Orientador: Elizete Aparecida Lomazi da Costa Pinto / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-10T19:54:47Z (GMT). No. of bitstreams: 1 Gumiero_AnaPauladosSantos_M.pdf: 1871009 bytes, checksum: 1d48409780e8bf7e61ec1a9519c9cd4d (MD5) Previous issue date: 2008 / Resumo: Introdução- A anemia falciforme (AF) causa hemólise crônica e acelerada que é reconhecida como um fator de risco para desenvolvimento de colelitíase. Esta complicação pode ocorrer em mais de 50% da população adulta com AF. A colecistectomia é a conduta consensual para pacientes sintomáticos, mas nos assintomáticos a sua indicação é controversa. Objetivos- Relatar a freqüência de colelitíase em pacientes com AF e descrever a opção de conduta médica em caso de diagnóstico desta complicação, numa coorte de pacientes seguidos num centro terciário de hematologia pediátrica. Pacientes e métodos- Estudo descritivo e retrospectivo, com revisão dos prontuários de 225 pacientes e registro dos dados relacionados à evolução clínica. Resultados- A freqüência cumulativa de colelitíase foi de 44,9%, sendo que metade dos pacientes eram assintomáticos. As idades médias no diagnóstico de colelitíase e no momento do tratamento cirúrgico foram, respectivamente, 12,5 anos (DP = 5 anos) e 14 anos (DP = 5,4 anos). A prevalência de colelitíase foi maior nos pacientes com fenótipos SS e Sß Talassemia, comparada à prevalência nos pacientes com fenótipo SC (?2= 0,001). Entre os pacientes sintomáticos (50%), a dor abdominal inespecífica foi o único sintoma ou o sintoma mais freqüentemente referido. Entre pacientes que realizaram colecistectomia (N = 44), 39 tiveram melhora ou resolução de seus sintomas após o procedimento. Durante o seguimento clínico dos pacientes assintomáticos e não tratados cirurgicamente (7 anos ± 4,8 anos), nenhuma criança apresentou complicação relacionada a colelitíase. Conclusões- A freqüência de colelitíase na população estudada foi de 44,9%. Um terço dos pacientes foi diagnosticado antes dos 10 anos de idade. Pacientes com fenótipos SS e Sß associaram-se à maior freqüência de litíase biliar. Os pacientes assintomáticos e não operados não apresentaram complicações num período de 7 anos de seguimento / Abstract: Background- Sickle cell disease (SCD) causes chronic and recurrent hemolysis which is a recognized risk factor for cholelithiasis. This complication occurs in 50% of adults with SCD. Surgery is the consensual therapy in symptomatic patients, but the surgical approach is still controversial in asymptomatic individuals. Aims- To describe the frequency and the outcome of children with SCD complicated with gallstones followed up in a tertiary pediatric hematology center. Patients and methods- In a retrospective and descriptive study, 225 charts were reviewed and data regarding patient¿s outcome were recorded. Results- The prevalence of cholelithiasis was 44,9% and half of the patients had no symptom. The mean age diagnosis of cholelithiasis and surgical treatment were 12.5 years (SD= 5) and 14 years (SD= 5.4), respectively. The prevalence of cholelithiasis was higher in patients with SS and Sß thalassemia when compared to patients with SC disease (?2 = 0.001). In 50% of symptomatic patients, recurrent abdominal pain was the single or predominant symptom. Thirty-nine of 44 operated patients reported symptom relieve after surgical procedure. Asymptomatic non-operated individuals were followed up for 7 years (SD = 4.8), and none of them presented complications related to cholelithiasis during this period. Conclusions- Cholelithiasis frequency in studied children was 44,9%. One-third of patients were diagnosed before 10 years of age. Patients with the SS or Sß phenotype showed higher frequency of cholelithiasis. About 50% of patients with gallstones had no symptom and most of them did not undergo surgery and did not present complications during a 7-year follow-up period / Mestrado / Pediatria / Mestre em Saude da Criança e do Adolescente

Submitted by Divisão de Documentação/BC Biblioteca Central (ddbc@ufam.edu.br) on 2018-04-12T14:56:26Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertação_Júlio F. A. Flôres.pdf: 3515655 bytes, checksum: 1e8754bf324f0131dfff4b0f1146868f (MD5) / Approved for entry into archive by Divisão de Documentação/BC Biblioteca Central (ddbc@ufam.edu.br) on 2018-04-12T14:57:01Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertação_Júlio F. A. Flôres.pdf: 3515655 bytes, checksum: 1e8754bf324f0131dfff4b0f1146868f (MD5) / Made available in DSpace on 2018-04-12T14:57:01Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertação_Júlio F. A. Flôres.pdf: 3515655 bytes, checksum: 1e8754bf324f0131dfff4b0f1146868f (MD5) Previous issue date: 2018-02-08 / Background. Acute appendicitis is a public health issue: its morbidity increases significantly if not diagnosed and treated in a timely manner and its complications may result in patient’s death. Several diagnostic methods and several instruments have been investigated and many have been validated by medical practice and medical teaching about appendicitis’ diagnosis. Alvarado’s criteria are part of this group; thus, their semiotic simplicity could justify their usage in the education of early-years medical students through the employment of a platform largely used by individuals of the corresponding age. Objectives. To develop a digital form composed of Alvarado’s Criteria for the diagnosis of acute appendicitis; to determine the form validity when applied by early-years medical students. Methods. An electronic form was developed using digital platform Google© Forms. Early-years medical students, after a lecture about the disease, evaluated abdominal pain syndrome patients selected by active search in medical records and responded to Alvarado’s Criteria digital form, deciding or not for the acute appendicitis hypothesis. These data, tabulated in Microsoft© Excel electronic spreadsheet, were then compared by the researcher to similar data contained in medical records, and confirmed or not the diagnosis of acute appendicitis. Variables were arranged in 2 x 2 tables and were submitted to subsequent statistical analysis. Results. An electronic form was developed using digital Google© Forms platform. This form was integrated by cloud computing to Microsoft© Excel electronic spreadsheet for the compilation of data concerning the Score of Alvarado. After a brief introductory lecture, early-years medical students were invited to fill the form out, by using their smartphones. Subsequently, they were supposed to indicate in the form which patients would carry the diagnosis of acute appendicitis among those with abdominal pain. For a sample of 211 patients, electronic application of Alvarado’s Criteria by students demonstrated sensitivity of 80%, specificity of 81%, positive predictive value of 17% and negative predictive value of 98% in the diagnosis of acute appendicitis. The accuracy of the studied method was 81%. Frequency of appendicitis (4%) in the observed population corresponded to usual described medical literature prevalence values for the disease. Conclusions. Results pointed to the feasibility of the employment of the digital platform and demonstrated that the validity of the inserted Alvarado Criteria could be satisfactorily measured when applied by medical students of initial years. / Justificativa. Apendicite aguda é uma questão de saúde pública: sua morbidade aumenta significativamente se não diagnosticada e tratada em tempo hábil e suas complicações podem resultar em morte do paciente. Diversos métodos diagnósticos e instrumentos vêm sendo investigados e muitos têm sido validados, dentro do ensino e da prática da Medicina, para o diagnóstico da doença. Os Critérios de Alvarado fazem parte desse grupo. Destarte, sua simplicidade semiótica poderia justificar seu ensino a estudantes de anos iniciais do Curso de Medicina, com a utilização de plataforma de utilização disseminada entre indivíduos da faixa etária correspondente. Objetivos. Desenvolver formulário digital contendo os Critérios de Alvarado para o diagnóstico de apendicite aguda; determinar a validade da aplicação do formulário por parte de estudantes dos anos iniciais do curso de graduação de Medicina. Métodos. Desenvolveu-se formulário eletrônico com a utilização da plataforma digital Google© Forms. Estudantes de Medicina, após preleção sobre a doença por parte do pesquisador, avaliaram pacientes com síndrome dolorosa abdominal, escolhidos por busca ativa em prontuários, decidindo ou não pela hipótese de apendicite aguda ao preencherem o questionário digital montado com os Critérios de Alvarado. Os dados, tabulados pelo sistema em planilha Microsoft© Excel, foram então cotejados com informações obtidas em prontuários pelo pesquisador, confirmando ou não o diagnóstico de apendicite aguda. As variáveis foram agrupadas em tabelas 2 x 2 com análise estatística subsequente. Resultados. Desenvolveu-se formulário eletrônico com a utilização da plataforma Google© Forms, integrando-a na nuvem com planilha do Microsoft© Excel para a compilação de dados referentes ao Escore de Alvarado. Após instrução inicial, alunos de anos iniciais do Curso de Medicina foram convidados a preencher o formulário, com a utilização de seus smartphones, na tentativa de indicar, entre pacientes com dor abdominal, quais os portadores de apendicite aguda. Para uma amostra de 211 pacientes, a aplicação eletrônica dos Critérios de Alvarado pelos estudantes demonstrou possuir sensibilidade de 80% e especificidade de 81%, valor preditivo positivo de 17% e valor preditivo negativo de 98%. A acurácia do método estudado foi de 81%. A frequência de apendicite (4%) nos pacientes observados correspondeu ao valor usualmente citado na literatura para prevalência da doença. Conclusões. Os resultados apontaram que o desenvolvimento da plataforma digital foi factível e demonstraram que a validade dos critérios de Alvarado inseridos pôde ser medida satisfatoriamente quando empregados por estudantes de Medicina de anos iniciais.

Background: Managers and health professionals, so-called stakeholders, at the system and clinical level in the acute care chain, are responsible for providing safe and high-quality care encompassing both nursing and medical aspects. In patients with acute abdominal pain (AAP), high-quality nursing care has been described as not always being delivered across the entire acute care chain. This patient group frequently seeks care across the acute care chain and the care procedures and quality may differ widely. The quality of nursing care provided to patients can be understood through the framework Fundamentals of Care. The framework is divided into three dimensions: establishing a relationship with the patient, integration of the patient’s fundamental care needs, and context of care. Stakeholders are one important part of the context of care and a prerequisite for delivery of high-quality care.  Aim: The overall aim was to explore managers’ and health professionals’ understanding of managing and conducting care of patients with AAP across the acute care chain.  Method: Individual interviews with open-ended questions were used in two studies and data were analysed with a conventional qualitative content analysis method. Participants represented ambulance services, emergency departments, and surgical departments. Managers at head nurse level (n=11) and operational level (n=6) at four hospitals were included in Study I. Registered nurses (n=11) and physicians (n=8) at five hospitals were included in Study II. Results: In Study I, managers described the adult patient group as challenging and heterogenous. The managers reflected on themselves as role models. Guidelines were used to organise care, but they often had a medical focus and the managers referred to others as being responsible for the guidelines. Managers who were registered nurses focused on the medical care of patients with AAP, while managers who were physicians underlined the value of nursing care to improve patient outcome. In Study II, health professionals described dedication to applying evidence-based practices. However, they used personal experience over guidelines in care provision. They described organisational barriers to delivering high-quality care, such as varying competence among colleagues, lack of available patient beds, and lack of collaboration across the acute care chain.  Conclusion: The stakeholders’ perspectives complemented each other, but their descriptions of managing and conducting care of patients with AAP did not always fit together, which revealed a gap in the everyday clinical practices as well as structural issues at the system level. These empirical descriptions of differing understanding may reveal some of the reasons why patients with AAP do not always experience high-quality care. To optimise patient care across the acute care chain, stakeholders need a shared understanding to meet patients’ fundamental care needs and enable provision of high-quality nursing and medical care.

Background: Periprocedural intravenous hydration is suggested to decrease the risk of post-ERCP pancreatitis (PEP). However, quality of evidence supporting this suggestion remains poor. Here we hypothesized that aggressive hydration(AH) could be an effective preventive measure. Methods: Pubmed, EMBASE, CINAHL, Google Scholar, Clinical Trials. gov, Clinical Key, International Standard Randomized Trial Number registry as well as secondary sources were searched through January 2019 to identify randomized controlled studies comparing AH to standard hydration (SH) for prevention of PEP. Pooled odds ratio (OR) and 95% confidence intervals (CIs) were calculated using the random-effects model. RevMan 5.3 was used for analysis. Results: A total of 9 RCTs, with 2094 patients, were included in the meta-analysis. AH reduced incidence of PEP by 56% compared to SH (OR = 0.44, CI:0.28–0.69; p = 0.0004). The incidence of post-ERCP hyperamylasemia also decreased with AH compared to SH (OR = 0.51; p = 0.001). Length of stay decreased by 1 day with AH (Mean Difference (MD): −0.89 d; p = 0.00002). There was no significant difference in adverse events related to fluid overload between two groups (OR:1.29; p = 0.81) and post-ERCP abdominal pain (OR:0.35; p = 0.17). Numbers of patient to be treated with AH to prevent one episode of PEP was 17. Final results of the meta-analysis were not affected by alternative effect measures or statistical models of heterogeneity. Conclusion: Aggressive hydration is associated with a significantly lower incidence of PEP and it appears to be an effective and safe strategy for the prevention of Post ERCP pancreatitis.

Several etiological models of recurrent abdominal pain (RAP) in children have been proposed but no one model has been able to adequately account for the symptoms of all children with RAP. The present study proposed that symptom presentation may provide a basis for treatment selection. Two etiological models were tested in the present study: the constipation model and the operant learning model. Subjects were assigned to either model based upon whether or not they presented with symptoms of constipation. The treatments derived from these two models were: daily dietary fiber supplements, and teaching children relaxation skills and teaching parents to respond to their child’s pain complaints by encouraging their child to cope with pain through relaxation. Thirteen subjects between the ages of six and 12 years of age were treated in a nonconcurrent multiple baseline A-B or A-B-C design. To control for nonspecific effects, some subjects in each model received the treatment suggested by the alternative model first. All four subjects in the constipation model showed substantial reductions in stomachache activity following the introduction of the dietary fiber treatment. Of the nine subjects in the operant learning model, one showed substantial reductions in stomachache activity following the introduction of the relaxation and parent instruction treatment, two showed reductions during both treatments, four responded to the dietary fiber treatment, and two showed no response to treatment. Results support the effectiveness of a dietary fiber treatment for children with RAP with symptoms of constipation. Minimal support was obtained for the effectiveness of a relaxation and parent instruction treatment for children with RAP without symptoms of constipation. Limitations, implications and directions for future research are discussed. / Ph. D.

Bakgrund: Genusbias, det vill säga felaktigheter i vården till följd av föreställningar om kön och stereotypa könsroller, eller brist på kunskap om relevanta biologiska skillnader, är vanligt förekommande i Sverige. Buksmärta är en vanlig sökorsak för tonåringar med många könsspecifika differentialdiagnoser, och risk för genusbias finns således även där. Syfte: Syftet med studien var att ur ett genusperspektiv beskriva handläggning av tonåringar med akut buksmärta. Metod: En kvalitativ, deskriptiv studie baserad på tre fokusgruppsintervjuer med sammanlagt 16 deltagare i form av sjuksköterskor, specialistsjuksköterskor och läkare med erfarenhet av att handlägga tonåringar med akut buksmärta. Intervjuerna har analyserats med kvalitativ innehållsanalys. Resultat: Ett övergripande tema framkom i studien: Komplexitet som påverkas av kunskap, rutiner och attityder. Det övergripande temat grundas på de tre huvudkategorierna: att beakta olika orsaker till buksmärta hos tonåringar; att handlägga akut buksmärta hos tonåringar kräver lyhördhet, tydliga rutiner och kunskap och att identifiera genusbias vid handläggning av akut buksmärta hos tonåringar. Slutsats: Handläggningen av tonåringar med akut buksmärta har brister och genusbias förekommer. Könsspecifika rutiner för tonåringar med buksmärta kan vara gynnsamt både för personal och patienter, och framförallt för flickor. Genusperspektivet bör belysas mer och ytterligare utbildning och forskning i området medicinsk genusbias är nödvändig. / Background: Gender bias; inaccuracies in the healthcare system related to gender and stereotype gender roles, or a lack of knowledge and awareness of relevant biological differences among the sexes, are common in Sweden. Abdominal pain is a common reason to why teenagers up seek healthcare, and there is a lot of gender specific differential diagnosis, which comes with is a risk for gender bias to occur. Aim: The aim of this study was to describe the caring-process of teenagers with acute abdominal pain from a gender perspective. Method: A qualitative, descriptive study based on three focus groups with a total amount of 16 participants whom where registered nurses, specialist nurses and doctors with experience of administrating teenagers with acute abdominal pain. The interviews where analyzed with qualitative content analysis. Result: An overall theme appeared in the study: Complexity affected by knowledge, routines and attitudes. The theme where based on three main categories: To consider different reasons of abdominal pain in teenagers; to administrate acute abdominal pain in teenagers demands sensitivity, clear routines and knowledge; to identify gender bias in the caring-process in teenagers with acute abdominal pain. Conclusion: The caring-process of teenagers with acute abdominal pain has inadequacies and gender biases exists. Gender specific routines for teenagers with abdominal pain could be favorable both for healthcare professionals and patient, and teenage girls. The gender perspective needs to be more illuminated and further education and research in the area medical gender bias is needed.

Cesarean section is a surgical procedure associated to high intensity abdominal pain, not relieved by drugs. Therefore, non-pharmacological strategies for analgesia has been used, as Transcutaneous Electric Nerve Stimulation (TENS). This study aimed to analyze the analgesic effect of TENS on abdominal pain after cesarean applied in abdominal or paravertebral region and in motor or sensitive amplitude, as its analgesic effect on pain intensity (at rest and during movement), deep pain intensity, cutaneous sensitivity, pressure pain threshold and range of motion, and analyze risk of bias, as scientific data of clinical trials which investigated TENS effects on abdominal pain after cesarean section. For meta-analysis, a systematic search in six databases, hand search and Google Scholar was performed. Ten randomized clinical trials published until December 2016, which investigated TENS effects on abdominal pain relief after cesarean compared to control or placebo group were included. Risk of bias analysis using Cochrane Collaboration tool and meta-analysis of pain intensity data was performed based on four of the included studies. On randomized double-blind clinical trial, the following outcomes (and their respective assessment instruments) were measured before and after a single TENS session: incisional and deep pain intensity at rest and during movement (Numerical Rating Scale), pressure pain threshold (digital algometer), cutaneous sensitive threshold (Von Frey filaments), temporal summation (temporal summation test) and range of motion for anterior flexion, right and left trunk rotation (fleximeter). On clinical trial, 80 cesarean postpartum women were included and allocated in four groups (peri-incisional (n=20), sensitive paravertebral (n=20), motor paravertebral (n=20) and placebo TENS (n=20)). On intragroup analysis, the following changes were observed: pain intensity decrease on both three groups treated with active TENS, at rest (peri-incisional and motor paravertebral group) and during movement (sensitive paravertebral group); cutaneous sensitive threshold decrease in one of the points close to the incision on peri-incisional group and in two points far from incision (periincisional and motor paravertebral groups). On pressure pain threshold, pressure increased on peri-incisional group and pressure pain intensity decreased on sensitive and motor paravertebral groups. Range of motion for right trunk rotation increased on sensitive paravertebral group, and pain intensity decreased during left trunk rotation (peri-incisional, sensitive and motor paravertebral groups) and right trunk rotation (peri-incisional and sensitive paravertebral groups). There was no difference on temporal summation. On clinical trial, active TENS favored pain intensity reduction, increase in pressure pain threshold, cutaneous sensitivity and lower pain during the assessed movements on the major active TENS groups. In addition to that, TENS applied on paravertebral region using sensitive amplitude seems to provide better analgesic effect. Meta-analysis results evidenced non-effectiveness of TENS on pain intensity decrease compared to placebo (MD = 2.08, 95% CI: -0,13 to 4,28, p = 0,07, I2 = 99%) and low quality of evidence was verified. / A cesariana é um procedimento cirúrgico associado a alta intensidade de dor abdominal, que não é completamente aliviada com medicamentos. Portanto, estratégias não farmacológicas para analgesia adicional podem ser usadas, tal como a estimulação elétrica nervosa transcutânea (TENS). Os objetivos deste estudo foram analisar o efeito analgésico da TENS na dor abdominal pós-cesariana quando aplicada no abdome ou na região paravertebral e em intensidade sensitiva ou motora, assim como seu efeito analgésico na intensidade de dor em repouso e em movimento, na dor profunda, na sensibilidade cutânea e na amplitude de movimento, além de analisar risco de viés, bem como a evidência científica, de ensaios clínicos que investigaram o efeito da TENS na dor abdominal pós-cesariana. Para a meta-análise, foi realizada uma pesquisa sistemática em seis bases de dados, além da busca manual e no google acadêmico. Dez ensaios clínicos aleatórios publicados até dezembro de 2016, que investigaram o efeito da TENS no alívio da dor abdominal pós-cesariana comparado ao grupo controle ou placebo, foram incluídos. Foi realizada análise de risco de viés dos estudos incluídos por meio da ferramenta da Colaboração Cochrane, e uma meta-análise para dados da intensidade de dor foi realizada com base em quatro destes estudos. No ensaio clínico controlado com distribuição aleatória e duplamente encoberto, foram medidos os seguintes desfechos (com os respectivos instrumentos) antes e após uma única aplicação da TENS: intensidade de dor incisional e profunda no repouso e no movimento (escala numérica), limiar de dor por pressão (algômetro digital), limiar sensitivo cutâneo (filamentos de von Frey), somação temporal (teste de somação temporal - algômetro digital) e amplitude dos movimentos de flexão anterior e rotação do tronco (flexímetro). No ensaio clínico, foram incluídas 80 puérperas de cesariana distribuídas em quatro grupos (TENS peri-incisional (n=20), TENS parvertebral sensitivo (n=20), TENS paravertebral motor (n=20) e TENS placebo (n=20)). Na análise intragrupo, foram observadas as seguintes alterações: redução da intensidade de dor nos três grupos tratados com TENS ativa, no repouso (grupos peri-incisional e paravertebral motor) e no movimento (grupo paravertebral sensitivo); redução do limiar sensitivo cutâneo no ponto próximo à incisão (grupo periincisional), e nos pontos distantes da incisão (grupos peri-incisional e paravertebral motor). No limiar de dor por pressão, a pressão aumentou no grupo peri-incisional, e a intensidade de dor durante a pressão aplicada diminuiu nos grupos paravertebral sensitivo e motor. A amplitude do movimento de rotação para a direita aumentou no grupo paravertebral sensitivo, e a dor diminuiu nos movimentos de rotação para a esquerda (grupos peri-incisional e paravertebral sensitivo e motor) e de rotação para a direita (grupos peri-incisional e paravertebral sensitivo). A somação temporal não alterou em nenhum dos grupos. No ensaio clínico, a estimulação ativa com TENS favoreceu redução da intensidade de dor, aumento do limiar de dor por pressão, da sensibilidade cutânea e menos dor durante os movimentos avaliados na maioria dos grupos em que a TENS foi usada ativamente. Ao estimular a região paravertebral em limiar sensitivo, a TENS parece apresentar melhor efeito analgésico. Os resultados da meta-analise evidenciaram a não efetividade da TENS na redução da intensidade de dor comparado ao placebo (MD = 2,07, 95% CI: 0,06 to 4,08, p = 0,04, I2 = 99%) e baixa qualidade da evidência foi verificada.

La douleur abdominale aiguë (DAA) est un problème de santé publique du fait de sa fréquence, du large éventail de pathologies causales et de son enjeu thérapeutique avec une nécessité d'opérer rapidement les patients à risque et de ne pas opérer la plupart des patients. Le retard ou l'insuffisance diagnostique d'une urgence abdominale, qu'elle soit non traumatique (en particulier en cas de strangulation, d'ischémie digestive ou de péritonite) ou traumatique, entrainera une augmentation de la morbi-mortalité. Il est donc primordial que la prise en charge diagnostique et thérapeutique repose sur de l'Evidence-Based Médecine, intégrant une expertise clinique avec les meilleurs examens para-cliniques dont les performances ont été validées par les recherches scientifiques. A ce jour, c'est la tomodensitométrie (TDM) qui s'est imposée comme l'examen complémentaire de référence en cas d'incertitude diagnostique, pour l'exploration d'une DAA. Or, les études publiées sur l'apport du scanner dans les DAA ont un certain nombre de limites : elles ne s'intéressent souvent qu'à une seule pathologie donnée et ne correspondent donc pas à la situation clinique de pathologies non identifiées, elles intègrent rarement des objectifs sur l'impact thérapeutique et présentent, pour la plupart, des faibles niveaux de preuve (niveau I ou II) sur l'échelle à 5 niveaux de la classification des études diagnostiques. Quel que soit le niveau de l'étude, des outils statistiques avancés peuvent être utilisés pour diminuer les biais d'interprétation, pour prendre en compte le degré d'incertitude diagnostique clinique, pour tenir compte de la faible prévalence de certaines pathologies urgentes et pour faciliter le transfert et la généralisation des résultats obtenus à la pratique clinique. L'objectif de cette thèse est donc de présenter des outils statistiques, en analysant les forces et limites des résultats obtenus, afin d'étayer les perspectives d'intégration dans une stratégie de prise en charge clinique. Certains de ces outils statistiques sont déjà connus et largement utilisés en imagerie, d'autres sont développés essentiellement dans les études thérapeutiques et enfin, certains sont totalement innovants.Ainsi, la première partie de cette thèse est consacrée à une mise au point sur la méthodologie de la recherche en imagerie, en exposant ses caractéristiques, ses faiblesses et ses perspectives d'évolution. La deuxième partie est constituée d'une production scientifique de 5 articles, 4 d'entre eux publiés, focalisée sur les urgences abdominales traumatiques et non traumatiques, illustrant à l'aide du développement des analyses statistiques, l'apport du scanner pour améliorer certaines stratégies diagnostiques et thérapeutiques. De cette façon, les méthodes de concordance diagnostique, de régression logistique multivariée, de construction de score diagnostique et de méta-analyse bivariée avec effets aléatoires sont explicitées. Nous avons dans le dernier article proposé une méthode d'analyse statistique innovante basée sur une notion de distance permettant d'intégrer l'incertitude diagnostique représentée par les multiples hypothèses diagnostiques face à une douleur abdominale. Cette approche permet ainsi de mesurer la valeur ajoutée de la TDM à la fois en termes d'exactitude diagnostique et de confiance diagnostique, en se rapprochant de la pratique clinique quotidienne. A l'avenir, ces outils statistiques pourraient être plus largement utilisés dans la recherche diagnostique afin d'améliorer la pertinence scientifique et l'impact clinique, à l'origine d'une meilleure prise en charge des patients, et d'une meilleure utilisation des ressources économiques. / Acute abdominal pain (AAP) is a public health problem, given its frequency, the numerous specific causes and the therapeutic impact, with patients at risk requiring urgent surgical care while most patients do not require surgery. Delayed diagnosis or misdiagnosis of an abdominal emergency, whether of non traumatic (such as bowel strangulation, or bowel ischemia, or peritonitis) or traumatic origin, will lead to increased morbidity and mortality. It is thus crucial that diagnostic and therapeutic management relies on Evidence-based Medicine, integrating clinical expertise and paraclinical tests that have been validated through scientific research. To date, computed tomography (CT) has become the reference examination to investigate AAP when diagnosis is uncertain. However, published studies evaluating the value of CT in AAP, have some limits: they often focus on a specific disease, and consequently do not meet the unsorted pathologies encountered in clinical practice, they sparsely include objectives on therapeutic impact, and most show low levels of evidence (level I or II) on the five level diagnostic studies scale. Whatever the study's level, advanced statistical methods can be used to reduce interpretation bias, take into account the clinical diagnostic uncertainty or the low prevalence of some urgent diseases, and to facilitate the transfer and generalisation of results into daily clinical practice.The aim of this work is to present statistical tools, by analysing the results' strengths and limits, in order to illustrate the perspective of integration within a clinical management strategy. Some of these statistical tools are known and largely used in imaging studies, others are essentially developed in therapeutic studies, and some are completely innovative.Thus, the first part of this thesis reports on a review of the methodological aspect of research in the field of medical imaging, showing its characteristics, its weaknesses and its development perspective.The second part is composed of 5 scientific articles - with 4 already published - and focus on traumatic and non traumatic abdominal emergencies, illustrating the value of CT in improving some diagnostic and therapeutic strategies, while detailing the statistical analyses. Hence, statistical methods for diagnostic agreement, multivariate logistic regression, diagnostic scoring-system building and bivariate random-effects meta-analysis are developed. In the last article, we propose a new statistical analysis method, based on a distance concept, allowing integrating the diagnostic uncertainty resulting from multiple diagnosis hypotheses in front of an AAP. This approach allows for investigating the added value of CT both in terms of diagnostic accuracy and diagnostic confidence, while getting close to daily clinical practice.In the future, these statistical tools could be implemented into diagnostic research in order to improve the scientific relevance and clinical impact, allowing for better patients' management, and better economic resource usage.

Background: Irritable bowel syndrome (IBS) is an extremely common condition affecting approximately 10-15% of the population. Lower abdominal pain is a common feature and, if the patient also has gynaecological symptoms such as heavy periods, they may be referred to a gynaecologist especially when the bowel symptoms are relatively mild. In this setting a laparoscopy is often undertaken and endometriosis commonly identified as this condition affects up to 10% of women. Consequently pain is frequently attributed to the endometriosis even when it is relatively mild. However it is a common observation amongst gynaecologists that women with mild endometriosis often have severe symptoms which do not seem to respond well to treatment. This raises the possibility that their pain may not actually be due to endometriosis or is being amplified by the visceral hypersensitivity which is a characteristic feature of irritable bowel syndrome.Methods: 20 patients with minimal-mild endometriosis, 20 with moderate-severe endometriosis, 20 healthy volunteers (HV) who have had laparoscopy for sterilisation, 20 IBS patients and 20 patients with pain who were found to have a normal pelvis (on laparoscopy) were studied. Gastrointestinal, gynaecological, and noncolonic symptoms were recorded as well as demography, quality of life and psychological status. Visceral sensitivity was assessed in all patients and abdominal distension was studied in a sub group of 26 endometriosis patients and 20 IBS patients.Results: 20 (100%) of IBS patients, 13 (65%) of minimal-mild endometriosis patients, 11 (55%) of moderate-severe endometriosis patients, 17 (85%) of laparoscopic negative pain patients and no healthy volunteers fulfilled ROME III criteria for IBS. Patients with endometriosis and IBS had similar levels of visceral sensitivity which were significantly lower than that observed in controls (p=0·002, p<0·001).In particular, both minimal-mild and moderate-severe endometriosis patients had significantly lower (mean-95% CI) pain thresholds in mmHg 28.1(24.5, 31.6) and 28.8(24.9, 32.6) respectively compared with controls 39·5 (36·0, 43·0) p=0.001and p=0.002. However, with few exceptions, there were no distinguishing features between patients in terms of demography, symptomatology and distension.Conclusion: Clinically, it is very difficult to distinguish between endometriosis and IBS. However, visceral hypersensitivity appears to be a major component of endometriosis and may explain the problem of excessive pain especially in patients with mild disease offering a potential new target for treatment

Der chronische Unterbauchschmerz stellt den behandelnden Arzt vor erhebliche differentialdiagnostische Probleme. Die vorgestellte Studie soll den Wert der Laparoskopie im diagnostischen Konzept aufzeigen. Dazu führten wir zwischen Oktober 1993 und Juni 1998 bei 100 Patienten mit der klinischen Diagnose «chronischer Unterbauchschmerz» eine Laparoskopie durch. Bei 14 Patienten ließ sich ein morphologisches Korrelat unabhängig von der Appendix finden. 86 Patienten wurden appendektomiert, wobei die histologische Untersuchung des Präparats in 82 Fällen (95,3%) einen pathologischen Befund aufwies. 80 Patienten (93%) blieben auch während der Nachuntersuchungen beschwerdefrei. Die Laparoskopie stellt ein sicheres Verfahren zur Diagnostik und Behandlung chronischer Unterbauchschmerzen dar. Bei fehlendem Korrelat für die Beschwerden sollte in gleicher Sitzung die laparoskopische Appendektomie durchgeführt werden. / The differential diagnosis chronic lower abdominal pain can be problematic, and this symptom may lead to several diagnostic procedures. The purpose of this study was to evaluate the usefulness of laparoscopy in the diagnostic concept. From October 1993 to June 1998 we performed 100 laparoscopies in patients with chronic or recurrent lower abdominal pain. In 14 patients we found a substrate for the reported pain, which was independent of the appendix. In 86 patients we performed an appendectomy. In 62 of the specimens (95.3%) the histological study showed pathological findings. 80 patients (93%) reported no further complaints during follow-up. Laparoscopy is a safe procedure for diagnostics and treatment of patients with chronic lower abdominal pain. If no other explanation for the symptoms is found, laparoscopic appendectomy should be performed. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.