, Refinement da técnica de experimentação humana de Russell e Burch (1959) – uma estrutura ética amplamente aceite para a realização de experimentação científica humanizada com animais. A utilização das técnicas de estudo angiomorfológico permitiu-me analisar e descrever a anatomia normal, a vascularização arterial macroscópica, a microangioarquitetura, por microscopia eletrónica de varrimento de moldes de corrosão vascular, e a histologia da parede do estômago da cobaia. Procedi, também, à definição dos critérios morfológicos que considerei suscetíveis de validação deste modelo animal para o estudo proposto. Por razões académicas, foi necessário abreviar o Projeto encurtando, em cerca de dois anos, o prazo disponível para conclusão do estudo. Apreciando-o com o Gabinete de Análise Epidemiológica e Estatística do Centro de Investigação do CHLC, EPE, optou-se, perante a escassez de elementos após já terem sido recrutados 46 animais, por uma amostra, suplementar, de dimensão de conveniência de oito cobaias (quatro em cada grupo), condicionada pelo limite temporal universitário e pelo respeito pela dignidade dos animais. Neste subgrupo procedi, por microscopia eletrónica de varrimento, à medição dos calibres arteriolares nos moldes vasculares do cárdia, do fundo e da zona dos vasos curtos gástricos tanto no GC como no GE efetuando 469 medições no primeiro e 461 no último. Os dados foram enviados ao Centro de Investigação do CHLC, EPE que procedeu à sua análise estatística (ANOVA). A referida análise revelou que as arteríolas do plexo mucoso e as do plexo submucoso do cárdia, do fundo e da região dos vasos curtos gástricos, mostraram aumento de calibre no GE. O aumento foi, estatisticamente, significativo por ser superior a 50% do calibre do GC. Nos vasos curtos, a diferença foi mais pequena, mas persistiu sendo, estatisticamente, significativa. Os vasos retos dilataram na base, na sua emergência do plexo seroso, apenas no fundo gástrico. Na cobaia a operação de Nissen – fundoplicatura total com laqueação dos vasos curtos gástricos –, provocou vasodilatação arteriolar do fundo gástrico. Considero que essa vasodilatação constituiu acomodação à modificação introduzida e infiro que o mesmo possa acontecer no ser humano. Admito, assim, que também ocorra vasodilatação no ser humano, na sequência da laqueação dos vasos curtos gástricos, pela analogia microvascular entre as duas espécies e que essa vasodilatação corresponda, igualmente, a um mecanismo de adaptação arteriolar visando, por exemplo, suprir a perda incorrida pela laqueação. A associação experimental entre laqueação dos vasos curtos gástricos e realização de fundoplicatura total, que exerce aumento inerente de pressão sobre a JEG, não só não provocou défice da microcirculação do esófago distal ou do estômago proximal como desencadeou um mecanismo de vasodilatação fúndica que reforça o conceito de segurança da operação de Nissen para tratamento da DRGE. -------------- ABSTRACT: The laparoscopic Nissen operation is considered to be the most appropriate antirefluxsurgery because it suitably replicates the standard physiology of the gastroesophageal valve in most patients with typical symptoms of gastroesophageal reflux disease (GERD). The technical criteria includes the safe shutdown of the diafragmatic crura(cruroplasty) and the creation of a complete fundoplication (360 degrees), short (lesser than two inches), floppy and without tension – a goal for which the proximal ligation of the gastric short vessels is crucial. The laparoscopic Nissen operation was performed in sixty women and forty men with GERD, without any operative mortality, at the Surgical Department of the Hospital dos Capuchos, CHLC, EPE. The one hundred patients, averaged 46 years old, complained of heartburn (90%), regurgitation (80%) and upper abdominal pain (54 %). The endoscopy process revealed Savary-Miller esophagitis of grade 0-I (62%), II (23%), III (8%), IV (7%), sliding hernia (71%), paraesophageal hernia (8%) or no herniation (21%). The pHmetry/24h diagnosed mixed pattern (38%), raised (20%), lying (20%) or inconclusive (22%). The manometry diagnosed hypotensive LES (35%), normal esophageal peristalsis (88%), mild hypomotility (5%) and was absent (7%). Hiatal hernia, severe esophagitis, ineffective symptomatic control with proton pump inhibitor and request for treatment discontinuation were the signs for surgical action. A laparoscopic ligation of short gastric vessels (70%), cruroplasty and fundoplication (silk 2/0), short (average size 1.5–2 cm) and floppy, without tension and without intraoperative calibration of the esophagus were thus performed. The laparoscopic Nissen fundoplication behaved safe and effective in treating GERD. In a group of 14 asymptomatic volunteers its reputation was confirmed with statistical significance by normalization of postoperative pHmetry/24h and manometry. 94% of the individuals remained asymptomatic up to 30.7 months (average) in the follow-up. Interrogating myself about the impact of this operation on the microcirculation of the gastric fundus I put premised on the possibility of the ligation of the short gastric vessels in the Nissen procedure can induce changes in the arteriolar diameter in the Wall of the gastric fundus. To explore the influence of ligation of the short gastric vessels and the fundoplication at the arteriolar caliber of the cardia, the fundus and the region of the short vessels of the gastric wall, I designed a project of experimental research in guinea pigs with two interdependent components: one veterinary and another technical where I applied angiomorphological studies. The project was developed at the Research Centre of the Department of Anatomy FCMUNL. For its accomplishment I got permission from the Scientific and Pedagogical Committee of the FCM-UNL, I requested for accreditation as a researcher at the General Directorate of Veterinary and, by resorting to the use of animals I submitted it to the Ethics Committee of the FCM-UNL, which approved it unanimously. The guinea pigs were divided into two experimental groups: an experimental group (EG), in which the Nissen procedure was performed and a control group (CG) in which only a gastric traction was done. Protocols of anesthesia, surgery and euthanasia were applied according to the 3Rs – Replacement, Reduction, Refinement of the technique of human experimentation of Burch and Russell (1959) – a widely accepted ethical framework for conducting scientific experiments using animals humanely. Using histological and angiomorphological techniques, I performed the analysis and the description of the normal, macro and microvascular, anatomy of the guinea pig stomach and I defined the morphological criteria that I considered susceptible for validation of this animal model for the proposed study. By means of scanning electron microscopy I measured the arteriolar calibers of the vascular casts of the cardia, of the fundus and of the short gastric vessels in both CG and EG, making 469 measurements in the former and 461 in the latter. The data were sent to the Research Center of the CHLC which conducted the statistical analysis (ANOVA). The data were sent to the Centre for Research of the CHLC, EPE which proceeded to statistical analysis (ANOVA). This analysis revealed that the arterioles plexus of the mucosal and submucosal plexus of the cardia, fundus and region of the short gastric vessels, showed increased caliber in EG. The increase was statistically significant for being greater than 50% CG gauge. In the short gastric vessels, the difference was smaller, but persisted and statistically significant. Straight vessels were dilated at the base, on its emergence of the plexus serous only in the fundus. In the guinea pig, the Nissen procedure - complete fundoplication with ligation of the short gastric vessels - caused arteriolar vasodilation on the gastric fundus. I believe that this vasodilation constituted some accommodation to the modification introduced and infer that the same might happen in humans. I admit therefore that vasodilation also occurs in humans following the ligation of the short gastric vessels by microvascular analogy between the two species and that this vasodilation corresponds also to na adaptation mechanism arteriolar, for example, to compensate the loss incurred by ligation. The association of experimental ligation of the short gastric vessels with conducting complete fundoplication, which exerts increased pressure on the EGJ, not only did not cause a microcirculation deficit of the distal esophagus or proximal stomach as triggered a mechanism of fundic vasodilation which reinforces the security concept of the Nissen procedure for treatment of GERD.

Dynamic adaptation of interaction models for stateful web services

Dissertação para obtenção do Grau de Mestre em Engenharia Informática

Isokinetic assessment of the flexor-extensor balance of the knee in athletes with total rupture of the anterior cruciate ligament

The purpose of this study was to assess the flexor-extensor group of muscles of the knee in young athletes diagnosed with a total rupture of the anterior cruciate ligament (ACL). Eighteen knees of 18 athletes (14 men and 4 women) with an average age of 21.6 years (range 16-32 years) were assessed with a Cybex 6000 model isokinetic apparatus. The average interval between occurrence of the injury and assessment was 10.2 months (range 2 - 48 months). There was an associated meniscal injury in eight of the knees. Athletes with any other kind of associated injury, limitation, or blockage of the movement of the joint, significant pain during the exam, or interval between injury and exam of less than two months were excluded from the study. The parameters studied were the peak torque-velocity and flexor-extensor relationships at the constant angular velocities of 60°/sec and 240°/sec. Previous warming-up was done by means of an ergometric bicycle and adaptation with 3 submaximal repetitions. The contra-lateral side, which presented no injury, was used as control. Peak torque (PT) at the constant velocity of 60°/sec was greater than that at 240°/sec for knees with and without injuries. However, there was no significant difference between the injured and uninjured sides at 60°/sec or at 240°/sec. The average value for the flexor-extensor relationship at 60°/sec on the injured was 60% (( 6), compared to 57% (( 10) on the contra-lateral side. At 240°/sec, the average value was 75% ((10) on the injured side, and 65% ((12) on the contra-lateral side. In conclusion, despite the complete rupture of the ACL of one knee, the average values for the flexor-extensor relationship were similar on the injured and uninjured sides at the velocity of 60°/sec. As the velocity increased, an increase in the values for the flexor-extensor relationship of the knee also occurred, indicating a tendency of the performance of the flexor muscle group to approach that of the extensor muscle group, and this tendency was more pronounced on the side of the injury.

A bio-inspired computational model for motion detection

Tese de Doutoramento (Programa Doutoral em Engenharia Biomédica)

Differential predictors of acute post-surgical pain intensity after abdominal hysterectomy and major joint arthroplasty

Author's personal copy