Objetivos: O objetivo desse estudo foi comparar a perviedade da artéria torácica interna esquerda (ATIE) dissecada por videotoracoscopia robótica para revascularização minimamente invasiva do ramo interventricular anterior (RIA) com a revascularização do miocárdio convencional. Métodos: De 2007 a 2010, 36 pacientes foram randomizados para revascularização do miocárdio minimamente invasiva (RMMI) ou revascularização do miocárdio convencional (RMC). Pacientes randomizados para o grupo RMMI foram submetidos à dissecção da ATIE por videotoracoscopia auxiliada pelo braço robótico AESOP seguida de uma minitoracotomia anterior esquerda no 4º espaço intercostal para anastomose com o RIA. Pacientes randomizados para o grupo RMC foram submetidos a revascularização do miocárdio convencional com esternotomia mediana completa, dissecção aberta da ATIE e anastomose ao RIA. Fluxometria por tempo de trânsito (FTT) foi utilizada para avaliação da perviedade da ATIE imediata. Após 24 meses uma tomografia multislice foi utilizada para avaliar a perviedade a médio prazo da ATIE. Resultados: O tempo médio de dissecção da ATIE no grupo RMMI foi de 50,1 ± 11,2 vs. 22,7 ± 3,3 min no grupo RMC. Não houve diferença significativa no fluxo médio da ATIE para o RIA entre os grupos estudados (46,17 ± 20,11 vs. 48,61 ± 23,42 mL/min, p=0,86) respectivamente. Não houve diferença significante na incidência de infecção de ferida profunda (0 vs. 2, p=0,48) e necessidade de reoperação por sangramento (0 vs. 1, p=1,00) nos grupos RMMI e RMC respectivamente. A angiotomografia mostrou perviedade da ATIE em 100% dos pacientes do grupo RMMI vs. 94,1% no grupo RMC (p=1,00). Não houve mortalidade nos grupos estudados. Conclusão: A revascularização do miocárdio minimamente invasiva do ramo interventricular anterior com dissecção da artéria torácica interna esquerda por videotoracoscopia robótica foi segura e factível. A perviedade da artéria torácica interna esquerda imediata e a médio prazo foi similar entre ambas as técnicas / Objective: The aim of this study was to compare the patency of left internal mammary artery (LIMA) robotically harvested for left anterior descendent (LAD) artery minimally invasive bypass with conventional LIMA to LAD off-pump bypass. Method: From 2007 to 2010, 36 patients were randomized to either LIMA robotically harvested to LAD artery minimally invasive bypass or standard LIMA to LAD off-pump bypass. Patients assigned to robotic group underwent robotic endoscopic harvesting of LIMA with the AESOP system followed by a small left thoracotomy in the 4th intercostal space for off-pump LAD bypass. Patients assigned to standard group underwent full median sternotomy, open LIMA harvesting followed by off-pump LAD bypass. Transit time flow measurement was used for intraoperative evaluation of LIMA to LAD patency. After a mean 24-month follow-up, Multislice Computed Tomography was used to evaluate LIMA to LAD midterm patency. Results: The mean LIMA harvesting time in robotic group was 50.1 ± 11.2 min vs. 22.7 ± 3.3 min in conventional group. There was no significant difference in intraoperative LIMA to LAD flow between robotic and conventional groups (46.17 ± 20.11 mL/min vs. 48.61 ± 23.42 mL/min, p=0.86). There were no significant differences in incidence of wound infection (0 vs. 2, p=0,48) and reoperation for bleeding (0 vs. 1, p=1.00) between robotic and conventional groups respectively. In robotic group, Multislice CT revealed patent LIMA graft in 100% patients vs. 94.1% patients in conventional group (p=1.00). There was no mortality in the study group. Conclusions: Minimally invasive LAD bypass using LIMA graft robotically harvested was safe and feasible. Early and mid-term LIMA patency was similar between both techniques

People often have very little knowledge about the impact of unsustainable human population growth on the environment and social well-being especially in developing countries. Therefore, an efficient method should be explored in order to educate, and if possible, to convince the members of the public to realize the environmental and social problems caused by the unsustainable population growth. Digital Game-Based Learning (DGBL) has been highlighted by some studies as an innovative tool for learning enhancement. While only a handful of studies have scientifically evaluated the impact of DGBL on knowledge outcomes, the approach is an attractive tool to increase knowledge and motivate engagement with environmental issues surrounding population growth because of its potential to improve learners’ motivation and engagement thereby compared to traditional learning approaches. Therefore, the three primary research questions for this study are: 1) "Can a single-player digital game be an appropriate and attractive learning application for the players to gain insight about the relationship between the growing human population and the environmental issues?" 2) "How can we design environmental games for the players to gain insights about the relationship between the growing human population and the environmental issues via playing a game?" and 3) "What are the obstacles preventing the players from adapting environmental knowledge obtained from the learning mediums into the real-life?" To inform the development of an efficacious DGBL game to impact learning outcomes, critical reviews of environmental issues related to population growth as well as critical reviews of commercial and serious environmental games in terms of their educational and motivational values were undertaken in this study. The results of these critical reviews informed the development of a Guideline for Environmental Games (or GEG). The GEG was developed by combining the engaging game technology with environmental learning and persuasion theories. The GEG was then used to inform the development of a prototype game called THE GROWTH; a single-player, quiz-based, city-management game targeting young adolescents and adults. Multiple evaluation methods of the game were used to answer the three key research questions mentioned earlier. These methods included: 1) The Randomized Controlled Trial approach (RCT) where the participants were systematically divided into the experimental and the control group respectively and their knowledge scores (quantitative data) compared and analyzed, 2) The participants’ abilities to recall and describe the environmental and well-being issues were collected and analyzed qualitatively using The Content Analysis method (CA) and, 3) The participants’ overall feedback on the learning mediums was collected and analyzed to evaluate the motivational values of THE GROWTH itself. To this end, THE GROWTH was evaluated with 82 Thai-nationality participants (70 males and 12 females). The results showed that participants assigned to play THE GROWTH demonstrated greater environmental and social-well-being knowledge related to population growth (F(1,40) = 43.86, p = .006) compared to the control group participants assigned to a non-interactive reading activity (consistent with material presented in THE GROWTH). Furthermore, participants who played THE GROWTH recalled on average more content presented in the game when compared to participants who were presented with similar content in the reading material (t (59) = 3.35, p = .001). In terms of level of engagement, the study suggested that participants assigned to the game were more engaging with their learning medium on average when compared to participants assigned to the non-interactive reading activity. This is evidenced by the longer time participants spent on the task, the activity observed from participants’ recorded gameplay, and their positive responses in the survey. The semi-structured interviews used in this study highlighted the participants’ attitudes towards the environmental, social, and technological issues. Although the participants’ perceived behavioural intention towards the environmental commitments were not statistically differed between the two study group, their responses still provide some evidences that leaps may occur from the learning mediums to the real-world context. Furthermore, these responses can be valuable evidences for the policy makers and for the future development of environmental serious games. Overall, the results suggested that digital environmental games such as THE GROWTH might be an effective and motivational tool in promote the learning about sustainable population size, the environment, and the social well-being. The game’s ability to convince the participants to change towards sustainable lifestyles, however, might be subjected to the future research and other real-world circumstances such as the governmental and public supports. In summary, the research in this thesis makes the following contributions to knowledge: • The Guideline for Environmental Games (GEG) contributes to knowledge about making theoretically-based environmental games. It has particular significance because the guideline was validated by demonstrating learning improvements in a systematic randomized controlled trial. • The use of Multi-Strategy Study Design where multiple systematic evaluation methods were used in conjunction to provide conclusive findings about the efficacy of DGBL to impact outcomes. • THE GROWTH itself is a contribution to applied research as an example of an effective DGBL learning tool.

Este estudo mostra como o rolamento do pé de pacientes com polineuropatia diabética pode ser melhorado com exercícios para pés e tornozelos, visando a recuperação muscular e articular comprometidos pela doença. Um ensaio clínico randomizado, paralelo, com um braço de crossover, e avaliador cego, foi conduzido. Cinquenta e cinco pacientes com polineuropatia diabética foram randomizados e alocados para o grupo controle (n=29) e grupo intervenção (n=26). A intervenção foi aplicada por 12 semanas, 2 vezes por semana, por 40 a 60 minutos cada sessão. As variáveis primárias foram definidas como as que descrevem o rolamento do pé: pressão plantar em seis regiões plantares de interesse. As variáveis secundárias foram a cinética e cinemática de tornozelo no plano sagital, e as medidas clínicas da função de pés e tornozelo (teste de função muscular manual, testes funcionais), de sinais e sintomas da polineuropatia diabética, exame físico dos pés e teste de confiança e equilíbrio em atividades da marcha. Os efeitos de tempo (baseline e 12 semanas), de grupo (controle e intervenção) e de interação foram calculados por meio de ANOVAs casewise 2 fatores, e para as comparações intragrupo do grupo intervenção (baseline, 12 semanas e 24 semanas) foram usadas ANOVAs para medidas repetidas. As variáveis não paramétricas foram comparadas entre grupos por meio de testes de Mann-Whitney e entre os tempos de intervenção por meio do teste de Wilcoxon. Adotou-se um ? de 5% para diferenças estatísticas e o coeficiente d de Cohen para descrição do tamanho do efeito da intervenção. Após 12 semanas de exercícios, observou-se mudanças positivas no rolamento do pé. Houve uma suavização do contato do calcanhar no apoio inicial, refletido pelo aumento do tempo do pico de pressão e da integral do pico de pressão. O médio-pé aumentou sua participação no rolamento observado pela diminuição da velocidade média do deslocamento do centro de pressão e aumento da integral do pico de pressão. O antepé lateral passou a realizar o apoio no solo antecipadamente em relação ao antepé medial, que previamente à intervenção aconteciam concomitantemente, e esse resultado foi evidenciado pela antecipação do tempo do pico de pressão em antepé lateral após a intervenção. A ação de hálux e dedos também aumentou (aumento de integral do pico de pressão e picos de pressão), em uma patologia marcada pela diminuição do contato do hálux e desenvolvimento de dedos em garra, que diminui o contato dos dedos com o solo. O grupo controle apresentou algumas pioras com relação à função muscular e parâmetros cinéticos e cinemáticos de tornozelo, enquanto que o grupo intervenção mostrou melhora na função de muitos grupos musculares, em testes funcionais e no pico de momento extensor na fase de aplainamento do pé. Apesar do protocolo de intervenção ter sido construído de modo a permitir que o paciente incorpore os exercícios na sua rotina diária, a aderência a este tipo de intervenção deve ser estudada, já que grande parte das variáveis retornaram ao baseline após o período de follow up. Ações preventivas são fundamentais para diminuir as complicações devastadoras da neuropatia diabética / This study shows how the foot rollover process during gait of patients with diabetic polyneuropathy can be improved with exercises for foot and ankle, aiming at the recovery of the muscles and joints affected by the disease. A clinical trial randomized, parallel, one arm of crossover, with blind assessment was conducted. Fifty-five patients with diabetic polineuropathy were randomly allocated to the control group (n = 29) and intervention group (n = 26). The intervention was applied for 12 weeks, twice a week, for 40 to 60 minutes per session. The primary variables were defined as those that describe the foot rollover: plantar pressure in 6 plantar areas of interest. The secondary variables were kinetic and kinematics of the ankle in the sagittal plane were calculated, and the clinical measures of foot and ankle function (manual muscle function testing, functional testing), signs and symptoms of diabetic polyneuropathy, physical examination of the feet and balance and confidence test in gait activities. The time effects (baseline and 12 weeks), group effects (control and intervention groups) and interaction effects were calculated using casewise two factos ANOVAs, and for intragroup comparisons of intervention group (baseline, 12 weeks and 24 weeks) it was used ANOVAs for repeated measures. The nonparametric variables were compared between groups using Mann-Whitney tests and between periods of assessment using Wilcoxon test. We adopted an ? of 5% for statistical differences and the Cohen\'s d coefficient for description of the effect size. After 12 weeks ofexercises, there were positive changes in the foot rollover process. There was a softening of heel contact in initial contact, reflected by the increase in time to peak pressure and the pressure time integral. The midfoot increased its participation observed by the decrease in speed of displacement of the center of pressure and increased pressure time integral. The lateral forefoot contact was earlier relative to the medial forefoot, that occurred at the same time before intervention, observed by the early time to peak pressure of lateral forefoot after the intervention. The participation of the hallux and toes also increased (increase of pressure time integral and peak pressure), in a pathology that is marked by decreased contact of the hallux and development of claw toes, which reduces contact of the toes with the ground. CG showed some worsening in relation to muscle function and kinematic and kinetic parameters of the ankle, while the IG showed improvement in the function of many muscles groups, functional tests and peak extensor moment during the forefoot contact. The intervention protocol was constructed to allow the patient to incorporate exercise into their daily routine, but adherence to treatment should be studied and motivational strategies need to be applied, since most of the variables returned to baseline after the follow up period (12 weeks after the intervention). Preventive actions are critical to reducing the devastating complications of diabetic neuropathy

INTRODUÇÃO: A Moléstia de Dupuytren (MD) é uma doença crônica progressiva fibroproliferativa caracterizada por contraturas em flexão dos dedos. A origem deste processo está na proliferação de miofibroblastos e na síntese de matriz extracelular. Diversas técnicas já foram descritas no tratamento da MD. A falta de uma técnica capaz de associar altas taxas de sucesso com baixos índices de complicações e recidivas estimulou a procura por novas técnicas. Acredita-se que a propriedade totipotente das células-tronco presentes no tecido adiposo seria capaz de atuar na proliferação e na diferenciação dos fibroblastos em miofibroblastos, interrompendo a formação da fibrose e consequentemente a progressão da deformidade dos dedos. OBJETIVO: O objetivo primário deste estudo foi avaliar o efeito do enxerto de gordura, rico em células-tronco, nos pacientes com MD, submetidos a fasciectomia parcial aberta, por meio de avaliação funcional e goniométrica, e comparar com a técnica convencional (sem adição de enxerto de gordura). MÉTODO: Dois grupos totalizando 45 pacientes (24 pacientes no Grupo Controle e 21 no Grupo com gordura) foram operados pela técnica da fasciectomia parcial aberta. No Grupo controle era realizada apenas a fasciectomia parcial aberta. No Grupo com gordura, era realizada a fasciectomia parcial aberta e injetado, no local da corda ressecada, o enxerto de gordura, após o processamento do lipoaspirado de adipócitos proposto por Coleman (2006). O estudo foi prospectivo, randomizado e terapêutico. Os desfechos foram avaliados pela medida goniométrica do Déficit de Extensão Passiva Total (DEPT) e pelo escore funcional Brief Michigan Hand Questionnaire (BMHQ). As avaliações eram feitas no pré-operatório, com 6 semanas, 6 meses, 1 ano e 2 anos de seguimento. RESULTADOS: Na comparação com 6 semanas de pós-operatório, houve um aumento significativo da dor no Grupo com Gordura [mediana 2 ± 2,82 versus 0 ± 1,86 no grupo Controle (p=0,045)]. Os resultados do DEPT, não mostraram diferença significativa entre os grupos. Observamos piores resultados do escore funcional BMHQ com 6 meses e 1 ano de pós-operatório no Grupo com gordura (p=0,040 e p=0,047, respectivamente). Observamos ainda 9 casos (43%) de complicações no Grupo com gordura e 2 (8%) no Grupo Controle (p=0,019). CONCLUSÃO: O uso do enxerto de gordura associado à fasciectomia parcial aberta promoveu piores resultados funcionais comparado com a fasciectomia parcial aberta convencional, no curto prazo (um ano de seguimento pós-operatório). No entanto, resta a dúvida de qual seriam os resultados a longo prazo e, se as células-tronco, presentes no enxerto de gordura, poderiam interferir na recidiva da doença futuramente / BACKGROUND: Dupuytren\'s disease (DD) is a progressive chronic fibroproliferative disease characterized by flexion contractures of the fingers. The origin of this process is the proliferation of myofibroblasts and extra-cellular matrix synthesis. Several techniques have been described to treat the DD. The lack of a technique capable to associate high success rates with low rates of complications and recurrence stimulated the search for new techniques. It is believed that the totipotent property of the adipose-derived stem cells present in the processed lipoaspirate tissue would be able to inhibit the proliferation and differentiation of fibroblasts in myofibroblasts, interrupting the formation of fibrosis and consequently the progression of finger deformity. The primary objective of this study was to evaluate the effect of adipose-derived stem cells in patients with DD who underwent to open limited fasciectomy and compare with the conventional technique of limited fasciectomy. METHODS: A total of 45 patients were assigned in two groups in a single blind, prospective, randomized, controlled trial. All the patients were treated by the limited fasciectomy technique. In the control group (24 patients), only limited fasciectomy was performed. In the study group (21 patients), after the limited fasciectomy procedure, autologous lipoaspirate was injected at the site of the resected cord. Outcomes were assessed by the Total Passive Extension Deficit (TPED) and by the Brief Michigan Hand Questionnaire (BMHQ) functional score. The evaluations were performed by occupational therapists in the preoperative and at 6 weeks, 6 months, 1 year and 2 years. RESULTS: The study group presented higher rates of pain at 6 weeks postoperative (median 2 ± 2,82 versus 0 ± 1,86 on control group, p=0,045). TPED showed no significant differences between groups. BMHQ score, at 6 months and 1 year after surgery, were significantly inferior in the study group (p=0,040 e p=0,047, respectively). Patients in the study group had higher incidence of complications (9 patients, 43% versus 2, 8% in the control group, p=0,019). CONCLUSIONS: The autologous lipoaspirate associated to limited fasciectomy demonstrates inferior results regarding to functional score and pain compared to conventional limited fasciectomy, in short-term. Further long-term analysis is required to observe the effect of adipose-derived stem cells in the recurrences rates

Objetivos: Comparar os efeitos de um mês de tratamento com aparelho de pressão aérea positiva (CPAP) e com placebo sobre a aparência e características objetivas da pele da face de pacientes com apneia obstrutiva do sono (AOS), num estudo randomizado e cruzado. Métodos: Foram incluídos pacientes consecutivos com AOS grave e sonolentos. Os pacientes realizaram três polissonografias (PSG): a primeira para confirmação da AOS e outras duas adicionais com uso de placebo (dilatador nasal) e para titulação de CPAP, antes do início de cada tratamento. Todos os pacientes foram aleatoriamente alocados em dois grupos de tratamento: 1) uso do placebo e 2) uso do CPAP. Após um mês com o primeiro tratamento e 15 dias de washout, houve cruzamento para o segundo tratamento. A face dos pacientes foi fotografada de modo padronizado nos três momentos experimentais. As fotografias foram apresentadas, em ordem aleatória, pelo Qualtrics Survey Software, e avaliadas on-line por 704 observadores para quantificação da aparência saudável (nada saudável até extremamente saudável), atraente (nada atraente até extremamente atraente) e cansada (nada cansada até extremamente cansada). A idade aparente também foi perguntada para cada observador. Foram realizadas avaliações quantitativas das características da pele da face dos pacientes, em cada momento experimental, incluindo a presença de acne, manchas, porosidade, rugas, textura, e uniformidade do tom da pele, por meio da captação de imagens pelo equipamento VISIATM System. Resultados: Foram avaliados 30 pacientes (idade=46±9 anos; 21 homens). Os pacientes utilizaram o placebo em 98% das noites do período de tratamento e a adesão ao CPAP foi de 94% das noites, com média de 6,0 ± 1,7 horas de uso por dia de tratamento. Após o tratamento com CPAP, em comparação ao momento basal e após tratamento placebo, foi observada melhora na qualidade objetiva do sono, sonolência, qualidade de vida e sintomas depressivos (P < 0,05). A avaliação das fotografias pelos observadores mostrou que os pacientes foram identificados como mais jovens após o uso de CPAP (P < 0,001), mas não foram observadas alterações quantitativas das características da pele da face, em comparação com o momento basal e após o uso de placebo. A análise de regressão linear identificou que a quantidade de dias de tratamento com CPAP, o tempo total de sono e a porcentagem do tempo total de sono com saturação de oxihemoglobina abaixo de 90% foram preditores da diminuição da idade atribuída após o uso de CPAP. Conclusão: Os pacientes com AOS graves e sonolentos apresentaram aparência mais jovem após um mês de tratamento com CPAP / Objectives: To compare the effects of one month with continuous positive airway pressure (CPAP) treatment and placebo intervention on the appearance and objective facial skin characteristics of patients with obstructive sleep apnea (OSA) in a randomized crossover study. Methods: Consecutive sleepy patients with severe OSA were included. The patients underwent three polysomnograms (PSG): first one to confirm OSA and two additional ones using placebo (nasal dilator) and for CPAP titration before starting each treatment period. All patients were randomly included into two treatment groups: 1) placebo use and 2) CPAP use. After one month with the first treatment and 15 days of washout, patients were crossed-over for the second treatment. Photographs from the patients\' faces were obtained in the three experimental moments. The photographs were presented in a random order by the Qualtrics Survey Software, and were evaluated online by 704 observers for quantifying healthy appearance (unhealthy to extremely healthy), attractive (unattractive to extremely attractive) and tired (not tired to extremely tired). Apparent age was also rated for each observer. Quantitative evaluations of the skin characteristics of the patients\' faces were also carried out at each experimental moment, including the presence of acne, patches, porosity, wrinkles, texture, and skin tone uniformity, through the capture of images by VISIATM System equipment. Results: 30 patients (age = 46±9 years, 21 men) were evaluated. During treatment period, the patients wearing placebo intervention on 98% of the nights and adherence to CPAP was 94%, with a mean of 6.0 ± 1.7 hours of use per day of treatment. After CPAP treatment, compared to baseline and after placebo treatment, improvement in the objective sleep quality, sleepiness, quality of life and depressive symptoms were observed (P <0.05). Observational assessment of the photographs showed that patients were evaluated as being younger after using CPAP (P < 0.001), but no quantitative changes in face skin characteristics were observed compared to the baseline and after the use of placebo. Linear regression analysis identified the number of days with CPAP treatment, total sleep time and percentage of total sleep time with oxyhemoglobin saturation below 90% were predictors of decreasing of rated age after CPAP treatment. Conclusion: Sleepy patients with severe OSA had a younger appearance after one month of CPAP treatment

<p>Uvod: Infertilitet pogađa 10-15% parova reproduktivnog doba. Vanetesna oplodnja (VTO) je najefikasniji vid tret-mana infertiliteta, ali uprkos značajnom napretku stopa uspeha VTO u proseku iznosi oko 30% po ciklusu. Glavnim razlogom neuspeha smatra se neadekvatan kvalitet embriona, dok se pretpostavlja da u 10-20% slučajeva razlog neuspeha leži u neadekvatnoj receptivnosti uterusa. Na osnovu inicijalnih istraživanja histeroskopija, koja predstvalja zlatni standard u dijagnostici i tretmanu patologije kavuma uterusa, se često izvodi u svakodnevnoj kliničkoj praksi kako bi se povećala uspe&scaron;nost VTO. Uprkos &scaron;irokoj primeni i dalje ne postoji dovoljno kvalitetnih dokaza o realnoj ulozi histeroskopije na ishod VTO kako kod patolo&scaron;kih stanja kavuma tako i rutinski, pre prvog ili rekurentnog poku&scaron;aja VTO. Cilj disertacije bio je da se utvrdi uticaj sprovođenja histeroskopije na ishod VTO, ustanovi učestalost prethodno neprepoznate patologije kavuma uterusa, kao i da se ispitaju stavovi pacijenata o primeni rutinske histeroskopije pred VTO. Materijal i metode: Istraživanje je sprovedeno u Kliničkom centru Vojvodine, u formi prospektivne studije u dve sukcesivne etape od 01.01.2015. do 01.04.2017. U prvoj etapi poređen je ishod VTO kod pacijentkinja kojima pred postupak VTO nije sprovedena histeroskopija (Grupa A), pacijentkinja kod kojih je dobijen uredan nalaz histeroskopije pred postupak VTO (Grupa B) i pacijentkinja gde je pred postupak VTO dobijen patolo&scaron;ki nalaz kavuma na histeroskopiji koji je u istom aktu tertian (Grupa C). Druga etapa istraživanja predstavljala je randomiziranu kontrolisanu studiju (RCT &ndash; randomised controlled trial). Nakon verifikacije urednog ultrazvučnog nalaza pred prvi postupak VTO, pacijentkinje su randomizirane u Grupu A2 kojima pred postupak VTO nije sprovedena histeroskopija i Grupu B2 kojima je pred postupak VTO sprovedena rutinska histeroskopija. Statistička analiza sprovedena je upotrebom odgovarajućeg softvera (JMP Ver. 9). Poređeni su podaci o osnovnim karakteristikama pacijenata, toka i ishoda ciklusa VTO. Primarni parametar ishoda bila je stopa kliničke trudnoće po embriotransferu. Pored analize ishoda primarno konstruisanih grupa, urađena je analiza i naknadno konstruisanih subgrupa, kao i predikcioni model uspeha VTO baziran na logističkoj regresiji. Rezultati: Studija je uključila 253 pacijentkinje (52 pacijentkinja iz Grupe A, 50 iz Grupe B, 50 iz Grupe C, 51 iz Grupe A2 i 50 iz Grupe B2). Nije postojala statistički značajna razlika u karakteristikama pacijentkinja, parametrima ovarijalne rezerve, broju dobijenih jajnih ćelija ni drugim parametrima toka postupka VTO među posmatranim grupama. U prvoj etapi istraživanja dobijena je statistički značajno (p=0,013) veća stopa kliničkih trudnoća kod pacijentkinja kojima je pred postupak VTO sprovedena histeroskopija - 50 % za Grupu B i 42% za grupu C u odnosu na 30,77% kod pacijentkinja bez histeroskopije (Grupa A), bez statistički značajne razlike među histeroskopskim grupama. U drugoj etapi istraživanja stopa kliničkih trudnoća prilikom upotrebe rutinske histeroskopije pred prvu VTO (Grupa B2) iznosila je 46% naspram 31,37% kod pacijentkinja bez histeroskopije pred prvu VTO (Grupa A2), iako uočena razlika nije dostigla statističku značajnost (p =0,089), uz relativan rizik (RR) za ostvarivanje kliničke trudnoće nakon primene histeoskopije uiznosio od 1,47 (95% CI 0,88-2,43) (p=0,13). Analizon subgrupa kod 100 pacijentkinja sa rutinski sprovedenom histeroskopijom pred VTO i 103 pacijentkinje bez histeroskopije pred VTO, dobijena je statistički značajnao veća stopa kliničkih trudnoća (48% naspram 31,07%, istim redom), uz RR od 1,54 (95% CI 1,08-2,20) (p=0,013), kao i stopa tekućih trudnoća od RR 1,49 (CI 1,01-2,19) (p= 0,039). Analiza ukupnog uticaja izvođenja histeroskopije pred VTO dobila je statistički značanjno veću stopu kliničkih trudnoća po ET za grupu histeroskopije uz RR 1,48 (CI 1,06-2,07) (p=0,017). Histeroskopijom je nakon urednog ultrazvučnog nalaza ustanovljeno postojanje patolo&scaron;kog nalaza kod 34,65% pacijenata i to 22,7% major patologije i 11,88% minor patologije kavuma. Nije postojala statistički značajna razlika u uspehu VTO u odnosu na sam nalaz histeroskopije. 98,67% pacijenata podržalo je rutinsku upotrebu histeroskopije pred prvi postupak VTO, dok je 83% pacijenata podržavlo rutinsku upotrebu histeroskopije pred svaki postupak VTO. U finalnom predikcionom modelu se uz AUC od 0,748 jedino postojanje visokokvalitetnog embriona uz odnos &scaron;ansi (OR) 7,91 (95% CI 1,80-56,06; p=0,0047), transfer blastociste uz OR 3,80 (95% CI 1,90-7,98; p=0,0001) i izvođenje histeroskopije pred VTO uz OR 2,13 (95% CI 1,14-4,08, p=0,0169) pokazalo statistički značajnim prediktorima trudnoće. Diskusija: Studija je dobila pozitivan uticaj histeroskopije na ishod postupka VTO, iskazan pre svega povećanjem stope kliničkih trudnoća nakon sprovođenja histeroskopije (bilo da je na histeroskopiji nađen uredan ili patolo&scaron;ki nalaz). Dodatna prednost histeroskopije predstavljala je i i detekcija prethodno nepropoznate patologije kavuma. Umeren efekat na ukupno pobolj&scaron;anje stope kliničkih trudnoća prilikom rutinskog sprovođenja histeroskopije pred prvu VTO, koji je statističku značajnost dostigao tek analizom subgrupa u skladu je sa nalazima novijih dobro dizajniranih studija koji donekle limitiraju nekritičku upotrebu histeroskopije. Biolo&scaron;ko obja&scaron;njenje potencijalnog pozitivnog uticaja histeroskopije najverovatnije leži u detekciji i tretmanu prethodno nepropoznate patologije kavuma, olak&scaron;avanju procedure embriotransfera, kao i humoralnim i molekularnim promenama koje nastaju u endometrijumu kao posledica odgovarajuće histeroskopske traume a koji su u dosa&scaron;anjim istraživanjima apostrofirani kao faktori koji mogu povećati receptivnost uterusa. Zaključak: Histeroskopija je efikasna, bezbedna i visoko prihvatljiva procedura koja dovodi do povećanja uspeha VTO u standardnim kliničkim indikacijama (prethodnog neuspelog postupka VTO i sumnje na patolo&scaron;ki nalaz kavuma uterusa) bilo da se na samoj histeroskopiji nađe uredan ili patolo&scaron;ki nalaz. Rutinska primena histeroskopije pred prvi postupak VTO se na osnovu rezultata studije ne može smatrati apsolutno opravdanom usled statistički nedovoljno značajnog povećanja stope kliničke trudnoće. Uzev&scaron;i u obzir visoku prihvatljivost od strane pacijenata i najverovatniji pozitivan efekat na stopu trudnoće primena rutinske histeroskopije pred prvu VTO bila bi opravdana ukoliko se implementira koncept ambulantne histeroskopije.</p> / <p>Introduction: Infertility affects 10-15% of all couples. In vitro fertilisation (IVF) is the most effective method of infertility treatment, but despite a significant improvement, success rate of IVF is still around 30% per cycle. The main reason for the IVF failure is inadequate embryo quality, but in 10-20% of cases the cause of IVF failure lies in impaired uterine receptivity. Based on earlier studies hysteroscopy, gold standard in the diagnosis and treatment of uterine cavity pathology, is often performed to increase IVF success. Despite its wide use, there is lack of high quality evidence regarding real contribution of hysteroscopy on IVF outcome in situations of uterine cavity pathology or routinely prior to first IVF or after recurrent implantation failure. The aim of this dissertation was to determine the influence of performing hysteroscopy on IVF outcome, as well as the incidence of previously unrecognized uterine pathology, and to examine patient&#39;s attitudes about performing routine hysteroscopy prior to IVF. Material and methods: The research was conducted in a prospective manner in two successive stages at Clinical Center of Vojvodina from 01.01.2015. until 01.04.2017. During first stage of the study IVF outcome was compared between patients who did not have a hysteroscopy prior to IVF (group A), patients with normal hysteroscopic finding prior to the IVF (Group B) and patients with abnormal hysteroscopic findings prior to IVF which was treated at the same time (Group C). The second stage of the study was a randomized controlled trial (RCT). After verification of normal ultrasound findings prior to the first IVF, patients were randomized to group A2 in who me hysteroscopy was not performed and group B2 who had routine hysteroscopy prior to first IVF. Statistical analysis was carried out using the appropriate statistical software (JMP Ver. 9). Patient characteristics, course and outcome of IVF cycle were compared between groups. The primary outcome was clinical pregnancy rate (CPR) per embryotransfer. In addition to analyzing the IVF outcomes in primarily defined groups, subgroup analysis was also performed, as well as IVF success pre-diction model based on logistic regression. Results: The study included 253 patients (52 patients in Group A, 50 in Group B, 50 in Group C, 51 in Group A2 and 50 in Group B2). There was no statistically significant difference in patient characteristics, ovarian reserve parameters, number of retrieved oocytes, or other relevant parameters of IVF course between the observed groups. In the first stage of the study there was statistically significant (p = 0.013) higher clinical pregnancy rate in patients who had a hysteroscopy before IVF - 50% for Group B and 42% for group C versus 30,77 % in patients without hysteroscopy before IVF (Group A), without statistically significant difference between hysteroscopic groups. In the second stage of the study, routine hysteroscopy prior to first IVF (Group B2) led to clinical pregnancy rate 46% versus 31.37% in patients without hysteroscopy prior to first IVF (Group A2), although without statistical significance (p = 0.089. Relative risk (RR) for achieving clinical pregnancy after performing hysteroscopy was 1.47 (95% CI 0.88-2.43) (p = 0.13). Subgroup analysis of 100 patients with routinely performed hysteroscopy before IVF and 103 patients without hysteroscopy prior to the IVF showed statistically significant higher rates of clinical pregnancies (48% versus 31.07%, in the same order), with RR of 1.54 (95% CI 1.08-2.20), (p = 0.013), and for ongoing pregnancies RR was 1.49 (95% CI 1.01-2.19) (p = 0.039). Overall effect of performing hysteroscopy prior to IVF resulted in a statistically significant increase in the clinical pregnancy with RR 1.48 (95% CI 1.06-2.07) (p = 0.017). After normal ultrasound finding hysteroscopy revealed 34.65% of pathological finding, 22.7% of major and 11.88% of minor pathology of the cavity). There was no statistically significant difference in IVF outcome based on hysteroscopy findings. 98.67% of patients supported the routine use of hysteroscopy before the first IVF procedure, while 83% of patients supported the routine use of the hysteroscopy before every IVF procedure. In the final prediction model, with the AUC of 0.748, only the presence of high quality embryos with odds ratio (OR) 7,91 (95% CI 1,80-56,06; p=0,0047), blastocyst transfer with OR 3,80 (95% CI 1,90-7,98; p=0,0001) and performing hysteroscopy prior to IVF with OR 2,13 (95% CI 1,14-4,08, p=0,0169) proved to be statistically significant predictors of pregnancy. Discussion: The study shoved a positive influence of hysteroscopy on the IVF outcome by increasing clinical pregnancy rate after performing hysteroscopy (whether hysteroscopy revealed normal or pathological finding). Additional benefit of hysteroscopy was detection of previously unrecognized uterine pathology. A moderate effect on the overall improvement in clinical pregnancy rate with use of routine hysteroscopy, which reached statistical significance only by subgroup analysis, is in line with findings of recent well designed studies that somewhat limit the noncritical use of hysteroscopy. A biological explanation of the potential positive effect of hysteroscopy is most likely due to detection and treatment of the previously unrecognized uterine pathology, facilitating embryotransfer procedure, as well as the humoral and molecular changes that occur in the endometrium as a consequence of the hysteroscopic trauma. Those changes were hypothesized as factors that can increase uterine receptivity by numerous research. Conclusion: Hysteroscopy is an effective, safe and highly acceptable procedure that increases IVF success when performed for accepted clinical indications (previous IVF failures, pathological findings of uterine cavity), whether hysteroscopy reveals normal or pathological finding. The routine use of hysteroscopy prior to first IVF based on this study can not be considered justified since increase in clinical pregnancy rate did not reach statistical significance. Given the high acceptance of this concept by the patients and moderate but probable positive effect on IVF outcome, implementation of routine hysteroscopy prior to first VTO would be justified only in office hysteroscopy setting.</p>

L’anémie est fréquente chez les patients pédiatriques en postopératoire de chirurgie cardiaque. Malgré le nombre important de patients transfusés, le taux d’hémoglobine (Hb) pour lequel les bénéfices surpassent les risques est inconnu chez ces patients. Récemment, Lacroix et al. ont démontré qu’une stratégie transfusionnelle restrictive n’était pas inférieure à une stratégie libérale en ce qui concerne le développement ou la progression du syndrome de défaillance multiviscérale (SDMV) et la mortalité chez les patients de soins intensifs pédiatriques (SIP).Devant le manque d’évidence, une analyse de sous-groupes des patients en postopératoire de chirurgie cardiaque de l’étude Transfusion Requirements in Pediatric Intensive Care (TRIPICU) a été réalisée. L’objectif de cette étude était de déterminer l’impact d’une stratégie transfusionnelle restrictive comparée à une stratégie libérale sur l’acquisition ou l’aggravation du syndrome de défaillance multiviscérale (SDMV) chez les enfants en postopératoire de chirurgie cardiaque. Cette étude n’a pas démontré de différences statistiquement, ni cliniquement significatives du nombre de patients ayant acquis ou aggravés un SDMV, ni des issues secondaires entre les stratégies transfusionnelles restrictive et libérale. L’analyse de sous-groupes permet de générer une hypothèse de recherche et les résultats devraient être confirmés par un essai randomisé contrôlé. / Anemia is frequent in pediatric patients following cardiac surgery. Despite frequent transfusions, the optimal hemoglobin threshold where benefits surpass risks is still unknown for these patients. Recently, Lacroix et al. showed that a restrictive transfusion strategy was not inferior to a liberal strategy concerning the development or progression of multiple organ dysfunction syndrome (MODS) and mortality in pediatric intensive care patients. In the absence of evidence, the aim of this study was to determine the impact of a restrictive versus a liberal transfusion strategy on new or progressive multiple organ dysfunction syndrome (MODS) in children following cardiac surgery. We conducted a subgroup analysis of the postoperative cardiac surgery patients of the Transfusion Requirements in Pediatric Intensive Care Unit (TRIPICU) study. Our study showed no statistically and clinically significant differences in the number of patients who acquired or worsened MODS, nor secondary outcomes between a restrictive and a liberal transfusion strategy. This subgroup analysis generates a research hypothesis that should be confirmed by a randomized controlled trial.

Le traitement antihypertenseur (TAH) réduit le risque cardiovasculaire (RCV). Son efficacité est établie à partir de nombreux essais et méta-analyses conduits sur différentes populations. L’effet du TAH suit en moyenne un modèle multiplicatif différent d’une classe médicamenteuse à l’autre et non constant dans le temps. Pour progresser vers une prescription personnalisée du TAH, nous avons suivi 3 objectifs: 1) La modélisation statistique de l’effet du TAH sur le risque d’accidents vasculaires cérébraux (AVC) et d’infarctus (IDM) dans différents sous-groupes de patients, selon le temps et la classe médicamenteuse. 2) La méta-analyse de l’effet du TAH sur le risque d’AVC, d’IDM et de mortalité après 80 ans, situation de prescription fréquente. 3) La mise en place, conduite et coordination de l’essai clinique IDEAL, randomisé en plan croisé et double insu dont l’objectif est d’étudier l’influence des caractéristiques individuelles sur la réponse pressionnelle à 2 classes de TAH. Les 2 premiers travaux ont été réalisés sur la base INDANA, méta-analyse sur données individuelles des essais évaluant le TAH contre placebo. Ils suggèrent sans être définitivement convaincants que la réduction du bénéfice au cours du temps sur le risque d’infarctus est plus nette chez la femme et sous bêtabloquants. Chez les patients très âgés le TAH reste efficace pour réduire le RCV, mais notre analyse de l’absence de réduction de la mortalité nous conduit à recommander d’éviter toute intensification du TAH à cet âge. L’essai IDEAL a inclus 124 patients chez lesquels la régression à la moyenne et l’évolution sous placebo expliquent une baisse de pression de même ordre que le TAH. / Antihypertensive treatment (AHT) reduces cardiovascular risk (CVR). Its efficacy is well established from numerous clinical trials and meta-analysis conducted in several populations. The AHT effect follows on average a multiplicative model. This model is different from one drug class to another, and is not constant during follow-up.In order to progress towards a personalized prescription of AHT, we followed 3 objectives: 1) The statistical modelling of AHT effect on stroke (ST) and myocardial infarction (MI) in different sub-groups of patients,depending on time of follow-up and first line drug class. 2) The meta-analysis of AHT effect on the risk of stroke,MI and total mortality in patients ages 80 years and older in whom AHT is frequently prescribed. 3) The set-up,conduct and coordination of the IDEAL study, a cross-over randomized double blind clinical trial in order to assess the influence of individual characteristics on blood pressure (BP) response to two AHT drug classes. The first two analyses were performed on the INDANA database, an individual patient data meta-analysis from trials that evaluated the effect of AHT against placebo. These analyses suggest that the decreased benefit of AHT over timeon MI prevention was mostly apparent in women and with first line beta-blocker. Treatment remained efficient invery old patients in reducing CVR, but the lack of mortality reduction led us not to recommend AHT intensificationin this age group. The IDEAL study included 124 patients for which the regression to the mean and the evolution under placebo phenomena explained a BP reduction similar to the one under AHT.

No description available.

Introdução. A intervenção coronária percutânea (ICP) é um dos tratamentos para pacientes com doença arterial coronária (DAC). Essa intervenção deve ser acompanhada de outras medidas terapêuticas com o intuito de reduzir as incapacidades e o risco de novos eventos coronários; de controlar a progressão da doença; e de melhorar a qualidade de vida. Essas medidas compreendem a prevenção secundária da DAC e estão, principalmente, relacionadas às mudanças no estilo de vida para o manejo de fatores de risco para DAC. O contato por telefone tem sido utilizado por profissionais da área da saúde para o seguimento do paciente e da família no cuidado com diversas condições crônicas, incluindo a DAC. Objetivo. Desenvolver, implementar e avaliar um programa educativo com seguimento por telefone, durante o período de quatro meses após a alta hospitalar, para pacientes submetidos à ICP com o objetivo de melhorar o estado de saúde percebido, a autoeficácia, a adesão aos medicamentos e o estado emocional desses pacientes, bem como comparar desfechos do Programa Educativo com os de serviços de rotina hospitalar. Método. Ensaio clínico controlado e aleatorizado, realizado no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto. A amostra deste estudo foi constituída pelos pacientes submetidos à primeira ICP, entre agosto de 2011 e junho de 2012. Os participantes foram aleatorizados para o Programa Educativo com Seguimento por Telefone (grupo intervenção [GI]: 30 participantes) ou cuidado conforme a rotina da instituição (grupo controle [GC]: 30 participantes). O referencial teórico que fundamentou o Programa Educativo aplicado neste estudo foi o construto de autoeficácia, presente na Teoria Social Cognitiva de Albert Bandura. O desfecho principal foi o estado de saúde percebido, avaliado pelo Medical Outcomes Survey 36- Item Short Form (SF-36), e os desfechos secundários foram a autoeficácia avaliada pela Escala de Autoeficácia Geral Percebida, a adesão aos medicamentos por meio do instrumento Medida de Adesão aos Tratamentos (MAT) e o estado emocional (ansiedade e depressão) avaliado pela Escala Hospitalar de Ansiedade e Depressão (HADS). Os desfechos foram avaliados antes do procedimento (T0) e seis meses após a ICP (T1). A análise foi por análise descritiva, análise de variância para medidas repetidas, teste de Qui-quadrado e risco relativo com intervalo de confiança de 95%. O nível de significância foi de 0,05. Este ensaio clínico foi registrado sob o número NCT01341093. Resultados. Na avaliação do estado de saúde percebido, com um nível de significância de 0,05, nenhuma interação (tempo e grupo) ou grupo foi estaticamente significante, mas houve interação entre tempo e grupo com valores de nível de significância entre 0,05 e 0,10 no Sumário do Componente Mental (p=0,08) e no domínio Aspectos Emocionais (p=0,07) e melhora no domínio Aspectos Sociais no GI (p=0,10). Na avaliação da autoeficácia, não houve diferenças entre os grupos ou tempos. Houve alta percentagem de participantes que relataram adesão aos medicamentos nos tempos T0 e T1, nos dois grupos (mais de 90% inicial e no seguimento). Na avaliação da ansiedade, seis meses após a ICP, houve aumento de não-caso de ansiedade no GI e diminuição no GC, e a associação entre as variáveis foi estatisticamente significante (p=0,04). Ao final do seguimento, o risco relativo do GI de ser não-caso de ansiedade foi de 1,6 (intervalo de confiança [IC] de 95%=1,0 a 2,4) quando comparado com o GC. Em relação à depressão, não houve evidência de diferenças no percentual de pacientes não- caso de depressão entre os grupos (GI e GC), tanto na internação como no seguimento. Ao final do seguimento, o risco relativo do GI de ser não-caso de depressão foi de 0,8 (intervalo de confiança [IC] de 95%=0,6 a 1,1), quando comparado com o GC. Conclusão. O Programa Educativo com Seguimento por Telefone é uma intervenção promissora para melhorar o estado de saúde percebido e para reduzir a ansiedade de pacientes submetidos à ICP. Pode ser necessário aperfeiçoar a intervenção para que haja efeitos na autoeficácia e na depressão. Os instrumentos para medidas de autoeficácia e de adesão aos medicamentos precisam ser melhorados / Introduction. Percutaneous coronary intervention (PCI) is one of the treatments available for coronary artery disease (CAD) patients. This intervention should be accompanied by other therapeutic interventions with the aim of reducing disabilities and the risk of new coronary events, controlling the progression of the disease, and improving the quality of life. These interventions comprise the secondary prevention of CAD and are mainly related to lifestyle changes, aiming to manage risk factors for CAD. Health professionals have used telephone follow-up to monitor patients and families in the delivery of care to different chronic conditions, including CAD. Objective. To develop, to implement and to assess an educational program with telephone follow-up, during four months after hospital discharge, for patients submitted to PCI, with the aim of improving the perceived health status, self-efficacy, medication adherence and emotional status of these patients, as well as to compare outcomes of the Educational Program with routine hospital services. Method. Randomized controlled clinical trial, developed at the Ribeirão Preto Medical School Hospital das Clínicas, Brazil. The study sample included patients who had been submitted to their first PCI between August 2011 and June 2012. The participants were randomly assigned to the Educational Program with Telephone Follow-up (intervention group [IG]: 30 participants) and routine care (control group [CG]: 30 participants). The theoretical framework that supported the Educational Program applied in this study was the self-efficacy construct in Albert Bandura\'s Social Cognitive Theory. The main outcome was the perceived health status, assessed using the Medical Outcomes Survey 36- Item Short Form (SF-36); and the secondary outcomes were self-efficacy, assessed using the Perceived General Self-Efficacy Scale; medication adherence, assessed using the Medida de Adesão ao Tratamento (MAT); and the emotional status (anxiety and depression), assessed using the Hospital Anxiety and Depression Scale (HADS). The outcomes were evaluated before the procedure (T0) and six months after the PCI (T1). Descriptive analysis was applied, as well as variance analysis for repeated measures, the chi-square test and relative risk, with the confidence interval set at 95%. Significance was set at 0.05. This clinical trial was registered under number NCT01341093. Results. In the assessment of the perceived health status, with significance set at 0.05, no interaction (time and group) or group was statistically significant, but interaction between time and group was verified, with significance levels ranging between 0.05 and 0.10 in the Mental Component Summary (p=0.08) and in the Emotional Aspects domain (p=0.07); as well as improvement in the Social Aspects domain for the IG (p=0.10). In the assessment of self-efficacy, no differences were found between the groups or times. Many participants indicated medication adherence at T0 and T1 in the two groups (more than 90% initially and during the follow-up). In the assessment of anxiety levels six months after the PCI, the number of non-cases of anxiety increased in IG and dropped in CG, with a statistically significant association between the variables (p=0.04). At the end of the monitoring, the relative risk of being a non-case of anxiety in IG corresponded to 1.6 (95% confidence interval [CI]=1.0 - 2.4) when compared to CG. As regards depression, no evidence was found of differences in the percentage of patients non-case of depression between the groups (IG and CG), neither during hospitalization nor during follow-up. At the end of the follow-up, the relative risk of IG being a non-case of depression corresponded to 0.8 (95% confidence interval [CI]= 0.6 - 1.1) when compared to CG. Conclusion. The Educational Program with Telephone Follow-up is a promising intervention to improve the perceived health status and reduce the anxiety of patients submitted to PCI. The intervention may need further development to influence self-efficacy and depression. Self-efficacy and medication adherence instruments need improvements