Abstract Gastric erosions are superficial mucosal breaks. With the exception of bleeding, they are considered harmless, but their aetiology, histopathology and long-term course have remained unknown and even the evolution of gastritis in patients with gastric erosions is unclear. The present study aimed to solve clinical significance and pathology of gastric erosions in a long-term follow-up study. Initially, 117 patients and 117 controls were studied in 1974–1981, and a follow-up study was performed in 1996. We evaluated the presence of Helicobacter pylori and Herpes simplex virus (HSV) infections, use of NSAIDs and alcohol, smoking, and assessed features of gastric histopathology. For follow-up, 52 patients and 66 controls were available. In the follow-up visit, 39% patients still had gastric erosions while 11% of the controls had developed erosions (p = 0.001). In H. pylori-positive subjects, peptic ulcer or a scar was more common in patients (17%) than in controls (4%, p = 0.006), but otherwise no increased morbidity or mortality was seen. High antibody titres against HSV predicted the persistence of erosions (p = 0.000), but H. pylori infection, use of NSAIDs, alcohol or smoking were not associated. Initially, inflammation was more active in the region of erosions than elsewhere in the antral mucosa, and more active inflammation in the erosion was associated with HSV seropositivity, H. pylori infection and the recent use of NSAIDs. Initially, H. pylori-positive subjects with chronic or recurrent erosions had higher scores of neutrophils compared to those with non-chronic/non-recurrent erosions. In H. pylori-positive subjects, body gastritis was initially less active in the patient group. With time, antral gastritis worsened only in the patient group. In H. pylori-negative subjects, there was no evolution of gastritis. These results show that a significant proportion of gastric erosions are chronic/recurrent but mostly without serious complications. However, H. pylori-positive patients have a significant risk to develop a peptic ulcer. A significant proportion of chronic gastric erosions is related to HSV infection. Focally enhanced inflammation modified by HSV or NSAID may be important in the pathogenesis of gastric antral erosions. Active inflammation in the erosions seems to predict their chronicity/recurrency. Patients with erosions share the characteristics of gastritis of the duodenal ulcer phenotype. / Tiivistelmä Eroosiot ovat mahalaukun pinnallisia limakalvovaurioita. Niitä pidetään vaarattomina lukuun ottamatta niihin liittyvää verenvuototaipumusta. Niiden etiologiaa, histopatologiaa ja taudinkulkua ei tunneta. Ei myöskään tiedetä eroosiopotilaiden mahan limakalvon tulehduksen kulkua. Tämän tutkimuksen tavoitteena oli selvittää mahalaukun eroosioiden kliininen merkitys ja patologia pitkäkestoisena seurantatutkimuksena. Alkujaan 117 potilasta ja 117 kontrollihenkilöä tutkittiin vuosina 1974–1981, ja seurantatutkimus tehtiin vuonna 1996. Selvitimme helikobakteerin ja Herpes simplex -viruksen (HSV) aiheuttamien infektioiden, tulehduskipulääkkeiden (NSAID) ja alkoholin käytön, sekä tupakoinnin esiintymistä. Lisäksi tutkimme histopatologisesti mahalaukun limakalvoa. Lopulta oli 52 potilaan ja 66 kontrollihenkilön aineisto käytettävissä. Seurantakäynnillä 39 prosentilla potilaista oli yhä mahalaukun eroosioita, kun taas kontrolliryhmästä vain 11 prosentilla oli kehittynyt eroosioita. Helikobakteeri -infektoituneilla maha- tai pohjukaissuolen haava/arpi oli yleisempää eroosioryhmässä (17 %) kuin kontrolleilla (4 %), mutta muuten ei esiintynyt lisääntynyttä sairastuvuutta tai kuolleisuutta. Tulehdus oli aktiivisempaa eroosioissa kuin viereisellä limakalvolla, ja tämä tulehdus liittyi korkeisiin HSV-vasta-ainetasoihin, helikobakteeri-infektioon ja NSAID:n käyttöön. Korkeat HSV-vasta-ainetasot ennustivat eroosioiden pysyvyyttä. Ensimmäisellä käynnillä aktiivinen tulehdus eroosioissa oli voimakkaampaa niillä helikobakteeri-infektoituneilla, joilla eroosiot olivat pysyviä kuin niillä, joilla eroosiot eivät uusineet. Helikobakteeri-infektoituneilla eroosiopotilailla mahalaukun runko-osan limakalvon tulehdus oli aluksi vähemmän aktiivista kuin vastaavilla kontrolliryhmän henkilöillä, mutta ajan myötä mahalaukun corpusosan limakalvon tulehdus voimistui vain eroosioryhmällä. Limakalvotulehdus ei edennyt helikobakteeri-infektoitumattomilla henkilöillä. Tulokset osoittavat, että merkittävä osa mahalaukun eroosioista on kroonisia/toistuvia, mutta enimmäkseen ilman vakavia komplikaatioita. Kuitenkin helikobakteeri-infektoituneilla eroosiopotilailla on merkittävä riski saada maha- tai pohjakaissuolen haava. HSV- infektio liittyy merkittävään osaan kroonisia mahalaukun eroosioita. Paikallisella tulehdusaktiivisuudella, jota HSV ja NSAID:n käyttö muokkaavat, saattaa olla tärkeä rooli eroosioiden synnyssä ja niiden kroonistumisessa. Eroosiopotilailla on samanlainen mahalaukun limakalvon tulehduksen jakauma kuin pohjakaissuolihaavaa sairastavilla.

Abstract In the Nordic countries, event-free survival (EFS) exceeds 80% in certain groups of children treated for acute lymphoblastic leukaemia (ALL). With the improved cure rates, however, there are more children suffering from neurological late effects, especially due to therapy directed at the central nervous system (CNS). The aim of this study is to examine the changes taking place in the nervous system after leukemia treatment and to evaluate the role of treatment in these changes in patients and in an animal model. Twenty-seven ALL survivors and healthy controls were examined by means of motor evoked potentials (MEPs). ALL survivors were also examined clinically. The children with ALL continued to show decreased motor nerve conduction in the peripheral nerves, but not within the CNS, five years after the cessation of treatment. Clinical neurological findings were obtained in 33% of the cases. The MEP results indicated reversibility of the motor injury due to CNS effects. Nineteen patients underwent perfusion magnetic resonance imaging (MRI) at the cessation of treatment or 4-8 years after the treatment. Seventeen of them also underwent single-photon emission computed tomography (SPECT). The studies showed small perfusion defects in SPECT, which were not visible by perfusion MRI. Methotrexate (Mtx) neurotoxicity was studied in a swine model using functional MRI, brain perfusion SPECT, iodine-123 labelled 2β-carbomethoxy-3β-(4-iodophenyl) tropane ([123I]β-CIT) SPECT and whole-hemisphere autoradiography with [125I]β-CIT in ten Mtx-treated animals and five control animals. Mtx-related changes in the brain could be detected as reduced or negative blood-oxygen-level-dependent (BOLD) responses to somatosensory activation in BOLD contrast MRI, which indicates changes in flow metabolism coupling. Perfusion defects in brain SPECT were seen in the Mtx group and the control group, which suggests that the perfusion defects seen in brain SPECT are probably multifactorial. The change in dopamine transporter (DAT) density in the Mtx group was not different from that in the controls. The abnormalities in nerve conduction after treatment in survivors of ALL were partly reversible years after the treatment. The patients had perfusion defects in SPECT imaging which were not seen in perfusion MRI. The clinical significance of these defects remains obscure. The animal model suggested perfusion defects to be multifactorial.

<p>We followed up with about 2,000 smallholder households in Senegal, two years after these households participated in a randomized controlled trial (RCT) aimed at reducing levels of aflatoxins in smallholders’ stored maize. In the initial intervention, treated households were provided with training on proper post-harvest practices, low-cost moisture meters for testing if maize was sufficiently dry to store, plastic tarps for drying maize of the ground, and hermetic (airtight) storage bags to mitigate aflatoxin development in stored maize. Using cross-sectional follow up data on aflatoxins levels and drying and storage practices from 2019 along with baseline demographic data from 2016, we estimate both the longer-term intention-to-treat (ITT) effects and the treatment on the treated (TOT) effects that the four inputs provided on households’ aflatoxins levels in stored maize. The ITT analyses estimate the intervention’s average effect by treatment group, but this may underestimate the true impact for households who complied with recommended post-harvest practices and adopted the recommended technologies. The TOT analyses estimate the local average treatment effects (LATE) of the intervention, that is its impacts on those who were driven by the intervention to follow best practices or use a given technology. Since the decision to follow these practices or adopt a technology was not random, we instrumented the usage decision with the exogenous, random treatment group assignment to get an unbiased estimate. Outside of our main models, we conducted a heterogeneity analysis to test if households with different characteristics benefit differently from the intervention. We interacted each treatment assignment with various household characteristics, including the woman’s level of involvement in the intervention. Additionally, we estimate the cost-effectiveness of providing training and a tarp, according to WHO guidelines for public health interventions. </p>

Abstract Cardiovascular diseases are the leading cause of death in developed countries. Approximately 50% of these events are due to sudden cardiac death (SCD) and often without preceding diagnosis of cardiac disease. Many risk factors for cardiac events have been identified and prevention strategies have improved markedly. The aim of this thesis was to evaluate the usability of the 12-lead electrocardiogram (ECG) to predict cardiac events. The study population consisted of 10,904 middle-aged general population subjects with ECG recordings between the years 1966–1972 with a long follow-up (30&#177;11 years). The first part of the thesis (I) focused on the prevalence and prognostic significance of fragmented QRS complex (fQRS). The prevalence of fQRS was 19.7%. Fragmented QRS complex did not predict mortality in subjects with no history of cardiac disease. Among subjects with underlying cardiac disease and lateral fQRS, the risk of cardiac death was 2.5-fold (P=0.001) and the risk of SCD was almost 3-fold (P=0.004). Other major electrocardiographic abnormalities were assessed in subjects without known cardiac disease for the risk of cardiac death, SCD and hospitalization due to coronary artery disease (II, III). Abnormal ECG was moderately associated with cardiac death after 10 and 30 years of follow-up (hazard ratio 1.7, P=0.009; hazard ratio 1.3, P&#62;0.001, respectively) (II). The risk of hospitalization was not associated with abnormal ECG findings. Abnormal ECG moderately predicted SCD during 10 and 30 years of follow-up (hazard ratio 1.6, P=0.052; hazard ratio 1.3, P=0.007) (III). The risk of SCD was 3-fold when &#8805;2 ECG abnormalities were present. In conclusion, lateral fQRS in middle-aged subjects with underlying cardiac disease was associated with increased risk of death. Certain abnormal ECG findings associated with the risk of non-arrhythmic cardiac mortality and arrhythmic death. The risk of arrhythmic mortality was substantially elevated when multiple ECG abnormalities were present in middle-aged population. / Tiivistelmä Sydänsairaudet ovat yleisin kuolinsyy kehittyneissä maissa. Noin 50 % näistä kuolemista aiheutuu äkillisestä sydänpysähdyksestä, suuri osa ilman aiempaa tietoa sairaudesta. Useita sydänsairauksien riskitekijöitä on tunnistettu ja ennaltaehkäisy on kehittynyt merkittävästi. Väitöstutkimuksen tavoitteena on tutkia 12-kytkentäisen sydänsähkökäyrän (EKG) käyttökelpoisuutta sydänsairauksien ilmenemisen ennustamisessa. Tutkimusväestöön kuului 10,904 keski-ikäistä suomalaista henkilöä. Aineisto kerättiin vuosina 1966-1972 ja seuranta-aika oli 30 (&#177;11) vuotta. Ensimmäisessä osajulkaisussa (I) tutkimme QRS-kompleksin fragmentaation vallitsevuutta ja sen vaikutusta ennusteeseen väestössä. Fragmentoituneen QRS-kompleksin esiintyvyys oli 19.7 %. Fragmentoitunut QRS-kompleksi ei lisännyt kuolemanriskiä henkilöillä, joilla ei ollut sydänsairautta. Henkilöillä, joilla oli todettu sydänsairaus, lateraalinen fQRS lisäsi sydänperäistä kuolleisuutta 2.5-kertaiseksi (P=0.001) ja rytmihäiriöperäistä kuolleisuutta 3-kertaiseksi (P=0.004). Tutkimme muiden poikkeavien EKG-löydösten ennustearvoa kuolleisuuteen ja sairaalahoidon tarpeeseen sepelvaltimokohtauksen vuoksi (II, III). Poikkeavien EKG-muutosten esiintymiseen liittyi lisääntyneen sydänperäisen kuoleman riski sekä 10 vuoden (riskitiheyssuhde 1.7, P=0.009) että 30 vuoden seurannassa (riskitiheyssuhde 1.3, P&#62;0.001) (II). Poikkeavat EKG-muutokset eivät ennustaneet sairaalahoitojaksoja. Poikkeava EKG ennusti rytmihäiriöperäisen kuoleman riskiä sekä 10 vuoden (riskitiheyssuhde 1.6, P=0.052) että 30 vuoden seurannassa (riskitiheyssuhde 1.3, P=0.007) (III). Äkkikuoleman riski oli 3-kertainen henkilöillä, joilla todettiin &#8805; 2 EKG-poikkeavuutta. Tutkimuksen yhteenvetona voidaan todeta, että fQRS lateraalisissa kytkennöissä lisäsi sydänperäisen kuoleman riskiä henkilöillä, joilla on todettu sydänsairaus. Tiettyihin poikkeaviin EKG-muutoksiin liittyi lisääntynyt ei-rytmihäiriöperäisen ja rytmihäiriöperäisen kuoleman riski. Useiden tutkittujen EKG-muutosten ilmentyminen samanaikaisesti lisäsi merkittävästi rytmihäiriöperäisen kuoleman riskiä keski-ikäisessä väestössä.

Degaardt, M & Rubensson, M. Postoperativt förlopp efter dagkirurgiskljumskbråcksoperation. Uppföljningssamtal som grund för kvalitetsutveckling.Examensarbete i omvårdnad 15 högskolepoäng. Malmö högskola: Hälsa ochsamhälle, Utbildningsområde omvårdnad, 2010.Syftet med denna studie var att göra en bedömning av den postoperativa förloppeti hemmet hos dagkirurgiska ljumskbråcksopererade patienter. Data insamlademed hjälp av högstrukturerade telefonintervjuer. En enkät med standardiseradefrågor och ikryssbara svarsalternativ som kommer har använts vidtelefonintervjuerna. Resultaten från de 52 intervjuerna visade att de flestapatienter inte överskred Numerical Rating Scale (NRS) 3 i vila eller rörelse dagett. På dag tre hade de flesta mer smärta vid rörelse än dag ett. De flestapatienterna följde ordinationen de fick av läkaren avseende smärtstillandetabletter. Generellt sett visade studien på få postoperativa komplikationer och högtillfredsställelse ur operationssynpunkt hos patienterna. / Degaardt, M. & Rubensson, M. Post-operative progress after one-day surgicalinguinal hernia operation. Follow-up interviews as a means for qualitydevelopment. Degree project in nursing, 15 credit points. Malmö University:Faculty of health and society, Department of nursing, 2010.The purpose of this study was to evaluate the post-operative progress for one-daysurgical inguinal hernia patients. Data was collected using structured telephoneinterviews three days after surgery. A questionnaire with standardized questionsand multiple-choice response opions was used. The results from the 52 interviewsshowed that most patients did not exceed Numerical Rating Scale (NRS) 3 dayone when at rest or moving around. On day three most patients had more painwhile moving than day 1. Most patients complied with the doctor’s prescription ofpainkillers. Generally the follow-up study showed the patients had fewcomplications and felt high satisfaction post surgery.

Yes / Payment incentives are known to influence healthcare but little is known about the impact of paying directly for achieved outcomes. In England, novel purchasing (commissioning) of National Health Service (NHS) stop smoking services, which paid providers for quits achieved whilst encouraging new market entrants, was implemented in eight localities (primary care trusts (PCTs)) in April 2010. This study examines the impact of the novel commissioning on these services. Accredited providers were paid standard tariffs for each smoker who was supported to quit for four and 12 weeks. A cluster-controlled study design was used with the eight intervention PCTs (representing 2,138,947 adult population) matched with a control group of all other (n=64) PCTs with similar demographics which did not implement the novel commissioning arrangements. The primary outcome measure was changes in quits at four weeks between April 2009 and March 2013. A secondary outcome measure was the number of new market entrants within the group of the largest two providers at PCT-level. The number of four-week quits per 1,000 adult population increased per year on average by 9.6% in the intervention PCTs compared to a decrease of 1.1% in the control PCTs (incident rate ratio 1108, p<0001, 95% CI 1059 to 1160). Eighty-five providers held 'any qualified provider' contracts for stop smoking services across the eight intervention PCTs in 2011/12, and 84% of the four-week quits were accounted for by the largest two providers at PCT-level. Three of these 10 providers were new market entrants. To the extent that the intervention incentivized providers to overstate quits in order to increase income, caution is appropriate when considering the findings. Novel commissioning to incentivize achievement of specific clinical outcomes and attract new service providers can increase the effectiveness and supply of NHS stop smoking services.

OBJETIVOS: Avaliar os efeitos da rubéola durante a gestação, sobre o feto, o recém-nascido e a criança. CASUÍSTICA E MÉTODO: Analisamos 35 gestantes com suspeita de rubéola que foram divididas em dois grupos. Grupo 1: 15 pacientes que apresentaram quadro clínico com comprovação sorológica. Grupo2: 20 pacientes com IgM positiva na rotina pré-natal, na ausência de quadro clínico. O seguimento ultrasonográfico mensal foi realizado em todas as pacientes e as do grupo 1 foram encaminhadas também para propedêutica invasiva. Foram também realizadas a ecocardiografia fetal e a Dopplervelocimetria. As placentas foram submetidas a exame anátomo-patológico. Os recém-nascidos vivos foram avaliados através de exame clínico e sorológico, além do potencial evocado auditivo, ultra-sonografia de crânio, fundo de olho e ecocardiografia pós-natal. RESULTADOS: No grupo 1: a infecção fetal ocorreu em 9 casos, sendo que o risco de transmissão vertical entre 2 a 14 semanas foi de 64,9%. A malformação ocorreu em 37,5% dos infectados. A ultrasonografia revelou crescimento intra-uterino retardado simétrico em todos os fetos infectados que atingiram o terceiro trimestre, tendo se iniciado, em média com 25,1 semanas. A cordocentese foi realizada em 9 pacientes e, todos os casos infectados, apresentavam IgM positiva e eritroblastose no sangue de cordão. A PCR no líquido amniótico foi positiva em todos os 3 casos em que ela foi realizada. 50% das placentas dos fetos infectados apresentava sinais sugestivos de infecção viral. A idade gestacional média do parto entre os infectados foi de 33,8 semanas e o peso médio ao nascimento foi 1365,6g.Todos os 6 nascidos-vivos infectados foram classificados como pequenos para a idade gestacional e apresentaram disacusia. A sobrevida entre os infectados, num seguimento pós-natal médio de 35,2 meses, foi de 62,5%. No grupo 2: a infecção não foi comprovada em nenhum dos recém-nascidos vivos, porém em um caso pudemos demonstrar a infecção congênita pelo vírus de Epstein-Barr. CONCLUSÕES: A transmissão vertical da rubéola no primeiro trimestre parece poder variar entre as populações, bem como a presença dos defeitos associados à infecção. Tanto o diagnóstico invasivo, como o ultrasonográfico apresentaram boa sensibilidade e especificidade. Pudemos estabelecer o padrão de crescimento fetal associado à infecção. A presença isolada de IgM positiva para rubéola na gestação não teve boa correlação com a presença de infecção neonatal, porém pode se associar à presença de outras infecções congênitas. / OBJECTIVES: Our aim was to analyse rubella effects on the fetus, new-born and child. MATERIAL AND METHODS: We analysed 35 patients with suspicious rubella during pregnancy. According to presence or absence of symptoms they were divided in two groups. Group 1: 15 patients presenting rash in which serology was positive. Grupo2: 20 symptomless patients found to have positive IgM during routine prenatal care. Monthly ultrasonographic evaluation was accomplished in all patients and in group 1 they were also offered prenatal invasive testing. Fetal echocardiography and Dopplers were performed. After birth, the placentas were submitted to pathological examination. The liveborn babies had clinical and serological examination. Auditory tests, brain scan, fundoscopy and postnatal echocardiography were also performed. RESULTS: In group 1: fetal infection occurred in 9 cases and vertical transmission between 2 to 14 weeks was 64,9%. Malformation was present in 37,5% of infected cases. Ultrasound revealed symmetrical intra-uterine growth retardation in all infected fetuses that reached the third trimester, and started around 25,1 weeks. Cordocentesis was accomplished in 9 cases and all the infected ones, presented positive IgM and erythroblastosis in cord blood. PCR in the amniotic fluid was positive in all 3 cases it was performed. 50% of the infected fetuses placentas presented signs of viral infection. The average gestacional age of delivery among infected cases was 33,8 weeks and medium birth weight was 1365,6g. All 6 liveborn infected babies were small for gestacional age and presented deafness. Survival among infected cases was 62,5%, medium follow-up was 35,2 months. In group 2: the infection was not demonstrated in any of neonates, although we could demonstrate a congenital infection caused by the Epstein-Barr virus. CONCLUSIONS: Vertical transmission of the rubella in the first trimester seems to vary among different populations, as well as the presence of the associated defects in the new-born. Invasive diagnosis and ultrasonographic follow-up presented good sensitivity and specificity. We could establish the pattern of fetal grown associated to the infection. The isolated presence of a positive rubella IgM in pregnancy did not correlated with congenital rubella, but it can be related to other congenital infections.

Vinte e seis pacientes com cardiomiopatia hipertrófica e fatores de risco de morte súbita, foram submetidos a implante de cardioversor-desfibrilador implantável de dupla-câmara, com seguimento médio de 19 meses. Observou-se quatro choques em arritmias letais, 4 pacientes apresentaram TVNS e 5 taquiarritmias supraventriculares. Ocorreu um óbito.Conclusões: Observamos: TPSV em 19,2%; TVNS em 15,4% e TVS/FV em 15,4%. Nenhuma variável clínica ou demográfica, discriminou o comportamento clínico ou funcional pós-implante de CDI; a recorrência de síncope pós implante de CDI, não se associou à presença de eventos arrítmicos e a hipertrofia maior que 30 mm se associou à choque precoce do CDI (p=0,003). / During 19 months of average follow-up period, we followed 26 patients with hypertrophic cardiomyopathy and high risk for sudden death, all treated by dual chamber implantable cardioverter-defibrillator. 4 patients had received appropriate ICD discharge, 4 patients with NSVT and 5 supraventricular arrhythmias. One death had occurred. Conclusions: we observed: supraventricular arrhythmias in 19,2%; NSVT in 15,4% and VT/VF in 15,4%. The clinical or demographic outcomes did not suggest any clinical or functional results after ICD implantation; syncope may occur after ICD implantation and no arrhythmias recordered by intracardiac electrograms and left-ventricular-wall thickness greater than 30 mm is associated with early ICD shocks (p=0,003).

Estudou-se prospectivamente o comportamento das calcificações, da atrofia, das alterações da substância branca e alterações vasculares nas imagens de tomografia computadorizada de crânio de 162 crianças e adolescentes infectados pelo vírus da imunodeficiência humana (HIV) por transmissão vertical e que estavam ou estiveram em acompanhamento clínico no Ambulatório de Infectologia Pediátrica do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, entre 1992 e 2002. Analisaram-se as possíveis correlações entre estas alterações e seu aspecto evolutivo. Para tal finalidade, foram avaliadas 606 tomografias computadorizadas de crânio (média de 3,74 exames por paciente), as quais constituíram o grupo de estudo. Após a caracterização quanto à presença ou não das alterações supracitadas, e suas possíveis inter-relações, realizou-se a análise estatística dos resultados obtidos através do teste exato de Fisher com nível de significância de 5%. Posteriormente, os mesmo aspectos foram avaliados em função do seu comportamento evolutivo em um subgrupo de 61 pacientes (média, 4,18 exames por paciente, totalizando 321 exames tomográficos). Estes pacientes tinham, pelo menos, quatro estudos tomográficos seriados (com intervalo mínimo de noventa dias entre os exames subseqüentes e pelo menos dois anos de intervalo total entre o primeiro e o último exame). As alterações tomográficas foram abordadas individual e qualitativamente segundo o critério de presença e intensidade. Inicialmente, o conjunto dos resultados foi tratado de forma individual (para cada paciente) e, depois, em relação à totalidade do grupo em questão. As calcificações foram encontradas em 46,30% dos pacientes; a atrofia, em 37,65%; as alterações da substância branca, em 25,93%; as anomalias vasculares, em 25,19%. Constatou-se uma correlação significativa entre as alterações de substância branca e a atrofia, bem como entre as calcificações e as alterações vasculares. A análise evolutiva destas características demonstrou haver um acréscimo significativo das alterações entre o momento inicial e o quarto momento no conjunto das alterações, sobretudo para as calcificações e para as alterações vasculares. Concluiu-se que as calcificações e a atrofia foram as alterações mais freqüentes nesta série de crianças e adolescentes com HIV adquirido por transmissão vertical. A atrofia e as alterações da substância branca apresentaram uma inter-relação importante na amostra descritiva, assim como as alterações vasculares e as calcificações mostraram uma associação evolutiva significativa em relação à sua progressão / We prospectively studied the behavior of calcifications, atrophy, white matter and vascular abnormalities on the images of computed tomography (CT) of 162 children and adolescents infected with the human immunodeficiency virus (HIV) acquired by vertical transmission, who are or were clinically followed in the Ambulatory of Pediatric Infectology of the Children Institute at the Clinics Hospital of University of São Paulo Medical School, from 1992 to 2002. We analyzed the possible correlation between these abnormalities, as well as, their evolutive aspects. For this purpose, we evaluated 606 CT scans (mean 3.74 exams per patient), which composed the group of study. After the characterization according to the presence or not of the anomalies mentioned above, and their possible inter-relations, we performed a statistical analysis of the obtained results with the Fisher test with a level of significance below 5%. Later, these aspects were evaluated regarding its evolutive behavior in a subgroup of 61 patients (mean, 4.18 exams per patient, summing 321 exams). These patients had, at least, four serial cranial CT (with minimum interval of ninety days between the subsequent exams and, at least, two years of total interval between the first and the fourth exam). The cranial CT abnormalities presented were assessed individually as absent or present. Initially, the set results were assessed individually (for each patient) and, later in relation to the totality of the group. Calcifications were found in 46.30% of all patients, atrophy in 37.65%, white matter abnormalities in 25.93% and vascular anomalies in 25.19%. We found a significant correlation between white matter abnormalities and atrophy, as well as, between calcifications and vascular anomalies. Evolutive analysis of these characteristics demonstrated a significant increase of the abnormalities between the first and the fourth moment, with emphasis to the calcifications and vascular anomalies. We concluded that, calcifications and atrophy were the most frequent abnormalities in this series of children and adolescents with HIV acquired by vertical transmission. Atrophy and white matter abnormalities presented a significant correlation in the descriptive sample, as well as, vascular anomalies and calcifications that also demonstrated a significant evolutive association regarding its progression

Introdução: Reservatórios gastroileais (GI) compostos podem apresentar vantagens em relação a segmentos intestinais isolados em cirurgias de reconstrução urinária em pacientes selecionados. Apresentamos aqui as técnicas laparoscópicas de gastroileocistoplastia (ampliação vesical) e de neobexiga gastroileal ortotópica (substituição vesical), realizadas de forma completamente intracorpórea em um modelo suíno experimental. Avalia-se sua viabilidade técnica e resultados funcionais. Métodos: Após padronização da técnica em estudo piloto (três animais), realizaram-se as cirurgias de gastroileocistoplastia (Grupo I; N = 5) e neobexiga GI ortotópica (Grupo II; N = 10), envolvendo os mesmos princípios de ressecção laparoscópica de cunha gástrica e íleo. No grupo II, a criação da neobexiga GI incluiu reimplante ureteral bilateral no segmento gástrico com técnica antirefluxo e anastomose uretro-ileal. Foram utilizados exclusivamente grampeadores e técnicas de sutura livre laparoscópica, de forma completamente intracorpórea. Análise pré e pós-operatória de dados laboratoriais, capacidade vesical, avaliação histológica e por imagem (uretrocistografia, urografia venosa) dos reservatórios resultantes foi concluída ao final do seguimento de 8 a 12 semanas (Grupo I) e quatro a oito semanas (Grupo II). Resultados: Os segmentos ileal e gástrico alcançaram a pelve do animal em todos os casos. Tempo cirúrgico foi de 5,2 h para o Grupo I e 7,4 h para o Grupo II. Não houve conversões ou óbitos intra-operatórios. Todos os reservatórios GI apresentavam-se viáveis por ocasião da eutanásia em ambos os grupos. No Grupo I, quatro dos cinco animais completaram sem intercorrências o seguimento de 8 (N = 2) e 12 (N = 2) semanas. Um animal apresentou deterioração clínica, sendo levado precocemente à eutanásia por pielonefrite e alcalose metabólica. Houve aumento da capacidade vesical (a uma pressão vesical de 20cmH2O) de 650ml para 1025ml (p < 0,05) após a cirurgia de ampliação vesical. No Grupo II, cinco dos 10 animais completaram o seguimento previsto em quatro (N = 3) e oito (N = 2) semanas, com mínima alteração da função renal (Cr pré e pós-operatório=1,4 e 2,2mg/dl, respectivamente; p = 0,09). Três animais tiveram a eutanásia antecipada devido a obstrução ureteral com pielonefrite (N = 2) e alcalose hipoclorêmica severa (N=1). Dois óbitos foram associados a obstrução ureteral bilateral e sepse. Capacidade vesical média das neobexigas foi de 400ml. Não houve casos de refluxo vesico-ureteral à cistografia. Porém, sete das 20 unidades renais (35%) apresentaram estenose uretero-gástrica. Obstrução intestinal (N = 1), fístula gástrica (N = 1) e urinoma (N = 1) foram outras complicações do Grupo II. Conclusões: A ressecção gástrica laparoscópica para ampliação e substituição vesicais é viável e reprodutível. A gastroileocistoplastia laparoscópica apresenta adequado resultado funcional após três meses no modelo suíno. A neobexiga GI laparoscópica é tecnicamente viável no modelo suíno, apesar de sua complexidade. A descrição inicial é apresentada. Aperfeiçoamento da técnica de reimplante ureteral anti-refluxo laparoscópico é necessário antes de sua aplicação clínica. / Introduction: Composite gastroileal (GI) urinary reservoirs may present advantages over the use of isolated intestinal segments for urinary reconstructive procedures in selected patients. Herein, we present the laparoscopic techniques of gastroileocystoplasty (bladder augmentation) and GI orthotopic neobladder (bladder substitution), performed completely intracorporeally in a porcine model. Technical feasibility and functional results of these procedures are evaluated. Methods: After a pilot study (three animals) to technically standardize the procedures, gastroileocystoplasty (Group I, N = 5) and GI orthotopic neobladder (Group II; N = 10) were performed applying the same principles of wedge gastric resection and ileal resection. In Group II, creation of the neobladder included bilateral ureteral reimplantation into the gastric segment with an anti-reflux technique and an urethro-ileoanastomosis. Staplers and free-hand laparoscopic suture techniques were utilized exclusively, in a completely intracorporeal manner. Preop and postoperative analysis of laboratory data, bladder capacity, image (cystourethrography, intravenous urography) and histological evaluation of the resulting GI reservoirs was concluded at the end of follow-up, at eight and 12 weeks (Group I) and four and eight weeks (Group II). Results: Ileal and gastric patches reached the animal pelvis in all cases. Operative times were 5.2h for Group I and 7.4h for Group II. No conversions or intraoperative deaths occurred. All GI reservoirs were viable by the time of euthanasia in both groups. In Group I, four of the five animals completed the scheduled follow-up of 8 (N = 2) and 12 (N = 2) weeks without complications. One animal received early euthanasia due to pyelonephritis and metabolic alkalosis. Bladder capacity (at a bladder pressure of 20cmH2O) increased from 650ml to 1025ml (p < 0.05) after the bladder augmentation procedure. In Group II, five of 10 animals completed the scheduled follow-up at four (N = 3) and eight (N = 2) weeks, with minimal alteration on renal function (pre and postoperative Cr = 1.4 and 2.2mg/dl, respectively; p = 0.09). Three animals had an early euthanasia due to ureteral obstruction and pyelonephritis (N=2) and severe hipochloremic alkalosis (N = 1). Two deaths were associated to bilateral ureteral obstruction and sepsis. Mean bladder capacity for the neobladders was 400ml. No cases of vesico-ureteral reflux were seen at cystourethrography. However, seven of 20 renal units (35%) presented with uretero-gastric stenosis. Bowel obstruction (N = 1), gastric fistula (N = 1) and urinoma (N = 1) were other complications in Group II. Conclusions: Laparoscopic gastric resection for bladder augmentation and substitution purposes is feasible and reproducible. Laparoscopic gastroileocystoplasty presents adequate functional results after three months in the porcine model. Laparoscopic GI neobladder is technically viable in the porcine model, despite its complexity. The initial report is presented. Refinements of laparoscopic anti-reflux ureteral reimplantation techniques are necessary before its clinical application.