Background: It is well recognised that the adenoma-carcinoma sequence is the mechanism by which most colorectal malignancies arise. Dysplastic adenomas are the precursor lesions which can progress to adenocarcinoma and premalignant sessile villous adenomas represent a particular challenge. Their early detection and removal can prevent rectal cancer. Local excision of low rectal tumors has become increasingly popular as technical advancement has rendered it easier and more effective. Local tumour excision avoids the complications of radical surgery. Transanal endoscopic operation (TEO) and Transanal endoscopic microsurgery (TEMS) are two equivalent techniques that have been widely adopted as the treatments of choice for large rectal adenomas and selected rectal cancers but has been under-employed in South Africa. The aim of this study was to evaluate TEO (the simpler and more affordable platform of the two) by describing the dimensions and anatomical parameters of specimens resected and using this to investigate whether any of these are predictive of recurrence, and to evaluate the incidence of complications of this less radical technique. Methods: In this single surgeon study, data was collected from pre-existing patient files (paper and electronic) during the first half of the time period and during the second half, was prospectively entered into a database. It includes all patients undergoing resection of benign and malignant rectal tumours by TEO at a private (Kingsbury Hospital) and public health institution (Groote Schuur Hospital) from January 2009 - May 2017. Electronic records, including operation notes, histology and radiology were reviewed. Results: Data was collected from January 2009 to May 2017. 110 patients in this study of which 87 (79.1%) were benign. There were 11 (12%) recurrences in this group. In the malignant group, there were 5 (21%) recurrences. The median tumour length was 4.5cm (IQR 2.5) and median tumour area was 16cm2 (IQR 20.11). For benign lesions, there was a significant difference in recurrence in patients presenting with incontinence (χ2 8.21, p-value<0.01, OR 16.7 (1.37-202.7)), lesions with involved surgical margins (χ2 6.29 p-value 0.01, OR 6.75 (95% CI 1.02 - 35.7)) and circumferential tumours (χ2 6.31 p-value 0.04, 6.5 (1.17-36.3)). The multinomial logistic regression model for benign lesions revealed that only incontinence and involved surgical margins were independent predictors of recurrence. Complications occurred in 21 (19.1%) patients with circumferential lesions, length of the tumour, and malignancy being predictive of complications. Conclusion: This study constitutes the only report of TEO or TEMS from a low- or middle-income country (LMIC). The results are in keeping with the published literature, demonstrating its safety and feasibility in a LMIC setting, which will reduce the need for expensive, highly morbid radical surgery for benign and malignant disease. The recommendation is for a wider introduction of TEO in South Africa and other LMIC countries with the provision of adequate training.

Introduction Human immunodeficiency virus (HIV) infection is becoming a global epidemic. In HIV-infected individuals, anorectal diseases are common and the commonest indications for surgical intervention. However, it has not been clear whether the cause and management of anorectal conditions differ in patients who are HIV negative and those who are HIV positive. Aim To compare the presentation of perianal diseases in HIV +ve and HIV –ve patients and to determine the best therapy for perianal diseases in HIV +ve patients Methods The study period was from 1999 to 2002. Patients seen at Helen Joseph Hospital during the author’s gastroenterology fellowship period and those from his private practice were recruited. Those who agreed to HIV testing and who were treated by the author were included in the study. The patients were categorized according to HIV status, CDC classification and perianal pathology. Standardized questionnaires were used for every patient. Patients were reviewed every two weeks after the procedure until fit for discharge. Results The sample comprised 241 patients: 100 HIV+ve (63 males and 37 females) and 141 HIV-ve (61 males and 80 females). The mean age of the HIV+ve patients was 34,8y (range 17-62y), and the mean age of the HIV-ve patients was 41y (range 5-82y). Follow-up was from two weeks to two years. The pathology included 62 (25 +ve, 37 -ve) haemorrhoids, 67 (27 +ve, 40 –ve) fistulas, 59 (25 +ve, 34 -ve) abscesses, 46 (11 +ve, 35 -ve) fissures, 24 (22 +ve, 2 -ve) anal ulcers, four (3 +ve, 1 -ve) anal warts, two (both +ve) pilonidal sinuses, three (all -ve) anal cancers and two (1 +ve, 1 -ve) hidradenitis suppurativa. Nine patients with haemorrhoids (4+ve, 5-ve) were treated conservatively, 11 patients with haemorrhoids (6+ve, 5-ve) had rubber band ligation and 42 patients with haemorrhoids (15+ve, 27-ve) had haemorrhoidectomy. Thirteen patients (1+ve, 12-ve; p<0.001) had complex fistulas and 8 patients (7+ve, 1-ve; p=0.006) had multiple fistulas. Ten HIV -ve patients with complex fistulas and seven patients with trans-sphincteric fistulas (3+ve, 4-ve) needed more than six weeks to heal after treatment. Thirty patients with anal fissures had sentinel piles, but there were none in the patients with anal ulcers (p<0.0001). Thirteen HIV +ve patients with anal ulcers had an abnormally weak anal tone, but only one HIV +ve patient with anal fissure had a weak anal tone (p<0.001). In the patients with anal fissure, 37 (8+ve, 29-ve) had a high anal tone, but none of the patients with anal ulcers had increased anal tone (p<0.0001). Of the 59 patients with perianal suppuration, 23 (8+ve, 15-ve) had primary fistulotomy as well as drainage of the abscess. Conclusions Multiple fistulas were more commonly seen in advanced HIV patients, whereas complex fistulas were more commonly seen in HIV negative individuals. Healing after fistula surgery is determined more by the type of fistula than the HIV status or stage. Anal fistulas associated with perianal suppuration can be treated the same way in both HIV negative and positive patients, without increased complications. Careful physical examination is essential to differentiate between anal ulcers and fissures. Both conditions are common, and have similar symptoms in HIV positive patients. They can, however, be readily and safely distinguished on clinical examination, since fissures are associated with high anal tone, and a sentinel pile, while the AIDS ulcer lacks the sentinel pile, and the pressure is low. Anal malignancies, especially squamous cell carcinoma, have been uncommon in our experience. With the addition of anti-retroviral therapy and antibiotics, haemorrhoids may be safely treated according to standard principles (rubber band ligation and haemorrhoidectomy, as appropriate). Our practice has favoured a conservative approach in patients with advanced HIV disease. However, anti-retroviral therapy and antibiotics may improve the safety and outcome after surgical procedures.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22325号 / 医博第4566号 / 新制||医||1041(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 妹尾 浩, 教授 萩原 正敏, 教授 小川 修 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Introduction: Intestinal obstruction is a common cause of hospital admissions and carries a mortality rate around 5%. We hypothesized that surgical intervention reduces mortality among these patients. Methods: We conducted a retrospective cohort study using the 2006 Nationwide Inpatient Sample (NIS) to analyze patients with a diagnosis of intestinal obstruction without hernia. We used multiple variable logistic regression to calculate the odds ratio for surgery as a predictor of death after adjusting for illness severity. Results: Among 38,931 patients, 17,544 (45.1%) underwent operative intervention for intestinal obstructions. Surgical patients were slightly younger than non-surgical patients (65 vs. 68 years), and had more severe illness, as measured by the disease staging: mortality scale (115.45 vs. 97.95, p&lt;0.001). After adjusting for illness severity, surgery was protective from mortality (adjusted odds ratio 0.617, 95% CI 0.535-0.710, p&lt;0.001). This finding was validated with 2 other methods of severity adjustment. Among surgery patients, there were fewer days to surgery among survivors (1 day) than non-survivors (2 days), p&lt;0.001. The risk of bowel necrosis increased as time from admission to surgery increased. A greater percentage of surgical patients (77.5%) were discharged home compared to non-surgical patients (76.3%), p=0.007. Conclusion: Surgery is associated with a reduced odds of in-hospital mortality among patients urgently or emergently admitted with intestinal obstruction without hernia. Delaying operative intervention is associated with an increased odds of bowel necrosis and death in these patients. / Clinical Research and Translational Medicine

Conselho Nacional de Desenvolvimento Científico e Tecnológico / The objective of the present study was to evaluate the use of a homologous bone pin, conserved in 98 % glycerin associated to hemicerclage with 910 polyglactin in transverse humerus osteosynthesis in domestic pigeons (Columba livia). The distal part of the tibialtarsus, conserved with bone marrow, was used as a bone pin. Twenty non-sexed healthy adult domestic were operated with this technique. Those animals were randomly separated in five groups of four individuals. The humerus was surgically transversely split up in its diaphysis and the bone pin, after rehydrated and cleaned of the bone marrow, was properly implanted in the sinus of the pneumatic bone. After reduction of the fracture, cranial and caudal holes were made and through them was passed a synthetic to make a Wollff pattern hemicerclage with a thread of 910 polyglactina. The animals were clinically evaluated, being under observation their general state, aspect of the surgical wound, and the use of the member to fly. X-rays were made immediately and every seven days after the surgery, to evaluate the behavior of the bone pin and the period of cicatrization of the fracture and its intensity. After the pre-established period for each group that was of 15, 30, 60, 90, and 120 days, the individuals underwent euthanasia in order to evaluate macroscopically the cicatrization of the fracture, as well as internally, after longitudinal cut, the pneumatic patency of the humerus and the presence of the bone pin and its integrity. The cicatrization of the fracture and the events that took place during the pre-determined periods were evaluated histologically. The conservation of the bone pin in glycerin at 98% was evaluated through microbiological exams. Clinically, it could be noticed excellent adaptation concerning the surgery and normality regarding the use of the member in all the animals. Radiologically, it could be observed cicatrization of the fracture in all the animals of the experiment, within 15 days of evaluation, important bone callus within 30 days and normal bone within 90 days. Macroscopically, bone callus was observed within 15 and 30 days and evolutionary reabsorption with complete and perfect remodeling within 90 days in all the animals, internally, pneumatic patency and presence of the pin. Histologically, it heading occured within 15 days after the surgery, with incomplete remodeling in 60 days, and complete remodeling in 90 days. Besides light to moderate inflammatory reaction in the initial period of evaluation, no other event was diagnosed in the subsequent periods. It was concluded that the implant of a homologous bone pin conserved in 98% glycerin, associated to hemicerclage with 910 polyglactina in Wolff pattern is a highly viable option to transverse humeral osteosynthesis of domestic pigeons. / O objetivo do presente estudo foi avaliar a utilização de um pino ósseo homólogo, conservado em glicerina a 98%, associado a hemicerclagem com poliglactina 910 na osteossíntese umeral transversa de pombos domésticos (Columba livia). Utilizou-se como pino ósseo a parte distal do tibiotarso, conservado com medula óssea. Foram operados com a técnica 20 pombos domésticos, adultos, não sexados, clinicamente sadios. Esses animais foram separados ao acaso em cinco grupos, com quatro indivíduos. O úmero foi seccionado cirurgicamente na sua diáfise, de forma transversa e o pino ósseo, após reidratado e limpo da medula óssea foi devidamente implantado no seio do osso pneumático. Orifícios cranial e caudal ao foco da fratura, após ser reduzida, foram efetuados e, por eles, passou-se um fio sintético para efetuar-se hemicerclagem em forma de Wolff com fio poligalactina 910. Os animais foram avaliados clinicamente, verificando-se o seu estado geral, aspecto da ferida cirúrgica e utilização do membro para o vôo. Radiografias foram realizadas imediatamente e a cada sete dias após a cirurgia, para avaliar o comportamento do pino ósseo e o tempo de cicatrização da fratura e sua intensidade. Após o período prédeterminado para cada grupo, que foi de 15, 30, 60, 90 e 120 dias, os indivíduos sofreram eutanásia e pode-se assim avaliar macroscopicamente a cicatrização da fratura, bem como internamente, após corte longitudinal, a patência pneumática do úmero e a presença do pino ósseo e sua integridade. Histologicamente avaliou-se a cicatrização da fratura, e os eventos ocorridos nos tempos pré-determinados. A conservação do pino ósseo em glicerina a 98% foi avaliada através de exames microbiológicos. Clinicamente pode-se notar excelente adaptação à cirurgia e normalidade do uso do membro em todos os animais. Radiológicamente pode-se observar cicatrização da fratura em todos os animais do experimento, aos 15 dias de avaliação, calo ósseo importante aos 30 dias e osso normal aos 90 dias. Macroscopicamente observou-se calo ósseo aos 15 e 30 dias e evoluindo para reabsorção com remodelação completa e perfeita aos 90 dias em todos os animais, internamente, patência pneumática e presença do pino. Histologicamente pode-se dizer que ocorreu cicatrização 15 dias após a cirurgia, cicatrização com remodelação incompleta aos 60 dias e remodelação completa a partir dos 90 dias. Nesse exame, além de leve a moderada reação inflamatória no período inicial de avaliação, nenhum outro evento foi diagnosticado nos períodos subseqüentes. Concluiu-se que o implante de um pino ósseo homólogo conservado em glicerina a 98%, associado a hemicerclagem com fio poliglactina 910 em forma de Wolff é uma opção altamente viável na osteossíntese umeral transversa de pombos domésticos.

Orientador: William Dias Belangero / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-19T13:05:04Z (GMT). No. of bitstreams: 1 Sawaia_RogerioNaim_D.pdf: 9806060 bytes, checksum: d75ddfca6472ebb85dbfad46a0daa1a4 (MD5) Previous issue date: 2011 / Resumo: INTRODUÇÃO: O tratamento cirúrgico das fraturas intertrocanterianas do fêmur ainda é motivo de estudo e controvérsias. As vantagens da utilização de técnicas minimamente invasivas para essas fraturas já despontam na literatura. O objetivo deste estudo foi avaliar as complicações da técnica minimamente invasiva que utiliza um implante e um instrumental desenvolvidos especificamente (Sistema Minus) para o tratamento dessas fraturas. CASUÍSTICA E MÉTODO: Foram estudados 172 pacientes com fratura intertrocanteriana do fêmur, tratados com o Sistema Minus, dos quais 52 pacientes foram excluídos do estudo por não terem preenchido os critérios de inclusão. No protocolo inicial foram registrados o gênero, a idade, detalhes operatórios como tempo cirúrgico, tempo de uso da fluoroscopia, qualidade da redução e da fixação da fratura. Como parâmetros clínicos foram incluídos a capacidade de marcha, dor, classificação da fratura segundo os critérios de Tronzo e o risco anestésico segundo a classificação de ASA. Dividimos as complicações em dois grupos. As complicações gerais, subdivididas em infecção e mortalidade e as complicações específicas, subdivididas em migração do implante, a perda da redução e a falta de união. Embora a migração do pino deslizante não seja considerada na literatura como uma complicação do DHS (Hrubna e Skotak, 2010)1, no presente estudo ela foi incluída. Cabendo salientar que foi considerada como migração, a impacção lateral da fratura sem a ocorrência de perda de redução. RESULTADOS: O gênero feminino ocorreu em 93 casos e obteve percentual de 77,5%, foi prevalente em relação ao masculino com 27 casos e 22,5%. A idade variou de 52 a 95 anos, com a média de 80,06 anos e desvio padrão de 7,87 anos. A média de idade do gênero masculino foi de 76,19 anos e desvio padrão de 8,321. O gênero feminino obteve a média de 81,18 anos com desvio padrão de 7,407. O tempo cirúrgico médio foi de 39,35 minutos, variando de 25 a 65 minutos. O tempo médio de radioscopia foi 1min7s, variando de 0,6 a 2 minutos e 3s. A redução foi considerada adequada em 92 casos (76,6%), quando obteve-se o alinhamento do eixo de carga, como valgo em 20 casos (16,6%) e como varo em oito casos (6,6%). O somatório médio do TAD (Tip Apex Distance) na incidência Ântero-posterior (AP) foi de 1,19cm, variando de 0,2 a 2,8cm; e no Perfil (P), de 1,14cm, variando de 0,3 a 2,52cm. Dos pacientes, 112 (93,3%) voltaram a andar e a dor pós-operatória em uma escala de 0 a 10, teve a média de 4,44. Dos 120 pacientes, 11 foram classificados como Tronzo I (9,1%), 24 como Tronzo II (20%), 58 como Tronzo III (48,3%), sete Tronzo III variante (5,8%) e 20 Tronzo IV (16,7%). As fraturas instáveis ocorreram em 85 (70,8%) pacientes, os quais 74 (61,6%) tinham idade superior a 75 anos. Já as fraturas estáveis em 35 (29,1%) pacientes, os quais 17 (14,1%) possuíam idade superior a 75 anos. Em relação ao risco anestésico, oito (6,6%) foram classificados como ASA I, 33 (27,5%) ASA II, 74 (61,6%) ASA III e cinco ASA IV (4,16%). Houve um caso de infecção (0,83%). Ocorreram 13 óbitos (10,8%) dentro do primeiro ano de pós-operatório. Desses, um (0,83%) foi classificado como Asa II, cinco (4,16%) como Asa III e sete (5,83%) Asa IV. Dos 85 pacientes com fraturas instáveis, 36 (30%) apresentaram complicações, como perda de redução em 7(5,88%) e migração do pino deslizante em 29 (24,1%). No grupo das 35 fraturas estáveis, as complicações ocorreram em 4 casos (3,33 %), sendo que a perda de redução ocorreu em um caso (0,83%) e a migração em 3 casos (2,5%). No total, a migração ocorreu em 33 casos (27,6%), sendo que desses, todos evoluíram para consolidação. A perda de redução ocorreu em oito (6,7%) e a falta de união, em um caso (0,83%). CONCLUSÃO: Concluímos que a técnica minimamente invasiva, Sistema Minus, é uma técnica segura, que permite a realização da cirurgia com baixa incidência de complicações, quando comparada aos demais métodos existentes / Abstract: INTRODUCTION: The surgical treatment of intertrochanteric fractures is still controversial, resulting in further studies. Many papers have appeared in reference to the advantages of minimal invasive procedures for these fractures. The aim of this study was to evaluate the complications of a minimal invasive procedure using a specific implant and instruments developed for the treatment of intertrochanteric fractures (Minus System). MATERIAL AND METHOD: One hundred and seventy two patients with intertrochanteric fractures of the femur were studied, and submitted to treatment with the Minus System. Fifty two patients were excluded from the study as they did not fulfil all criteria for inclusion. The initial protocol registered gender, age, operative details such as length of operation, length of fluoroscopy use, quality of reduction and fixation of the fracture. The clinical parameters considered included deambulatory ability, pain, Tronzo fracture classification and anesthesia risk according to ASA classification. Complications were divided into two groups: general complications (infection and mortality rate) and specific complications (implant migration, loss of reduction and non-union). Although the migration of a sliding nail has not been considered in the literature as a DHS complication (Hrubna e Skotak, 2010)1 RESULTS: There were 93 feminine cases (77.5%) prevailing on 27 masculine cases (22.5%). Age span was 52 to 95 years, with an average of 80.06 years (standard deviation of 7.87 years). The average age for men was 76.19 years with a standard deviation of 8.321. The average age for women was 81.18 years with a standard deviation of 7.407. The average operative length of time was 39.35 minutes (25 to 65 minutes). The average time of fluoroscopy was 1min 7sec (0.6 to 2min 3sec). Fracture reduction was considered adequate in 92 cases (76.6%), , in the present study it was taken into account. It is important to mention that migration here is the lateral impaction of the fracture without loss of reduction. when alignment with weight-bearing axis was obtained, valgus in 20 cases (16.6%) and varus in eight cases (6.6%). The average Tip Apex Distance (TAD) on an anteroposterior view was 1.19cm (variation of 0.2 to 2.52 cm) and lateral view was 1.14cm (variaton of 0.3 to 2.52cm). One hundred and twelve patients (93,3%) were able to walk with postoperative pain (average of 4.4 on a pain scale of 0 to 10). The classification of the 120 patients is as follows: 11 patients with Tronzo I (9,1%), 24 cases of Tronzo II (20%), 58 Tronzo III (48.3%), seven Tronzo III variant (5.8%) and 20 Tronzo IV (16.7%). Unstable fractures occured in 85 (70.8%) patients, and 74 (61.6%) were over 75 years of age. There were 35 stable fractures (29.1%), with 17 patients (14.1%) over 75 years of age. As to the anesthesia risk eight (6.6%) were classified as ASA I, 33 (27.5%) ASA II, 74 (61.6%) ASA III and five patients as ASA IV (4.16%). There was one case of infection (0.83%). During the first postoperative year there were 13 deaths (10.8%). Of these, one patient (0.83%) had been classified as ASA II, five (4.16%) as ASA III and seven (5.83%) as ASA IV. There were 36 patients (30%) with complications out of 85 patients with unstable fractures, with loss of reduction in seven (5.88%) and migration of the sliding nail in 29 (24.1%). In the group of 35 stable fractures there were complications in four cases (3.3 %), with loss of reduction in one case (0.83%) and migration in three (2.5%). The total number of migrations was 33 (27.5%), but resulted in union in all patients. The loss in reduction occurred in eight patients (6.7%) and non-union in one case (0.83%). CONCLUSION: The minimal invasive procedure, the Minus System, is a safe procedure, that provides adequate surgery with a low incidence of complications, when compared to other existing techniques / Doutorado / Fisiopatologia Cirúrgica / Doutor em Ciências

Made available in DSpace on 2016-01-26T12:51:15Z (GMT). No. of bitstreams: 1 andrelisavendramiparra_dissert.pdf: 255722 bytes, checksum: 4cfa68a8c15a9090edf5aca7d76d2217 (MD5) Previous issue date: 2007-05-16 / Cardiac transplantation aims at the improvement of survival as well as quality of life of patients with end-stage Chronic Cardiac Failure. Socioeconomic status is believed to have an important role in the success of the surgical procedure. This study, therefore, aimed at identifying the impact of socioeconomic status on survival of patients listed for heart transplantation as well as in cardiac transplant recipients. A retrospective longitudinal cohort study was carried out using data obtained from the medical charts 70 patients treated in the Hospital de Base da Faculdade de Medicina de São José do Rio Preto. The socioeconomic evaluation was made through the following indicators: monthly income, education, conditions of housing, profession, profession of the family members, presence of caregiver and distance to the hospital. These data are used in the classification for defined stratus: Low Inferior (BI), Low Superior (BS), Inferior Medium (MI), Medium (M), Superior Medium (MS), High (H). Seventy-six per cent of patients on the waiting list for heart transplantation were classified in the low socioeconomic class; 77% of such patients had low educational level, 77% adequate housing, 94% a caregiver, 59% no social insurance after retirement, and 60% received financial support from other nongovernmental entities. Forty-four per cent of patients had a positive serology for Chagas disease. Probability of survival at 100 days of follow up in the waiting list was 68% for Chagas disease and 79% for non-Chagas disease patients (p>0,05). With regard to cardiac transplant recipients, 84% of them were classified in the low socioeconomic class, 73% had low educational level, 75% adequate housing, 93% caregiver, 57% no social insurance after retirement, and 32% had financial support from other nongovernmental entities. Thirty-two cardiac transplant recipients had a positive serology for Chagas disease. Survival probability at 100 days of follow up for cardiac transplant recipients was 62% for Chagas disease and 81% for non-Chagas disease patients (p>0,05). The data obtained in this work demonstrate that socioeconomic status not only has no impact on patients on the waiting list for heart transplantation, but also on outcome of cardiac transplant recipients because patients in the low socioeconomic status had a similar prognosis than patients in the median socioeconomic class. Thus, socioeconomic status has no unfavorable prognosis for both patients on the waiting list as well as for cardiac transplant recipients. / O transplante cardíaco é uma técnica cirúrgica que visa a melhora da qualidade de vida e a sobrevida de pacientes com Insuficiência Cardíaca Crônica terminal. As variáveis sócio-econômicas têm importante papel no sucesso do procedimento cirúrgico, portanto, objetivou-se identificar através deste estudo o impacto dos fatores sócio-econômicos na sobrevida de pacientes em fila de espera de transplante cardíaco e pós transplante cardíaco. Realizou-se estudo retrospectivo, do tipo coorte longitudinal, utilizando-se os dados obtidos dos prontuários de setenta pacientes tratados no Hospital de Base da Faculdade de Medicina de São Jose do Rio Preto. A avaliação sócioeconômica foi feita através dos indicadores: renda mensal, escolaridade, condições de moradia, profissão, ocupação dos membros da família, presença de cuidador e distância ao hospital. Esses dados são utilizados na classificação: Baixa Inferior (BI), Baixa Superior (BS), Médio Inferior (MI), Médio (M), Médio Superior (MS), Alto (A). Observou-se que 86% dos pacientes em fila de transplante cardíaco pertenciam a classe social baixa, 76% desses pacientes tinham apenas o ensino fundamental, 77% apresentavam moradia adequada, 94% possuíam uma pessoa responsável pelos seus cuidados, 59% não possuíam aposentadoria, 69% recebiam auxílio financeiro. Quarenta e quatro por cento dos pacientes em fila de transplante cardíaco tinham sorologia positiva para a doença de Chagas. A probabilidade de sobrevida aproximadamente 100 dias após a inclusão na fila de transplante cardíaco era de 68% para chagásicos e 79% para não chagásicos (p>0.05). Em relação aos pacientes em pós transplante cardíaco observou-se que 84% dos pacientes pertenciam a classe social baixa, 73% desses pacientes tinham apenas o ensino fundamental, 75% apresentavam moradia adequada, 93% possuíam uma pessoa responsável pelos seus cuidados, 57% não possuíam aposentadoria, 32% recebiam auxílio financeiro. Trinta e seis por cento dos pacientes Nota de Resumo que realizaram o transplante cardíaco tinham sorologia positiva para a doença de Chagas. A probabilidade de sobrevida em aproximadamente 100 dias após o transplante cardíaco era de 62% para chagásicos e 81% para não chagásicos (p>0.05). Os dados obtidos neste trabalham revelam que os fatores sócio-econômicos e culturais não influenciaram na sobrevida dos pacientes em fila de transplante cardíaco, pois os pacientes com status socioeconômico baixo tiveram o prognóstico similar àquele visto nos pacientes no status socioeconômico mediano. Assim, o status socioeconômico baixo não tem impacto desfavorável nem nos doentes na fila de espera como nos receptores de transplante cardíaco.

Made available in DSpace on 2016-01-26T12:51:15Z (GMT). No. of bitstreams: 1 isabelathomaztakakura_dissert.pdf: 1870282 bytes, checksum: 871ee642969bbc10aeb356aeefd91988 (MD5) Previous issue date: 2007-05-10 / Recent studies have shown that low heart rate variability (HRV) is a clear indication of an increased risk for severe ventricular arrhytmia and sudden cardiac. However, the traditional techniques of data analysis in time and frequency domain are often not sufficient to characterize the complex dynamics of heart beat generation. Hence, different attempts have been reported to apply the concept of nonlinear dynamics (chaos domain) to this problem as the methods Detrended Fluctuation Analysis (DFA), Autocorrelation (Tau), Hurst Exponent (HE), Lyapunov Exponent (LE), Poincaré Plot (SD1 e SD2). Objective: We speculated that patients with decreased chaotic behavior in the preoperative period would tend to present higher morbidity and mortality in the length of postoperative stay. Methods: Seventy-two non-selected patients (mean age 58.4±10.2 years) with coronary artery disease and elective coronary artery bypass graft surgery (CABG) indication, were studied. We had their HRV with Polar Advanced S810 and analyzed with the above chaos, time and frequency domain variables. The occurrences of relevant events during the length of postoperative stay as neurological, infectious and renal complications, severe arrhytmias or death were compared. The Fisher s Test was used to compare the occurrence of events. We described Sensibility, Specificity, Positive Predictive Value, Positive Likelihood Ratio and ODDS Ratio (CI 95%). Results: In comparison of groups death versus no death (Scenario 1) of the Lyapunov Exponent, for example, the ODDS Ratio was 11.5 (CI 95% 1.261 to 104.92, P=0.0171). The Scenario 3 (2 or more events versus 0 to 1 event) xxiv showed the Odds Ratio 12.414 (CI 95% 1.515 to 101.72, P=0.0048). Conclusions: The patients with decreased HRV evaluated from some nonlinear dynamic analysis methods before CABG surgery present higher morbidity and mortality in the length of postoperative stay. / Estudos recentes têm mostrado que a baixa variabilidade da freqüência cardíaca (VFC) é um claro indicador de maior risco para arritmia ventricular grave e morte súbita. Contudo, as técnicas tradicionais de análises de dados no domínio do tempo e da freqüência nem sempre são suficientes para caracterizar a dinâmica complexa da geração do batimento cardíaco. Conseqüentemente, diferentes tentativas têm sido feitas para aplicar o conceito de dinâmica não-linear (domínio do caos) para este problema, como os métodos não-lineares: Análise de Flutuações Depurada de Tendências (DFA), Autocorrelação (Tau), Expoente de Hurst (HE), Expoente de Lyapunov (LE), Desvio-padrão da perpendicular à linha de identidade no gráfico de Poincaré (SD1e SD2). Objetivo: Assim, o objetivo deste trabalho foi demonstrar se a redução do comportamento caótico (avaliado por métodos de dinâmica nãolinear) no período pré-operatório à revascularização do miocárdio acarretaria maior morbidade e mortalidade no período pós-operatório, durante a internação. Método: No presente estudo, 72 pacientes não-selecionados (média de idade de 58,4±10,2 anos) com doença arterial coronária e indicação eletiva de cirurgia foram incluídos e sua VFC foi captada pelo Polar Advanced S810 por meio da análise dos intervalos RR. A VFC foi analisada por variáveis do domínio do tempo (SDNN, RMSSD), do domínio da freqüência (LF nu, HF nu, a relação LF/HF) e do domínio do caos, citadas acima. A ocorrência de eventos relevantes durante o pós-operatório foi avaliada, como complicações neurológicas, infecciosas e renais, arritmias graves ou morte. O Teste Exato de xxii Fisher foi usado para comparar a ocorrência de eventos. Também foram registrados a Sensibilidade, Especificidade, Valor Preditivo Positivo, Valor Preditivo Negativo, Likelihood Ratio Positivo e ODDS Ratio com 95% de Intervalo de Confiança para a ocorrência de eventos. Um valor de P &#8804; 0.05 foi considerado significante. Resultados: De acordo com medidas feitas pelo Expoente de Lyapunov, por exemplo, o Cenário 1 (comparando grupo de pacientes que faleceram no pós-operatório hospitalar com o grupo dos que não faleceram) evidenciou Odds Ratio de 11,5 (IC 95% 1,261 a 104,92) com valor de P de 0,0171 e o Cenário 3 (2 ou mais eventos contra 0 a 1 evento) evidenciou Odds Ratio de 12,414 (IC 95% 1,515 a 101,72) com valor de P de 0,0048. Conclusão: A avaliação da VFC por métodos de dinâmica não-linear em pacientes no período pré-operatório da cirurgia de revascularização do miocárdico, mostrou tratar-se de ferramenta promissora como preditora de maior morbidade e mortalidade durante o período de pós-operatório hospitalar.