O índice de área hiperbárica (IAH), uma nova metodologia de análise da MAPA, foi relacionado a alterações cardíacas, em especial o índice de massa ventricular esquerda (IMVE). Utilizou-se método baseado em limites pressóricos pré-definidos para os períodos de vigília e sono, considerando-se a área excedente a tais limites durante o exame como o índice hiperbárico. Observou-se relação linear direta e significativa entre IAH e IMVE. Observou-se também maior participação dos IAH de sono, sistólicos e diastólico, em determinar alterações de IMVE / The hyperbaric index area (HIA), a new methodology for ABPM analysis, was tested for its relationship to cardiac alterations, particularly with left ventricular mass index (LVMI). Calculation was based on pre-defined pressure limits for ABPM periods of sleep and activity, considering the exceeding area during the time of exam as the hyperbaric index. It was observed a statistically significant linear relation between HIA and LVMI. It was also observed a greater relation for the sleep HIA, both systolic and diastolic with changes in LVMI

INTRODUÇÃO: Os efeitos do consumo de café na frequência e ritmo cardíaco, na pressão arterial e risco cardiovascular permanecem um assunto controverso. O objetivo desse estudo foi avaliar os efeitos do consumo de café filtrado nas torra escura e média na frequência cardíaca (FC), na frequência de extrassístoles, na variabilidade de frequência cardíaca (VFC), na pressão arterial, na tolerância ao exercício e em isquemia e angina em voluntários com doença arterial coronariana (DAC). MÉTODOS: Em um ensaio clínico randomizado e com crossover, comparamos o efeito do consumo de 450 a 600 ml de café nas torras escura e média em 41 voluntários com DAC, com idade média de 64,5 ± 6,7 anos, sendo que 33 eram do sexo masculino (80,5%). Após período de washout (período basal) e após cada período de quatros semanas de consumo de café (em ambas torras), os voluntários foram submetidos a teste ergométrico (TE), monitorização ambulatorial da pressão arterial (MAPA) e eletrocardiografia dinâmica (Holter). RESULTADOS: O consumo contínuo de café não exerceu nenhum efeito deletério na isquemia miocárdica desencadeada por esforço no teste ergométrico. O tempo total de exercício (deltaT Exercício) foi de 566,59 ± 192,40, 599,39 ± 205,60 e 602,22 ± 210,24 segundos (s), respectivamente para o momento basal (após washout), após consumo de café torra escura e após consumo de café torra média (média ± DP, p = 0,002). Na MAPA, as variáveis encontradas após período basal, após consumo de café torra escura e após consumo de café torra média foram, respectivamente: pressão arterial sistólica (PAS) de 110,59 ± 12,05, 111,83 ± 12,89 e 114,32 ± 11,89 mmHg (média ± DP, p = 0,065); e pressão arterial diastólica (PAD) de 64,10 ± 8,99, 64,85 ± 9,31 e 66,27 ± 9,59 mmHg (média ± DP, p = 0,143). Os valores a seguir foram obtidos através do Holter após período basal, após consumo de café torra escura e após consumo de café torra média, respectivamente: FC Média de 67,38 ± 8,44, 66,51 ± 8,11, e 67,44 ± 8,54 (média ± DP, p = 0,59); frequência de extrassístoles supraventriculares (ESV) de 21 (75), 22 (59), e 18 (85) [mediana (intervalo interquartil), p = 0,77]; frequência de extrassístoles ventriculares (EV) de 8 (426), 10 (123), e 8 (36) [mediana (intervalo interquartil), p = 0,17]; e desvio padrão de todos os intervalos RR normais (SDNN) de 129,87 ± 32,82, 134,74 ± 30,90, e 128,31 ± 28,12 (média ± DP, p = 0,16). CONCLUSÕES: Neste estudo, o consumo contínuo de café aumentou a tolerância ao exercício, não afetou de forma significativa a pressão arterial, o ritmo e a frequência cardíaca e não aumentou a frequência de extrassístoles ventriculares e supraventriculares. Com relação a presença de isquemia e/ou angina no TE, não ocorreram modificações relacionadas ao consumo de café em ambas torras / BACKGROUND: The effect of coffee on heart rate (HR), cardiac rhythm, blood pressure (BP) and cardiovascular risk has long been a controversial issue. The aim of this study was to compare the effects of dark roast (DR) and medium-dark roast (MDR) paper-filtered coffee on HR, premature complexes, heart rate variability (HRV), BP, total exercise time (deltaT Exercise) and exercise-induced angina pectoris in volunteers with coronary artery disease (CAD). METHODS: In a randomized crossover trial, we compared the effects of consuming three to four cups (150 mL) of DR and MDR coffee per day for 4 weeks in 41 volunteers with CAD, with 64.5 ± 6.7 years old, 33 men (80.5%). At baseline and after each 4-week period of drinking, the subjects were submitted to treadmill test, ambulatory blood pressure monitoring (24-h ABPM) and 24-hour Holter electrocardiograms (24-h Holter). RESULTS: The continuous coffee consumption had no deleterious effect on exercise-induced angina pectoris on treadmill test. The deltaT Exercise at baseline and after ingesting DR and MDR were 566.59 ± 192.40, 599.39 ± 205.60 and 602.22 ± 210.24 seconds, respectively (mean ± SD, p = 0.002). The analyzed parameters on 24-h ABPM at baseline and after 4 weeks of DR and MDR coffee consumption were, respectively: systolic BP of 110.59 ± 12.05, 111.83 ± 12.89 and 114.32 ± 11.89 mmHg (mean ± SD, p = 0.065); and diastolic BP of 64.10 ± 8.99, 64.85 ± 9.31 e 66.27 ± 9.59 mmHg (mean ± SD, p = 0,143). The following values were obtained on 24-h Holter at baseline and after 4 weeks of DR and MDR coffee consumption, respectively: average HRs of 67.38 ± 8.44, 66.51 ± 8.11, and 67.44 ± 8.54 (mean ± SD, p = 0.59); premature atrial complexes of 21 (75), 22 (59), and 18 (85) [median (IQR), p = 0.77]; premature ventricular complexes of 8 (426), 10 (123), and 8 (36) [median (IQR), p = 0.17]; and standard deviations of normal to normal R-R intervals (SDNNs) of 129.87 ± 32.82, 134.74 ± 30.90, and 128.31 ± 28.12 (mean ± SD, p = 0.16). CONCLUSIONS: In this study, continuous coffee consumption increased total exercise time, did not significantly affect blood pressure, HR or HRV and did not increase the frequency of premature complexes in volunteers with CAD. Furthermore, continuous coffee consumption had no deleterious effect on exercise-induced angina pectoris

Abstract Left ventricular hypertrophy (LVH), a common complication of elevated blood pressure (BP), is a risk factor for cardiovascular (CV) morbidity and mortality. Adiponectin has been shown to have cardioprotective effects and is inversely associated with LVH. BP can be measured at a clinical visit, as a momentary value. Ambulatory blood pressure (APB) measurement (ABPM) is a method of repeated BP measurements through a defined period, targeted to evaluate the circadian BP profile. High BP and ABPM have been shown to be associated with LVH and left ventricular diastolic dysfunction (LVDD). A high sodium intake has been associated with elevated BP and adverse CV outcome. The aim of this study was to investigate the associations between adiponectin and left ventricular mass index (LVMI), a measure of LVH, ABPM and the development of LVDD during long-term follow-up, ABPM and the change in LVMI during long-term follow-up, and the role of dietary sodium intake in the incidence of AF. Adiponectin has been shown to have vasoprotective, anti-inflammatory and cardioprotective effects. Hypoadiponectinemia has been associated with hypertension, coronary artery disease (CAD) and LVH. In this study, adiponectin levels were inversely associated with LVMI, even after adjustment with conventional risk factors of LVH, in a fairly large sample of middle-aged subjects. Elevated BP and pulse pressure (PP) have been associated with echocardiographic measures of LVDD. In this study, the association between APBM and the development of LVDD during a 20-year follow-up was evaluated. Ambulatory PP (APP) was shown to independently associate with the development of LVDD, even after adjustment with conventional risk factors of LVDD. APBM has been associated with LVH in cross-sectional assessments and has also been shown to have predictive value in future LVMI or LVH. In a few studies the predictive value of APP in future LVMI was observed. In the present study, an increase in APP was shown to predict the change in LVMI during long-term follow-up. In this study, the association between dietary sodium intake and the incidence of AF was evaluated. A high sodium intake predicted the occurrence of AF, which is a novel finding. In conclusion, this study offers novel findings about predictive factors in the entity of cardiac remodelling. / Tiivistelmä Vasemman kammion hypertrofia on yleinen kohonneen verenpaineen seuraus ja sen on todettu olevan sydän- ja verisuonitapahtumien riskitekijä. Adiponektiinin on osoitettu suojaavan vasemman kammion hypertrofialta. Ambulatorinen verenpaineen mittaus on menetelmä, jossa verenpaine mitataan määritellyllä ajanjaksolla toistuvasti, mikä antaa kuvan verenpaineesta vuorokauden eri jaksoissa. Kohonneella ambulatorisella verenpaineella on osoitettu olevan yhteys vasemman kammion hypertrofiaan sekä vasemman kammion diastoliseen vajaatoimintaan. Runsas natriumin saanti on yhteydessä kohonneeseen verenpaineeseen sekä sydän- ja verisuonisairauksiin. Tämän tutkimuksen tarkoituksena on selvittää yhteyksiä adiponektiinin ja vasemman kammion massaindeksin välillä, ambulatorisen verenpaineen ja vasemman kammion diastolisen vajaatoiminnan kehittymisen välillä, ambulatorisen verenpaineen ja vasemman kammion massaindeksin muutoksen välillä sekä natriumin saannin ja eteisvärinän ilmaantuvuuden välillä. Adiponektiinilla on todettu olevan suotuisia vaikutuksia verisuonistoon, tulehdusreaktion hillintään sekä sydänlihakseen. Matalan adiponektiinitason on osoitettu olevan yhteydessä verenpainetautiin, sepelvaltimotautiin sekä vasemman kammion hypertrofiaan. Tässä tutkimuksessa adiponektiinihormonilla osoitettiin olevan käänteinen yhteys vasemman kammion massaindeksiin, vaikka perinteiset riskitekijät otettiin huomioon. Kohonneella verenpaineella sekä pulssipaineella on osoitettu olevan yhteys vasemman kammion diastoliseen vajaatoimintaan. Tässä tutkimuksessa arvioitiin ambulatorisen verenpaineen merkitystä vasemman kammion diastolisen vajaatoiminnan kehittymisessä. Ambulatorinen pulssipaine osoittautui riskitekijäksi, vaikka perinteiset riskitekijät otettiin huomioon. Ambulatorisella verenpaineella ja pulssipaineella on osoitettu olevan yhteys vasemman kammion hypertrofiaan poikkileikkaustutkimuksissa ja seurantatutkimuksissa. Tässä tutkimuksessa ambulatorisen pulssipaineen nousun havaittiin ennustavan vasemman kammion massaindeksin kasvua pitkäaikaisseurannassa. Tässä tutkimuksessa korkean natriumin saannin todettiin olevan yhteydessä lisääntyneeseen eteisvärinän ilmaantuvuuteen. Tätä yhteyttä ei ole aiemmin todettu muissa tutkimuksissa. Tässä tutkimuksessa löydettiin uusia riskitekijöitä sydämen patologisiin ilmentymiin liittyen.

Estudamos 62 pacientes, que com teste ergométrico positivo, manifestaram angina estável e estavam sob controle farmacológico. Todos apresentavam cinecoronariografia mostrando obstrução >70% em pelo menos uma das principais artérias coronárias. Objetivamos avaliar parâmetros eletrocardiográficos e de pressão arterial, durante procedimento odontológico restaurador sob anestesia local com e sem vasoconstritor em presença de doença arterial coronária. As idades variaram de 39 a 80, média de 58,7±8,8 anos, sendo 51 (82,3%) homens. Trinta pacientes foram randomizados para receber anestesia local com solução de lidocaína a 2% com adrenalina 1:100.000 e os demais para lidocaína a 2% sem vasoconstritor. Todos os pacientes foram submetidos à monitorização ambulatorial da pressão arterial (MAPA) e eletrocardiografia dinâmica por 24 horas, iniciados 2 horas antes do procedimento odontológico. Consideramos 3 períodos de registro: (1) basal - os 60 minutos que antecederam ao procedimento odontológico; (2) procedimento - desde o início da anestesia até o final do procedimento odontológico restaurador; (3) subseqüente completar das 24 horas. A análise de variância com medidas repetidas mostrou que houve elevação significativa da pressão arterial sistólica e diastólica do período basal para o procedimento nos dois grupos estudados (aproximadamente 14mmHg e 5 a 7mmHg) respectivamente, quando analisados separadamente e quando confrontados não apresentaram diferença de comportamento entre si. A freqüência cardíaca não se alterou nos dois grupos estudados. Depressão do segmento ST >1mm ocorreu em 10 (17,9%) pacientes; todos os eventos ocorreram no mínimo 2 horas após o término do procedimento odontológico. Extra - sístoles supra-ventriculares e/ou extra-sístoles ventriculares em número maior do que 10/hora estiveram presentes em 17 (30,4%) pacientes durante as 24 horas e durante o período do procedimento em 7 (12,5%), sendo 4 (13,8%) do grupo que recebeu anestesia sem adrenalina e 3 (11,1%) do grupo que recebeu anestesia com adrenalina e o teste Exato de Fisher não mostrou diferença entre os grupos. Concluímos que não houve diferença em relação ao comportamento de pressão arterial, freqüência cardíaca, evidência de isquemia e arritmias entre os grupos. O uso associado de vasoconstritor mostrou-se, portanto, seguro dentro dos limites do estudo. / We enrolled 62 patients with positive exercise stress test who presented with stable angina and were receiving drug therapy. All had a coronary angiography screening showing >70% obstruction in at least one of the main coronary arteries. The study aimed to compare electrocardiographic and blood pressure parameters during restorative dentistry procedure under local anesthesia, both with and without vasoconstrictor, in the presence of coronary artery disease. Ages ranged from 39 to 80, (mean ± SD) 58.7±8.8 years, 51 (82.3%) of them were male. Thirty patients were randomly assigned to receive 2% lidocaine local anesthesia with 1:100,000 epinephrine, the others receiving 2% lidocaine without vasoconstrictor. All the patients underwent ambulatory blood pressure and 24-hour Holter monitoring, beginning two hours ahead of the dental procedure. Recording were made during (1) baseline - 60-minute period before dental procedure began; (2) procedure - from beginning of anesthesia until the end of the procedure; and (3) subsequent 24-hour period. Analysis of variance with repeat measures showed significant diastolic and systolic blood pressure increases from baseline to the period of the procedure, in the two study groups (approximately 14 mm Hg, and 5 to 7 mm Hg, respectively); both in a separate analysis and in a comparative analysis no significant difference between them could be confirmed. Heart rate did not change in neither of the two groups. ST-segment >1 mm depression was detected in 10 (17.9%) patients; all these events occurred at least two hours after the end of the dentistry procedure. Premature supraventricular systoles and/or premature ventricular systoles in a greater number than 10/hour were seen in 17 (30.4%) patients in the 24-hours period after the procedure; during the procedure they occurred in 7 (12.5%) patients, of whom 4 (13.8%) were in the group without, and 3 (11.1%) in the group with vasoconstrictor. The Fisher\'s exact test revealed no difference between the groups. We concluded that there was no difference of blood pressure, heart rate, evidence of ischemia or arrhythmia episodes between the groups. Thus, the associated use of vasoconstrictor proved to be safe within the limits of this study

O índice de área hiperbárica (IAH), uma nova metodologia de análise da MAPA, foi relacionado a alterações cardíacas, em especial o índice de massa ventricular esquerda (IMVE). Utilizou-se método baseado em limites pressóricos pré-definidos para os períodos de vigília e sono, considerando-se a área excedente a tais limites durante o exame como o índice hiperbárico. Observou-se relação linear direta e significativa entre IAH e IMVE. Observou-se também maior participação dos IAH de sono, sistólicos e diastólico, em determinar alterações de IMVE / The hyperbaric index area (HIA), a new methodology for ABPM analysis, was tested for its relationship to cardiac alterations, particularly with left ventricular mass index (LVMI). Calculation was based on pre-defined pressure limits for ABPM periods of sleep and activity, considering the exceeding area during the time of exam as the hyperbaric index. It was observed a statistically significant linear relation between HIA and LVMI. It was also observed a greater relation for the sleep HIA, both systolic and diastolic with changes in LVMI

Thesis (MMed (Obstetrics and Gynaecology))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: OBJECTIVE: The aim of this study was to compare the accuracy of non-invasive blood pressure measurements, using automated and manual devices, against invasive intra-arterial blood pressure measurements in patients with pre-eclampsia, during a hypertensive blood pressure peak. STUDY DESIGN: In this prospective study, women admitted to the Obstetrics Critical Care Unit, with confirmed pre-eclampsia and acute severe hypertension, who had an intra-arterial line in situ, were asked to participate. During an intra-arterial blood pressure peak, both an automated oscillometric and a blinded manual aneroid sphygmomanometric blood pressure was recorded. These two methods of blood pressure measurements were compared to intra-arterial blood pressure measurements. The accuracy of a mean arterial pressure (MAP) ≥ 125mmHg in detecting a systolic blood pressure (SBP) ≥ 160mmHg, using all three methods, was also determined. RESULTS: There was poor correlation between intra-arterial SBP and automated and manual SBP (r = 0.34, p < 0.01; r = 0.41, p < 0.01 respectively). The mean differences between automated and manual SBP compared to the intra-arterial SBP was 24 ± 17mmHg (p < 0.01) and 20 ± 15 mmHg (p < 0.01) respectively. There was better correlation between intra-arterial diastolic blood pressure (DBP) and automated and manual DBP (r = 0.61, p < 0.01; r = 0.59, p < 0.01 respectively). The mean differences of the automated and manual DBP was not statistically significant when compared to the intra-arterial DBP. There was poor correlation between the intra-arterial MAP and the automated MAP (r = 0.44, p < 0.01) and good correlation with the manual MAP (r = 0.56, p < 0.01). The mean differences of the automated and manual MAP were statistically significant (5 ± 13mmHg, p < 0.01; 8 ± 11mmHg, p < 0.01 respectively). The sensitivity of automated and manual methods in detecting a SBP ≥ 160mmHg was 23.4% and 37.5% respectively. A MAP ≥ 125mmHg in detecting a SBP ≥ 160mmHg, when using intra-arterial, automated and manual methods of blood pressure measurements showed low sensitivity (35.9%, 21.9% and 17.2% respectively). CONCLUSION: This study demonstrated that both the automated and manual methods of blood pressure measurements were not an accurate measure of the true systolic intra-arterial blood pressure, when managing pre-eclamptic patients with acute severe hypertension. In such situations, intra-arterial blood pressure monitoring should be used when possible. When this is not possible, manual aneroid sphygmomanometry is recommended. Underestimating blood pressure, particularly SBP, may lead to severe maternal morbidity and mortality. / AFRIKAANSE OPSOMMING: DOELWIT: Die doel van hierdie studie is om die akuraatheid van nie invasiewe bloeddruk metings, wanneer geneem met outomatiese en manuele aparate, te vergelyk met intra-arteriele bloed druk metings in pasiente met pre-eklampsie, gedurende ‘n hipertensiewe bloeddruk piek. STUDIE ONTWERP: In hierdie prospektiewe beskrywende dwarssnit studie, was pasiente wat toegelaat was tot die Obstetriese Kritieke Sorg Eenheid met pre-eklampsie, akute erge hipertensie en ‘n intra-arteriele lyn in situ gevra om deel te neem. Gedurende ‘n intra-arteriele erge hipertensiewe piek is beide die outomatiese ossilometriese en die geblinde aneroide sfigmometer lesing neergeskryf. Hierdie twee metodes van non invasiewe bloed druk lesings is vergelyk met intra-arteriele bloed druk lesings. Die akuraatheid van ‘n gemiddelde arteriele bloeddruk ≥ 125mmHg om ‘n sistoliese bloeddruk ≥ 160mmHg op te tel met gebruik van al die drie metodes is ook uitgewerk. RESULTATE: Daar was swak korrelasie tussen intra-arteriele sistoliese bloed druk (SBD) metings en outomatiese en manuele SBD (r = 0.34, p < 0.01; r = 0.41, p < 0.01 onderskeidelik). Die gemiddelde verskille tussen outomatiese en manuele SBD wanneer vergelyk met intra-arteriele SBD was 24 ± 17mmHg (p < 0.01) en 20 ± 15 mmHg (p < 0.01) onderskeidelik. Beter korrelasie was gevind tussen intra-arteriele diastoliese bloed druk (DBD) en outomatiese en manuele DBD (r = 0.61, p < 0.01; r = 0.59, p < 0.01 onderskeidelik). Die gemiddelde verskille tussen outomatiese en manuele DBD wanneer dit vergelyk was met intra-arteriele DBD was nie statisties betekenisvol nie. Daar was swak korrelasie tussen intra arteriele gemiddelde arteriele bloeddruk en outomatiese gemiddelde arteriele bloeddruk (r = 0.44, p < 0.01) en beter korrelasie met manuele gemiddelde arteriele bloeddruk (r = 0.56, p < 0.01). Die gemiddelde verskille van outomatiese en manuele gemiddelde arteriele bloeddruk was betekenisvol (5 ± 13mmHg, p < 0.01; 8 ± 11mmHg, p < 0.01 onderskeidelik). Die sensitiwiteit van outomatiese en manuele metodes om ‘n intra-arteriele SBD ≥ 160mmHg op te tel was 23.4% en 37.5% onderskeidelik. Die vermoë van ‘n gemiddelde arteriele bloeddruk ≥ 125mmHg om ‘n SBD ≥ 160mmHg op te tel, gemeet deur intra-arterieel, outomatiese en manuele metodes het lae sensitiwiteit getoon (35.9%, 21.9% en 17.2% onderskeidelik). GEVOLGTREKKING: Hierdie studie het gedemonstreer dat outomatiese en manuele metodes van bloeddruk meting nie akurate metodes is om ware intra-arteriele sistoliese bloeddruk te meet in pasiente met erge pre-eklampsie tydens ‘n erge hipertensiewe episode nie. In hierdie omstandighede moet intra-arteriele bloeddruk gemeet word indien beskikbaar. Indien dit nie beskikbaar is nie moet die manuele aneroiede sfigmomanometer gebruik word. Onderskatting van bloeddruk, veral sistoliese bloeddruk, kan lei tot erge moederlike morbiditeit en mortaliteit.

Purpose: The purpose of this study was to compare the adverse events that occur with general anesthesia for dental rehabilitation between a hospital setting and dental clinic setting. Methods: A retrospective chart review was performed examining patients who had received dental rehabilitation with general anesthesia at the Virginia Commonwealth University Department of Pediatric Dentistry. Subjects were either treated in the Pediatric Dental Clinic or the Hospital Ambulatory Surgery Center (ASC) from July 2005 to December 2006. Anesthesia records of induction, intubation, maintenance, emergence and recovery were compared between the two settings.Results: There were a total of 422 charts reviewed with n=193 cases in the dental clinic and n=229 cases in the ASC. Patients in the dental clinic setting were slightly older (t = 2.63, df = 420, p-value = 0.0089), and healthier (chi-square = 45.9, df = 2, p-value Conclusion: Overall, the prevalence of adverse events occurring with dental rehabilitation under general anesthesia in the dental clinic setting was lower compared to adverse events in the hospital-based ambulatory surgical setting.

Les travaux de cette thèse sont les fruits de collaboration depuis 2008 entre l’ICL et le Centre Ingénierie et Santé (CIS) de l'Ecole des Mines de Saint Etienne. CIS et ICL sont tous deux membres de l'Institut Fédératif de Recherche en Science, Ingénierie et Santé (IFRESIS) et participent tous deux aux travaux du Cancéropôle Lyon Auvergne Rhône-Alpes (CLARA) dont Franck Chauvin animait l'axe IV sur Epidémiologie, SHS, Information du Patient et Organisation des Soins. Cette thèse a été initiée avec la volonté de développer une recherche originale sur l'optimisation de la production de soins en cancérologie.Nous nous intéressons à différentes problématiques de la gestion de soins des patients dans un hôpital de jour en cancérologie. Nous visons à équilibrer au mieux les besoins journaliers en lits tout en prenant en compte l'adhérence aux protocoles de soins, les contraintes des oncologues et les aléas des flux de patients. Pour un hôpital de jour en oncologie, nous avons identifié et étudié les décisions suivantes : I. Le planning médical une fois par an afin de déterminer les périodes de travail des oncologues dans une semaine. Nous avons proposé une formulation originale sous forme d'un modèle de programmation linéaire en nombres mixtes (MIP) et une approche en 3-étapes. II. L’affectation des nouveaux patients qui détermine le jour de la chimiothérapie pour chaque patient entrant. Nous avons présenté trois stratégies de planification et nous avons décrit un algorithme de simulation pour évaluer ces stratégies de planification. Les stratégies de planification proposées exploitent les informations contenues dans les protocoles de soins des patients et utilisent l’optimisation Monte Carlo III. La planification des rendez-vous. Nous avons présenté deux méthodes pour la résolution de ce problème : une approche basée sur la relaxation Lagrangienne et une heuristique basée sur une optimisation par recherche localeIV. La planification des jours fériés : permet de remédier au problème des semaines comportant des jours fériés. Nous avons développé un modèle en programmation linéaire en nombres mixtes permettant de répartir rapidement la charge du jour férié sur les jours en amont et en aval sans trop dégradé l’efficacité du traitement, ni surcharger le travail de l’HDJ. / This research is performed in close collaboration with the cancer center ICL. The « Institut de Cancérologie de la Loire » (Loire Cancer Institute), a.k.a. ICL, is a French public comprehensive cancer center providing oncology.This thesis addresses the problem of determining the work schedule, called medical planning, of oncologists for chemotherapy of oncology patients at ambulatory care units. A mixed integer programming (MIP) model is proposed for medical planning in order to best balance bed capacity requirements under capacity constraints of key resources such as beds and oncologists. The most salient feature of the MIP model is the explicit modeling of specific features of chemotherapy such as treatment protocols. The medical planning problem is proved to be NP-complete. A three-stage approach is proposed for determining good medical planning in reasonable computational time.

A large number of elective surgical patients in Sweden and elsewhere have their surgical procedure performed in a day surgery context. The surgical care event, with its postoperative surveillance, is brief at the surgery unit and patients are discharged home with the intention that they should manage postoperative recovery mainly themselves. However, several patients attest to being in an exposed situation when assuming responsibility for recovery at home. The overall aim of this thesis was to attain comprehensive knowledge of postoperative recovery following day surgery from a patient perspective. A questionnaire, the Post-discharge Surgical Recovery scale, was translated into Swedish and evaluated regarding its psychometric properties in a Swedish context. A sample of 607 day surgery patients who had undergone orthopaedic, general or gynaecological surgery self-rated their recovery at postoperative Days 1, 7 and 14 using the Post-discharge Surgical Recovery scale and the Quality of Recovery-23. Health-related quality of life was assessed before and 30 days after the surgical procedure, using the EQ-5D. In a second sample, 31 patients were interviewed in their homes regarding their recovery after day surgery. The interviews were conducted on postoperative Days 11-37, and focused on the meaning of recovery, self-care and perceptions of recovery. Data were explored by means of a phenomenographic analysis. The Post-discharge Surgical Recovery scale showed satisfactory psychometric properties when used among Swedish day surgery patients. Following discharge, recovery included both physical and emotional perspectives. Recovery varied, and influencing factors were found to be type of surgery, age, perceived health and emotional status on the first postoperative day. Orthopaedic patients had a more protracted recovery process compared to general surgery and gynaecological patients, along with more postoperative pain and lower health-related quality of life. Patients perceived that postoperative recovery comprised different internal and external factors and a large amount of responsibility regarding their recovery and surgical outcome. To be prepared for recovery at home, patients wanted knowledge and understanding about the normal range of recovery following their specific surgical procedure, and needed support from different sources in their surroundings. This thesis provides insight into day surgery patients’ postoperative situation. Based on the studies, individualized and well thought-out support appears favourable in order to have confident and well prepared patients at home. In contrast to smooth and easy patient care at the surgery unit, the postoperative phase seems to be a weak link in the day surgical continuity of patient care. Postoperative care needs to be further improved to increase quality and patients’ overall satisfaction with the day surgical experience. Attention should be paid to patients’ physical and emotional resources and needs.

O diagnóstico e acompanhamento da hipertensão arterial (HA) no paciente pediátrico dependem da acurácia e da representatividade da medida da pressão arterial (PA). A monitorização ambulatorial da pressão arterial (MAPA), apesar de suas vantagens em relação à medida casual, apresenta custo elevado e pode trazer desconforto ao paciente. A medida residencial da pressão arterial (MRPA), apesar de pouco estudada na criança, apresenta-se como um alternativo potencial à MAPA. Os objetivos deste estudo foram comparar as medidas da PA aferidas no consultório, na MRPA, na Liga de Hipertensão e pela MAPA avaliando o efeito do ambiente/observador e determinando a freqüência de valores compatíveis com HA nessas 4 situações. Este estudo foi transversal,prospectivo e foram incluídos pacientes com HA e PA controlada ou não no consultório. Foram analisadas as médias das pressões arteriais sistólicas e diastólicas. A MRPA foi realizada com aparelho OMRON HEM 705 CP por 14 dias, em dois períodos (manhã ou tarde e noite). Na véspera do início da MRPA, o paciente compareceu à Liga de Hipertensão do HC-FMUSP para colocação do equipamento da MAPA (SPACELABS 90207). Foram analisados os dados de 40 pacientes (14 meninas e 26 meninos), idade média 12,1±3,6 anos. Não houve diferença estatística entre as médias das pressões sistólicas (ANOVA p=0,3100) e diastólicas (ANOVA p=0,7700) no consultório com as médias diurnas da MRPA e nem com as médias sistólicas (ANOVA p=0,8240) e diastólicas(ANOVA p=0,1530) do período noturno da MRPA. As médias das pressões sistólicas e diastólicas da Liga e da MAPA foram maiores do que as médias do consultório e da MRPA (p<0,001), porém não houve diferença estatística entre as médias sistólicas e diastólicas da Liga com a MAPA (p=0,077) e (p=0,962) respectivamente. As médias das pressões diastólicas da MRPA foram menores do que as médias do consultório (p=0,001). Em relação à freqüência de pacientes com PA não controlada, esta foi maior na Liga de Hipertensão (Mc Nemar p<0,005), enquanto as comparações entre consultório MRPA diurna, consultório-MAPA vigília, MRPA diurna- MAPA vigília não foram significantes (Mc Nemar p>0,05). Na MAPA sono, os pacientes apresentaram maior freqüência de PA controlada do que na MRPA noturna. Dez pacientes apresentaram PA não controlada no consultório, a MAPA confirmou o diagnóstico em 7/10 (17,5%) pacientes, enquanto 5/10 (12,5%) confirmaram pela MRPA. Nesse grupo, a hipertensão do avental branco ocorreu em 3/10 (7,5%) pacientes diagnosticados pela MAPA e em 5/10 (12,5%) diagnosticados pela MRPA.Trinta pacientes apresentaram valores de PA controlados no consultório, destes 24/30 (60%) pacientes confirmaram o diagnóstico pela MAPA e 26/30 (65%) pela MRPA. A hipertensão mascarada ocorreu em 6/30 (15%) pacientes diagnosticados pela MAPA e em 4/30 (10%) diagnosticados pela MRPA. Nesse estudo demonstrou-se concordância entre MAPA e MRPA (teste de Mc Nemar p<0,01) com boa reprodutibilidade à avaliação do índice Kappa (0,557). / The diagnosis and monitoring of hypertension in pediatric patients depend on the accuracy and reproducibility of blood pressure (BP) measurement. Ambulatory blood pressure monitoring (ABPM), despite its advantages over office BP, is costly and can cause discomfort to the patient. The blood pressure measured at home (HBP), although poorly studied in children, represents a potential alternative to ABPM. The objectives of this study were to compare BP measurement in four clinical conditions: office BP , casual BP measured at Liga de Hipertensão, HBP and ABPM, evaluate the effect of environment / observer and to determine the frequency of BP values compatible with the diagnosis of hypertension. This study was cross-sectional and prospective and included patients with arterial hypertension with/without properly controlled BP in the office. The means of systolic and diastolic BP were analyzed in the 4 clinical conditions. HBP was measured for 14 days using a validated fully automatic Omron HEM 705 CP device. ABPM was measured with SpaceLabs 90207 non-invasive portable oscilometric device. We analyzed data from 40 patients (14 girls and 26 boys), mean age 12.1 ± 3.6 (SD) years. There was no difference between systolic (ANOVA p = 0.3100) and diastolic (ANOVA p= 0.7700) BP in the office and daytime HBP nor with nightime systolic HBP ( ANOVA p = 0.8240) and diastolic HBP(ANOVA p = 0.1530). The average systolic and diastolic BP at the Liga de Hipertensão and ABPM were higher than office and HB P (p <0001), but there was no difference in the average systolic (p= 0.077) and diastolic (p = 0.962) BP between Liga and ABPM. The diastolic HBP was lower than office diastolic BP (p = 0001). The frequency of BP values compatible with hipertension was higher at the Liga de Hipertensão (Mc Nemar p <0005), while comparisons between officedaytime HBP, office- daytime ABPM and daytime HBP-ABPM were not significant (Mc Nemar p> 0.05). The BP measurements during nightime ABPM showed a higher frequency of values compatible with hypertension than the night HBP one. Ten patients were diagnosed hypertension in the office, ABPM confirmed the diagnosis in 7 / 10 (17.5%) patients, while 5 / 10 (12.5%) were confirmed by HBP. In this group, white-coat hypertension occurred in 3 / 10 (7.5%) patients as diagnosed by the ABPM and 5 / 10 (12.5%) as diagnosed by HBP.Thirty patients presented BP values within normal limits in the office, 24 / 30 (60%) patients confirmed this diagnosis by ABPM and 26/30 (65%) by HBP. Masked hypertension was diagnosed in 6 / 30 (15%) patients diagnosed by the ABPM and in 4 / 30 (10%) by HBP. This study confirmed a correlation between ABPM and HBP measurements (Mc Nemar test p <0.01) with good reproducibility as evaluated by the Kappa index (0.557).