Background: Community acquired pneumonia (CAP) is a high incidence disease resulting in about 260,000 hospital admissions per year in Germany, more than myocardial infarction or stroke. Worldwide, CAP is the most frequent infectious disease with high lethality ranging from 1.2 % in those 20–29 years old to over 10 % in patients older than 70 years, even in industrial nations. CAP poses numerous medical challenges, which the PROGRESS (Pneumonia Research Network on Genetic Resistance and Susceptibility for the Evolution of Severe Sepsis) network aims to tackle: Operationalization of disease severity throughout the course of disease, outcome prediction for hospitalized patients and prediction of transitions from uncomplicated CAP to severe CAP, and finally, to CAP with sepsis and organ failure as a life-threatening condition. It is a major aim of PROGRESS to understand and predict patient heterogeneity regarding outcome in the hospital and to develop novel treatment concepts. Methods: PROGRESS was designed as a clinical, observational, multi-center study of patients with CAP requiring hospitalization. More than 1600 patients selected for low burden of co-morbidities have been enrolled, aiming at a total of 3000. Course of disease, along with therapy, was closely monitored by daily assessments and long-term follow-up. Daily blood samples allow in depth molecular-genetic characterization of patients. We established a well-organized workflow for sample logistics and a comprehensive data management system to collect and manage data from more than 50 study centers in Germany and Austria. Samples are stored in a central biobank and clinical data are stored in a central data base which also integrates all data from molecular assessments. Discussion: With the PROGRESS study, we established a comprehensive data base of high quality clinical and molecular data allowing investigation of pressing research questions regarding CAP. In-depth molecular characterization will contribute to the discovery of disease mechanisms and establishment of diagnostic and predictive biomarkers. A strength of PROGRESS is the focus on younger patients with low burden of co-morbidities, allowing a more direct look at host biology with less confounding. As a resulting limitation, insights from PROGRESS will require validation in representative patient cohorts to assess clinical utility. Trial registration: The PROGRESS study was retrospectively registered on May 24th, 2016 with ClinicalTrials.gov: NCT02782013

The increasing diversity of the United States creates a pressing public health need to investigate methods to increase the engagement, retention, and efficacy of mental health services for racial/ethnic minority (REM) youth. Evidence from the adult psychotherapy treatment literature suggests that enhancing therapist cultural competence leads to increases in client satisfaction, alliance, and retention (Constantine, 2002; Sodowsky, Kuo-Jackson, Richardson, & Corey, 1998; Worthington, Soth-McNett, & Moreno, 2007). However, this relationship has not been adequately explored in youth mental health services, due in part, to a lack of valid and reliable measurement. This research project included measure development and initial validation of the Youth Therapist Observational Cultural Competence Scale (YTOCCS) with the aim of creating an observer-rated measure of youth therapist cultural competence. The measure was developed from a review of the theoretical and empirical literature and integrated the surveyed opinions of practicing child therapists, caregivers of REM children involved in the mental health system, and experts in therapist cultural competence. The study used an extreme group design based on child-therapist alliance selecting 32 recordings of 8 unique child-therapist dyads. Three coders were trained using a standardized manual and independently double coded early treatment sessions from an effectiveness trial for individual child cognitive-behavioral therapy conducted in community clinics. The measure demonstrated good reliability as measured by intraclass correlation coefficient, adequate internal consistency, and evidence supported initial validity through demonstrated significant between-group differences. Future studies are warranted to refine the measure and to explore the factor structure of the measure.

Les observations des supernovae, du fond diffus cosmologique, et plus récemment la mesure des oscillations acoustiques des baryons et des effets de lentilles gravitationnelles faibles, favorisent le modèle cosmologique LambdaCDM pour lequel l'expansion de l'Univers est actuellement en accélération. Ce modèle fait appel à deux composants insaisissables, la matière sombre et l'énergie sombre. Deux approches semblent particulièrement prometteuses pour sonder à la fois la géométrie de l'Univers et la croissance des structures de matière noire, l'analyse des distorsions faibles des galaxies lointaines par cisaillement gravitationnel et l'étude des oscillations acoustiques des baryons. Ces deux méthodes demandent de très grands relevés du ciel, de plusieurs milliers de degrés carrés, en imagerie et en spectroscopie. Dans le contexte du relevé spectroscopique de la mission spatiale EUCLID, dédiée à l'étude des composantes sombres de l'univers, j'ai réalisé des simulations pixels permettant l'analyse des performances instrumentales. La méthode proposée peut se résumer en trois étapes. La première étape est de simuler les observables, c'est à dire principalement les sources du ciel. Pour cela j'ai développé une nouvelle méthode, adapté à la spectroscopie, qui permet d'imiter un relevé existant, en s'assurant que la distribution des propriétés spectrales des galaxies soit représentative des observations actuelles, en particulier la distribution des raies d'émission. La seconde étape est de simuler l'instrument et de produire des images équivalentes aux images réelles attendues. / The observations of the supernovae, the cosmic microwave background, and more recently the measurement of baryon acoustic oscillations and the weak lensing effects, converge to a LambdaCDM model, with an accelerating expansion of the today Universe. This model need two dark components to fit the observations, the dark matter and the dark energy. Two approaches seem particularly promising to measure both geometry of the Universe and growth of dark matter structures, the analysis of the weak distortions of distant galaxies by gravitational lensing and the study of the baryon acoustic oscillations. Both methods required a very large sky surveys of several thousand square degrees. In the context of the spectroscopic survey of the space mission EUCLID, dedicated to the study of the dark side of the universe, I developed a pixel simulation tool for analyzing instrumental performances. The proposed method can be summarized in three steps.The first step is to simulate the observables, ie mainly the sources of the sky. I work up a new method, adapted for spectroscopic simulations, which allows to mock an existing survey of galaxies in ensuring that the distribution of the spectral properties of galaxies are representative of current observations, in particular the distribution of the emission lines. The second step is to simulate the instrument and produce images which are equivalent to the expected real images. Based on the pixel simulator of the HST, I developed a new tool to compute the images of the spectroscopic channel of EUCLID. The new simulator have the particularity to be able to simulate PSF with various energy distributions and detectors which have different pixels

Introduktion: Hypotermi innebär att patientens kärntemperatur är under 36 grader. Alla patienter riskerar att bli hypoterma vid kirurgiska ingrepp om inga förebyggande åtgärder utförs. Det går att förebygga hypotermi med antingen värmetillförande åtgärder eller genom att bibehålla patientens normala temperatur. Hypotermi kan leda till komplikationer för patienten så som sämre sårläkning, postoperativa sårinfektioner, ökad risk för trycksår, hjärtproblem och ökad blödningsbenägenhet. Trots att studier har visat på kunskap om ämnet är hypotermi vanligt förekommande vid kirurgiska ingrepp. Syfte: Syftet med studien var att undersöka i vilken utsträckning omvårdnadsåtgärder utfördes av operationsteamet för att förebygga hypotermi intraoperativt. Metod: Studien var en kvantitativ strukturerad observationsstudie. Data samlades in under 43 operationer på två sjukhus i södra Sverige. Observationerna utgick från ett protokoll som skapades utefter AORN (Association of perioperative registered nurses) och NICE:s (National institute for health och care excellence) riktlinjer och innehöll 12 förebyggande omvårdnadsåtgärder för att förhindra hypotermi. Resultat: Samtliga patienter fick varma täcken och varma intravenösa vätskor. All personal följde WHO:s checklista och majoriteten undvek att exponera patienten i onödan. Omvårdnadsåtgärder som inte utfördes lika frekvent var varmluftstäcke, varma spolvätskor, fot och benvärmare samt temperaturmätning på patienten. Aluminiumtäcke, värmemadrass, värmemössa och varm huddesinfektion användes aldrig. På de patienter som en temperatur togs på hade omvårdnadsåtgärderna en god effekt då majoriteten av patienterna inte längre var hypoterma i slutet av den intraoperativa fasen. Slutsats: Operationsteamet använde sig alltid av förebyggande omvårdnadsåtgärd för att förhindra hypotermi, några i högre utsträckning än andra. Några patienter var fortfarande hypoterma i slutet av den intraoperativa fasen vilken kan tyda på att en förbättring skulle kunna ske på de omvårdnadsåtgärder som inte användes lika frekvent. / Introduction: The definition of hypothermia is when the patients core temperature is below 36 degrees. All the patients have an increased risk of becoming hypothermic during surgical procedures if no preventive measures are taken. Hypothermia is preventable with either heat inducing measures or by maintaining the patient’s normal temperature. Hypothermia can lead to complications for the patients such as impaired wound healing, Increased risk of postoperative wound infection, increased risk of bedsores, heart conditions and increased tendency to bleed. Although studies have shown knowledge of this topic hypothermia is a common occurrence in surgical procedures. Aim: The aim of this study was to investigate in which extension nursing measures were used by the operations team to prevent hypothermia intraoperatively. Method: The study was a quantitative structured observational study. Data was collected during 43 operations at two hospitals in southern Sweden. The observations followed a protocol that was created along AORN (Association of perioperative registered nurses) and NICE: s (National institute for health and care excellence) recommendations and contained 12 nursing measures to prevent hypothermia. Result: All the patients received warm blankets and warm intravenous fluids. All the operating staff used the WHO: s checklist and the majority avoided unnecessary patient exposure. The nursing measures that were used less frequently were warm air blankets, feet-and leg warmers and temperature measurement on the patient. Aluminum blankets, heating mattress, heat caps and warm skin antisepsis were never used. On the patients of whom a temperature was taken, the nursing measures had a good effect since the majority of the patients were no longer hypothermic at the end of the intraoperative phase. Conclusion: The operation team always used care measures to prevent hypothermia, some to a greater extent than others. Some patients were still hypothermic at the end of the intraoperative phase, which may indicate that an improvement could occur in the nursing measures that weren’t used as frequently.

Introdução: A obesidade é uma doença crônica de incidência global e crescente que se tornou nas últimas décadas um dos maiores problemas de saúde pública nas sociedades urbanas. A intervenção cirúrgica, ou cirurgia bariátrica, tem sido apontada como eficaz no tratamento das formas graves de obesidade e a derivação gástrica em Y de Roux (DGYR) é o tipo mais realizado no mundo e no Brasil. O acompanhamento contínuo de todos os indivíduos submetidos à DGYR por equipe multidisciplinar é recomendado por se tratar de uma cirurgia de grande porte com riscos de complicações em longo prazo, entre elas as deficiências nutricionais. Por isso, as consultas nutricionais pós-operatórias são um componente importante desse seguimento. Objetivos: Estimar a prevalência de adesão ao seguimento nutricional ambulatorial pós-cirurgia bariátrica e avaliar a associação dessa adesão com fatores selecionados em um grupo de obesos moderados com comorbidades e obesos mórbidos submetidos à DGYR. Métodos: Estudo de coorte retrospectiva utilizando-se dados de prontuários hospitalares de 241 adultos de ambos os sexos submetidos à derivação gástrica pelo Sistema Único de Saúde entre 2006 e 2008 no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Considerou-se aderente o indivíduo que compareceu a quatro ou mais consultas nutricionais nos 12 primeiros meses após a cirurgia. Para estimar a associação da adesão ao seguimento nutricional pós-cirúrgico com os fatores idade, sexo, estado conjugal, escolaridade, situação empregatícia, distância entre a residência e o hospital, estratégias para perda de peso no período pré-operatório, índice de massa corpórea (IMC) no précirúrgico imediato, presença de comorbidades e duração da internação após a cirurgia, foram calculadas as Razões de Prevalência (RP) e os intervalos de 95% de confiança (IC 95%); para a análise ajustada utilizou-se regressão múltipla de Poisson. Resultados: A população de estudo foi caracterizada pelo predomínio de mulheres (80,9%), pela média de idade de 44,4 anos (±11,6), pela média de IMC pré-operatório de 47,2kg/m2 (±6,16) e 78,4% dos participantes apresentaram uma ou mais comorbidades. Convivência com companheiro foi relatada por 51,5% da população, 41,9% referiram ter ensino fundamental incompleto como nível de escolaridade, 50,9% não possuíam atividade remunerada, 44,7% residiam à distância de até 16 km do hospital e 11,6% ficaram internados por seis ou mais dias após a cirurgia. A prevalência de adesão nessa população foi de 56,0% (IC 95% 49,7-62,3). A análise multivariada revelou que somente duração da internação maior ou igual a seis dias foi associada à adesão ao seguimento nutricional pós-cirúrgico (RP=1,46 IC 95% 1,15-1,86). Conclusões: A prevalência de adesão encontrada nesta população foi semelhante às dos estudos internacionais, mas menor do que a prevalência mínima de 75% recomendada para que o centro seja reconhecido como de excelência em cirurgia bariátrica. Os indivíduos que ficaram internados por mais tempo no pós-cirúrgico mostraram-se significantemente mais aderentes ao seguimento nutricional, podendo sugerir que o maior contato desses com a equipe multiprofissional pode ter contribuído para aumentar a percepção da gravidade da doença e da necessidade de cuidados contínuos com a saúde, e consequentemente ter levado à maior assiduidade às consultas ambulatoriais / Introduction: Obesity is a global chronic disease with increasing incidence during the past decades and has become one of the major public health problems in the urban societies. The surgical intervention, or bariatric surgery, has been considered as an effective treatment of the severe forms of obesity and the Roux-en-Y gastric bypass (RYGB) has been the commonest surgical procedure worldwide, including in Brazil. The long term outpatient postoperative follow up after bariatric surgery by a multidisciplinary team has been recommended to all individuals submitted to RYGB because it is a major surgery which can cause complications such as nutritional deficiencies. Therefore, nutritional assessment in the postoperative period is an important component of the follow up. Objectives: To estimate the prevalence of adherence to outpatient postoperative nutritional follow up after bariatric surgery and to analyze the association between adherence and selected factors in a group of moderately obese with comorbidities and morbidly obese adults who underwent RYGB. Methods: Retrospective cohort study using data from hospital records of 241 adults of both sexes who were submitted to RYGB by the Unified Health System between 2006 and 2008 at the Hospital das Clínicas - Medical School, University of São Paulo. It was considered adherent the individuals who attended four or more nutritional appointments in the first 12 months after surgery. To estimate the association between adherence to postoperative nutritional follow up and factors such us age, sex, marital status, education, employment status, distance between home and hospital, strategies for weight loss in the preoperative period, body mass index (BMI) in the immediate pre-surgical, presence of comorbidities and duration of hospitalization after surgery, were calculated the Prevalence Ratios (PR) and the 95% confidence intervals (95% CI); for the adjusted analysis, Poisson multiple regression was used. Results: The study population was characterized by the predominance of women (80.9%), the mean age of 44.4 years (±11.6), the mean of preoperative BMI of 47.2kg/m2 (±6.16) and 78.4% of participants presented one or more comorbidities. Living with partner was reported by 51.5% of the population, 41.9% had incomplete primary education level, 50.9% had no paid work, 44.7% lived at a distance of up to 16km to the hospital and 11.6% were hospitalized for six or more days after surgery. The prevalence ratio of adherence in this population was 56.0% (95% CI 49.7- 62.3). Multivariate analysis revealed that only length of hospital stay greater than or equal to six days was associated with adherence to nutritional follow up in the postoperative period (PR=1.46 95% CI 1.15-1.86). Conclusions: The prevalence of adherence found in this population was similar to those of international studies, but less than the minimum prevalence of 75% recommended for services to be recognized as a bariatric surgery center of excellence. Individuals who were hospitalized for longer than six days after surgery were significantly more adherent to the nutritional follow-up. This may have happened because they had longer contact with the multidisciplinary team which may have contributed to increase their perception of disease severity and the need for long term health care, and consequently, it may have led to higher assiduity to the nutritional appointments

Variações temporais na tensão de cisalhamento do vento, na Plataforma Continental Sudeste do Brasil (PCSE), perturbam o equilíbrio geostrófico gerando movimentos com frequências próximas à inercial local. Estas perturbações se propagam horizontalmente e verticalmente, interagindo com o fluxo médio e alterando as características hidrográficas e hidrodinâmicas. Foram analisados dados observacionais de corrente, registrados por correntógrafos fundeados às isóbatas de 50 m e 100 m, ao largo de Arraial do Cabo (RJ) e Ubatuba (SP), de vento registrados por bóias meteorológicas e de salinidade e temperatura perfilados em função da profundidade em estações hidrográficas, obtidos no âmbito do Projeto DEPROAS (Dinâmica do Ecossistema de Plataforma da Região Oeste do Atlântico Sul), entre 2001 e 2002. Os resultados das análises indicaram que a média de duração dos eventos de oscilações inerciais é 7,5 dias com desvio padrão de 3,8 dias, sendo 6,8 o número médio de oscilações em cada evento (desvio padrão de 3,3 oscilações). O período inercial efetivo médio foi calculado em 26,5 h com deslocamento médio da frequência inercial em 12,2%, devido ao desvio Doppler causado pelas interações com a vorticidade relativa do fluxo básico. As correntes inerciais horizontais, filtradas a partir das séries correntográficas, apresentaram valores entre 3 e 10 cm/s. Foi observada propagação vertical das oscilações inerciais e calculado o valor da velocidade de grupo vertical em -2,59 .10-2 cm.s-1. A partir desse resultado, foi obtido o valor de 28,3 m de profundidade para o valor máximo de velocidade vertical das partículas de água na onda interna inercial forçada pela oscilação das isotermas, em acordo com resultados observados de máxima corrente inercial logo abaixo da camada de mistura. O valor calculado para a amplitude da oscilação vertical das isotermas foi 17,2 m, próximo aos 19 m registrado com os resultados observacionais em períodos de mudança do campo de ventos. O modelo numérico hidrodinâmico ROMS (Regional Ocean Modelling System) comprovou resultados observacionais em relação à capacidade de mudanças na tensão de cisalhamento do vento, em períodos menores que o inercial local, gerarem oscilações inerciais. Os resultados numéricos com o ROMS permitiram analisar a interação das oscilações inerciais com o fluxo médio em diferentes regiões da PCSE, através de diferentes condições de estratificação da coluna de água e, a partir da trajetória de pseudoderivadores, estimar os raios das trajetórias com ordem 10 km. / Temporal variations in the wind stress, on the South Brazil Bight, disturb the geostrophic equilibrium and generate motion with near inertial frequencies. The disturbances propagate horizontally and vertically, interacting with the basic motions and altering the hydrodynamics and hydrographic characteristics. Observational data of currents, collected by currentmeters deployed in the 50 m and 100 m isobaths, offshore Arraial do Cabo (RJ) and Ubatuba (SP), of winds collected in meteorological buoys and of salinity and temperature vertically profiled in hydrographic stations, during the project DEPROAS (Dinâmica do Ecossistema de Plataforma da Região Oeste do Atlântico Sul), in the years of 2001 and 2002, have been analyzed. Results showed that the mean duration of the inertial oscillations events is 7.5 days, with standard deviation of 3.8 days, being 6.8 the mean number of oscillations in each event (standard deviation of 3.3 oscillations). The calculated mean effective inertial period is 26.5 h, with a mean difference of the local inertial frequency of 12.2% due to the Doppler shift caused by interactions with the relative vorticity of the basic flow. The horizontal inertial currents, filtered from the current time series, presented values between 3 and 10 cm/s. Vertical propagation of the inertial oscillations were observed and the calculated value for the vertical group velocity was -2.59 . 10-2 cm/s. From these results, the calculated value for the depth of maximum water vertical velocity was 28.3 m for the internal inertial wave forced by the isotherms oscillations, in accordance with results observed of maximum vertical velocities occurring below the mixing layer. The calculated value for the amplitude of vertical oscillations of isotherms was 17.2 m, approximately equal to the 19 m observed in the data set during periods of wind shift. The numerical hydrodynamical model ROMS (Regional Ocean Modeling System) confirmed the observational results that changes in the wind field with periods smaller than the local inertial period generate inertial oscillations. The numerical results with ROMS allowed to analyze the interaction between the inertial oscillations and the basic flow in different regions of the South Brazil Bight, due to vertical different stratification characteristics of the sea water, and from the trajectories of pseudo-drifters it was possible to estimate the radius of the trajectories as having order of magnitude of 10 km.

La médecine fondée sur les preuves a conféré à l’essai contrôlé randomisé (ECR) le plus haut niveau de preuve dans l’évaluation de l’effet des médicaments, et par extension de toute intervention en santé. Cependant, le recours aux études observationnelles s’avère également nécessaire (i) pour conforter, en situation réelle, les résultats issus des ECR dont la validité externe est limitée, (ii) dans des situations, notamment lorsqu’il s’agit d’interventions complexes, où l’ECR n’est pas toujours réalisable pour des questions éthiques et/ou organisationnelles. Toutefois, les études observationnelles sont sujettes à différents types de biais, et notamment au biais d’indication. Ce travail de thèse explore les différentes techniques d’analyse statistique des résultats permettant de maîtriser ce biais. Dans une première partie, les aspects théoriques ont été abordés. Les différentes techniques disponibles ont été identifiées, analysées et comparées : les techniques d’ajustement multivarié, celles utilisant un score de propension (SP) et celles utilisant une variable instrumentale (VI). Pour approfondir les connaissances sur la question, une revue systématique de la littérature a été effectuée. Elle a mis en évidence la faible concordance entre les résultats obtenus en utilisant un SP et ceux obtenus en utilisant une VI, lorsque ces deux techniques étaient utilisées dans une même étude pour évaluer la même intervention. Dans une seconde partie, l’utilisation de SP et/ou VI a été testée dans trois exemples d’évaluation d’interventions complexes à partir de données de pratiques courantes recueillies dans le cadre de deux études observationnelles de cohorte : (i) l’évaluation de l’effet d’un réseau de soins spécialisé dans l’insuffisance cardiaque (IC) sur la mortalité ; (ii) l’évaluation de l’effet des stratégies médicamenteuses appropriées dans l’IC sur la mortalité ; (iii) l’évaluation de l’effet des stratégies antithrombotiques chez les patients hémodialysés sur le risque hémorragique. / Evidence-based medicine placed randomized controlled trials (RCT) at the highest level of evidence to evaluate the effects of medications and, by extension, of all health interventions. Nevertheless, observational studies are necessary (i) to support, in real-world settings, the results of RCTs, the external validity of which is limited, and (ii) in situations where RCTs are not feasible for ethical or practical reasons, particularly when evaluating complex interventions. However, observational studies are particularly prone to confounding by indication. This thesis focuses on analytical methods to reduce this bias. In its first part, the theoretical aspects were addressed. Available methods were identified, reviewed and compared: multivariate adjustment methods, methods using a propensity score (PS) and methods using an instrumental variable (IV). To further knowledge on this issue, a systematic literature review was performed. This review revealed that more and more observational studies simultaneously use PS and IV approaches to evaluate the same intervention, often leading to nonconcordant results that may be dif?cult to interpret. In a second part, the use of PS and/or VI methods was tested in three evaluations of complex interventions in real-world settings, using data from two cohort studies: (i) to evaluate the effectiveness on mortality of a community-based multidisciplinary disease management programme for heart failure (HF) patients; (ii) to evaluate the effectiveness of recommended drug prescriptions on mortality in patients with HF; (iii) to evaluate the effect of antiplatelet and anticoagulant therapies on the risk of major bleeding events in chronic hemodialysis patients

Introdução: Desde a década de 1960 diversos estudos tentam demonstrar o efeito do envelhecimento na motilidade esofágica, com resultados e populações estudadas discordantes. Objetivos: Avaliar os resultados manométricos em pacientes idosos (>= 60 anos) e comparálos com os achados manométricos de pacientes < 60 anos, correlacionando-os com dados clínicos e exames diagnósticos. Analisar os resultados manométricos do grupo idoso estratificando-os por década e compará-los entre si e com os resultados do grupo não idoso. Métodos: Estudo transversal, retrospectivo, realizado em hospital terciário da cidade de São Paulo, com avaliação de prontuários dos pacientes que realizaram manometria esofágica de janeiro de 2003 a dezembro de 2011. Foram incluídos: idosos (>= 60 anos) e controles não idosos ( < 60 anos) de ambos os sexos. Os critérios de inclusão foram idade >= 18 anos com indicação para manometria esofágica. Foram excluídos se submetidos à cirurgia prévia do trato gastrointestinal (gastrectomia, esofagectomia, miotomia esofágica, fundoplicatura), à procedimentos endoscópicos prévios (dilatação esofágica, injeção de toxina botulínica) e/ou ausência de endoscopia digestiva alta prévia até um ano antes do procedimento. Esses foram avaliados quanto ao sexo, queixa principal para indicação da manometria esofágica, comorbidades, medicações em uso, tabagismo, etilismo, e resultado da endoscopia, da manometria esofágica e da pHmetria de 24 horas. Os dados estatísticos foram analisados com o software SPSS versão 19. Resultados: O estudo incluiu 1175 pacientes (936 idosos e 239 não idosos) com idade entre 19 a 92 anos, sendo 76,5% do sexo feminino no grupo idoso e 72,8% no não idoso. Eram tabagistas ativos 6,1% no grupo idoso e 15,5% no não idoso. Os grupos não diferiram quanto ao etilismo (p=0,412). Disfagia (20,7%) e tosse (12%) foram as queixas mais frequentes no grupo idoso e pirose (57,3%), regurgitação (28,5%) e disfonia (13,8%) no não idoso. Hipertensão Arterial Sistêmica, dislipidemia, osteoartrose, osteoporose, Diabetes Melito, cardiopatia, neoplasia e dispepsia foram as doenças mais frequentes no grupo idoso, e pacientes sem doenças no não idoso. Outros medicamentos, diuréticos, inibidores da enzima conversora da angiotensina, antiinflamatórios não-esteroidais, ácido acetil salicílico, hipoglicemiante, ?-bloqueador, bloqueador do canal do cálcio, hipolipemiante, bifosfonado e cálcio foram as medicações mais frequentes utilizadas por idosos, e nenhuma medicação mais frequente no grupo não idoso. Hérnia hiatal e outros achados foram os resultados de endoscopia do grupo idoso mais frequentes, e resultado Normal e esofagite erosiva grau I de Savary-Miller mais frequentes no não idoso. Na pHmetria, o grupo idoso apresentou médias maiores de DeMeester e % total do tempo com pH < 4,0. Os resultados de exame de Manometria relaxamento do esfíncter inferior do esôfago normal (91,1% vs 84,8%) e peristalse normal (87,4% vs 76%) foram mais frequentes no grupo não idoso. Na conclusão da manometria foram encontrados: Acalásia em 5,9% no grupo idoso e 2,9% no não idoso; Distúrbio Hipercontrátil em 10,4% no grupo idoso e 9,2% no não idoso; Distúrbio Hipocontrátil em 47,6% no grupo idoso e 28,5% no não idoso; e resultado Normal em 36,1% no grupo idoso e 49,4% no não idoso. Quando estratificados por década, os grupos evidenciaram resultados semelhantes à comparação entre idoso e não idoso quanto ao sexo, tabagismo, etilismo, queixas principais, doenças associadas, medicações em uso, e resultados da endoscopia, da pHmetria e da manometria (menor percentual de resultado Normal e maior percentual de Distúrbio Hipocontrátil no grupo idoso; p=0,007). Mesmo quando se excluiu as variáveis que poderiam alterar a motilidade esofágica e as que apresentaram diferença estatisticamente significativa, em relação à conclusão da manometria, se manteve o menor percentual de resultado Normal e maior percentual de Distúrbio Hipocontrátil no grupo idoso em relação ao não idoso. Conclusão: O grupo idoso em relação ao não idoso evidenciou menor percentual de pressão média do corpo esofágico, peristalse normal e relaxamento do esfíncter inferior do esôfago normal. Quanto à conclusão da manometria o grupo idoso apresentou menor percentual de resultado Normal e maior de Distúrbio Hipocontrátil. Mesmo após exclusão das variáveis que poderiam alterar a motilidade esofágica a diferença quanto à conclusão da manometria se manteve. Na estratificação por década (\"60 a 69 anos\", \"70 a 79 anos\" e \">= 80 anos\") na conclusão da manometria houve menor percentual de resultado Normal e maior de Distúrbio Hipocontrátil em relação aos não idosos, porém os grupos idosos não diferiram entre si / Introduction: Since the 1960 several studies attempt to demonstrate the effect of aging on esophageal motility, with results and dissenting populations studied. Objectives: to evaluate the manometric results in elderly patients ( >= 60 years) and compare them with the manometric findings of patients < 60 years, correlating with clinical data and diagnostic tests. Analyze the manometric results of the elderly group stratifying them by decade and compare them with each other and with the non-elderly group. Methods: a retrospective, cross-sectional study, conducted in a tertiary hospital in the city of São Paulo, with evaluation of medical records of patients who performed esophageal manometry of January 2003 to December 2011. Were included: elderly ( >= 60 years) and non-elderly controls ( < 60 years) of both sexes. Inclusion criteria were age >= 18 years with an indication for esophageal manometry. Were excluded if prior surgery of the gastrointestinal tract (gastrectomy, esophagectomy, esophageal myotomy, fundoplication), the prior endoscopic procedures (esophageal dilation, injection of botulinum toxin) and/or absence of upper gastrointestinal endoscopy prior to one year before the procedure. These were assessed as to sex, chief complaint about indication of esophageal manometry, comorbidities, medications in use, smoking, alcoholism, and result of the endoscopy, esophageal manometry and pHmetry. The statistical data were analyzed with SPSS software version 19. Results: the study included 1175 patients (936 elderly and 239 non-elderly) aged between 19 to 92 years, with 76.5% female in the elderly group and 72.8% in the non-elderly. Were smokers 6.1% in the elderly group and 15.5% in the non-elderly. The groups did not differ with regard to alcoholism (p = 0.412). Dysphagia (20.7%) and cough (12%) were the most frequent complaints in the elderly group and heartburn (57.3%), regurgitation (28.5%) and dysphonia (13.8%) in the non-elderly. Hypertension, dyslipidemia, osteoarthritis, osteoporosis, Diabetes Mellitus, heart disease, neoplasia, and dyspepsia were the most frequent diseases in the elderly group and patients without disease in non-elderly. Other medications, diuretics, angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory medications, acetylsalicylic acid, hypoglycemic, beta-blocker, calcium channel blocker, hypolipidemic, biphosphonate and calcium were the most frequently used medications for the elderly, and any medication more often in the non-elderly group. A hiatal hernia and other findings were the results of endoscopy more frequent of the elderly group, and Normal result and Erosive Esophagitis grade I of Savary-Miller more frequent in nonelderly. In pHmetry, the elderly group presented higher averages DeMeester and % total time with pH < 4.0. The results of manometry test relaxation of the lower esophageal sphincter (91.1% vs. 84.8%) and normal peristalsis (87.4% vs. 76%) were more frequent in the non-elderly group. At the conclusion of the manometry were found: achalasia in 5.9% in the elderly group and 2.9% in the non-elderly; Hipercontrátil disorder in 10.4% in the elderly group and 9.2% in non-elderly; Hipocontrátil disorder in 47.6% in the elderly group and 28.5% in non-elderly; and Normal result in 36.1% in the elderly group and 49.4% in non-elderly. When stratified by decade, the groups showed similar results to the comparison between elderly and non-elderly as sex, smoking, alcoholism, main complaints, associated diseases, medications in use, and the results of pHmetry, endoscopy and manometry (lower percentage of Normal result and higher percentage of Hipocontrátil Disorder in the elderly group; p = 0.007). Even when deleted the variables that could alter the esophageal motility and that showed statistically significant difference, in relation to the conclusion of manometry, remained the lowest percentage of Normal result and higher percentage of Hipocontrátil Disorder in the elderly group in relation to the non-elderly. Conclusion: The elderly group in relation to the non-elderly showed lower percentage of average pressure of esophageal body, normal peristalsis and normal relaxation of the lower esophageal sphincter. As to the conclusion of the manometry the elderly group showed lower percentage of Normal result and higher Hipocontrátil Disorder. Even after exclusion of variables that could change the esophageal motility the difference regarding the completion of manometry remained. In the stratification by decade (\"60 to 69 years,\" \"70 to 79 years\" and \">= 80 years\") at the conclusion of the manometry there was less Normal result and higher percentage of Hipocontrátil Disorder in relation to the non-elderly, but the elderly groups did not differ among themselves

OBJETIVOS: O objetivo do estudo foi avaliar se a transfusão de hemácias no intraoperatório de cirurgia cardíaca com circulação extracorpórea está associada a complicações clínicas incluindo choque cardiogênico, arritmia, insuficiência renal aguda, isquemia miocárdica, choque séptico, necessidade de reintubação orotraqueal, acidente vascular cerebral ou mortalidade durante a internação hospitalar. DESENHO: Estudo clínico de coorte retrospectivo e unicêntrico com escore de propensão, realizado no Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. PACIENTES: Pacientes adultos submetidos à cirurgia cardíaca eletiva com circulação extracorpórea no período de janeiro de 2004 a dezembro de 2008. DESFECHO PRIMÁRIO: Complicações clínicas durante a internação hospitalar (choque cardiogênico, arritmia, insuficiência renal aguda, isquemia miocárdica, choque séptico, necessidade de reintubação orotraqueal, acidente vascular cerebral ou mortalidade hospitalar). DESFECHO SECUNDÁRIO: 1- Avaliar o efeito da transfusão de hemácias no intraoperatório no tempo livre de inotrópicos e vasopressores, tempo de ventilação mecânica e tempo de permanência na UTI e internação hospitalar. 2- Avaliar o efeito do número das unidades de hemácias transfundidas no intraoperatório na ocorrência de mortalidade hospitalar, choque cardiogênico, arritmia, isquemia miocárdica, choque séptico, acidente vascular cerebral e reintubação orotraqueal. 3- Avaliar o efeito da anemia à admissão e durante internação hospitalar na ocorrência de complicações pós-operatórias. INTERVENÇÃO: Não houve intervenção. RESULTADOS: Foram incluídos 2851 pacientes na análise final, dos quais 1471(51,6%) foram expostos a transfusão de hemácias e 1380 (48,4%) não receberam transfusão no intraoperatório. Os pacientes transfundidos apresentaram maior incidência das seguintes complicações: mortalidade (2,1% vs 0,4%, P < 0,001), insuficiência renal aguda (9,1% vs 3,9%, P<0,001), reintubação orotraqueal (3,8% vs 1,4%, P < 0,001) e choque séptico (2,2% vs 0,4%, P < 0,001). Os pacientes transfundidos também apresentaram maior tempo de internação hospitalar [16 dias (12-23) vs 13 dias (9-18), P < 0,001] e em unidade de terapia intensiva [3 dias (2-6) vs 2 dias (2-4), P < 0,001]. A concentração da hemoglobina menor que 9 g/dL ocorreu em 1847 pacientes (64,7%) durante a internação hospitalar e foi associada a maior risco de insuficiência renal aguda e de acidente vascular cerebral. O escore de propensão identificou 588 pacientes pareados em relação à exposição à transfusão, e essa análise demonstrou que a transfusão intraoperatória de hemácias não aumentou a ocorrência de complicações no período de internação hospitalar. Contudo a transfusão de 4 ou mais unidades de hemácias está associada a maior ocorrência de mortalidade hospitalar, choque cardiogênico e IRA, maior incidência de reintubação orotraqueal, choque séptico e AVC. Além de uma relação direta entre as unidades de hemácias transfundidas e a ocorrência de morte. CONCLUSÃO: Esse estudo observacional demonstrou que a anemia é frequentemente detectada no pós-operatório de cirurgia cardíaca, e está associada a maior incidência de complicações. Além disso, a transfusão de hemácias no intraoperatório não modifica a ocorrência das complicações pós-operatórias em pacientes submetidos a cirurgia cardíaca. No entanto a transfusão de 4 ou mais hemácias está associada a maior incidência de complicações clínicas, além de uma relação dose-dependente. Estratégias como detecção precoce de anemia e emprego de técnicas alternativas à transfusão no manejo devem ser estimuladas no ambiente perioperatório / OBJECTIVE: The objective of this study was to evaluate whether the transfusion of red blood cells in the intraoperative cardiac surgery with extracorporeal circulation is associated with complications after cardiac surgery. DESIGN: A retrospective cohort study with a propensity score analysis, performed at Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. PATIENTS: Adult patients undergoing elective cardiac surgery with cardiopulmonary bypass in the period of January to 2008 December. PRIMARY OUTCOME: Clinical complications during hospital stay (cardiogenic shock, arrhythmia, cardiogenic shock, acute kidney injury, myocardial ischemia, septic shock, tracheal reintubation, stroke or hospital mortality). SECONDARY OUTCOME: 1- Evaluate the effect of intraoperative red blood cell transfusion in inotropic and vasopressor free time, mechanical ventilation time, length of ICU stay and hospital stay. 2- Evaluate the effect of the number of units of transfused red blood cells intraoperatively on the occurrence of hospital mortality, cardiogenic shock, arrhythmia, myocardial ischemia, septic shock, stroke and orotracheal reintubation. 3- Evaluate the effect of anemia on admission and during hospitalization in the occurrence of postoperative complications. RESULTS: In the final analysis, 2851 patients were included. Of these patients, 1471(51.6%) were exposed to red blood cell transfusion (RBC) and 1380 (48.4%) were not exposed to RBC during intraoperative. Transfused patients had higher incidence of the following complications: mortality (2.1% vs. 0.4%, P < 0.001), acute kidney injury (9.1% vs. 3.9%, P < 0,001), tracheal reintubation (3.8% vs. 1.4%, P < 0.001) and septic shock (2.2% vs. 0.4%, P < 0.001). Transfused patients also had a longer length of hospital stay [16 days (12-23) vs. 13 days (9-18), P<0.001] and prolonged intensive care unit stay [3 days (2-6) vs. 2 days (2-4), P < 0.001]. Hemoglobin lower than 9 g/dL was found in 1847 patients (64.7%) during hospital stay and was associated to a higher risk of acute kidney injury and stroke. The propensity score identified 588 paired patients in relation to transfusion exposure, and this analysis demonstrated that intraoperative transfusion of red blood cells did not increase the occurrence of complications during hospitalization. However, transfusion of 4 or more units of red blood cells is associated with a higher occurrence of hospital mortality, cardiogenic shock and acute renal failure, a higher incidence of orotracheal reintubation, septic shock and stroke. In addition to a direct relationship between the units of transfused red blood cells and the occurrence of death. CONCLUSIONS: This observational study demonstrated that anemia is frequently detected in the postoperative period of cardiac surgery, and is associated with a higher incidence of complications. In addition, red blood cell transfusion in the intraoperative does not modify the occurrence of postoperative complications in patients undergoing cardiac surgery. However, transfusion of 4 or more erythrocytes is associated with a higher incidence of clinical complications, in addition to a dose-dependent relationship. Strategies such as early detection of anemia and use of alternative techniques to transfusion in management should be stimulated in the perioperative environment

Introdução: O estrato da população com 60 anos ou mais está crescendo mais rapidamente do que grupos etários mais jovens em todo o mundo. Há um aumento desproporcional nas visitas de idosos aos serviços médicos de emergência (SME), com taxas mais altas de resultados adversos. Objetivos: Descrever as características sociodemográficas do usuário do SME de um hospital terciário e investigar diferenças nos desfechos por sexo e idade. Desenho: Estudo analítico observacional transversal. Fonte de dados: Dados administrativos eletrônicos de saúde (2009 a 2013). Local do estudo: Pronto-Socorro do Instituto Central do Hospital das Clínicas, São Paulo, Brasil. Participantes: 222.387 adultos que visitaram o serviço de emergência terciária uma ou mais vezes durante o período. Métodos: As principais variáveis categóricas foram sexo, ano e faixa etária, que incluiu \"adultos jovens\": 18 a 39 anos; \"adultos maduros\": 40-59; \"idosos jovens\": 60-79; e \"muito idosos\": 80- 109. As variáveis contínuas foram idade, tempo de internação e tempo de permanência na UTI. Os desfechos foram hospitalização, estadia na Unidade de Terapia Intensiva (UTI) e óbito. Análise estatística: Calculamos a estatística descritiva; em seguida, construímos modelos lineares mistos generalizados (GLMM) para cada desfecho e estimamos as razões de chances (odds ratios - OR) com intervalo de confiança de 95% para as variáveis categóricas independentes. O nível de significância foi estabelecido em 5%, com correção de Bonferroni. Resultados: Analisamos 333.028 atendimentos consecutivos não programados no SME. A proporção dos atendimentos atribuídos aos adultos jovens diminuiu anualmente (44,4% para 38,2%), enquanto a de pessoas com 60 anos ou mais aumentou (24,1% para 29,9%). Os OR para internação, internação em UTI e mortalidade associada a idosos foram 3,49 (IC 95% = 3,15-3,87), 1,27 (1,15-1,39) e 5,93 (5,29-6,66) respectivamente, tendo como referência adultos jovens. O sexo masculino foi discretamente associado a hospitalização (OR= 1.37, IC 95%=1,30-1,44) e a mortalidade (OR=1.14, IC 95%=1,07-1,21). O tempo de permanência na UTI e o tempo de internação não diferiram entre os grupos etários. Conclusões: Entre 2009 e 2013, diminuiu a proporção de visitas dos adultos jovens no SME, enquanto a das pessoas com 60 anos ou mais cresceu. As taxas de hospitalização e de mortalidade aumentaram com a idade em ambos os sexos. A idade é um fator de risco relevante para hospitalização e mortalidade, mas não para internação em UTI. Os muito idosos correm maior risco e demandam estratificação adicional em subgrupos / Background: The stratum of the population aged 60 years or over is growing faster than younger age-groups worldwide. There is a disproportional increase in Emergency Department (ED) visits by older people, with higher rates of adverse outcomes. Objectives: To describe the sociodemographic characteristics of ED users in a tertiary hospital and to investigate differences in outcomes by sex and age. Design: Observational cross-sectional analytic study. Data source: Administrative electronic health data (2009 to 2013). Setting: The ED of the Instituto Central do Hospital das Clínicas, São Paulo, Brazil. Participants: 222,387 adults who visited the tertiary ED one or more times during the period. Measurements: The main categorical variables were sex, year and age-group, which included \'young adults\': 18-39 years; \'adults\': 40-59; \'young-older adults\': 60-79; and \'old-older adults\': 80- 109. The continuous variables were age, length of hospital stay (LOS) and length of Intensive Care Unit stay (LIS). Outcomes were hospitalization, use of intensive care unit (ICU) and mortality. Statistical analysis: We calculated descriptive statistics; then, built generalized linear mixed models for each outcome to produce estimated Odds Ratios (95% confidence interval) for independent categorical variables. The significance level was 5% with Bonferroni correction. Results: We analyzed 333,028 consecutive unscheduled ED visits. The proportion of visits attributed to young adults decreased annually (44.4% to 38.2%), while those of people aged 60 or over increased (24.1% to 29.9%). ORs for hospitalization, intensive care use and mortality associated with old-older adults were 3.49 (95% CI= 3.15-3.87), 1.27 (1.15-1.39) and 5.93 (5.29-6.66) respectively, with young adults as the reference. Male sex was weakly associated with hospitalization (OR= 1.37, 95%CI=1,30-1,44) and mortality (OR=1.14, 95%CI=1,07-1,21). LOS and LIS did not differ among age groups. Conclusions: Between 2009 and 2013, the proportion of \'young adults\' ED visits reduced while those of people aged 60 or over increased. Hospitalization, ICU stay and mortality rates increased with age. Age is an important risk factor for hospitalization and mortality, but not for ICU admission. Old-older people are at the greatest risk and demand further subgroup stratification