Objectives: Adequate organ perfusion, as well as appropriate blood pressure levels at the time of unclamping, is crucial for early and long-term graft function and outcome in simultaneous pancreas–kidney transplantation (SPKT). However, the optimal intraoperative mean arterial pressure (MAP) level has not well been defined. Methods: From a prospectively collected database, the medical data of 105 patients undergoing SPKT at our center were retrospectively analyzed. A receiver operating characteristic (ROC) analysis was preliminarily performed for optimal cut-off value for MAP at reperfusion, to predict early pancreatic graft function. Due to these results, we divided the patients according to their MAP values at reperfusion into <91 mmHg (n = 47 patients) and >91 mmHg (n = 58 patients) groups. Clinicopathological characteristics and outcomes, as well as early graft function and long-term survival, were retrospectively analyzed. Results: Donor and recipient characteristics were comparable between both groups. Rates of postoperative complications were significantly higher in the <91 mmHg group than those in the >91 mmHg group (vascular thrombosis of the pancreas: 7 (14%) versus 2 (3%); p = 0.03; pancreatitis/intraabdominal abscess: 10 (21%) versus 4 (7%); p = 0.03; renal delayed graft function (DGF): 11 (23%) versus 5 (9%); p = 0.03; postreperfusion urine output: 106 ± 50 mL versus 195 ± 45 mL; p = 0.04). There were no significant differences in intraoperative volume repletion, central venous pressure (CVP), use of vasoactive inotropic agents, and the metabolic outcome. Five-year pancreas graft survival was significantly higher in the >91 mmHg group (>91 mmHg: 82% versus <91 mmHg: 61%; p < 0.01). No significant differences were observed in patient and kidney graft survival at 5 years between both groups. Multivariate Cox regression analysis affirmed MAP < 91 mmHg as an independent prognostic predictor for renal DGF (HR 3.49, 1.1–10.8, p = 0.03) and pancreas allograft failure (HR 2.26, 1.0–4.8, p = 0.01). Conclusions: A MAP > 91 mmHg at the time point of reperfusion was associated with a reduced rate of postoperative complications, enhancing and recovering long-term graft function and outcome and thus increasing long-term survival in SPKT recipients.

Submitted by PPG Odontologia (odontologia-pg@pucrs.br) on 2018-03-28T17:56:00Z No. of bitstreams: 1 ALEXANDRE_WEBER_DIS.pdf: 783948 bytes, checksum: 88cfac1ab658550afa3a87b25b872da9 (MD5) / Rejected by Tatiana Lopes (tatiana.lopes@pucrs.br), reason: Devolvido devido ? falta de folha de rosto no pdf. on 2018-04-12T12:05:10Z (GMT) / Submitted by PPG Odontologia (odontologia-pg@pucrs.br) on 2018-05-29T12:15:20Z No. of bitstreams: 1 ALEXANDRE_WEBER_DIS.pdf: 783948 bytes, checksum: 88cfac1ab658550afa3a87b25b872da9 (MD5) / Rejected by Sheila Dias (sheila.dias@pucrs.br), reason: Devolvido novamente devido ? falta de folha de rosto no pdf . on 2018-06-07T12:52:13Z (GMT) / Submitted by PPG Odontologia (odontologia-pg@pucrs.br) on 2018-06-08T19:05:42Z No. of bitstreams: 1 ALEXANDRE_WEBER_DIS.pdf: 359121 bytes, checksum: 86424efdd5d668baacef118324363a8f (MD5) / Approved for entry into archive by Sheila Dias (sheila.dias@pucrs.br) on 2018-06-19T11:16:25Z (GMT) No. of bitstreams: 1 ALEXANDRE_WEBER_DIS.pdf: 359121 bytes, checksum: 86424efdd5d668baacef118324363a8f (MD5) / Made available in DSpace on 2018-06-19T11:45:42Z (GMT). No. of bitstreams: 1 ALEXANDRE_WEBER_DIS.pdf: 359121 bytes, checksum: 86424efdd5d668baacef118324363a8f (MD5) Previous issue date: 2017-12-20 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES / Objetivo: Comparar, em pacientes tratados com pr?tese total da articula??o temporomandibular (ATM), a qualidade de vida relacionada ? sa?de bucal antes e ap?s a cirurgia, utilizando a forma curta do perfil de impacto na sa?de bucal (OHIP-14). Material e M?todos: Os participantes foram convidados a completar o OHIP-14 antes da cirurgia (T0) e aos 2 meses (T1), 6 meses (T2) e 1 ano ap?s a cirurgia (T3). A intensidade da dor e a gravidade dos sintomas foram avaliadas usando uma escala visual anal?gica (EVA). Resultados: Dez pacientes tratados com pr?tese de ATM com acompanhamento de 1 ano foram inclu?dos. Entre T0 e T3, os escores m?dios diminu?ram significativamente de 1,1 ? 1,0 para 0,1 ? 0,2 na limita??o funcional, de 3,4 ? 0,6 para 0,0 ? 0,1 em dor f?sica, de 2,9 ? 0,9 para 0,1 ? 0,2 em desconforto psicol?gico, de 2,2 ? 1,5 para 0,1 ? 0,3 em defici?ncia f?sica e de 1,7 ? 0,9 para 0,0 ? 0,0 em defici?ncia psicol?gica (p <0,001 para todas as compara??es). Houve tamb?m uma diminui??o significativa no escore total m?dio de OHIP-14 entre T0 (12,32 ? 5,18) e T3 (0,44 ? 0,65) (p <0,001). Observou-se melhora significativa na dor na ATM de T0 a T3 (p <0,001), com melhorias tamb?m observadas na dor de cabe?a e na fadiga muscular. Conclus?es: Nossos resultados sugerem que a reposi??o total da ATM reduz os sintomas e a dor, levando a uma melhora na qualidade de vida dos pacientes e no bem-estar psicol?gico. / Objective: To compare, in patients treated with total temporomandibular joint (TMJ) prostheses, oral health-related quality of life before and after surgery using the short form of the Oral Health Impact Profile (OHIP-14). Material and Methods: Participants were asked to complete the OHIP-14 before surgery (T0) and at 2 months (T1), 6 months (T2), and 1 year after surgery (T3). Pain intensity and symptom severity were rated using a visual analogue scale (VAS). Results: Ten patients treated with TMJ prostheses completed the 1-year follow-up and were included. Between T0 and T3, mean scores decreased significantly from 1.1?1.0 to 0.1?0.2 in functional limitation, from 3.4?0.6 to 0.0?0.1 in physical pain, from 2.9?0.9 to 0.1?0.2 in psychological discomfort, from 2.2?1.5 to 0.1?0.3 in physical disability, and from 1.7?0.9 to 0.0?0.0 in psychological disability (p < 0.001 for all comparisons). There was also a significant decrease in the mean total OHIP-14 score between T0 (12.32?5.18) and T3 (0.44?0.65) (p < 0.001). Significant improvement was observed in TMJ pain from T0 to T3 (p < 0.001), with improvements also seen in headache and muscle fatigue. Conclusions: Our results suggest that total TMJ replacement reduces symptoms and pain, leading to an improvement in patients? quality of life and psychological well-being.

INTRODUÇÃO: Aproximadamente 10% dos pacientes com doença arterial coronária (DAC) apresentam angina refratária, condição crônica causada por insuficiência coronariana, que não pode ser controlada pela combinação de tratamento medicamentoso, angioplastia ou cirurgia de revascularização miocárdica (RM). Os preditores de eventos cardiovasculares neste grupo crescente de pacientes são escassos. Os ensaios para a troponina T cardíaca ultrassensível (TnTc-us) são valiosos biomarcadores que podem ser utilizados para determinar o prognóstico de pacientes com DAC estável, mas não há evidência que esta habilidade se mantenha em indivíduos com doença mais grave e extensa, como ocorre na angina refratária. Os objetivos deste estudo são: avaliar a eficácia de um protocolo de otimização terapêutica para pacientes encaminhados por angina refratária, os preditores de óbito e infarto do miocárdio (IM), assim como o papel da TnTc-us como ferramenta prognóstica neste cenário. MÉTODOS: Estudo prospectivo e observacional que incluiu 117 pacientes (83 homens, 62,7 ± 9,4 anos), por amostragem consecutiva, de Outubro de 2008 a Setembro de 2013. Os critérios de inclusão foram: angina pectoris estável classificada pela Canadian Cardiovascular Society (CCS) de II a IV, evidência de isquemia miocárdica documentada por um teste não invasivo e DAC obstrutiva considerada desfavorável para RM após a avaliação de uma coronariografia recente por um \"Heart Team\". O tratamento medicamentoso foi titulado de acordo com a tolerância dos pacientes durante um período de três meses e a seguir, o seguimento ambulatorial foi semestral. As dosagens de TnTc-us foram obtidas na consulta inicial e após três meses. O desfecho primário foi a incidência combinada de óbito por todas as causas e IM não fatal. RESULTADOS: Houve significativa prevalência de DAC triarterial (75,2%), angina CCS III ou IV (60,7%) e antecedentes de procedimentos de RM prévia (91,5%). A maioria dos pacientes apresentou função ventricular preservada (61,5%). Valores de TnTc-us acima do limite de detecção (3 ng/L) foram encontrados em 79,5% dos pacientes e 27,4% apresentaram concentrações acima do percentil 99 para indivíduos saudáveis (14 ng/L). Os preditores independentes de valores mais elevados de TnTc-us foram: disfunção ventricular esquerda, não usar bloqueadores de canais de cálcio, pressão arterial sistólica elevada, e ritmo de filtração glomerular reduzido. A melhora de ao menos uma classe funcional CCS foi alcançada em 50% dos pacientes (P < 0,001) e 25,9% se apresentaram sem angina ou com angina CCS I após três meses de tratamento. Houve redução significativa nos episódios de angina (P < 0,001) e no consumo de nitrato sublingual (P = 0,029). Não houve redução dos níveis de TnTc-us após 3 meses de otimização terapêutica. Durante um seguimento mediano de 28 meses (intervalo interquartil de 18 a 47,5 meses), a taxa de eventos combinados foi estimada em 13,4% (5,8% para óbito) pelo método de Kaplan-Meier. Preditores univariados para o desfecho composto foram os níveis de TnTc-us e disfunção ventricular esquerda. Após análise de regressão multivariada através do modelo de regressão de risco proporcional de Cox, apenas a TnTc-us foi independentemente associada com os eventos avaliados, tanto como variável contínua (HR por aumento em cada unidade do logarítimo natural: 2,83; IC 95% de 1,62 a 4,92; P < 0,001) quanto como variável categórica (HR para concentrações acima do percentil 99: 5,14; IC 95% de 2,05 a 12,91; P < 0,001). CONCLUSÕES: O protocolo de otimização terapêutica demonstrou ser bem tolerado e eficaz em reduzir os sintomas de angina em grande parte dos pacientes inicialmente considerados refratários. No entanto, esta melhora clínica não foi acompanhada por redução nas concentrações plasmáticas de troponina T ultrassensível, um biomarcador que nosso estudo revelou como o mais forte preditor de óbito e infarto do miocárdio não fatal nos pacientes com angina refratária. A incidência de eventos cardiovasculares neste estudo foi menor do que a relatada anteriormente e se aproximou da taxa observada entre os pacientes com doença arterial coronária complexa passível de revascularização miocárdica / BACKGROUND: Approximately 10% of patients with symptomatic coronary artery disease (CAD) suffer from refractory angina, a chronic condition caused by coronary insufficiency which cannot be controlled by a combination of medical therapy, angioplasty and coronary bypass surgery. The predictors of cardiovascular events in this growing group of patients are limited. High-sensitivity cardiac troponin T (hs-cTnT) assays are valuable biomarkers that may be used to determine the prognosis of patients with stable CAD, but there is no evidence that this ability would be retained in individuals with more severe and extensive disease, as is the case in refractory angina. The aims of this study are to evaluate the effectiveness of a maximally tolerated medical therapy, the predictors of death and nonfatal myocardial infarction (MI), as well as the role of hs-cTnT as a prognostic tool in this setting. METHODS: We prospectively enrolled 117 consecutive patients (83 men, 62.7 ± 9.4 years) in this study between October 2008 and September 2013. All patients had angina as classified by the Canadian Cardiovascular Society (CCS) II to IV at their first visit, and evidence of myocardial ischemia via any stress test. A heart team ruled out myocardial revascularization feasibility after assessing recent coronary angiograms. Optimal medical therapy was up-titrated over three months. Patients were followed every 6 months via outpatient visits; plasma hs-cTnT levels were determined at baseline and after three months. The primary endpoint was the composite incidence of death and nonfatal MI. RESULTS: There were high prevalence of three-vessel CAD (75.2%), angina CCS class III or IV (60.7%) and history of previous myocardial revascularization (91.5%); most of the patients had preserved left ventricular function (61.5%). Hs-cTnT values were either at or above the limit of detection (3 ng/L) in 79.5% of patients and we noted concentrations either at or greater than the 99th percentile of healthy individuals (14 ng/L) in 27.4% of patients. The independent predictors of higher concentrations of hs-cTnT were as follows: left ventricular dysfunction, no calcium channel blocker use at baseline, elevated systolic blood pressure and reduced glomerular filtration rate. The improvement of at least one CCS functional class occurred in 50% of patients (P < 0.001) and 25.9% were free from angina or were CCS I after three months of medical therapy. There was a significant reduction in the number of angina attacks (P < 0.001) and a reduction in short-acting nitrate consumption (P = 0.029). There was no reduction in hs-cTnT levels after the three-month medical therapy optimization. During a median follow-up period of 28.0 months (interquartile range, 18.0 to 47.5 months), an estimated 28.0-month cumulative event rate of 13.4% (5.8% for allcause death) was determined via the Kaplan-Meier method. Univariate predictors of the composite endpoint were as follows: hs-cTnT levels and left ventricular dysfunction. Following a multivariate analysis via a Cox proportional-hazards regression model, only hs-cTnT was independently associated with the events in question, either as a continuous variable (HR per unit increase in the natural logarithm, 2.83; 95% CI, 1.62 to 4.92; P < 0.001) or as a categorical variable (HR for concentrations above the 99th percentile, 5.14; 95% CI, 2.05 to 12.91; P < 0.001). CONCLUSIONS: In patients initially diagnosed with refractory angina, the optimal medical therapy protocol was well tolerated and effective in reducing the symptoms of angina in most patients. However, such clinical improvement was not accompanied by a decrease in plasma concentrations of high-sensitivity troponin T, a biomarker that our study identified as the strongest predictor of death and nonfatal myocardial infarction in patients with refractory angina. The incidence of cardiovascular events in this study was lower than that previously reported, leading to outcomes approaching those of patients with complex coronary artery disease who are suitable for myocardial revascularization

Neutropenia febril (NF) constitui complicação frequente do tratamento quimioterápico do câncer e está associada a altas taxas de morbimortalidade. O reconhecimento dos principais fatores associados ao desenvolvimento de desfechos clínicos desfavoráveis na NF é fundamental, uma vez que estes podem ser utilizados como marcadores prognósticos ou alvos terapêuticos. Este estudo objetiva determinar os principais fatores associados com mortalidade, tempo de hospitalização, incidência de bacteremia por patógenos multirresistentes e incidência de choque séptico no início da febre em pacientes hospitalizados com NF secundária à quimioterapia citotóxica para o câncer. Na presente coorte prospectiva composta por 305 episódios consecutivos de NF (em 169 pacientes com câncer) realizada em um hospital terciário no período de outubro de 2009 a agosto de 2011, as seguintes questões de pesquisa foram avaliadas: impacto do tempo de início da antibioticoterapia na mortalidade em 28 dias; fatores relacionados com tempo de hospitalização; impacto dos fatores microbiológicos da bacteremia no desenvolvimento de choque séptico no início do episódio de NF; fatores de risco para bacteremia por patógenos multirresistentes; impacto da bacteremia por Staphylococcus coagulase-negativo na mortalidade em 28 dias. Em 5 publicações distintas, os seguintes resultados foram notados: o atraso do início da antibioticoterapia está associado a maiores taxas de mortalidade em 28 dias; neoplasia hematológica, regimes quimioterápicos de altas doses, duração da neutropenia e bacteremia por Gram-negativos multirresistentes estão associados com períodos prolongados de internação por NF; infecção de corrente sanguínea polimicrobiana, bacteremia por Escherichia coli e bacteremia por Streptococcus viridans estão associados a choque séptico no início do episódio de NF; idade avançada, duração da neutropenia e presença de cateter venoso central estão associados com bacteremia por patógenos multirresistentes; bacteremia por Staphylococcus coagulase-negativo está associada a menores taxas de mortalidade em 28 dias quando comparado à bacteremia por outros patógenos. / Febrile neutropenia (FN) is a common complication of cancer chemotherapy and is associated with high morbidity and mortality rates. Recognition of the main factors associated with the development of adverse clinical outcomes in FN is crucial, given that these factors can be used as prognostic markers or therapeutic targets. This study aims to determine the main factors associated with mortality, length of hospital stay, incidence of bacteremia by multidrug-resistant pathogens and incidence of septic shock at the onset of fever in hospitalized patients with FN secondary to cancer cytotoxic chemotherapy. In the present prospective cohort of 305 FN episodes (in 169 cancer patients) conducted at a tertiary hospital from October 2009 to August 2011, the following research questions were evaluated: impact of time to antibiotic administration on 28-day mortality; factors associated with length of hospital stay; impact of microbiological factors of bacteremia on the development of septic shock at the onset of FN; risk factors for bacteremia by multidrug-resistant pathogens; impact of coagulasenegative Staphylococcus bacteremia on 28-day mortality. In 5 distinct publications, the following results were noted: delay of antibiotic administration is associated with higher 28-day mortality rates; hematologic malignancy, high-dose chemotherapy regimens, duration of neutropenia and bacteremia by multidrug-resistant Gram-negative bacteria are associated with prolonged length of hospital stay; polymicrobial bloodstream infection, bacteremia by Escherichia coli, and bacteremia by viridans sreptococci are associated with septic shock at the onset of FN; advanced age, duration of neutropenia and presence of indwelling central venous catheters are associated with bacteremia by multidrug-resistant pathogens; coagulase-negative Staphylococcus bacteremia is associated with lower 28-day mortality rates compared with bacteremia by other pathogens.

Neutropenia febril (NF) constitui complicação frequente do tratamento quimioterápico do câncer e está associada a altas taxas de morbimortalidade. O reconhecimento dos principais fatores associados ao desenvolvimento de desfechos clínicos desfavoráveis na NF é fundamental, uma vez que estes podem ser utilizados como marcadores prognósticos ou alvos terapêuticos. Este estudo objetiva determinar os principais fatores associados com mortalidade, tempo de hospitalização, incidência de bacteremia por patógenos multirresistentes e incidência de choque séptico no início da febre em pacientes hospitalizados com NF secundária à quimioterapia citotóxica para o câncer. Na presente coorte prospectiva composta por 305 episódios consecutivos de NF (em 169 pacientes com câncer) realizada em um hospital terciário no período de outubro de 2009 a agosto de 2011, as seguintes questões de pesquisa foram avaliadas: impacto do tempo de início da antibioticoterapia na mortalidade em 28 dias; fatores relacionados com tempo de hospitalização; impacto dos fatores microbiológicos da bacteremia no desenvolvimento de choque séptico no início do episódio de NF; fatores de risco para bacteremia por patógenos multirresistentes; impacto da bacteremia por Staphylococcus coagulase-negativo na mortalidade em 28 dias. Em 5 publicações distintas, os seguintes resultados foram notados: o atraso do início da antibioticoterapia está associado a maiores taxas de mortalidade em 28 dias; neoplasia hematológica, regimes quimioterápicos de altas doses, duração da neutropenia e bacteremia por Gram-negativos multirresistentes estão associados com períodos prolongados de internação por NF; infecção de corrente sanguínea polimicrobiana, bacteremia por Escherichia coli e bacteremia por Streptococcus viridans estão associados a choque séptico no início do episódio de NF; idade avançada, duração da neutropenia e presença de cateter venoso central estão associados com bacteremia por patógenos multirresistentes; bacteremia por Staphylococcus coagulase-negativo está associada a menores taxas de mortalidade em 28 dias quando comparado à bacteremia por outros patógenos. / Febrile neutropenia (FN) is a common complication of cancer chemotherapy and is associated with high morbidity and mortality rates. Recognition of the main factors associated with the development of adverse clinical outcomes in FN is crucial, given that these factors can be used as prognostic markers or therapeutic targets. This study aims to determine the main factors associated with mortality, length of hospital stay, incidence of bacteremia by multidrug-resistant pathogens and incidence of septic shock at the onset of fever in hospitalized patients with FN secondary to cancer cytotoxic chemotherapy. In the present prospective cohort of 305 FN episodes (in 169 cancer patients) conducted at a tertiary hospital from October 2009 to August 2011, the following research questions were evaluated: impact of time to antibiotic administration on 28-day mortality; factors associated with length of hospital stay; impact of microbiological factors of bacteremia on the development of septic shock at the onset of FN; risk factors for bacteremia by multidrug-resistant pathogens; impact of coagulasenegative Staphylococcus bacteremia on 28-day mortality. In 5 distinct publications, the following results were noted: delay of antibiotic administration is associated with higher 28-day mortality rates; hematologic malignancy, high-dose chemotherapy regimens, duration of neutropenia and bacteremia by multidrug-resistant Gram-negative bacteria are associated with prolonged length of hospital stay; polymicrobial bloodstream infection, bacteremia by Escherichia coli, and bacteremia by viridans sreptococci are associated with septic shock at the onset of FN; advanced age, duration of neutropenia and presence of indwelling central venous catheters are associated with bacteremia by multidrug-resistant pathogens; coagulase-negative Staphylococcus bacteremia is associated with lower 28-day mortality rates compared with bacteremia by other pathogens.

Neutropenia febril (NF) constitui complicação frequente do tratamento quimioterápico do câncer e está associada a altas taxas de morbimortalidade. O reconhecimento dos principais fatores associados ao desenvolvimento de desfechos clínicos desfavoráveis na NF é fundamental, uma vez que estes podem ser utilizados como marcadores prognósticos ou alvos terapêuticos. Este estudo objetiva determinar os principais fatores associados com mortalidade, tempo de hospitalização, incidência de bacteremia por patógenos multirresistentes e incidência de choque séptico no início da febre em pacientes hospitalizados com NF secundária à quimioterapia citotóxica para o câncer. Na presente coorte prospectiva composta por 305 episódios consecutivos de NF (em 169 pacientes com câncer) realizada em um hospital terciário no período de outubro de 2009 a agosto de 2011, as seguintes questões de pesquisa foram avaliadas: impacto do tempo de início da antibioticoterapia na mortalidade em 28 dias; fatores relacionados com tempo de hospitalização; impacto dos fatores microbiológicos da bacteremia no desenvolvimento de choque séptico no início do episódio de NF; fatores de risco para bacteremia por patógenos multirresistentes; impacto da bacteremia por Staphylococcus coagulase-negativo na mortalidade em 28 dias. Em 5 publicações distintas, os seguintes resultados foram notados: o atraso do início da antibioticoterapia está associado a maiores taxas de mortalidade em 28 dias; neoplasia hematológica, regimes quimioterápicos de altas doses, duração da neutropenia e bacteremia por Gram-negativos multirresistentes estão associados com períodos prolongados de internação por NF; infecção de corrente sanguínea polimicrobiana, bacteremia por Escherichia coli e bacteremia por Streptococcus viridans estão associados a choque séptico no início do episódio de NF; idade avançada, duração da neutropenia e presença de cateter venoso central estão associados com bacteremia por patógenos multirresistentes; bacteremia por Staphylococcus coagulase-negativo está associada a menores taxas de mortalidade em 28 dias quando comparado à bacteremia por outros patógenos. / Febrile neutropenia (FN) is a common complication of cancer chemotherapy and is associated with high morbidity and mortality rates. Recognition of the main factors associated with the development of adverse clinical outcomes in FN is crucial, given that these factors can be used as prognostic markers or therapeutic targets. This study aims to determine the main factors associated with mortality, length of hospital stay, incidence of bacteremia by multidrug-resistant pathogens and incidence of septic shock at the onset of fever in hospitalized patients with FN secondary to cancer cytotoxic chemotherapy. In the present prospective cohort of 305 FN episodes (in 169 cancer patients) conducted at a tertiary hospital from October 2009 to August 2011, the following research questions were evaluated: impact of time to antibiotic administration on 28-day mortality; factors associated with length of hospital stay; impact of microbiological factors of bacteremia on the development of septic shock at the onset of FN; risk factors for bacteremia by multidrug-resistant pathogens; impact of coagulasenegative Staphylococcus bacteremia on 28-day mortality. In 5 distinct publications, the following results were noted: delay of antibiotic administration is associated with higher 28-day mortality rates; hematologic malignancy, high-dose chemotherapy regimens, duration of neutropenia and bacteremia by multidrug-resistant Gram-negative bacteria are associated with prolonged length of hospital stay; polymicrobial bloodstream infection, bacteremia by Escherichia coli, and bacteremia by viridans sreptococci are associated with septic shock at the onset of FN; advanced age, duration of neutropenia and presence of indwelling central venous catheters are associated with bacteremia by multidrug-resistant pathogens; coagulase-negative Staphylococcus bacteremia is associated with lower 28-day mortality rates compared with bacteremia by other pathogens.

INTRODUÇÃO: Aproximadamente 10% dos pacientes com doença arterial coronária (DAC) apresentam angina refratária, condição crônica causada por insuficiência coronariana, que não pode ser controlada pela combinação de tratamento medicamentoso, angioplastia ou cirurgia de revascularização miocárdica (RM). Os preditores de eventos cardiovasculares neste grupo crescente de pacientes são escassos. Os ensaios para a troponina T cardíaca ultrassensível (TnTc-us) são valiosos biomarcadores que podem ser utilizados para determinar o prognóstico de pacientes com DAC estável, mas não há evidência que esta habilidade se mantenha em indivíduos com doença mais grave e extensa, como ocorre na angina refratária. Os objetivos deste estudo são: avaliar a eficácia de um protocolo de otimização terapêutica para pacientes encaminhados por angina refratária, os preditores de óbito e infarto do miocárdio (IM), assim como o papel da TnTc-us como ferramenta prognóstica neste cenário. MÉTODOS: Estudo prospectivo e observacional que incluiu 117 pacientes (83 homens, 62,7 ± 9,4 anos), por amostragem consecutiva, de Outubro de 2008 a Setembro de 2013. Os critérios de inclusão foram: angina pectoris estável classificada pela Canadian Cardiovascular Society (CCS) de II a IV, evidência de isquemia miocárdica documentada por um teste não invasivo e DAC obstrutiva considerada desfavorável para RM após a avaliação de uma coronariografia recente por um \"Heart Team\". O tratamento medicamentoso foi titulado de acordo com a tolerância dos pacientes durante um período de três meses e a seguir, o seguimento ambulatorial foi semestral. As dosagens de TnTc-us foram obtidas na consulta inicial e após três meses. O desfecho primário foi a incidência combinada de óbito por todas as causas e IM não fatal. RESULTADOS: Houve significativa prevalência de DAC triarterial (75,2%), angina CCS III ou IV (60,7%) e antecedentes de procedimentos de RM prévia (91,5%). A maioria dos pacientes apresentou função ventricular preservada (61,5%). Valores de TnTc-us acima do limite de detecção (3 ng/L) foram encontrados em 79,5% dos pacientes e 27,4% apresentaram concentrações acima do percentil 99 para indivíduos saudáveis (14 ng/L). Os preditores independentes de valores mais elevados de TnTc-us foram: disfunção ventricular esquerda, não usar bloqueadores de canais de cálcio, pressão arterial sistólica elevada, e ritmo de filtração glomerular reduzido. A melhora de ao menos uma classe funcional CCS foi alcançada em 50% dos pacientes (P < 0,001) e 25,9% se apresentaram sem angina ou com angina CCS I após três meses de tratamento. Houve redução significativa nos episódios de angina (P < 0,001) e no consumo de nitrato sublingual (P = 0,029). Não houve redução dos níveis de TnTc-us após 3 meses de otimização terapêutica. Durante um seguimento mediano de 28 meses (intervalo interquartil de 18 a 47,5 meses), a taxa de eventos combinados foi estimada em 13,4% (5,8% para óbito) pelo método de Kaplan-Meier. Preditores univariados para o desfecho composto foram os níveis de TnTc-us e disfunção ventricular esquerda. Após análise de regressão multivariada através do modelo de regressão de risco proporcional de Cox, apenas a TnTc-us foi independentemente associada com os eventos avaliados, tanto como variável contínua (HR por aumento em cada unidade do logarítimo natural: 2,83; IC 95% de 1,62 a 4,92; P < 0,001) quanto como variável categórica (HR para concentrações acima do percentil 99: 5,14; IC 95% de 2,05 a 12,91; P < 0,001). CONCLUSÕES: O protocolo de otimização terapêutica demonstrou ser bem tolerado e eficaz em reduzir os sintomas de angina em grande parte dos pacientes inicialmente considerados refratários. No entanto, esta melhora clínica não foi acompanhada por redução nas concentrações plasmáticas de troponina T ultrassensível, um biomarcador que nosso estudo revelou como o mais forte preditor de óbito e infarto do miocárdio não fatal nos pacientes com angina refratária. A incidência de eventos cardiovasculares neste estudo foi menor do que a relatada anteriormente e se aproximou da taxa observada entre os pacientes com doença arterial coronária complexa passível de revascularização miocárdica / BACKGROUND: Approximately 10% of patients with symptomatic coronary artery disease (CAD) suffer from refractory angina, a chronic condition caused by coronary insufficiency which cannot be controlled by a combination of medical therapy, angioplasty and coronary bypass surgery. The predictors of cardiovascular events in this growing group of patients are limited. High-sensitivity cardiac troponin T (hs-cTnT) assays are valuable biomarkers that may be used to determine the prognosis of patients with stable CAD, but there is no evidence that this ability would be retained in individuals with more severe and extensive disease, as is the case in refractory angina. The aims of this study are to evaluate the effectiveness of a maximally tolerated medical therapy, the predictors of death and nonfatal myocardial infarction (MI), as well as the role of hs-cTnT as a prognostic tool in this setting. METHODS: We prospectively enrolled 117 consecutive patients (83 men, 62.7 ± 9.4 years) in this study between October 2008 and September 2013. All patients had angina as classified by the Canadian Cardiovascular Society (CCS) II to IV at their first visit, and evidence of myocardial ischemia via any stress test. A heart team ruled out myocardial revascularization feasibility after assessing recent coronary angiograms. Optimal medical therapy was up-titrated over three months. Patients were followed every 6 months via outpatient visits; plasma hs-cTnT levels were determined at baseline and after three months. The primary endpoint was the composite incidence of death and nonfatal MI. RESULTS: There were high prevalence of three-vessel CAD (75.2%), angina CCS class III or IV (60.7%) and history of previous myocardial revascularization (91.5%); most of the patients had preserved left ventricular function (61.5%). Hs-cTnT values were either at or above the limit of detection (3 ng/L) in 79.5% of patients and we noted concentrations either at or greater than the 99th percentile of healthy individuals (14 ng/L) in 27.4% of patients. The independent predictors of higher concentrations of hs-cTnT were as follows: left ventricular dysfunction, no calcium channel blocker use at baseline, elevated systolic blood pressure and reduced glomerular filtration rate. The improvement of at least one CCS functional class occurred in 50% of patients (P < 0.001) and 25.9% were free from angina or were CCS I after three months of medical therapy. There was a significant reduction in the number of angina attacks (P < 0.001) and a reduction in short-acting nitrate consumption (P = 0.029). There was no reduction in hs-cTnT levels after the three-month medical therapy optimization. During a median follow-up period of 28.0 months (interquartile range, 18.0 to 47.5 months), an estimated 28.0-month cumulative event rate of 13.4% (5.8% for allcause death) was determined via the Kaplan-Meier method. Univariate predictors of the composite endpoint were as follows: hs-cTnT levels and left ventricular dysfunction. Following a multivariate analysis via a Cox proportional-hazards regression model, only hs-cTnT was independently associated with the events in question, either as a continuous variable (HR per unit increase in the natural logarithm, 2.83; 95% CI, 1.62 to 4.92; P < 0.001) or as a categorical variable (HR for concentrations above the 99th percentile, 5.14; 95% CI, 2.05 to 12.91; P < 0.001). CONCLUSIONS: In patients initially diagnosed with refractory angina, the optimal medical therapy protocol was well tolerated and effective in reducing the symptoms of angina in most patients. However, such clinical improvement was not accompanied by a decrease in plasma concentrations of high-sensitivity troponin T, a biomarker that our study identified as the strongest predictor of death and nonfatal myocardial infarction in patients with refractory angina. The incidence of cardiovascular events in this study was lower than that previously reported, leading to outcomes approaching those of patients with complex coronary artery disease who are suitable for myocardial revascularization

In recent years, the transplant community has explored and adopted tools for quantifying clinical insight into illness severity and frailty. This dissertation work explores the interplay between objective and subjective assessments of physical health status and the implications for liver transplant candidate and recipient outcomes. The first aim characterizes national epidemiologic trends and the impact of Centers for Medicare and Medicaid quality improvement policies on likelihood of waitlist removal based on the patient being too frail to benefit from liver transplant (“too sick to transplant”). This aim includes more than a decade (2002–2012) of comprehensive national transplant waitlist data (Scientific Registry of Transplant Recipients (SRTR)). The second aim will assess and define objective parameters of liver transplant patient frailty by measuring decline in lean core muscle mass (“sarcopenia”) using abdominal CT scans collected retrospectively at a single U.S. transplant center between 2006 and 2015. The relationship between these objective sarcopenia measures and subjective functional status assessed using the Karnofsky Functional Performance (KPS) scale are described and quantified. The third aim quantifies the extent to which poor functional status (KPS) pre-transplant is associated with worse post-transplant survival and includes national data on liver transplantations conducted between 2005 and 2014 (SRTR). The results of this dissertation will help providers in the assessment of frailty and subsequent risk of adverse outcomes and has implications for strategic clinical management in anticipation of surgery. This research will also to serve to inform national policy on the design of transplant center performance measures.

<p>Studija se sastojala od dva dela &ndash; eksperimentalnog i kliničkog. Eksperimentalni deo je sproveden na Fakultetu tehničkih nauka u Novom Sadu na Departmanu za mehanizaciju i konstrukciono ma&scaron;instvo. Trideset dve zglobne povr&scaron;ine gornjeg okrajka golenjače sa pripojem prednje ukr&scaron;tene veze je uzeto tokom totalne aloartroplastike kolena kod trideset dva pacijenta kod kojih je preoperativno načinjena AP i profilna radiografija sa standardnim uvećanjem u cilju merenja veličine kolena a uz prethodno potpisanu saglasnost pacijenata. Zatim je načinjeno trodimenzionalno skeniranje prostorne povr&scaron;ine pripoja prednje ukr&scaron;tene veze na golenjači u odnosu na ravan zglobne povr&scaron;ine golenjače heptičkim uređajem &bdquo;Phantom Omni&reg;&ldquo; radi utvrđivanja korelacije između povr&scaron;ine pripoja prednje ukr&scaron;tene veze na golenjači i veličine platoa golenjače. U eksperimentalni deo su bili uključeni pacijenti oba pola metodom slučajnog izbora kod kojih je ugrađivana totalna proteza kolena a koji su prethodno potpisali informisani pristanak pacijenta na operativni zahvat na Klinici za ortopedsku hirurgiju i traumatologiju Kliničkog centra Vojvodine. Klinički deo studije je bio retrospektivno-prospektivnog karaktera i obuhvatio je ukupno 60 pacijenata izabranih metodom slučajnog izbora od kojih je ispitivanu grupu činilo 30 pacijenata u kojih je do&scaron;lo do ponovne rupture prednje ukr&scaron;tene veze levog ili desnog kolena nakon urađene primarne rekonstrukcije te je načinjena ponovna rekonstrukcija veze, i kontrolnu grupu koju je činilo 30 pacijenata u kojih je zbog rupture prednje ukr&scaron;tene veze načinjena primarna rekonstrukcija nakon koje nije do&scaron;lo do ponovne rupture. Kod svih pacijenata je rekonstrukcija prednje ukr&scaron;tene veze kolena rađena kalemom kost-tetiva-kost. Ishod rekonstrukcije je procenjivan na osnovu Tegner bodovne skale, Lysholm i IKDC bodovne skale za koleno, artrometrijskog merenja Lachman testa, Pivot shift testa, poloţaja kalema i urađeno je poređenje dobijenih rezultata u ispitivanoj (revizionoj) i kontrolnoj grupi. U klinički deo istraţivanja su bili uključeni pacijenti oba pola, ţivotne dobi od 18 do 40 godina koji su operisani na Klinici za ortopedsku hirurgiju i traumatologiju Kliničkog centra Vojvodine u Novom Sadu a koji su dali informisani pristanak za uključivanje. Kriterijumi za isključivanje pacijenata iz kliničkog dela istraživanja su bili životna dob manja od 18 i veća od 40 godina, pojava težih op&scaron;te-hirur&scaron;kih komplikacija i prestanak želje pacijenta da dalje učestvuje u ovom istraživanju. Nakon sveobuhvatne analize dobijenih rezultata istraţivanja, zaključeno je da postoji korelacija između povr&scaron;ine pripoja prednje ukr&scaron;tene veze na golenjači i veličine platoa golenjače. Formula, načinjena matematičko-statističkim metodama za ovo istraživanje, adekvatna je i praktično primenljiva za predikciju povr&scaron;ine pripoja prednje ukr&scaron;tene veze na golenjači u velikom procentu slučajeva a na osnovu samo dva radiografska parametra izmerenih preoperativno &ndash; prednje-zadnjeg i unutra&scaron;nje-spolja&scaron;njeg dijametra platoa golenjače. Kori&scaron;ćenje ove formule može da doprinese pobolj&scaron;anju rezultata hirur&scaron;kog lečenja pacijenata sa pokidanom prednjom ukr&scaron;tenom vezom kolena. Takođe, zaključeno je da je uzrok neuspeha primarne rekonstrukcije multifaktorijalan kao i da nema statistički značajne razlike u ishodu između ispitanika sa dobrom i ispitanika sa lo&scaron;om pozicijom kalema. Potvrđena je pretpostavka da je ishod ponovne rekonstrukcije prednje ukr&scaron;tene veze kolena slabiji u odnosu na ishod primarne.</p> / <p>This study consisted of two parts &ndash; experimental and clinical. Experimental part was conducted at the Department of Mechanization and Design Engineering of The Faculty of Technical Sciences, University of Novi Sad. Thirty two proximal tibial articular surfaces together with the anterior cruciate ligament insertion of thirty two patients were harvested during total knee arthroplasty. All patients had standard preoperative AP and profile radiographs with standard magnification in order to acquire the knee measurements. All patients previously signed the informed consent. The harvested proximal tibial articular surfaces were 3D scanned by a haptic device called &bdquo;Phantom Omni&reg;&ldquo; in order to determine the correlation between the size of the anterior cruciate ligament insertion site and the size of the tibial plateau. Thirty two randomly chosen patients of both sexes which had a knee arthroplasty were included in the experimental part of this study. All of the patients signed the informed consent at The Clinic for Orthopedic Surgery and Traumatology of The Clinical Centre of Vojvodina. The clinical part was a retrospective-prospective study. This part included 60 randomly chosen patients divided into two groups. The test group consisted of 30 patients who had undergone a revision anterior cruciate ligament reconstruction. The control group consisted of 30 patients who had undergone only primary anterior cruciate ligament reconstruction. A bone-tendon-bone graft was used for the reconstruction in all cases. The outcome was assessed by using Tegner activity scale, Lysholm knee scoring scale, IKDC score, arthrometric evaluation, Pivot shift test and the position of the graft. The results were compared between the test group and the control group. The clinical part of the study included 60 patients of both sexes, age 18-40 which were operated at The Clinic for Orthopedic Surgery and Traumatology of The Clinical Centre of Vojvodina. All of the patients signed the informed consent for participation in this study. The exclusion criteria were age under 18 and above 40, occurrence of severe general surgical complications and a patient wish to be excluded from further investigation. After a thorough analysis of the results, we concluded that the correlation between the size of the anterior cruciate ligament tibial insertion site and the size of the tibial plateau exists. Formula which was created for this study by using mathematical and statistical methods, is adequate and practically applicable for the prediction of size of the anterior cruciate ligament tibial insertion site in the majority of cases based on just two preoperative radiographic parameters &ndash; AP and profile diameter of the tibial plateau. The use of this formula may improve the outcome of the anterior cruciate ligament reconstruction. We also concluded that the cause of the primary anterior cruciate ligament reconstruction failure is multifactorial as well as that there is no statistically significant difference between the patients with good and the patients with poor graft position. We confirmed the assumption that the outcome of the revision anterior cruciate ligament reconstruction is poorer than the outcome of the primary anterior cruciate ligament reconstruction.</p>

Les maladies neuromusculaires génétiques (MNMs) sont des maladies rares et à ce titre elles ont été longtemps négligées. À l’heure actuelle, il existe peu de traitements pour les MNMs et ceux-ci sont encore symptomatiques. La prise en charge est donc principalement axée sur l'accompagnement et la prévention des atteintes fonctionnelles. Les mesures rapportées par les patients permettent d'évaluer le bénéfice perçu par les malades concernant leur prise en charge par les services de soins. Les mesures rapportées par les patients sont des indicateurs importants pour juger de l'efficacité des programmes de soins ou de réadaptation fonctionnelle. Pour mesurer la qualité de vie liée à la santé des patients adultes français atteints d'une MNM il n'existait que des outils génériques. Ce travail de doctorat a été réalisé sur les données recueillies dans huit centres de référence sur les MNMs français (Angers, Créteil, Garches, Lille, Nancy, Nice, Paris myologie, Reims) depuis 2006. Il a été réalisé en trois phases successives. Phase I: une analyse principalement qualitative des interactions verbales entre les participants de cinq groupes de discussion de patients atteints d'une MNM a permis de construire une banque d'items. Phase II: une analyse exploratoire principalement quantitative a permis de sélectionner les items de la banque afin de créer un nouveau questionnaire: le QoL-NMD. Phase III: une analyse de confirmation purement quantitative sur un échantillon distinct a permis de vérifier la validité des propriétés psychométriques du questionnaire QoL-NMD. / Due to their rarity genetic neuromuscular diseases (NMDs) have been neglected for a long time. Currently, there are few treatments available for NMDs and they are still symptomatic. The care is thus focus on the support and the prevention of health-related functional limitations. Patient reported outcome measures enable assessing patients' perceived benefit in medical care units. Patient-reported outcome measures are important indicators to assess the efficiency of medical care or rehabilitation programs. Only generic tools were available to measure quality of life for french adult patients with a NMD. This PhD work was carried out using data gathered from eight French NMD reference centers (Angers, Créteil, Garches, Lille, Nancy, Nice, Paris myologie, Reims) since 2006. It was realised into three successive phases. Phase I: a mainly qualitative analysis of verbal interactions between participants of five focus groups composed of patients with a NMD enabled the construction of an item bank. Phase II: a mainly quantitative exploratory analysis enabled to select the items from the bank in order to construct a new questionnaire: the QoL-NMD. Phase III: a purely quantitative confirmatory analysis on an independant sample enabled to verrify the Qol-NMD psychometric properties validity.