INTRODUÇÃO: Treinamento muscular inspiratório (TMI) tem se mostrado capaz de aumentar a espessura diafragmática. Sabe-se que o diafragma crural age como um esfincter externo do esfíncter inferior do esôfago (EIE), mas é desconhecido se pacientes com hipotonia do EIE se beneficiariam do TMI, a fim de aumentarem a pressão respiratória média (PRM), consequentemente havendo melhora dos sintomas de refluxo gastroesofágico. OBJETIVO: Determinar o resultado dos efeitos do TMI nas pressões respiratória média nos pacientes com doença do refluxo gastroesofágico e seu efeito no tônus do esfíncter inferior do esôfago e compará-los com o grupo controle. MÉTODOS: Vinte pacientes foram incluídos no grupo caso e nove no grupo controle. Todos pacientes tinham a pressão expiratória máxima (PEM) entre cinco e 10mmHg e foram submetidos à manometria esofágica e teste de função pulmonar antes e após oito semanas de treinamento utilizando o threshold IMT (Respironics, Cedar Grove, NJ) duas vezes ao dia. A medida da pressão inspiratória máxima (Pimax) foi aferida a cada duas semanas. O grupo caso teve o threshold IMT ajustado progressivamente, a cada quinze dias, sempre a 30% da nova Pimax. O grupo controle realizou o treinamento com o mesmo aparelho, sob uma pressão constante de 7cmH2O. O nível de significância estatística foi estabelecido a 5% (p £ 0,05). RESULTADOS: A média de idade do grupo caso foi 50,1 ± 18 e no grupo controle de 51,3± 11 anos. Após oito semanas de treinamento utilizando o threshold IMT houve uma melhora na PRM em 15 (75%) pacientes, representando um ganho médio de 46,6% (p<0,01), enquanto no grupo controle, seis (66%) pacientes obtiveram um aumento médio de 26,2% (p<0,01). Não houve diferença estatisticamente significante entre os grupos (p= 0,507). A PEM também aumentou quando comparada com a inicial (p<0,01), mas não diferiu entre os grupos (p= 0,727). Observou-se uma melhora na Pimax no grupo 1 (40% versus 19,6%). Houve um aumento na pressão expiratória máxima (Pemax) em ambos os grupos após as oito semanas de IMT (p< 0,05). CONCLUSÕES: O treinamento muscular inspiratório aumentou as pressões respiratória média e expiratória máxima ao longo das oito semanas em ambos os grupos. Não houve diferença com significância estatística entre os grupos sugerindo que o aumento na pressão do esfíncter inferior do esôfago ocorre independentemente da resistência aplicada ao threshold IMT. Mais estudos são necessários para determinar o impacto clínico desse aumento pressórico e confirmar ou afastar a manutenção dessas pressões a longo prazo / INTRODUCTION: Inspiratory muscle training (IMT) has been shown to increase diaphragm thickness. It is known that the diaphragmatic crural fibers act as an external LES, but it is unknown if patients with hypotensive lower esophageal sphincter (LES) would benefit from IMT increasing the mid-respiratory pressure (MRP), and as such relieving gastroesophageal reflux symptoms. AIM: Evaluate the effect of inspiratory muscle training on MRP in patients with gastroesophageal reflux disease and hypotensive LES and compare it with the control group. PATIENTS AND METHODS: Twenty consecutive patients (progressive loading group) and 9 controls (sham group) were included. All of them had end expiratory pressure (EEP) between 5 and 10mmHg and underwent esophageal manometry and pulmonary function tests before and after 8 weeks of training using a threshold IMT (Respironics, Cedar Grove, NJ) twice daily. The maximal inspiratory pressure (Pimax) measurement was repeated each 2 weeks. The progressive loading group had their threshold IMT set at 30% of their new Pimax. Sham-treated patients (same device but minimal resistance to the air flow) had their threshold set at 7cmH2O and it was maintained constant during the period. The significance level was set at 5% (p £ 0.05). RESULTS: The mean age of progressive loading group was 50.1 ± 11.3 years and sham group was 51.3± 6.3. Following eight weeks of training using a threshold IMT there was an increase in MRP in 15 (75%) patients, representing an average gain of 46.6% (p<0.01), while in the sham group, six (66%) patients had their MRP raised with mean increase of 26.2% (p< 0.01). There was no significant difference between the groups (p= 0.507). EEP also increased when compared with before measured (p<0.01), but did not differ between groups (p= 0.727). It has also been observed an improvement in the Pimax in progressive loading group (40% versus 19.6%). It was observed a gain in the maximal expiratory pressure (Pemax) as well in both groups after the 8-week program of IMT (p< 0.05). CONCLUSION: Inspiratory muscle training increased MRP and EEP in patients of active and sham-treated group after an 8-week program. There was no significant statistical difference between groups suggesting that the increase in pressure at LES occurs regardless to the resistance loading of threshold IMT. Extended follow-up is necessary to document the long-term benefits of such improvements

The thesis deals with monetary disequilibrium in the theory of endogenous money. In the new consensus economics, money is endogenous and passive. Money market is not considered and if yes, then only in an implicit equilibrium, whereas mechanisms ensuring this equilibrium are not discussed. In post-Keynesian economics, there is an explicit discussion, whether monetary disequilibrium may occur. Horizontalists argued for equality of money supply and money demand. On the other hand, arguments of some structuralists based on an independent demand for money function show that monetary disequilibrium may occur. The thesis therefore analyses mechanisms ensuring equilibrium in the money market. The only mechanism among them which enables the passivity of money is the reflux mechanism. However, it can not be regarded as universal since not all economic subjects which create demand for money are in debt to the banking system. For that reason accommodation of some factors of money demand function is necessary and money is endogenous and active. Econometric tests studying independent money demand and the consequent possibility of monetary disequilibrium based on Granger causality tests seem to be methodologically problematic and showing mixed results. Monetary disequilibrium can not be ruled out. Contemporary monetary policy based mainly on new consensus approach thus omits one channel of monetary policy transmission. Theoretical analysis suggests that monetary equilibrium has to be (at least partly) restored through changes in factors of money demand, which can lead to changes of other macroeconomic variables including inflation.

A presente tese de doutorado propõe investigar mapas peptídicos urinários via eletroforese capilar acoplada ao espectrômetro de massas e avaliar se existe correlação entre estes e a presença de refluxo vésico-ureteral (RVU), visando desenvolver um novo método não invasivo para diagnosticar RVU em crianças, e ainda averiguar a existência de possíveis biomarcadores para a doença. Vinte e quatro amostras de urina de crianças positivas para RVU e quinze saudáveis, anteriormente submetidas à uretrocistografia miccional, foram disponibilizadas ao nosso grupo. Estas foram filtradas para eliminar proteínas de alta massa molar e pré-concentradas em coluna de fase reversa C2. Os mapas peptídicos foram obtidos via CE-MS em um eletrólito composto por 0,8% de ácido metanóico e 20% de metanol; já o líquido auxiliar consistia em 0,8% de ácido metanóico e 60% de metanol. Diversos métodos de classificação de aglomerados foram experimentados com os mapas peptídicos. Todos indicaram que as variáveis mais importantes para este discernimento eram os picos mais intensos ordenados em blocos de tempo. Entre os métodos de classificação não supervisionada, PCA (Principal Component Analysis) foi o mais perceptível na tarefa de distribuir os conjuntos de amostras. Para este, a porcentagem de acertos entre as amostras positivas foi de 75% e, entre as amostras negativas foi de 86,7%. No entanto, a taxa de erro encontrada por este método foi de 20,5%, não cumprindo o objetivo proposto. Entre os métodos de classificação supervisionada, SVM (Support Vector Machines) foi o selecionado, exprimindo melhor habilidade em prever que os modelos lineares e boa capacidade de generalização. O método otimizado apontou para o uso da função de base radial, o que está de acordo com outros trabalhos na área. Outras três variáveis ajustadas foram o parâmetro capacidade, o responsável por controlar a amplitude da função gaussiana e o &#949;-insensitive loss function. A validação cruzada LOO (leave-one-out) realizada para a rede treinada pelo SVM exibiu 0,00454 para a raiz quadrada da média dos erros e coeficiente de correlação próximo de um, indicando que o ajuste dos dados foi bem realizado. Empregando um mínimo de 80% das amostras para treinamento e 10% para verificação, o modelo foi capaz de classificar corretamente as amostras restantes. Três grupos de amostras para testes foram separados e a rede foi capaz de classificá-los corretamente. Biomarcadores específicos para RVU foram pesquisados durante o trabalho. Peptídeos que apareceram em mais de 70% das amostras de urina positivas para RVU e em menos de 15% das amostras de urina saudáveis foram selecionados. Espectros MS2 foram obtidos para estes peptídeos, e a pesquisa em bancos de espectros indicou um fragmento da imunoglobulina G como um possível candidato. No entanto, a existência de um biomarcador específico para RVU é ainda incerta, carecendo de uma investigação mais aprofundada para se concretizar este objetivo. Nos mapas peptídicos existem disparidades entre os dois grupos de amostras, que foram correlacionadas nesta tese com a presença de refluxo vésico-ureteral, sendo o nosso espaço amostral classificado corretamente / The present doctorate thesis intends to investigate urinary peptides maps by capillary electrophoresis coupled with mass spectrometry (CE-MS) to evaluate whether there is a correlation between these maps and vesicoureteral reflux (VUR) pathology, with the purpose of developing a new non invasive method for RVU diagnosis in children, and to investigate possible biomarkers for the illness. Twenty four urine samples of positive children for RVU and fifteen healthy children samples, previously submitted to the miccional cystourethrography, were available. Samples were filtered to eliminate proteins of high molar mass and preconcentrated in reversed-phase C2 columns. Peptide enriched samples were submitted to analysis by CE-MS in an electrolyte consisted of 0.8% formic acid and 20% methanol; sheath liquid was composed of 0.8% formic acid and 60% methanol. Diverse cluster analysis techniques were attempted to classify the peptide maps. The most important variables for screening were the most intense peaks organized by blocks of time. Among the non supervised methods, PCA (Principal Component Analysis) performed best in the task of discriminating the sample sets. For PCA, 75% of positive samples and 86.7% of negative samples were correctly assigned. However, the error found for this method was 20.5%, not fulfilling the purpose. Among the supervised methods, SVM (Support Vector Machines) performed best, exhibiting better prediction ability than the linear models and good generalization. The optimized method used a radial basis function, which is in agreement with literature. Three other variables were adjusted: the capacity parameter, responsible for controlling the Gaussian function amplitude and the e- insensitive loss function. The LOO (leave-one-out) cross-validation for the training set showed 0.005011 for the root-mean-square error (RMS) and a coefficient of correlation close to one, indicating good fitting and consistency. With a minimum of 80% samples for training and 10% for verification, the model was capable to classify correctly the remaining samples. Three sample groups for tests had been separated and the net was capable to classify them correctly. Specific biomarkers for VUR were searched. Peptides that appeared in more than 70% of positive urine samples for VUR and less than 15% of negative samples were selected. MS2 spectra were acquired for these peptides and database search pointed to an IgG fragment as a possible candidate biomarker. However, the existence of a specific biomarker for VUR is not conclusive with the present data and a more thorough investigation must be pursued. Nevertheless, the peptidic maps inspected in this work carried enough information that allowed discrimination of two sample sets, one of them correctly associated with VUR

A presente tese de doutorado propõe investigar mapas peptídicos urinários via eletroforese capilar acoplada ao espectrômetro de massas e avaliar se existe correlação entre estes e a presença de refluxo vésico-ureteral (RVU), visando desenvolver um novo método não invasivo para diagnosticar RVU em crianças, e ainda averiguar a existência de possíveis biomarcadores para a doença. Vinte e quatro amostras de urina de crianças positivas para RVU e quinze saudáveis, anteriormente submetidas à uretrocistografia miccional, foram disponibilizadas ao nosso grupo. Estas foram filtradas para eliminar proteínas de alta massa molar e pré-concentradas em coluna de fase reversa C2. Os mapas peptídicos foram obtidos via CE-MS em um eletrólito composto por 0,8% de ácido metanóico e 20% de metanol; já o líquido auxiliar consistia em 0,8% de ácido metanóico e 60% de metanol. Diversos métodos de classificação de aglomerados foram experimentados com os mapas peptídicos. Todos indicaram que as variáveis mais importantes para este discernimento eram os picos mais intensos ordenados em blocos de tempo. Entre os métodos de classificação não supervisionada, PCA (Principal Component Analysis) foi o mais perceptível na tarefa de distribuir os conjuntos de amostras. Para este, a porcentagem de acertos entre as amostras positivas foi de 75% e, entre as amostras negativas foi de 86,7%. No entanto, a taxa de erro encontrada por este método foi de 20,5%, não cumprindo o objetivo proposto. Entre os métodos de classificação supervisionada, SVM (Support Vector Machines) foi o selecionado, exprimindo melhor habilidade em prever que os modelos lineares e boa capacidade de generalização. O método otimizado apontou para o uso da função de base radial, o que está de acordo com outros trabalhos na área. Outras três variáveis ajustadas foram o parâmetro capacidade, o responsável por controlar a amplitude da função gaussiana e o &#949;-insensitive loss function. A validação cruzada LOO (leave-one-out) realizada para a rede treinada pelo SVM exibiu 0,00454 para a raiz quadrada da média dos erros e coeficiente de correlação próximo de um, indicando que o ajuste dos dados foi bem realizado. Empregando um mínimo de 80% das amostras para treinamento e 10% para verificação, o modelo foi capaz de classificar corretamente as amostras restantes. Três grupos de amostras para testes foram separados e a rede foi capaz de classificá-los corretamente. Biomarcadores específicos para RVU foram pesquisados durante o trabalho. Peptídeos que apareceram em mais de 70% das amostras de urina positivas para RVU e em menos de 15% das amostras de urina saudáveis foram selecionados. Espectros MS2 foram obtidos para estes peptídeos, e a pesquisa em bancos de espectros indicou um fragmento da imunoglobulina G como um possível candidato. No entanto, a existência de um biomarcador específico para RVU é ainda incerta, carecendo de uma investigação mais aprofundada para se concretizar este objetivo. Nos mapas peptídicos existem disparidades entre os dois grupos de amostras, que foram correlacionadas nesta tese com a presença de refluxo vésico-ureteral, sendo o nosso espaço amostral classificado corretamente / The present doctorate thesis intends to investigate urinary peptides maps by capillary electrophoresis coupled with mass spectrometry (CE-MS) to evaluate whether there is a correlation between these maps and vesicoureteral reflux (VUR) pathology, with the purpose of developing a new non invasive method for RVU diagnosis in children, and to investigate possible biomarkers for the illness. Twenty four urine samples of positive children for RVU and fifteen healthy children samples, previously submitted to the miccional cystourethrography, were available. Samples were filtered to eliminate proteins of high molar mass and preconcentrated in reversed-phase C2 columns. Peptide enriched samples were submitted to analysis by CE-MS in an electrolyte consisted of 0.8% formic acid and 20% methanol; sheath liquid was composed of 0.8% formic acid and 60% methanol. Diverse cluster analysis techniques were attempted to classify the peptide maps. The most important variables for screening were the most intense peaks organized by blocks of time. Among the non supervised methods, PCA (Principal Component Analysis) performed best in the task of discriminating the sample sets. For PCA, 75% of positive samples and 86.7% of negative samples were correctly assigned. However, the error found for this method was 20.5%, not fulfilling the purpose. Among the supervised methods, SVM (Support Vector Machines) performed best, exhibiting better prediction ability than the linear models and good generalization. The optimized method used a radial basis function, which is in agreement with literature. Three other variables were adjusted: the capacity parameter, responsible for controlling the Gaussian function amplitude and the e- insensitive loss function. The LOO (leave-one-out) cross-validation for the training set showed 0.005011 for the root-mean-square error (RMS) and a coefficient of correlation close to one, indicating good fitting and consistency. With a minimum of 80% samples for training and 10% for verification, the model was capable to classify correctly the remaining samples. Three sample groups for tests had been separated and the net was capable to classify them correctly. Specific biomarkers for VUR were searched. Peptides that appeared in more than 70% of positive urine samples for VUR and less than 15% of negative samples were selected. MS2 spectra were acquired for these peptides and database search pointed to an IgG fragment as a possible candidate biomarker. However, the existence of a specific biomarker for VUR is not conclusive with the present data and a more thorough investigation must be pursued. Nevertheless, the peptidic maps inspected in this work carried enough information that allowed discrimination of two sample sets, one of them correctly associated with VUR

<p>The overall aims of our studies were to identify risk factors for respiratory symptoms and asthma in indoor environment but even to look at some personal risk factors such as body mass index and gastroesophageal reflux. The study population is based on participants of the European Community Respiratory Health Survey I and II. </p><p> In the first study, water damage and visible moulds were reported in 7.4% and 17% of the homes respectively. The combination of water damage and visible moulds was independently associated with attacks of breathlessness when resting and after activity and also to long term cough. In the second study, the prevalence of nocturnal GER increased with higher BMI and the same pattern could be seen for habitual snoring. Reported onset of asthma, wheeze and night-time symptoms increased in prevalence along with the BMI gradient. In the multivariable analysis, obesity and nocturnal GER were independent risk factors for onset of asthma, wheeze and night-time symptoms. Habitual snoring was an independent risk factor for onset of wheeze and night-time symptoms, but not for onset of asthma. In the third study, a total of 18% of the subjects reported indoor dampness in the last 12 months and 27% of the subjects reported indoor dampness since the previous survey. Respiratory symptoms and asthma were significantly more prevalent in individuals exposed to indoor dampness and indoor dampness was a risk factor for respiratory symptoms and asthma after adjusting for possible confounders. Indoor dampness was an independent risk factor for onset of respiratory symptoms but not for asthma onset. Remission of respiratory symptoms was less likely to occur if subjects reported indoor dampness. In the fourth study, the lowest prevalence of atopy and the lowest levels of all indoor allergens, bacteria and moulds were found in Iceland. A positive association was found, between cat allergen exposure and asthma symptoms and between bronchial hyperresponsiveness and the amount of viable mould in indoor air.</p>

The overall aims of our studies were to identify risk factors for respiratory symptoms and asthma in indoor environment but even to look at some personal risk factors such as body mass index and gastroesophageal reflux. The study population is based on participants of the European Community Respiratory Health Survey I and II. In the first study, water damage and visible moulds were reported in 7.4% and 17% of the homes respectively. The combination of water damage and visible moulds was independently associated with attacks of breathlessness when resting and after activity and also to long term cough. In the second study, the prevalence of nocturnal GER increased with higher BMI and the same pattern could be seen for habitual snoring. Reported onset of asthma, wheeze and night-time symptoms increased in prevalence along with the BMI gradient. In the multivariable analysis, obesity and nocturnal GER were independent risk factors for onset of asthma, wheeze and night-time symptoms. Habitual snoring was an independent risk factor for onset of wheeze and night-time symptoms, but not for onset of asthma. In the third study, a total of 18% of the subjects reported indoor dampness in the last 12 months and 27% of the subjects reported indoor dampness since the previous survey. Respiratory symptoms and asthma were significantly more prevalent in individuals exposed to indoor dampness and indoor dampness was a risk factor for respiratory symptoms and asthma after adjusting for possible confounders. Indoor dampness was an independent risk factor for onset of respiratory symptoms but not for asthma onset. Remission of respiratory symptoms was less likely to occur if subjects reported indoor dampness. In the fourth study, the lowest prevalence of atopy and the lowest levels of all indoor allergens, bacteria and moulds were found in Iceland. A positive association was found, between cat allergen exposure and asthma symptoms and between bronchial hyperresponsiveness and the amount of viable mould in indoor air.

Two hydrogeologic models explore reflux dolomitization using two outcrop datasets at different scales to constrain transient boundary conditions and heterogeneous petrophysical properties. A platform-scale petrophysical model of the Permian San Andres Formation was built from outcrop and subsurface data following a reservoir modeling approach that preserves outcrop heterogeneity and incorporates a sequence stratigraphic framework. This model was used as input for hydrogeological simulations of hypersaline fluid flow and solute transport during the accumulation and compaction of the platform. Boundary conditions change over time, as relative sealevel fluctuations drive sedimentation, depositional environment migration, topographic gradients, and location, size and salinity of the brine source. The potential volume and distribution of dolomite formed is inferred by a magnesium mass-balance. The composite result of reflux events at various orders of stratigraphic hierarchy is a complex dolomite pattern that resembles that observed on San Andres outcrops. Dolostone bodies across the platform may be generated by different combinations of favorable conditions, including proximity to the brine source, zones of higher permeability, permeability contrasts, and latent reflux. A meter-scale reactive transport model of the Albian Upper Glen Rose Formation simulates deposition of three high-frequency cycles punctuated by three brine reflux events. The simulator determines flow, solute and reactive transport along the flow paths, revealing the spatial and temporal distribution of calcite dissolution, and precipitation of dolomite and sulfate. The model recreates fully and partially dolomitized cycles within the time and lithological constrains on Glen Rose outcrops. Our results show that the distribution of dolomite within a high-frequency cycle may be the net result of intercycle processes, whereby dolomitizing fluids sourced from younger cycles flow across stratigraphically significant boundaries. We also show that variations in dolomite abundance and the unfulfilled dolomitization potential control the contemporaneous propagation of multiple dolomite fronts and the coalescence of discrete dolomite bodies. Results show that reflux is an effective and efficient mechanism to dolomitize carbonate formations that progresses simultaneously with sediment accumulation. Dolomitization is the cumulative result of many short-lived reflux events, sourced in different locations and times, and amalgamation of successive dolostone bodies. This model contrasts with previous studies that approached dolomitization of a carbonate platform as a discrete reflux event and current interpretations that relate dolomite bodies to their most immediate stratigraphic surfaces. / text

Introdução: Pirose e regurgitação são manifestações da Doença do Refluxo Gastresofágico (DRGE) que ocorrem freqüentemente no terceiro trimestre da gravidez, porém seu impacto na qualidade de vida de gestantes é pouco conhecido. Objetivos: 1. Mensurar a qualidade de vida em gestantes no terceiro trimestre da gravidez com Pirose e Regurgitação; 2. Avaliar a relação entre Pirose e Regurgitação e a dieta. Pacientes e Métodos: Gestantes no terceiro trimestre acompanhadas ambulatorialmente foram entrevistadas para colher dados referentes à história obstétrica, freqüência, intensidade e passado de P e R, qualidade de vida (mensurada a partir do questionário genérico SF-36), ingestão alimentar (avaliada por recordatório de 24h) e medidas antropométricas; Resultados: Foram estudadas consecutivamente 82 gestantes: 62 com pirose e/ou regurgitação e 20 assintomáticas. Pirose foi relatada por 62 (76%) gestantes e regurgitação por 58 (71%). A idade gestacional média foi 33,8±3,7 semanas, 35 (43%) apresentavam história familiar positiva de pirose e/ou regurgitação e 57 (70%) não apresentavam tais sintomas fora da gravidez. Houve redução estatisticamente significativa na qualidade de vida das gestantes sintomáticas nos seguintes domínios: Para pirose, em Limitação Física e Aspectos Sociais; para regurgitação, em Limitação Física, Aspectos Sociais, Aspectos Emocionais e Dor. Houve concordância entre presença de pirose em gestações passadas e a atual. Gestantes com pirose apresentaram-se significativamente com maior peso corporal. Ácidos graxos poli e monoinsaturados, cafeína, ácido ascórbico e sulfato ferroso foram significativamente associados com pirose e/ou regurgitação. Conclusões: 1.Pirose e / ou regurgitação diminuíram a qualidade de vida em gestantes no terceiro trimestre; 2. ácidos graxos, cafeína, ácido ascórbico e sulfato ferroso estiveram associados com pirose e/ou regurgitação. / Goals: (1) To measure health-related quality of life of third-trimester pregnant women with heartburn and/or regurgitation; (2) to investigate the association between these symptoms and diet. Background: Heartburn and regurgitation are frequent in the third trimester of pregnancy, but their impact on health-related quality of life has not been thoroughly investigated. Methods: The following data were collected for 82 third-trimester pregnant women: obstetric history, heartburn and regurgitation frequency and intensity, history of heartburn and regurgitation, health-related quality of life (SF-36 questionnaire), diet (24-hour recall), and anthropometrical measurements. Results: Sixty-two women (76%) had heartburn, and 58 (71%), regurgitation; 20 were asymptomatic. Mean gestational age was 33.8±3.7 weeks; 35 (43%) women had a family history of heartburn and/or regurgitation, and 57 (70%) did not have these symptoms before pregnancy. A significant reduction in quality of life was observed in terms of physical problems and social functioning for women with heartburn; physical problems, social functioning, emotional problems, and pain for women with regurgitation. There was agreement between reports of heartburn for present and previous pregnancies. Weight was significantly greater in pregnant women with heartburn. Polyunsaturated and monounsaturated fatty acids, caffeine, ascorbic acid and ferrous sulphate were significantly associated with heartburn and regurgitation. Conclusions: Heartburn and/or regurgitation affected health-related quality of life of third trimester pregnant women; (2) fatty acids, caffeine, ascorbic acid and ferrous sulphate were significantly associated with heartburn and regurgitation.

O refluxo gastroesofágico (RGE) tem sido diagnosticado em uma elevada proporção de lactentes com apnéia e episódios de ALTE (apparent life threatening events) ou eventos com aparente risco de vida, entretanto, a relação entre eles per-manece pouco entendida. A proposta deste estudo é avaliar a coexistência de apnéia e refluxo gastroesofágico em um grupo de lactentes durante o sono e vigília, através da utilização da polissonografia e, pela inclusão de um canal para aferição do pH na porção distal do esôfago, determinar a relação temporal entre estes dois eventos e aferir a associação entre ALTE e RGE. Método: A população em estudo constituiu-se de lactentes com história clínica compatível com eventos sugestivos de RGE, além de alguma anormalidade do ponto de vista ventilatório, os quais realizaram polissonografia com a inclusão de um canal para registro contínuo do pH esofágico. Os estudos polissonográficos foram analisados individualmente, em três etapas assim constituídas: Etapa 1 - realização do escore dos eventos respiratórios e dos estágios de sono e vigília, com o pesquisador cego para a ocorrência de RGE; Etapa 2 - indicação do escore isolado dos eventos de RGE; Etapa 3 - reintrodução de canal do pH e estabelecimento da correlação temporal entre os dois eventos, levando-se em consideração o período compreendido entre um minuto antes da queda do pH abaixo de 4,0, até um minuto após a elevação do pH acima de 4,0. A relação entre a história clínica de ALTE e a ocorrência de RGE durante o estudo polissonográfico também foi aferida. A partir de dados publicados na literatura, foi calculada uma amostra de 88 indivíduos (lactentes). A amostra final constituiu-se de 89 pacientes. Resultados: Quarenta pacientes apresentaram RGE e quarenta e nove não. Ambos os grupos tinham composição semelhante quanto à idade, peso, duração total do estudo polissonográfico, duração do tempo total de sono durante o estudo e história de ALTE. Ocorreu uma média de 2,82 episódios de RGE por paciente (1-20 episódios/ paciente). Os episódios de RGE foram mais freqüentes e longos durante o sono que durante os períodos de vigília. O número de eventos obstrutivos/minuto de sono (densidade de apnéias) foi significativamente maior durante os períodos de RGE (mediana 0,4), se comparados aos períodos sem RGE (mediana 0,2), p = 0,002. Em relação às apnéias centrais, não houve diferença estatisticamente significativa, p = 0, 039. Em 62% dos períodos de RGE, houve associação temporal com eventos obstrutivos, dos quais a apnéia obstrutiva precedeu o RGE em 67% dos casos. A correlação entre história de ALTE e a presença de RGE não foi estatisticamente significativa. Conclusões: Os resultados sugerem que a apnéia obstrutiva em lacten-tes está freqüentemente associada com RGE do ponto de vista de temporalidade, e é mais provável que ela ocorra precedendo um episódio de refluxo. Especula-se que a apnéia obstrutiva no lactente possa, em algumas circunstâncias, ser a causa e não a conseqüência do RGE. / Gastroesophageal Reflux (GER) has been diagnosed in a high proportion of infants with apnea and ALTE (APPARENT LIFE THREATENING EVENTS), however, the temporal relationship between these episodes remain unclear. The purpose of this study was, using polysomnographyc studies, during sleep and wakefulness, with an addition of an esophageal pH probe, evaluate the coexistence of apnea and GER, determine the temporal relationship between these two events and assess whether a relationship exists between the presence of ALTE and GER. Methods: Study population was infants with a clinical suspicion of GER and a presence of a respiratory abnormality who underwent polysomnography with a distal pH probe. Polysomnographic studies were evaluated in three steps: Step 1 - scoring of respiratory events and sleep stages disregarding pH channel; Step 2 - scoring of GER episodes; Step 3 - using all channels at the same time, a temporal correlation between the GER and apnea was assessed taking into account a period of one minute before a pH drop less than 4.0 for more than 15 seconds up to one minute after elevation of pH more than 4.0. The relationship between clinical history of ALTE and the occurrence of GER during polysomnography was also evaluated. From literature data, a sample size was calculated as 88 subjects (infants). A final sample of 89 patients was included. Results: Forty patients had GER, forty- nine did not have. Both groups had the same status regarding age, weight, total polysomnographic study duration, total sleep time duration and history of ALTE. There was a mean of 2.82 episodes of GER per patient (1-20 episodes/ patient). GER episodes were more frequent and longer during sleep than wakefulness. The number of obstructive events/ minute of sleep (apnea density) was significantly higher during GER episodes (median 0.4) compared to free GER periods (median 0.2), p = 0.002; while for central apneas there was no statistically significance, p = 0.039. In sixty-two percent (62%) of GER episodes there were a temporal association with obstructive episodes, where obstructive apnea preceded GER in 67% of these episodes. There was no correlation between clinical story of ALTE and the occurrence of GER. Conclusion: The results indicates that obstructive apnea in infants is often temporally related to gastroesophageal reflux and more likely to follow than precede obstructive apnea. The authors speculate that obstructive apnea may be the cause rather than a consequence of GER.

Introdução: O complexo anatômico-funcional localizado na junção esôfagogástrica é uma barreira ao refluxo gastresofágico. A pressão e o volume intragástricos necessário para vencer essa barreira são denominados Pressão de Vazão Gástrica e Volume de Vazão Gástrico e são utilizados em modelos animais para medir a sua competência, entretanto, a sua validação ainda não foi determinada. Objetivos: Desenvolver um modelo experimental suíno e validar a pressão e o volume intragástricos para estudo da barreira antirrefluxo. Métodos: Suínos da raça Large White com 8 semanas de vida, do sexo feminino foram utilizados neste experimento. Após a anestesia dos animais, foi realizada a manometria esofágica e um cateter de pHmetria posicionado 5 cm acima do esfíncter esofágico inferior. Uma sonda Foley de três vias foi introduzida no estômago através de gastrostomia e o duodeno obliterado através de um laço com gaze úmida. HCL (0,1N) foi infundido lentamente no estômago e medidos a pressão e o volume intragástricos, em tempo real em sistema digital. A pressão e o volume intragástricos no momento da queda abrupta do pH esofágico (pH< 3) foram definidas como Pressão de Vazão Gástrica (PVG) e Volume de Vazão Gástrico (VVG). Após o experimento, a sonda Foley foi retirada, o duodeno liberado e a gastrostomia ocluida com pontos cirúrgicos. Os animais foram mantidos em local apropriado até a repetição dos experimentos sete dias após. Resultados: Dez animais (peso médio = 20 Kg) foram estudados. Os valores médios (± DP) nos dias 0 e 7 foram, respectivamente: PVG 7,66 ± 3,02 versus 7,07 ± 3,54 (p =0,510 teste t de student e 0,557 para o teste exato de Wilcoxon) e VVG 636,70 ± 216.74 versus 608,30 ± 276,66; (p =0,771 teste t de Student e 0,846 para teste de Wilcoxon) não apresentaram diferença estatística significativa. Entretanto, quando aplicado o Coeficiente de Correlação de Concordância a reprodutibilidade foi significativa apenas para a PVG (CCC de 0,648), mas não para a VVG (CCC de 0,27). Conclusão: O modelo animal desenvolvido identifica reprodutibilidade para a PVG, mas não para a VVG. A PVG pode ser utilizada com confiança para o estudo da barreira anti-refluxo. / Introduction: The anatomic functional complex situated at the esophago-gastric junction is a barrier to gastroesophageal reflux. The intragastric pressure and volume necessary to overcome this barrier is called Gastric Yield Pressure and Gastric Yield Volume and used in animal models to measure the anti-reflux competence. However, its validation has not been determined. Objectives: Develop an experimental pig model and validate the intragastric pressure and volume to study the anti-reflux barrier. Methods: Large White pigs two month-old females were used in this experiment. After anesthesia esophageal manometry and a pH sensor placed 05 cm above the lower esophageal sphincter. A threeway Foley catheter was introduced into the stomach through a gastrostomy and duodenum tied with a wet gauze. The Foley probe allowed simultaneous HCl (0.1 N) infusion into the stomach and real time measurement of the intragastric pressure and volume on a digital system system. The intragastric pressure and volume simultaneous to a sudden fall in esophageal pH (pH <3) were defined as the Gastric Yield Pressure (GYP) and the Gastric Yield Volume (GYV). After the experiment, the Foley was removed, the duodenum untied and gastrostomy occluded with surgical stitches. The animals were kept in an appropriate room and the experiment repeated after seven days. Results: Ten animals (mean weight = 20 kg) were studied. The mean values (± SD) on days 0 and 7 were, respectively: GYP 7.66 ± 3.02 and 7.07 ± 3.54 (p = 0,510 student t test and 0.557 for Wilcoxon’s exact test) and GYV 636.70 ± 216.74 and 608.30 ± 276.66, (p =0,771 student t test and 0.846 for Wilcoxon) had no significant statistic difference. However, when the concordance correlation coefficient was applied reproducibility was found only for GYP (CCC = 0,648) but not for GYV (CCC = 0.27). Conclusion: The developed animal model disclosed reproducibility for GYP but not for GYV. GYP may be used with confidence to study the anti-reflux barrier.