Nos últimos tempos, observa-se um grande crescimento na utilização de computadores como ferramenta de auxílio nas mais diversas áreas, sendo a Medicina uma das principais áreas dessa utilização. Inúmeras aplicações da Informática podem ser encontradas na área médica, citando-se os sistemas de apoio ao diagnóstico como uma das mais marcantes. Esses sistemas têm como principal objetivo auxiliar o profissional da área no processo de tomada de decisões, o qual pode ocorrer em diferentes etapas de sua atividade. Esse processo normalmente envolve uma grande quantidade de dados e informações, que podem ser armazenadas e processadas muito mais rapidamente por computador. O objetivo principal desse trabalho é o desenvolvimento de um sistema computacional baseado na técnica de redes neurais artificiais, para auxílio ao médico radiologista na confirmação de diagnóstico das chamadas lesões intersticiais pulmonares. O exame radiológico para esse grupo é de difícil interpretação mesmo para profissionais bem treinados, visto o grande número de patologias assim classificadas e a semelhança entre elas. Os dados para treinamento da rede neural são obtidos por protocolo gerado por especialistas, através da revisão de casos com diagnóstico confirmado para determinadas patologias. O sistema desenvolvido é baseado em uma rede neural do tipo perceptron multicamadas, que funciona como um classificador de padrões – dado um conjunto de dados de entrada, a saída é classificada entre determinadas patologias. Nessa pesquisa, são levantados elementos para justificar a utilização de redes neurais artificiais em sistemas de apoio ao diagnóstico, objetivando uma ferramenta confiável para o auxílio ao profissional no seu dia-a-dia, e também uma ferramenta educacional de auxílio ao treinamento e qualificação para os estudantes da área médica. / It is observed that a big growing in the use of computers as a tool to help in several areas, specially in medicine, happened in the past years. A big number of applications of these computers can be found in Medicine, such as the Diagnosis Support System, which is one of the most remarkable. These systems have as its main objective to help in the phases its activity. This process usually involves a lot of data and information, which can be stored by a computer very quickly. The most important objective of this project is the development of a computer system based in artificial neural network to help the Radiologist in the confirmation of the diagnosis of the so-called Interstitial Lung Disease. The radiological examination for this group has a difficult interpretation even to well-trained professionals, due to the big number of classified as well as similar pathologies in this area. The data for the neural net are obtained through a protocol generated by specialists, through the review of cases with confirmed diagnosis for certain pathologies. The developed system is based in a kind of multilayer perceptron neural net, which run as a classifier of patterns. A number of data is given as entry data, afterwards the exit is classified among certain pathologies. In this research, elements to justify the use of the artificial neural net in diagnosis support systems are raised, objectifying a reliable tool to help professionals who use it day by day and also as an educational tool to help in the training and qualification of medical school students.

Nos últimos tempos, observa-se um grande crescimento na utilização de computadores como ferramenta de auxílio nas mais diversas áreas, sendo a Medicina uma das principais áreas dessa utilização. Inúmeras aplicações da Informática podem ser encontradas na área médica, citando-se os sistemas de apoio ao diagnóstico como uma das mais marcantes. Esses sistemas têm como principal objetivo auxiliar o profissional da área no processo de tomada de decisões, o qual pode ocorrer em diferentes etapas de sua atividade. Esse processo normalmente envolve uma grande quantidade de dados e informações, que podem ser armazenadas e processadas muito mais rapidamente por computador. O objetivo principal desse trabalho é o desenvolvimento de um sistema computacional baseado na técnica de redes neurais artificiais, para auxílio ao médico radiologista na confirmação de diagnóstico das chamadas lesões intersticiais pulmonares. O exame radiológico para esse grupo é de difícil interpretação mesmo para profissionais bem treinados, visto o grande número de patologias assim classificadas e a semelhança entre elas. Os dados para treinamento da rede neural são obtidos por protocolo gerado por especialistas, através da revisão de casos com diagnóstico confirmado para determinadas patologias. O sistema desenvolvido é baseado em uma rede neural do tipo perceptron multicamadas, que funciona como um classificador de padrões – dado um conjunto de dados de entrada, a saída é classificada entre determinadas patologias. Nessa pesquisa, são levantados elementos para justificar a utilização de redes neurais artificiais em sistemas de apoio ao diagnóstico, objetivando uma ferramenta confiável para o auxílio ao profissional no seu dia-a-dia, e também uma ferramenta educacional de auxílio ao treinamento e qualificação para os estudantes da área médica. / It is observed that a big growing in the use of computers as a tool to help in several areas, specially in medicine, happened in the past years. A big number of applications of these computers can be found in Medicine, such as the Diagnosis Support System, which is one of the most remarkable. These systems have as its main objective to help in the phases its activity. This process usually involves a lot of data and information, which can be stored by a computer very quickly. The most important objective of this project is the development of a computer system based in artificial neural network to help the Radiologist in the confirmation of the diagnosis of the so-called Interstitial Lung Disease. The radiological examination for this group has a difficult interpretation even to well-trained professionals, due to the big number of classified as well as similar pathologies in this area. The data for the neural net are obtained through a protocol generated by specialists, through the review of cases with confirmed diagnosis for certain pathologies. The developed system is based in a kind of multilayer perceptron neural net, which run as a classifier of patterns. A number of data is given as entry data, afterwards the exit is classified among certain pathologies. In this research, elements to justify the use of the artificial neural net in diagnosis support systems are raised, objectifying a reliable tool to help professionals who use it day by day and also as an educational tool to help in the training and qualification of medical school students.

Introdução: Poucos estudos têm sido direcionados às mudanças histopatológicas nas pequenas vias áreas e seu possível papel no processo de remodelamento, nas pneumonias intersticiais idiopáticas. Objetivos: Estudar aspectos morfológicos, morfométricos e de imunohistoquímica das pequenas via aéreas na Fibrose Pulmonar Idiopática/ Pneumonia Intersticial Usual (FPI/ UIP) e Pneumonia Intersticial Não-específica (NSIP). Métodos: Foram estudadas as pequenas vias aéreas em biópsias pulmonares de 29 pacientes com FPI/ UIP e 08 com NSIP. As biópsias foram comparadas com 13 pacientes com Bronquiolite Constritiva Crônica (BC) - como controle positivo - e 10 pulmões controles normais de autópsia. Foram analisados semi e quantitativamente aspectos arquiteturais, inflamatórios, estruturais das vias aéreas, além da expressão de TGF-β, MMP -2, -7, -9, e seus inibidores (TIMP-1, -2). Resultados: Comparados com os controles, pacientes com FPI/ UIP, NSIP e BC apresentaram inflamação bronquiolar, inflamação e fibrose peribronquiolar aumentadas e áreas luminais diminuídas. Pacientes com FPI/ UIP tiveram paredes das vias aéreas mais espessadas, devido ao aumento de todos os compartimentos. Pacientes com NSIP apresentaram área do epitélio aumentada, enquanto pacientes com BC tiveram maior lâmina própria. Todos os grupos estudados demonstraram expressão epitelial bronquiolar aumentada de MMP-7 e -9 comparados ao controle. Conclusão: As pequenas vias aéreas são patologicamente alteradas e podem fazer parte do processo de remodelamento nas pneumonias intersticiais idiopáticas. / Background: Few studies have addressed small airway (SA) histopathological changes, and their possible role in the remodeling process, in idiopathic interstitial pneumonias. Objectives: To study morphological, morphometrical and immunohistochemical features of SA in Idiopathic Pulmonary Fibrosis (Usual Interstitial Pneumonia - UIP) and Non-Specific Interstitial Pneumonia (NSIP). Methods: We analyzed SA pathology in lung biopsies of 29 patients with UIP and of 8 with NSIP. Biopsies were compared with lung tissue of 13 patients with Constrictive Bronchiolitis (CB) - as a positive control - and 10 normal autopsied control lungs. We analyzed, semi-quantitatively, SA structure, inflammation, architectural features and the bronchiolar epithelial immunohistochemical expression of TGF-β, MMP -2, -7, -9, and their tissue inhibitors (TIMP-1, -2). Results: Compared to controls, patients with UIP, NSIP and CB presented increased bronchiolar inflammation, peribronchiolar inflammation and fibrosis and decreased luminal areas. UIP patients had thicker walls, due to an increase in most airway compartments. NSIP patients presented increased epithelial areas, whereas patients with CB had larger inner wall areas. All of the groups studied presented increased bronchiolar expression of MMP-7 and MMP-9, compared to the controls. Conclusion: We conclude that SA are pathologically altered and may take part in the lung remodeling process in idiopathic interstitial pneumonias.

O objetivo desse estudo foi avaliar o comprometimento de pequenas vias aéreas na Fibrose Pulmonar Idiopática (FPI) analisando curvas Pressão- Volume (PV) do sistema respiratório. Coletamos curvas PV de doze pacientes antes da biopsia pulmonar, que confirmou FPI em sete pacientes e Pneumonite de Hipersensibilidade em cinco. Todas as curvas foram ajustadas com modelo sigmóide, V = a + b / (1 + e -(P-c/d)), e exponencial V = A - B . e -k.P (aplicado apenas à parte superior). O modelo exponencial, apesar do bom ajuste à parte superior, não representou a parte inicial da curva, gerando parâmetros sem significado. O modelo sigmóide ajustou bem toda a curva e gerou parâmetros com significado fisiológico, que sugerem a presença de colapso de pequenas vias aéreas na FPI. / The objective of this study was to evaluate small airways compromise in Idiopathic Pulmonary Fibrosis (IPF) using pressure-volume (PV) curves of the respiratory system. We collected PV curves from twelve patients before lung biopsy, which confirmed IPF in seven patients and Hipersensitivity Pneumonia in five. All curves were fitted with a sigmoid model, V = a + b / (1 + e -(P-c/d)), and an exponential model, V = A - B . e -k.P (applied only to the superior part of the curve). The exponential model, despite having a good fit to the superior part of the curve, did not represent the initial part, and yielded parameters with no physiological meaning. The sigmoid model had a good fit to the entire curve and yielded parameters with physiological meaning, suggesting the presence of small airways collapse in IPF.

<p>Tuberkulos (tbc) är en luftburen droppsmitta orsakad av mykobakterium tuberkulosis. Tbc är den sjukdom som efter AIDS orsakar flest dödsfall, trots att botande behandling finns. Behandlingen är krävande för den tbc-smittade att genomgå och bygger på en kombination av en rad antibiotika som måste intas under minst sex månader. Ett avvikande i behandlingen kan resultera i att mykobakterium tuberkulosis blir resistent mot de ordinerade antibiotika. Följsamhet av långtidsbehandlingar som tbc-behandling graderas till 50 %. Syftet med litteraturstudien var att ur ett globalt perspektiv beskriva hur sjuksköterskan kan påverka följsamhet vid tbc-behandling i syfte att minska resistensutvecklingen av mykobakterium tuberkulosis. Studien genomfördes som en litteraturstudie där 12 vetenskapliga artiklar granskades och analyserades. Resultatet visar tydligt att specifika faktorer påverkar följsamhet och därigenom resistensutvecklingen. Faktorerna innefattar patientundervisning, behandlingsstrategier, omgivningens påverkan och stöd.  Undervisningen resulterar i att patienten får ökad förståelse för behandlingen. För att minska stigmatiseringen och det lidande den innebär för den tbc-smittade är även omgivningen i behov av ökad kunskap och information om tbc. Ett flertal studier visar att DOTS-strategin är betydelsefull för ökad följsamhet vid antituberkulos behandling. Litteraturstudien medför ett förslag om att sjuksköterskeprogrammet ska öka fokuseringen på följsamhet vid läkemedelsanvändning. Sjuksköterskan är i behov av att redan under grundutbildningen få kunskap om ansvarsfull antibiotikahantering som leder till en följsamhetsomtanke.</p> / <p>Tuberculosis (TB) is an airborne droplet infection caused by mycobacterium tuberculosis. TB is the disease after AIDS that is most deadly, even though curative treatment exists. The treatment is demanding for the TB-infected to undergo and consists of a combination of a number of antibiotics that must be administered for at least six months. A dissenting in anti-tuberculosis treatment might result in mycobacterium tuberculosis strains that are resistant to antibiotics. As adherence to long-term treatment is graded at a low percentage (50 %) the aim of the literature study was from a global perspective to develop a working-strategy for nurses that promote compliance in TB-treatment in order to reduce resistance development of mycobacterium tuberculosis. The study was conducted as a literature study where 12 research articles were reviewed and analyzed. The results describe specific factors that are essential to compliance. These factors comprise patient education, treatment strategies, social influences and support. As knowledge gives the patient a better understanding for the treatment it provokes compliance. The social environment of the TB-infected patient demands increased knowledge in order to reduce stigma. Several studies show that the DOTS strategy is important for increasing compliance in anti-tuberculosis treatment. The literature study results in a proposal for the nursing program to focus more on compliance in taking medication. The nursing program’s attendants need to gain knowledge about prudent antibiotic treatment that leads to a compliance concern.</p>

Background: Patients with sleep apnea have frequent apneas and hypopneas during sleep. Apneas can be either central or obstructive. The apnea-hypopnea index (AHI) is the mean number of apneas and hypopneas per hour of sleep. Aims: 1) To evaluate the effect of a mandibular advancement device on obstructive apneas and sleep; 2) to evaluate the influence of body position on central apnea frequency; 3) to investigate whether obstructive or central apnea is related to mortality in patients with stroke; and 4) to investigate sleep and sleeping positions in women. Methods: Subjects were investigated during whole-night sleep respiratory recordings, either polysomnography including continuous recordings of EEG, EOG, EMG, airflow, respiratory effort, ECG, pulse oximetry and body position, or simplified sleep apnea recordings without EEG, EOG and EMG. Results: The frequency of obstructive apneas, hypopneas and arousals decreased and rapid eye movement (REM) sleep increased in patients with mild, moderate and severe sleep apnea during treatment with a mandibular advancement device. Central apneas were more prevalent in the supine position compared with the non-supine position in patients with Cheyne-Stokes respiration. The mean ± SD central AHI was 41 ± 13 in the supine position and 26 ± 12 in the non-supine position, p&lt;0.001. Stroke patients with obstructive sleep apnea ran an increased risk of death during 10 ± 0.6 years of follow-up with an adjusted hazard ratio of 1.76 (95% CI 1.05-2.95) compared with controls, independent of hypertension, age, body mass index, gender, smoking, diabetes mellitus, atrial fibrillation, Mini-Mental State Examination and Barthel-ADL. Central apnea was not related to early death. Total sleep time, sleep efficiency, rapid eye movement sleep, slow wave and time in the supine position decreased with age in women. Sleep quality in women was reduced with age, body mass index, obstructive sleep apnea, smoking, alcohol and hypertension. Conclusions: Obstructive sleep apneas and arousals are reduced and REM sleep is increased using a mandibular advancement device in patients with mild, moderate and severe sleep apnea. The frequency of central apneas and hypopneas is increased in the supine position in patients with Cheyne-Stokes respiration. Stroke patients with obstructive sleep apnea run an increased risk of early death. Central sleep apnea was not related to early death among the present patients. Normal values for sleep stages and sleeping positions are presented in a population-based sample of women. Age, body mass index, obstructive sleep apnea, smoking, alcohol and hypertension reduce sleep quality in women.

Background: Tobacco smoking is the main cause of chronic obstructive pulmonary disease, COPD, but the mechanisms by which cigarette smoke induces COPD are still elusive. T lymphocytes have been implicated in the pathogenesis of the disease, but their role in the airway inflammation in COPD is not fully understood. The aim of this thesis was therefore to address T lymphocyte subsets and their activation in the airways of subjects with COPD, in comparison to smokers with normal lung function (S) and never smokers (NS). Methods: Subjects with moderate to severe COPD were recruited along with controls. They were all non-atopic and clinically stable, without any exacerbation during at least three months prior to inclusion. Only medication with short-acting β2-agonists and/or anti-cholinergic drugs was permitted. All subjects underwent bronchoscopy with endobronchial mucosal biopsy sampling as well as bronchial wash, BW, and bronchoalveolar lavage, BAL, collection. Biopsies were immunohistochemically stained for inflammatory cells and markers. BW and BAL fluids were prepared for differential cell counts. Soluble markers were measured in BW and lymphocyte subsets were determined in BAL using flow cytometry. Results: In biopsies, an increase in epithelial CD3+ and CD8+ cells was found in COPD, compared to NS. In BAL fluid, CD8+ cells were enhanced, whereas CD4+ cells were reduced in subjects with COPD and S, compared to NS. Furthermore, CD4+ and CD8+ cells were more activated both in COPD and S, in terms of increased expression of CD25, CD69 and HLA-DR. NKG2D-expressing CD8+ T cells in BAL fluid were enhanced in both COPD and S. CD4+CD25bright cells were upregulated in COPD and S, suggesting the presence of regulatory T cells. Further analyses of T cell subsets with the more specific markers for regulatory T cells, FoxP3 and CD127, indicated a smoking-induced expansion of non-regulatory T cells, which tended to normalize after smoking cessation in COPD. Currently smoking subjects with COPD still expressed high proportions of activated non-regulatory CD4+ T cells. The data on FoxP3 expression further indicated that the increase in CD25 expression in COPD and S was not only associated with the expansion of regulatory T cells. As CD127 expression is reported to be inversely associated with FoxP3, the data indicate the expansion of a non-regulatory CD25+ population in smokers and patients with stable COPD. The immunohistochemical staining for the NKG2D ligands MICA and MICB on epithelial cells was unchanged. Conclusion: The results of this thesis suggest a role for CD4+ and CD8+ T-cells in clinically stable COPD, indicating that T-cells are of importance in the long-term inflammatory response in COPD. Regardless of current smoking habits, activated CD8+ T lymphocytes were found to be increased in BAL fluid from subjects with COPD, suggesting that changes in CD8+ T cells are associated with a persistent immune response and, thus, of importance in COPD pathogenesis. In contrast, the expansion of non-regulatory CD25+CD4+ cells in BAL fluid seemed to be preferentially smoke-related. In summary, the data indicate that, among airway T cells, changes in CD8+ cells seem to be highly associated with COPD pathogenesis, whereas changes in CD4+ cells appear to be related to cigarette smoke-induced responses. Further, a non regulatory population of helper T cells was identified in BAL fluid of COPD patients, which may contribute to the persistent cytotoxic T cell responses.

Reactive airways dysfunction syndrome (RADS), a form of irritant-induced asthma (IIA) has been observed in humans following acute chlorine (Cl 2) gas exposure in occupational and domestic settings. Following Cl 2 injury, subepithelial fibrosis, mucous hyperplasia, and non-specific airway hyperresponsiveness have been reported. Based on the disease profile, we hypothesized that pulmonary damage may be oxidative in nature. / The aim of this work was to develop a murine model of irritant-induced asthma in order to investigate the pathogenic processes and potential oxidative mechanisms involved in response to Cl2 exposure, with a secondary aim of examining the role of iNOS in response to Cl2 inhalation. / A/J, C57BI/6J (wild type) and iNOS-1- mice exposed to various concentrations of Cl2 were mechanically ventilated for measurement of lung mechanics and responses to i.v. methacholine (MCh). Bronchoalveolar lavage was performed to examine total protein, cell populations and nitrate/nitrates. Tissues were harvested for histology and immunocytochemistry for iNOS, 3NT and carbonyl residues. To examine the role of iNOS, a subset of animals were treated with a selective iNOS inhibitor (1400W) and non-selective NOS inhibitor LNAME. / Chlorine exposure caused airway hyperresponsiveness, which appeared to be mitigated by iNOS blockade with 1400W, however this was not the case in iNOS-1- mice. Cl2 exposure also caused increases in total BAL protein, total cells, NOx, neutrophils, iNOS, 3NT and carbonyl residues. / In conclusion, chlorine exposure causes lung injury, similar to reactive airways dysfunction syndrome, characterized by airway hyperresponsiveness, epithelial sloughing, inflammatory cell influx, oxidative injury and increases in both the activity and expression of iNOS. Chlorine-induced airway hyperresponsiveness is mitigated, in part, by selective blockade of iNOS with the use of pharmacological intervention.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 5 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 6 uppsatser.