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  • About
  • The Global ETD Search service is a free service for researchers to find electronic theses and dissertations. This service is provided by the Networked Digital Library of Theses and Dissertations.
    Our metadata is collected from universities around the world. If you manage a university/consortium/country archive and want to be added, details can be found on the NDLTD website.
11

Sistema de previsão de enchentes: integração de modelos de previsão de chuva, simulação hidrológica e hidrodinâmica

ALVES, Fellipe Henrique Borba 24 February 2017 (has links)
Submitted by Pedro Barros (pedro.silvabarros@ufpe.br) on 2018-08-28T22:10:21Z No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) DISSERTAÇÃO Fellipe Henrique Borba Alves.pdf: 14338383 bytes, checksum: 8f642c7124b0b97eb6b6d04da6fc748b (MD5) / Approved for entry into archive by Alice Araujo (alice.caraujo@ufpe.br) on 2018-09-06T22:01:53Z (GMT) No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) DISSERTAÇÃO Fellipe Henrique Borba Alves.pdf: 14338383 bytes, checksum: 8f642c7124b0b97eb6b6d04da6fc748b (MD5) / Made available in DSpace on 2018-09-06T22:01:53Z (GMT). No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) DISSERTAÇÃO Fellipe Henrique Borba Alves.pdf: 14338383 bytes, checksum: 8f642c7124b0b97eb6b6d04da6fc748b (MD5) Previous issue date: 2017-02-24 / A Região Nordeste do Brasil é comumente associada às secas prolongadas. No entanto, áreas específicas estão susceptíveis à ocorrência de chuvas intensas, onde podem ser geradas enchentes catastróficas. Nesse contexto, para a bacia do rio Una, em Pernambuco, foi desenvolvido um modelo de previsão de enchentes, capaz de integrar informações de previsão de chuva, modelagem hidrológica e modelagem hidrodinâmica. Neste trabalho buscou-se analisar dados dos modelos de previsão de chuva ETA 40 Km e APAC 9 Km, avaliar a distribuição da vazão gerada através de modelo hidrológico HEC-HMS e testar novos coeficientes de calibração, simular no modelo hidrodinâmico HEC-RAS o efeito da construção de barragens nas cidades de Palmares, Água Preta e Barreiros para o maior evento de chuva já registrado, ocorrido em 2010. Os resultados encontrados indicaram relevante diferença quantitativa e posicional nos dados dos modelos de previsão. O modelo hidrológico HEC-HMS teve melhorias na distribuição de vazão ao longo da bacia e na estabilidade global das vazões geradas. O modelo hidrodinâmico demonstrou redução significativa na vazão de pico a montante das áreas urbanas de Palmares, Água Preta e Barreiros, respectivamente. No entanto, mesmo com redução expressiva de vazão, as inundações nesses municípios ainda podem ocorrer caso eventos semelhantes ao de 2010 venham a acontecer. / Northeast Brazil is commonly associated with prolonged drought effects. However, in specific areas are likely to occur from intense rainfall events, where such events generate catastrophic flooding. In this context, an Advanced Flood Forecasting Model was developed for an Una river basin in Pernambuco, capable of integrating information on rainfall forecasting, hydrological modeling and hydrodynamic modeling. The objective of this work is to analyze the data of the ETA 40 km and APAC 9 km rain forecast models, to evaluate a flow distribution generated through a HEC-HMS hydrological model and to test new calibration coefficients, to simulate in hydrodynamic model HEC-RAS the effect of flood control dams and generate a flood spot in the cities of Palmares, Água Preta and Barreiros, considering the largest rainfall event ever recorded in 2010. The results indicated the quantitative difference and the data of the forecast models, the HEC-HMS hydrological model had improvements in the flow distribution along the basin and in the overall stability of the flows generated, the hydrodynamic model demonstrated a reduction in the upstream peak flow of the urban areas of Palmares, Água Preta and Barreiros, respectively. However, even with expressive flow reduction, such as floods in municipalities can still occur if events similar to the year 2010 occur again.
12

Examining the Impact of Canadian Political Satire Shows on Generation Y: A Qualitative Investigation of This Hour Has 22 Minutes

Attalla, Jessica January 2015 (has links)
In contemporary society, political satire shows are prominent programs that seem to resonate with the viewing public. This thesis seeks to observe the meanings that generation Y attach to the Canadian political satire show, This Hour Has 22 Minutes. Focusing on the Canadian context, this research examines how members of generation Y view political satire shows, specifically This Hour Has 22 Minutes and if this show caters to their attitudes, concerns and interests more so than traditional news media. The theoretical framework guiding this study is the uses and gratifications theory. This research implements a qualitative phenomenological research approach in the form of focus groups. This study concludes that this generation still maintains, however, that when looking to be informed, they connect more with traditional news media given that these programs provide them with all the facts and stories in a more reliable manner. This study contributes to the field of communication because it demonstrates the rationale and experiences of generation Y in relation to political news.
13

Design and Proof-of-Concept Implementation of Proxy-based Stream Handling for an Enterprise Service Bus

Hedlund, Tim January 2014 (has links)
Traffic for real-time entertainment applications has increased over the past years and now holds one of the largest portions of the traffic on the Internet. This trend has been spotted by Ida Infront who wishes to integrate and support a streaming protocol in their Enterprise Service Bus (ESB). This thesis first surveys three streaming protocols and techniques (SIP, RTSP and HTTP-base streaming) in terms of general usage areas and suitability for integration with the company ESB. Second, this thesis investigates how these protocols can be implemented using a proxy-based design together with the ESB. After describing one design alternative for each protocol, the thesis finally presents a proof-of-concept implementation of an RTSP proxy. The proxy is implemented and tested for performance and added packet jitters under different loads. The main contribution of the thesis is a reverse RTSP proxy application that integrates with the ESB and offers both routing and logging functionalities. In tests where we put the proxy under load we see that the CPU and memory usage is low and that the bottleneck appears to be the network bandwidth. But we also see a small added jitter that potentially could scale and must be taken into account when using such a proxy application.
14

Principals' Perception of Social Emotional Learning in High Achieving High Schools

Peterson, Braden Jeffrey 04 May 2022 (has links)
School leaders are increasingly being required to support students beyond academic metrics. The Covid-19 pandemic caused unanticipated closures in schools throughout the country forcing many students to an unfamiliar online environment. In the months that followed, anxiety and loneliness rose dramatically, requiring staff to re-think how to best support the social emotional needs of students. The purpose of this study was to identify how principals perceive their role in providing social emotional learning (SEL) support for all students in high-achieving schools (HAS) in both in-person and virtual learning environments. Using a phenomenological research design, principals from high achieving schools were interviewed to identify their perceived role in providing SEL for all students. This research suggests that relationships are essential in providing SEL in a meaningful way and principals rely on a variety of staff to ensure students are receiving SEL in traditional (in-person) and virtual environments. Principals expressed a deepened urgency for SEL needs due to the global pandemic of Covid-19. The role of the principals is uniquely positioned to support both the structural and interpersonal supports needed to develop SEL for all students. As the growing evidence supports the inclusion of SEL-related activities, principal and teacher preparation programs should include SEL training as part of the curriculum as part of pre-service training. Additionally, school divisions should provide in-service opportunities for those already in the field. The findings from this research underscore the important role that principals have in promoting a SEL-supportive culture. Implications of these findings and suggestions for future research are also shared. / Doctor of Education / The purpose of this study was to identify how principals perceive their role in providing SEL support for all students in high-achieving schools (HAS) in both in-person and virtual learning environments. Due to the widespread closure of in-person schooling across the country in the fall of 2020, school leaders have been forced to think differently on implementing support for the whole child. Using a phenomenological research design, principals from high achieving schools were interviewed to identify their perceived role in providing SEL for all students. A review of the literature shows SEL can be delivered at both the classroom and whole-school level and has academic, behavioral, and societal benefits. Findings showed that principals are uniquely positioned to develop SEL-supportive cultures by providing a common vision, structural supports, and opportunities to increase long-term relationships. Principals utilized a variety of people and places to provide SEL for all students, with a strong emphasis on building relationships. The capacity of both school leaders and teachers plays an important role in providing SEL with fidelity. Principal's expressed a deepened understanding of the urgency of SEL. In light of limited pre-service training at both the teacher and administrative level, additional professional development is needed in this area as schools seek to address the whole child.
15

L'écran de l’écriture : les adaptations cinématographiques de Wojciech J. Has comme opérateurs de lecture des textes de Jean Potocki, Bolesław Prus et Bruno Schulz / The screen of writing : the film adaptations of Wojciech J. Has as operators of reading texts of Jean Potocki, Bolesław Prus and Bruno Schulz

Neau, Jessy 31 March 2017 (has links)
Cette thèse propose une approche renouvelée de l’adaptation cinématographique de la littérature, par l’étude d’un corpus composé de plusieurs textes littéraires et de leurs adaptations cinématographiques réalisées par le même cinéaste, Wojciech Jerzy Has (1925-2000). L’originalité de notre analyse de corpus réside dans le fait de placer les films, et non les textes, comme éléments premiers et centraux dans l’organisation de notre démarche. Les textes littéraires, par le choix de cette approche target-oriented (Cattrysse 2014) qui part plutôt de la cible que de la source, deviennent ainsi les points d’arrivée plutôt que les points de départ de l’épreuve du corpus. Nous proposons un champ d’expérimentation qui fait de trois films réalisés par Wojciech Has l’impulsion d’un itinéraire d’analyses à la fois textuelles et filmiques, incluant les textes hétérogènes adaptés par ce réalisateur (ceux de Jean Potocki, Bruno Schulz et Bolesław Prus). Ce mode d’organisation crée des modes de relation inédits entre les textes et les films, mais aussi des textes entre eux, alors qu’aucune relation d’intertextualité déclarée ne motive leurs mises en rapport : le roman de Potocki, Manuscrit trouvé à Saragosse, les nouvelles de Bruno Schulz ainsi que La Poupée de Bolesław Prus appartiennent à trois siècles différents, des Lumières finissantes à l’entre-deux guerres mondiales. La logique de renversement du trajet critique traditionnel que nous mettons en œuvre, en mobilisant les ressources du cinéma à capter et projeter une expérience de lecture, révèle des analogies avec l’analyse textuelle : les notions de figure et de montage permettent de faire de l’adaptation un jeu de réécriture (Ropars 1990), ayant vocation à altérer le texte. C’est notamment par un certain nombre de figures apparentées au fantastique qu’une cohérence a posteriori est donnée au corpus textuel : les trois films de Has mettent en scène des doubles, des automates, des labyrinthes et des configurations autoréflexives qui créent de nouveaux points de contact entre les textes. Notre recherche double alors l’expérimentation de cet opérateur cinématographique de la littérature d’un opérateur fantastique, qui agit comme élément de cohésion dans le jeu différentiel entre littérature et cinéma. / This dissertation proposes a renewed approach to the topic of film adaptation, by studying several literary texts together with their film adaptations directed by the same filmmaker, Wojciech Jerzy Has (1925-2000). The originality of our analysis lies in placing films, not texts, as primary and central elements in the organization of our approach. By the choice of a target-oriented approach (Cattrysse 2014), literary texts become the points of arrival rather than the starting points of this comparative analysis. Three films directed by Wojciech Has give the impulse to an itinerary of analyzes that includes various texts adapted by this director (those of Jan Potocki, Bruno Schulz and Bolesław Prus). This mode of organization creates unprecedented modes of relation between the texts and the films, but also between texts themselves, while no relation of explicit intertextuality justifies their connections: Jan Potocki’s Zaragoza Manuscript (1794-1810), Bolesław Prus’ The Doll (1890) the short stories of Bruno Schulz (1934-1937) belong to three different centuries. The reversal of the traditional critical path that we are implementing in this work, by mobilizing the resources of films to capture and project the experience of reading, reveals analogies between filmic and textual analysis. The notions of figure and montage will allow to discover how adaptations can also qualify as rewritings (réécritures) (Ropars 1990), a concept that points towards films that alter the text.It is by the unveiling of some figures related to the fantastic genre that a posterior coherence is given to the texts adapted by Has: the three films present doubles, automata, labyrinth experiences and self-reflexive configurations, creating new relationships between heterogeneous texts. Our research doubles the experimentation of this cinematographic operator of the literature with a fantastic operator, which acts as an element of cohesion in the differential game between literature and cinema.
16

Análise comparativa da reatividade anti-LID-1, NDO-LID, NDO-HSA e PGL-1 em hanseníase / Comparative analysis of the reactivity anti-LID-1, NDO-LID, NDOHSA and PGL-1 in leprosy

Fabri, Angélica da Conceição Oliveira Coelho 14 August 2015 (has links)
Submitted by Renata Lopes (renatasil82@gmail.com) on 2018-08-21T12:03:55Z No. of bitstreams: 1 angelicadaconceicaooliveiracoelho.pdf: 3773705 bytes, checksum: e753f755e09e6a5c7102c48ac076e08f (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2018-08-21T14:22:17Z (GMT) No. of bitstreams: 1 angelicadaconceicaooliveiracoelho.pdf: 3773705 bytes, checksum: e753f755e09e6a5c7102c48ac076e08f (MD5) / Made available in DSpace on 2018-08-21T14:22:17Z (GMT). No. of bitstreams: 1 angelicadaconceicaooliveiracoelho.pdf: 3773705 bytes, checksum: e753f755e09e6a5c7102c48ac076e08f (MD5) Previous issue date: 2015-08-14 / PROQUALI (UFJF) / A infecção subclínica pode ser avaliada por meio de teste sorológico, que determina imunoglobulinas circulantes. O objetivo do presente estudo foi analisar a reatividade de diferentes antígenos em casos novos de hanseníase, contatos domiciliares de casos e em população de área endêmica, com o intuíto de identificar o melhor antígeno para o diagnóstico sorológico da hanseníase e detecção de indivíduos infectados pelo Mycobacterium leprae. Trata-se de um estudo transversal de natureza exploratória e analítica. A reatividade anti-LID1, NDO-LID, NDO-HSA e PGL-1 foi avaliada por meio do enzyme-linked immunosorbent assay. Foram analisadas amostras de sangue total em papel de filtro Whatman de 2494 indivíduos da população de sete municípios da microrregião de Almenara e de soro de 94 casos novos de hanseníase e 104 contatos domiciliares de casos residentes no município de Uberlândia. O Banco de Dados foi criado no Software Epi Info versão 3.5.1 e análise realizada no software Statistical Package for the Social Sciences for Windows 18 e no GraphPad Prism versão 5. Para análise estatística foram utilizados os seguintes testes: Kolmogorov-Smirnov, Kruskal-Wallis one-way (H), Mann-Whitney (U) com correção de Bonferroni, kappa, Spearman (rho), teste Qui-quadrado de Pearson e regressão logística binária. Foi observado maior soropositividade no grupo de casos multibacilares (MB), em contatos domiciliares de casos MB e nos indivíduos residentes nos municípios de Almenara e Jequitinhonha. Obteve-se correlação positiva entre a sorologia e o índice baciloscópico, concordância substancial e significativa no grupo de casos novos de hanseníase e correlação positiva para todos os antígenos testados. Os testes anti-LID-1 e anti-NDO-LID apresentaram melhor performance para identificar os contatos domiciliares e ou indivíduos da população infectados pelo M. leprae. O PGL-1 nativo teve maior positividade do que o NDO-HSA para todas as formas clínicas da hanseníase e no grupo de contatos domiciliares. A prevalência de soropositividade na população foi superior à taxa de detecção de casos de hanseníase em todos os municípios avaliados. A faixa etária, a renda familiar, residir em município endêmico, conhecer alguém que teve ou tem hanseníase, ter ou ter tido caso de hanseníase na familia e residir ou ter residido com caso de hanseníase são fatores que podem explicar a diferença de soropositividade anti-NDO-LID. Apenas a faixa etária e conhecer alguém que teve ou tem hanseníase é capaz de explicar a diferença de soropositividade anti-NDO-HSA. E em relação ao LID-1 nenhuma variável foi explicativa. Todos os antígenos analisados podem auxiliar na diferenciação e caracterização da hanseníase MB e na identificação de indivíduos expostos ao M. leprae, porém o NDO-LID apresentou melhor performance na identificação desses indivíduos e dos casos paucibacilares, quando comparado aos testes envolvendo os antígenos LID-1 e NDO-HSA separadamente, portanto fornece benefício adicional a esses antígenos e poderia ser utilizado como ferramenta auxiliar na vigilância epidemiológica da hanseníase. / The subclinical infection can be evaluated by serologic test which determine circulating immunoglobulins. The aim of this study was to analyze the reactivity of different antigens in leprosy cases, household contacts of index cases and the population of the endemic area to identify the best antigen for the diagnosis of leprosy and detection of individuals infected with Mycobacterium leprae. It is a cross-sectional study of exploratory and analytical nature. The reactivity anti-LID-1, NDO-LID, NDO-HAS e PGL-1 were evaluated using the enzymelinked immunosorbent assay. The whole blood in Whatman filter paper of 2494 individuals from the general population of seven municipalities in the micro-Almenara and serum of 94 patients with leprosy and 104 household contacts of patients residing in Uberlândia were analyzed. The database was created in Epi Info software version 3.5.1 and analysis in the software Statistical Package for Social Sciences for Windows 18 and GraphPad Prism version 5. For statistical analysis the following tests were used: Kolmogorov-Smirnov, Kruskal Wallis one-way (H), Mann-Whitney (U) with Bonferroni correction, kappa, Spearman (rho), chisquare test of Pearson and binary logistic regression. Identied higher seropositivity in the group of MB patients, household contacts of MB patients and in individuals living in the municipalities of Almenara and Jequitinhonha. Observed positive correlation between serology test and bacterial index, substantial agreement and significant in patients positive and positive correlation for all antigens. The LID-1 and NDO-LID antigens showed greater ability to identify household contacts or the general population infected with M. leprae, but the performance of the NDO-LID was better. The native PGL-1 had higher seropositivity than the NDO-HSA for all clinical forms of leprosy and household contacts. The seropositivity prevalence in the general population was higher than the detection rate of leprosy cases in all evaluated municipalities. The age, family income, living in a city endemic, knowing someone who had or has leprosy, had or have the case in the family and live or lived with leprosy case are factors that can explain the anti-NDO-LID seropositivity difference. Only the age range and know someone who had or has leprosy is able to explain the anti-NDO-HSA seropositivity difference. And for the LID-1 no variable explained the anti-LID-1 seropositivity difference. All serological tests analyzed can assist in the differentiation and characterization of MB leprosy and the identification of individuals exposed to M. leprae, but NDO-LID performed better in identifying these individuals and PB patients, when compared to the tests involving the LID-1 and NDO-HSA antigens separately, therefore provides additional benefit to these antigens and could be used as an auxiliary tool in epidemiological surveillance of leprosy.
17

Maltraitance infligée à l'enfant : difficultés et freins à la prise en charge médico-légale : étude comparée entre France et Syrie / Abuse inflicted on the child : difficulties and obstacles to forensic care : a comparative study between France and Syria

Nassour, Bashar 09 March 2016 (has links)
Cette thèse, développée dans une approche comparatiste et différentialiste de la maltraitance faite à l'enfant (0 à 18 ans), en France et en Syrie, concerne la médecine légale, inscrite dans un contexte d'éthique médicale. La problématique initiale évoque le signalement de la part du médecin, et ses freins, question qui débouche sur l'interrogation suivante : Comment la décision du médecin, toujours première, peut-elle intégrer la dimension psychologique et socioculturelle de la maltraitance, pour que les conséquences du signalement (ou du non signalement) soient au bénéfice de l'enfant et sa famille ? L'Histoire et l'évolution de la maltraitance à enfant sont exposées, pour les deux pays (peu d'informations pour la Syrie). L'enfant, sujet vulnérable, est considéré dans sa globalité psychologique et socioculturelle, face aux données afférant à sa protection. Ensuite, l'approche médicale (tableaux cliniques de maltraitance le plus couramment observés), suivie de la prise en charge globale de l'enfant, dans les sociétés française et syrienne, sont exposées. Enfin, les aspects juridiques de la protection de l'enfant, face au signalement et ses freins, sont présentés comme relevant d'une problématique éthique, située entre médecine et droit, dans des espaces socioculturels spécifiques. Ces données prennent concrètement corps dans des études de cas cliniques, en service de médecine légale : CHU de Dijon, en France, et Centre hospitalier de la région d'Alep, en Syrie (synthèse de Dao sur 249 cas, en 2002, compte tenu de la situation politique actuelle). Via le témoignage du Dr. Catherine Bonnet, cette étude s'ouvre sur un approfondissement des questions du viol et de l'inceste, et met en lumière certaines difficultés à déboucher sur des décisions judiciaires qui, bien que correctes du côté du droit, peuvent s'avérer délétères pour l'enfant et sa famille, sur les plans psychologique, affectif et social ; la situation des deux pays est différenciée, ici aussi. La conclusion, d'ordre moral et éthique, renvoie à la responsabilité de la famille (bientraitance et éducation de l'enfant) et au constat d'une articulation difficile entre le travail du médecin et les décisions judiciaires qui devraient permettre un vrai soin et une protection efficace de l'enfant maltraité, question qui suscite notre interrogation finale : À l'échelon mondial, faudrait-il élaborer une législation commune, spécifique pour l'enfant ? / This research is a comparative and differential approach of child abuse (0-18 years), in France and Syria. It concerns forensic medicine in the context of medical ethics. The initial issue evokes the reporting abuse and its obstacles, and leads to the following question: How the always main decision of the doctor can integrate the psychological and socio-cultural dimension of child abuse in order that the reporting (or the no reporting) benefits the child and family? The history and evolution of child abuse are exposed, for both countries (some information only for Syria). The child, subject vulnerable, is considered as a psychological and sociocultural entity, as to his/her protection. Then, the medical approach (clinical cases of abuse commonly observed), and the medical management of the child are exposed in the French and Syrian societies. Finally, the legal aspects of child protection are reported with its obstacles as part of an ethical issue, between medicine and law, in specific socio-cultural dimensions. These data are updated in the study of clinical cases, in forensic services: CHU of Dijon, in France, and one hospital, in the area of Aleppo, in Syria (Dao’s synthesis of 2002, on 249 cases, given the current political situation). Then, considering the testimony of the Dr Catherine Bonnet, this study opens the reflection on rape and incest, and highlights some difficulties due to certain judicial decisions which, although correct in view of the law, may be deleterious for the child and his family, if we consider a psychological, emotional and social point of view. Both countries situation is differentiated, again. The moral and ethical conclusion refers to the responsibility of the family (welfare and education of the child). It also refers to a difficult relationship between the doctor’s practice and the judicial decisions that should allow a true care and an effective protection of the abused child. This issue arouses our final questioning: at the world level, perhaps it may be necessary to develop a specific legislation for the child ?
18

Vnitřní krajina? / Inner landscape - space and time according to The Sandglass by Wojciech Jerzy Has

Mielnik, Tomasz January 2014 (has links)
The thesis titled "Inner landscape - space and time in The Sandglass by W.J.Has " explores the concepts of space and time in the movie The Sandglass in the context of novel by Bruno Schulz. It compares the concept of time and space in the novel and film. By using specific examples, it explores the archetypal and mythological nature of space and time in this movie, which together form an autonomous world.
19

Nové algoritmy pro kódování videosekvencí / New video coding algorithms

Zach, Ondřej January 2020 (has links)
Předložená dizertační práce se zabývá moderními algoritmy pro kódovaní videosekvencí, zejména algoritmem High Efficiency Video Coding, a jeho použítím v prostředí online streamování. Vzhledem k tomu, že chování koncových diváků směřuje ke sledování video obsahu kdykoli a kdekoli, způsob, jakým je obsah doručen k divákovi, se stává stejně důležitým, jakým je samotné kódování. V této práci se zaměřujeme na užití HEVC ve službách založených na HTTP adaptivním streamování, zejména ve službách využívajích DASH. Dále se zabýváme dalšími aspekty, které mají vliv na kvalitu zážitku (Quality of Experience) tak, jak jej vnímá koncový uživatel. Takovými jsou na příklad přítomnost reklamy či další systémové parametry. Abychom mohli sbírat názory uživatelů, pro naše experimenty často používáme crowdsourcing. Z tohoto důvodu je část této práce věnována samotnému crowdsourcingu a tomu, jak jej lze využít pro hodnocení kvality videa.
20

Predictive Value of HAS-BLED Score Regarding Bleeding Events and Graft Survival following Renal Transplantation

Hau, Hans Michael, Eckert, Markus, Laudi, Sven, Völker, Maria Theresa, Stehr, Sebastian, Rademacher, Sebastian, Seehofer, Daniel, Sucher, Robert, Piegeler, Tobias, Jahn, Nora 02 November 2023 (has links)
Objective: Due to the high prevalence and incidence of cardio- and cerebrovascular diseases among dialysis-dependent patients with end-stage renal disease (ERSD) scheduled for kidney transplantation (KT), the use of antiplatelet therapy (APT) and/or anticoagulant drugs in this patient population is common. However, these patients share a high risk of complications, either due to thromboembolic or bleeding events, which makes adequate peri- and post-transplant anticoagulation management challenging. Predictive clinical models, such as the HAS-BLED score developed for predicting major bleeding events in patients under anticoagulation therapy, could be helpful tools for the optimization of antithrombotic management and could reduce peri- and postoperative morbidity and mortality. Methods: Data from 204 patients undergoing kidney transplantation (KT) between 2011 and 2018 at the University Hospital Leipzig were retrospectively analyzed. Patients were stratified and categorized postoperatively into the prophylaxis group (group A)—patients without pretransplant anticoagulation/antiplatelet therapy and receiving postoperative heparin in prophylactic doses—and into the (sub)therapeutic group (group B)—patients with postoperative continued use of pretransplant antithrombotic medication used (sub)therapeutically. The primary outcome was the incidence of postoperative bleeding events, which was evaluated for a possible association with the use of antithrombotic therapy. Secondary analyses were conducted for the associations of other potential risk factors, specifically the HAS-BLED score, with allograft outcome. Univariate and multivariate logistic regression as well as a Cox proportional hazard model were used to identify risk factors for long-term allograft function, outcome and survival. The calibration and prognostic accuracy of the risk models were evaluated using the Hosmer–Lemshow test (HLT) and the area under the receiver operating characteristic curve (AUC) model. Results: In total, 94 of 204 (47%) patients received (sub)therapeutic antithrombotic therapy after transplantation and 108 (53%) patients received prophylactic antithrombotic therapy. A total of 61 (29%) patients showed signs of postoperative bleeding. The incidence (p < 0.01) and timepoint of bleeding (p < 0.01) varied significantly between the different antithrombotic treatment groups. After applying multivariate analyses, pre-existing cardiovascular disease (CVD) (OR 2.89 (95% CI: 1.02–8.21); p = 0.04), procedure-specific complications (blood loss (OR 1.03 (95% CI: 1.0–1.05); p = 0.014), Clavien–Dindo classification > grade II (OR 1.03 (95% CI: 1.0–1.05); p = 0.018)), HAS-BLED score (OR 1.49 (95% CI: 1.08–2.07); p = 0.018), vit K antagonists (VKA) (OR 5.89 (95% CI: 1.10–31.28); p = 0.037), the combination of APT and therapeutic heparin (OR 5.44 (95% CI: 1.33–22.31); p = 0.018) as well as postoperative therapeutic heparin (OR 3.37 (95% CI: 1.37–8.26); p < 0.01) were independently associated with an increased risk for bleeding. The intraoperative use of heparin, prior antiplatelet therapy and APT in combination with prophylactic heparin was not associated with increased bleeding risk. Higher recipient body mass index (BMI) (OR 0.32 per 10 kg/m2 increase in BMI (95% CI: 0.12–0.91); p = 0.023) as well as living donor KT (OR 0.43 (95% CI: 0.18–0.94); p = 0.036) were associated with a decreased risk for bleeding. Regarding bleeding events and graft failure, the HAS-BLED risk model demonstrated good calibration (bleeding and graft failure: HLT: chi-square: 4.572, p = 0.802, versus chi-square: 6.52, p = 0.18, respectively) and moderate predictive performance (bleeding AUC: 0.72 (0.63–0.79); graft failure: AUC: 0.7 (0.6–0.78)). Conclusions: In our current study, we could demonstrate the HAS-BLED risk score as a helpful tool with acceptable predictive accuracy regarding bleeding events and graft failure following KT. The intensified monitoring and precise stratification/assessment of bleeding risk factors may be helpful in identifying patients at higher risks of bleeding, improved individualized anticoagulation decisions and choices of antithrombotic therapy in order to optimize outcome after kidney transplantation

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