INTRODUÇÃO: O refluxo gastroesofágico (RGE) é a passagem involuntária do conteúdo gástrico para a luz do esôfago. É uma condição comum nos lactentes e crianças menores, sendo, na maioria das vezes, considerado fisiológico, no entanto, pode determinar manifestações clínicas e levar à doença do refluxo gastroesofágico (DRGE). O objetivo deste estudo foi avaliar a ultra-sonografia como meio diagnóstico da DRGE, comparando-a com a pHmetria e histopatologia nos pacientes acima de dois anos de idade. MÉTODO: Foram avaliadas 45 crianças, com idade entre dois e 14 anos, com suspeita clínica de RGE por meio da ultra-sonografia, pHmetria e endoscopia digestiva alta com biópsia. As variáveis estudadas foram a presença do refluxo gastroesofágico, a medida do ângulo de His, o comprimento do esôfago intra-abdominal, o número e tempo de duração do RGE, presença de esofagite e hérnia hiatal. Na análise estatística, calculouse a sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo, com p<0,05. Aplicou-se a regressão logística para estimar o desfecho DRGE e esofagite. RESULTADOS: A ultra-sonografia apresentou sensibilidade de 91,7%, especificidade de 61,9%, valor preditivo positivo de 73,3% e valor preditivo negativo de 86,7% para o diagnóstico da DRGE quando comparada à pHmetria. Na análise univariada o ângulo de His mostrou-se o preditor com melhor especificidade para o desfecho DRGE e esofagite, 71,4% e 72,7%, respectivamente. CONCLUSÃO: A ultrasonografia mostrou-se um exame não invasivo, de baixo custo e preciso na avaliação da junção esofagogástrica, a sua alta sensibilidade e boa especificidade quando comparada à pHmetria, permite o seu emprego na avaliação inicial da criança com suspeita de DRGE / INTRODUCTION: Gastroesophageal reflux (GER) is an involuntary passage of the gastric content to the esophagus. Most of the time, it is considered a physiologic condition as it is very common on breast feeding babies and small children, however, it may determine clinical manifestations and lead to gastroesophageal reflux disease (GERD). The aim of this study was to evaluate ultrasonography as a mean of GERD diagnosis, comparing it with pH monitoring and histopathology in patients older than 2 years of age. METHOD: 45 children aged 2 to 14 years old were evaluated, who had been clinically suspected with GER were submitted to ultrasonography, pH monitoring and upper endoscopy with biopsy. Variables for this study were the presence of gastroesophageal reflux, angle of His measurement, length of intra-abdominal esophagus, time duration and frequency of GER, presence of oesophagitis and hiatus hernia. The statistical analysis measured the sensibility, specificity, positive and negative predictive values considering p<0.05. Logistic regression was applied to estimate GERD outcome and oesophagitis. RESULTS: Ultrasonography results showed sensibility of 91.7%, specificity of 61.9%, and positive predictive value of 73.3% and negative predictive value of 86.7% for the diagnosis of GERD when compared to pH monitoring. In the single variable analysis, the angle of His showed to be the predictor with best specificity for GERD and oesophagitis outcome, 71.4% and 72.7%, respectively. CONCLUSION: Ultrasonography showed to be a harmless exam with low costs and precise in the assessment of the esophagi-gastric junction, and its high sensibility and good specificity when compared to pH monitoring allows it to be performed in the early evaluation of children suspected with GERD

O principal fator de risco para tuberculose (TB) em receptores de transplante de células-tronco hematopoiéticas (TCTH) é viver em regiões de alta endemicidade da doença, uma vez que a imunossupressão favorece a reativação da tuberculose latente (TBL). O diagnóstico da TBL pela prova tuberculínica (PT) tem limitações nos imunocomprometidos e testes de detecção de interferon gama podem ser vantajosos. Os objetivos do presente estudo foram comparar a PT com o QuantiFERON® TB-Gold In-Tube (QFT-GIT) no diagnóstico da TBL e determinar a incidência de TB em duas coortes de pacientes submetidos ao TCTH. Duas coortes foram analisadas prospectivamente. Coorte1: receptores de TCTH incluídos desde o período pré-transplante. Coorte 2: receptores de TCTH com doença do enxerto contra o hospedeiro (DECH) crônica em atividade. A PT e o QFT-GIT foram realizados imediatamente após a inclusão em ambas as coortes. Pacientes na coorte 1 com diagnóstico de TBL receberam profilaxia com isoniazida (INH) por nove meses. Na coorte 2, os pacientes foram acompanhados clinicamente, sem receber profilaxia. TB ativa foi investigada prospectivamente de acordo com definição de caso e por coletas periódicas de escarro. Entre os candidatos ao TCTH, a prevalência de TBL detectada pela PT foi de 4,7% e de 7,1% pelo QFT-GIT. Entre os receptores com DECH crônica a prevalência de TBL detectada pela PT foi de 5,3% e de 12,5% pelo QFT-GIT. A comparação entre as técnicas revelou boa concordância (kappa=0.60). Não houve casos de TB na coorte 1. A incidência cumulativa de TB na coorte 2 foi de 3%. Em comparação com alguns estudos, nossos resultados apresentaram menor prevalência de TB, com menos resultados indeterminados pelo QFT-GIT e melhor concordância entre ambos os testes. É provável que a introdução de profilaxia com INH seja benéfica também para os pacientes com DECH crônica. / The main risk factor for tuberculosis (TB) in hematopoietic stem cell transplant recipients (HSCT) is to live in regions of high endemicity of the disease, since immunosuppression favors the reactivation of latent tuberculosis infection (LTBI). The diagnosis of LTBI by the tuberculin test (TT) has limitations in the immunocompromised hosts and the interferon gamma release assays (IGRAs) may be advantageous. The objectives of the present study were to compare the TT with QuantiFERON® TB-Gold In-Tube (QFT-GIT) in the diagnosis of LTBI and to determine the incidence of TB in two cohorts of patients undergoing HSCT. Two cohorts were analyzed prospectively. Cohort 1: HSCT recipients included since the pre-transplant period. Cohort 2: TCTH recipients with active chronic graft versus host disease (GVHD). TT and QFT-GIT were performed immediately after inclusion in both cohorts. Patients in cohort 1 with diagnosis of LTBI received prophylaxis with isoniazid (INH) for 9 months. In cohort 2, the patients were followed up clinically, without receiving prophylaxis. Active TB was investigated prospectively according to a case definition criteria and periodic sputum sampling. Among the HSCT candidates, the prevalence of LTBI detected by TT was 4.7% and 7.1% by QFT-GIT. Among the recipients with chronic GVHD, the prevalence of LTBI detected by TT was 5.3% and 12.5% by QFT-GIT. The comparison between the techniques showed good agreement (kappa = 0.60). There were no cases of TB in cohort 1. The cumulative incidence of TB in cohort 2 was 3%. Compared with some studies, our results showed a lower prevalence of LTBI, with less indeterminate results by QFT-GIT and better agreement between both tests. It is likely that prophylaxis with INH is also beneficial for patients with chronic GVHD.

INTRODUÇÃO: Vários sistemas de derivações eletrocardiográficas são utilizados na espécie equina e os principais incluem o método de Einthoven, o Ápice-base e o Dubois. O intuito desses sistemas é de captar ondas e complexos de modo que o processo de condução elétrica seja avaliado de maneira eficaz. A disposição dos eletrodos pela metodologia de Dubois tenta posicionar o coração do equino no meio de um triângulo virtual dentro do tórax, assim como descrito por Einthoven, que se baseou no modelo humano. Entretanto, ao se fazer um paralelo com o posicionamento desses eletrodos no ser humano é possível verificar que, apesar da centralização do coração do equino no triangulo virtual, as referências de direita e de esquerda não são respeitadas. Este fato é explicado pela relação entre o ventrículo direito e o ventrículo esquerdo, que nos equinos e outros animais domésticos (na maioria quadrúpedes) se faz no sentido crânio-caudal, enquanto que a posição do coração dentro do tórax do ser humano (bípede) é predominantemente no sentido ântero-súpero-póstero-inferior. OBJETIVOS: O objetivo primário desta tese é o estabelecimento de uma nova e mais adequada metodologia de aquisição eletrocardiográfica para a espécie equina e o objetivo secundário é usar as medidas das variáveis eletrocardiográficas aqui encontradas como valores de referência para essa espécie. MATERIAIS E MÉTODOS: Foram utilizados 22 cavalos da raça Puro Sangue Inglês, sendo 11 fêmeas e 11 machos, com idades variando entre 2 e 5 anos, residentes do Jockey Club de São Paulo, Brasil. Foram realizados 2 eletrocardiogramas sequenciais em cada animal, sendo o primeiro pelo método de Dubois e o segundo de acordo com a nova metodologia aqui instituída, a qual foi nomeada de método Fré. Foi realizado ecocardiograma prévio em todos os equinos e estudo Holter em quatro animais do experimento, os quais foram submetidos à análise de TWA. RESULTADOS: Pelo eletrocardiograma, foi constatado que as derivações esquerdas do plano frontal (DI e aVL) apresentaram complexo QRS de maior duração e amplitude pela nova metodologia e o inverso ocorreu nas derivações inferiores (DII, DIII e aVF), com p < 0,0001. CONCLUSÃO: O método Fré proposto neste estudo mostrou ser mais adequado, quando comparado ao método de Dubois, na obtenção dos fenômenos elétricos cardíacos que ocorrem nos animais da espécie equina. As medidas eletrocardiográficas obtidas pelo método Fré podem ser usados como referência de valores normais para a espécie equina / INTRODUCTION: Many electrocardiographic methods are used for the equine species, among which the most used include Einthoven, Base-apex and Dubois lead systems. They aim to capture waves and complexes to evaluate the process of electric heart conduction in the most effective way. Placement of the electrodes by the Dubois lead system attempts to position the equine heart at the center of a virtual triangle inside the animal\'s thorax, as described by Einthoven, who based his system on the human model. However, in attempting to make a parallel with the positioning of electrodes in the human torso, it is possible to find out that, despite the centralization of the equine heart inside the virtual triangle, the references of right and left are not respected. This can be explained by the relationship between the right and left ventricles, which in the equines and pets (mostly quadrupeds) is done in the cranio-caudal direction, while the position of the heart inside the human thorax (biped) determines that this relationship is predominantly in the anterior-superior-posterior-inferior direction. OBJECTIVES: The primary objective of this thesis is the establishment of a new and most suitable methodology of electrocardiographic acquisition in equines and the secondary objective is the establishment of the electrocardiographic variables thus obtained as reference for this species. MATERIALS AND METHODS: Twenty-two Thoroughbred horses were used, 11 females and 11 males, aged 2 to 5 years old, all reared at the São Paulo Jockey Club, Brazil. Two sequential electrocardiograms were recorded from each animal, the first according to the Dubois lead system and the second according to the new methodology here suggested, which was denominated Fré lead system. All the horses had a previous echocardiogram recorded, in addition to a Holter-ECG obtained from four animals of this experiment, which were subjected to TWA analysis. RESULTS: Through the electrocardiogram it was observed that the values obtained in the left leads of the frontal plane (DI and aVL) showed a larger and taller QRS complex by the new methodology, the reverse happening with the inferior leads such as DII, DIII and aVF, with p < 0,0001. CONCLUSION: The Fré lead system proposed here is more suitable when compared to the Dubois lead system to acquire the cardiac electric phenomena in equines. Electrocardiographic measurements obtained by the Fré lead system can be used as normal reference values for equines

A reação em cadeia por polimerase (PCR) e suas variantes tem sido, desde o isolamento do metapneumovírus humano (hMPV), a técnica mais utilizada para a detecção do vírus em secreções respiratórias de diferentes grupos de pacientes. Entretanto, a interpretação de estudos abordando aspectos epidemiológicos e patogenéticos da infecção pelo hMPV tem sido dificultada pelo uso de uma grande variedade de técnicas de PCR \"in house\" na ausência de uma técnica \"padrão ouro\" claramente definida. A avaliação da sensibilidade, especificidade e reprodutibilidade de qualquer técnica molecular \"in house\" é um passo crucial para podermos comparar estudos realizados por diferentes grupos de pesquisa e diferentes grupos de pacientes. Este estudo teve como objetivos a padronização de duas técnicas de PCR - convencional e em tempo real - para a detecção do hMPV em secreções respiratórias e a avaliação da concordância existente entre as técnicas. Entre 228 amostras de lavado de nasofaringe coletadas de receptores de transplante de células tronco hematopoiéticas com sintomas de infecção respiratória aguda, 10 (4,4%) foram positivas para a presença do hMPV pela técnica de PCR convencional enquanto que 11 (4,8%) foram positivas pela técnica de PCR em tempo real. A concordância entre as técnicas, medida pelo índice Kappa para um intervalo de confiança de 95%, foi de 0,95, ou seja, quase perfeita. / The polymerase chain reaction (PCR) has been, since the isolation of the virus in 2001, the most used technique for detection of human metapneumovirus (hMPV) in respiratory specimens of several groups of patients. However, the interpretation of studies regarding the epidemiology and pathogenesis of hMPV infection has been hindered by the use of a great variety of PCRs techniques for hMPV detection, in the absence of a clearly defined \"gold standard\". The assessment of the sensitivity, specificity and reproducibility of any in-house molecular technique is a crucial step to allow the comparison of studies conducted in different settings and different groups of patients. The aim of the present study was to standardize two in-house PCR assays a conventional PCR and a real-time PCR for detecting hMPV in nasopharyngeal aspirates and to evaluate the agreement between the two assays. Of 228 samples of nasopharyngeal aspirates obtained from hematopoietic stem cell transplant recipients with acute respiratory symptoms, 10 (4.4%) were positive for hMPV by conventional PCR whereas 11 (4.8%) were positive by real-Time PCR. The agreement of both assays, measured by Kappa Index, was almost perfect (0.95, 95% confidence interval).

Introduction – La place des tests de diagnostic rapide (TDR) et des règles de décision cliniques (RDC) pour le diagnostic des pharyngites à streptocoque du groupe A (SGA) chez l’enfant varie selon les recommandations internationales en raison de doutes sur la stabilité des performances diagnostiques du TDR et d’une validation insuffisante des RDC. Méthodes – Dans une étude prospective multicentrique (n=17) ambulatoire réalisée au sein du réseau clinique pédiatrique ACTIV de 2009 à 2011, 1776 enfants avec pharyngite ou sains ont été soumis à des prélèvements de gorge pour réaliser un TDR et une mise en culture (test de référence). Nous avons étudié l’effet indépendant de variables liées aux patients et aux médecins sur les performances diagnostiques du TDR, exploré systématiquement les faux-Positifs (FP) du TDR et réalisé une validation externe et une comparaison des RDC existantes. Résultats – La sensibilité du TDR (en moyenne 87%) variait selon la présentation clinique (âge, signes cliniques), l’inoculum bactérien et le phénomène de portage (paramètres aussi liés entre eux), et selon des variables liées aux médecins (dont le type d’activité clinique). La valeur prédictive négative du TDR était élevée (autour de 90%) et stable. Les FP du TDR étaient positifs pour le SGA en PCR. Aucune RDC n’était satisfaisante en termes de calibration et de discrimination. Conclusion – Le TDR est suffisant pour le diagnostic de pharyngite à SGA si les cliniciens évaluent leurs propres performances et les améliorent si besoin. Aucune RDC ne peut être recommandée en pratique clinique en pédiatrie. / Background – The roles of rapid antigen detection tests (RADT) and clinical prediction rules (CPR) for the diagnosis of group A streptococcus (GAS) in children with pharyngitis vary across international clinical guidelines. This might be related to unstable diagnostic accuracy of RADTs and insufficient validation of CPRs. Methods – In a prospective multicenter (n=17) office-Based study that took place in France within the ACTIV network between 2009 and 2011, 1776 children with pharyngitis or healthy controls underwent throat swabs to perform a RADT and a throat culture (reference standard). We assessed the independent effect of patient- and physician-Level characteristics on the accuracy of a RADT, systematically re-Analyzed RADT false-Positive results, and externally validated and compared existing CPRs. Results – RADT sensitivity (overall 87%) varied according to clinical signs and symptoms, bacterial inoculum size and GAS throat carriage (factors also related to each other), and according to physician-Level characteristics (including type of clinical practice). RADT negative predictive value was high (about 90%) and stable. RADT false-Positives were positive for GAS when using a new PCR technique. No CPR had sufficient performances regarding calibration and discrimination. Conclusions – RADTs are sufficient for diagnosing GAS pharyngitis if clinicians accept diagnostic accuracy monitoring and adequate training when needed. No CPR can be recommended for use in pediatrics.

No description available.

This thesis addresses the three principal questions concerning the development of CT urography for investigating haematuria and each question is the subject of a separate chapter. The questions are: What is the reasoning behind using CT urography? What is the optimum diagnostic strategy using CT urography? What are the problems with using CT urography and how may solutions be provided? Haematuria can signify serious disease such as urinary tract stones, renal cell cancer, upper tract urothelial cancer (UTUC) and bladder cancer (BCa). CT urography is defined as contrast enhanced CT examination of kidneys, ureters and bladder. The technique used here includes unenhanced, nephrographic and excretory-phases for optimized diagnosis of stones, renal masses and urothelial cancer respectively. The reasoning behind using excretory-phase CT urography for investigating haematuria is based on results showing its high diagnostic accuracy for UTUC and BCa. Patients with haematuria are classified as low risk or high risk for UTUC and BCa, by a risk score, determined by the presence/absence of risk factors: age > 50 years, visible or nonvisible haematuria, history of smoking and occupational exposure. The optimum diagnostic strategy for patients at high risk for urothelial cancer, uses CT urography as a replacement test for ultrasonography and intravenous urography and as a triage test for flexible and rigid cystoscopy, resulting in earlier diagnosis and potentially improving prognosis. For patients at low risk, ultrasonography, unenhanced and nephrographic-phase CT urography are proposed as initial imaging tests. Problems with using CT urography include false positive results for UTUC, which are eliminated by retrograde ureteropyelography-guided biopsy, an innovative technique, for histopathological confirmation of diagnosis. Recommendations for the NHS and possible future developments are discussed. CT urography, including excretory-phase imaging, is recommended as the initial diagnostic imaging test before cystoscopy for patients with haematuria at high risk for urothelial cancer.