Introdução: O balão de contrapulsação intra-aórtico (BIA) é usado em uma variedade de contextos relacionados à disfunção miocárdica. Na cirurgia cardíaca, seu papel em desfechos clínicos é motivo de debate devido a resultados conflitantes de análises retrospectivas e limitações de recentes estudos prospectivos. Objetivo: O objetivo do presente estudo foi avaliar a eficácia e segurança do BIA eletivo na ocorrência de um desfecho composto de complicações clínicas incluindo mortalidade em pacientes de alto risco submetidos a cirurgia cardíaca de revascularização miocárdica (RM). Métodos: Estudo clínico prospectivo e randomizado realizado no Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Foram incluídos 181 pacientes adultos submetidos a cirurgia cardíaca de RM no período de abril de 2014 a junho de 2016, com um ou mais dos seguintes critérios: fração de ejeção menor ou igual a 40% e/ou EuroScore maior ou igual a 6. Os pacientes foram randomizados para uso do BIA logo após a indução anestésica ou para grupo controle. Após 24 horas do procedimento, o suporte com o balão intra-aórtico era suspenso se o paciente apresentasse índice cardíaco maior ou igual a 2,2 L/min/m2 com suporte inotrópico mínimo (dobutamina menor ou igual a 5 mcg/Kg/min) ou se o paciente apresentasse efeito colateral grave relacionado ao balão. O desfecho primário foi um composto de mortalidade e complicações graves em 30 dias após a cirurgia (choque cardiogênico, necessidade de reoperação, acidente vascular cerebral, insuficiência renal aguda, infecção de ferida esternal profunda e tempo de ventilação mecânica prolongada). Resultados: Dos pacientes incluídos no estudo, 90 foram alocados para a estratégia de uso do balão intra-aórtico eletivo e 91 para a estratégia controle. O desfecho primário foi observado em 47,8% do grupo BIA e em 46,2% do grupo controle (P=0,456). Não houve diferenças significativas entre os grupos BIA e controle respectivamente, em relação à ocorrência de óbito em 30 dias (14,4% vs 12,1%, P=0,600), choque cardiogênico (18,0% vs 18,9%, P=0,982), reoperação (3,4% vs 4,4%, P=1,000), tempo de ventilação mecânica prolongado (5,6% vs 7,7%, P=0,696), insuficiência renal aguda (22,2% vs 14,3%, P=0,123), acidente vascular cerebral (2,2% vs 2,2%, P=0,123) ou infecção de ferida operatória profunda (7,8% vs 14,3%, P=0,249). O tempo de uso de inotrópico foi significativamente maior no grupo BIA em comparação ao grupo controle (51 horas [32-94] vs 39 horas [25-66], P=0,007). O tempo de internação em UTI foi mais prolongado no grupo BIA comparado ao grupo controle (5 dias [3-8] vs 4 dias [3-6], P=0,035). O tempo de internação hospitalar foi semelhante entre os grupos (13 dias [9-18] vs 11 dias [8-17], P=0,302). Não houve diferença em relação a incidência de complicações relacionadas ao uso do BIA entre os dois grupos. Conclusão: A estratégia de uso do balão intra-aórtico eletivo em pacientes de alto risco submetidos a cirurgia de revascularização miocárdica não reduziu o desfecho combinado de óbito e/ou complicações graves em 30 dias / Introduction: The intra-aortic balloon pump (IABP) is used in a variety of clinical settings in which myocardial function is reduced. In cardiac surgery, its role on clinical outcomes is debated due to conflicting results of retrospective analysis and limitations of recent prospective studies. Objective: The purpose of this study was to evaluate the efficacy and safety of elective IABP use on outcomes in high-risk patients undergoing cardiac surgery. Methods: A prospective randomized controlled trial that evaluated 181 patients undergoing coronary artery bypass at the Heart Institute/University of Sao Paolo from 2014 April to 2016 June. Inclusion criteria were left ventricular ejection fraction (LVEF) <= 40% and/or EuroSCORE>= 6. Eligible patients were randomly assigned, in a 1:1 ratio, to IABP group (n=90) or control group (n=91). Removal of IABP catheter was accomplished after 24 hours of the procedure under the following circumstances: cardiac index >= 2.2 L/min/m2 and dobutamine infusion dose <= 5 ?g/kg/min. The catheter was immediately removed if a severe adverse event related to the procedure was detected. The primary outcome was the composite endpoint of mortality and major morbidity in 30 days after cardiac surgery (cardiogenic shock, need for reoperation, stroke, acute renal failure, mediastinitis and prolonged mechanical ventilation ( > 24 hours). Results: The primary outcome was observed in 47,8% in the IABP group and 46,2% in the control group (P=0,456). There were no differences in the primary outcome: 30-day mortality (14,4% vs 12,1%, P=0,600), cardiogenic shock (18,0% vs 18,9%, P=0,982), need for reoperation (3,4% vs 4,4%, P=1,000), prolonged mechanical ventilation (5,6% vs 7,7%, P=0,696), acute renal failure (22,2% vs 14,3%, P=0,123), stroke (2,2% vs 2,2%, P=0,123) or mediastinitis (7,8% vs 14,3%, P=0,249). Patients from the IABP group had a greater duration of inotrope use (51 hours [32-94] vs 39 hours [25-66], P=0,007) and longer intensive care unit length of stay (five days [3-8] vs four days [3-6], P=0,035). The length of hospital stay was similar (13 days [9-18] vs 11 days [8-17], P=0,302). There were no differences on the incidence of complications related to the IABP use in both groups. Conclusions: The elective IABP use did not reduce 30-day major complications in high-risk patients undergoing cardiac surgery

Estudou-se pela ecocardiografia em imagem fundamental, 30 pacientes no período pós-operatório de cirurgia cardíaca que encontravam se sob ventilação mecânica. Analisou-se o índice de escore de delineamento endocárdico (IEDE), a fração de ejeção do ventrículo esquerdo (FEVE) pelo método de estimativa visual, e os fluxos transvalvares pelo Doppler espectral e mapeamento de fluxo em cores antes e após a administração de um contraste ecocardiográfico a base de microbolhas. O IEDE passou de 1,53±0,63 para 2,01±0,56 após o uso do contraste (p < 0.001) e a FEVE pôde ser estimada em 27 de 30 exames após o uso do mesmo. Houve uma mudança na quantificação da insuficiência mitral em 5 exames, no gradiente de pico transvalvar aórtico em 1 paciente e no gradiente transvalvar de pico tricúspide em 8 pacientes / We studied by echocardiography in fundamental imaging (FI), thirty mechanically ventilated post cardiac surgery patients. LV endocardial border delineation score index (EBDSI), estimated left ventricular ejection fraction (LVEF) and color and spectral Doppler were analyzed before and after intravenous injection of ultrasound contrast. The use of contrast resulted in a significant increase in the number of well-delineated segments. EBDSI was 1.53±0.63, before contrast, increasing to 2.01±0.56 after it (p < 0.001). The LVEF could be evaluated in 27 of 30 exams after contrast. There was a change in the quantification of mitral regurgitation in 5 exams, in the aortic transvalvular peak gradient in 1 patient and measurement of peak flow velocity of tricuspid regurgitation in 8 patients

INTRODUÇÃO: A literatura tem postulado que a ventilação por pressão positiva não invasiva (VNI) pode facilitar o desmame de um grupo específico de pacientes. O objetivo deste estudo foi comparar a utilização da VNI como método alternativo na supressão da ventilação mecânica no pós-operatório de cirurgia cardíaca. MÉTODOS: Neste estudo prospectivo controlado e randomizado, foram estudados 100 pacientes submetidos a cirurgia de revascularização do miocárdio ou cirurgia valvar. Os pacientes foram admitidos na Unidade de Terapia Intensiva (UTI), sob ventilação mecânica e randomizados posteriormente em grupo estudo (n= 50), que utilizou VNI com dois níveis pressóricos após extubação, e grupo controle (n= 50), que utilizou a técnica convencional de supressão da ventilação mecânica. Foram analisados os tempos correspondentes à anestesia, cirurgia, circulação extracorpórea e ventilação mecânica na UTI. As variáveis gasométricas, hemodinâmicas e radiológicas foram avaliadas antes e após a extubação. RESULTADOS: Os grupos controle e estudo apresentaram comportamento semelhante quanto ao tempo de desmame ventilatório e as outras variáveis estudadas não apresentaram diferença estatística. A utilização da VNI por 30\' após a extubação, nos pacientes com atelectasias, promoveu diferença significativa na PaCO2 no grupo coronariano e na PaO2 no grupo submetido à cirurgia valvar. CONCLUSÃO: O tempo para supressão da ventilação mecânica foi similar nos grupos. Fatores extrísecos interferiram na evolução do desmame. O uso da VNI por 30 minutos após extubação apresentou diferença estatisticamente significante nas variáveis gasométricas em pacientes com atelectasias / INTRODUCTION: It was postulated that noninvasive positive pressure ventilation (NPPV) could facilitate ventilatory weaning in specific patients. The aim was to compare NPPV as alternative ventilatory weaning method with a standard ventilatory weaning protocol in the immediate postoperative period of cardiac surgery. METHODS: One hundred consecutive patients submitted to coronary artery bypass grafting or valvar surgery were addmitted in the Intensive Care Unit (ICU) and mechanicanically ventilated. They were randomly assigned to a study group (n=50) wich use NPPV witn bilevel presssure in the airways and a control group (n=50) witch used the conventional weaning thecnique. The outcome measures were anestesie, surgery, cardiopulmonar bypass and mechanical ventilation time. Arterial blood gases, hemodynamics and chest X-rays were assessed pre and post extubation. RESULTS: Weaning times were similar in both groups, and no differences were found in the studied variables. There were statistic significance considering PaCO2 in coronary and PaO2 in valvar group using NPPV 30\' after extubation, when atelectasis was detected. CONCLUSION: The ventilatory weaning time was similar in both groups. Extrinsics factors had interfered in weaning evolution. NPPV use during 30\' after extubation had statistical significance in gasometric variables in patients with athelectasis

Introdução: A hiperidrose primária consiste em uma sudorese excessiva em regiões limitadas do corpo. A simpatectomia torácica videotoracoscópica é um dos tratamentos propostos para a hiperidrose primária palmar, aliando alto sucesso terapêutico com baixo risco. A fisiopatologia da hiperidrose primária ainda não está totalmente esclarecida. Objetivos: Analisar as características morfométricas dos gânglios simpáticos torácicos (G3), removidos cirurgicamente de pacientes portadores de hiperidrose palmar. Como controle foram utilizados os gânglios simpáticos, removidos no mesmo nível (G3), de pacientes doadores de órgãos por morte encefálica, sabidamente sem hiperidrose. Foram estudadas a estereologia e a apoptose celular e as fibras do sistema colágeno /elastina da matriz extracelular. Métodos: Estudo transversal, no qual foram incluídos 40 gânglios simpáticos torácicos (G3) removidos do hemitórax esquerdo, provenientes de pacientes com hiperidrose palmar (Grupo I), submetidos à simpatectomia videotoracoscópica, e 14 gânglios simpáticos de pacientes controle sabidamente sem hiperidrose (Grupo II), removidos por esternotomia mediana. Resultados: Em relação ao sexo, a proporção de mulheres e homens foi de 30:10, no Grupo I, e 7:7 no Grupo II, com p = 0,103. A idade no Grupo I, variou de 10 a 42 anos, com uma média de 23,73 (+ 7,51) e no Grupo II variou de 17 a 68 anos, com uma média de 37,57 (+ 16,65) , apresentando um p = 0,009. A média das células ganglionares nos pacientes do Grupo I foi de 14,25 (+ 3,81) e no Grupo II foi de 10,65 (+ 4,93) com p = 0,007. A média das células ganglionares coradas pela caspase (apoptose) no Grupo I foi de 2,37 (+ 0,79) e no Grupo II foi de 0,77 (+ 0,28) com p < 0,001. A mediana da área de colágeno corada pelo Picrosírius no Grupo I foi de 0,80 IQ (0,08-1,87) e no Grupo II foi de 2,36 IQ (0,49-5,98) com p = 0,061. Conclusões: Os pacientes portadores de hiperidrose primária palmar apresentam um maior número de células ganglionares no gânglio simpático, em relação aos do grupo controle. Há um número maior de células ganglionares simpáticas em apoptose na hiperidrose. Os pacientes portadores de hiperidrose apresentam menos colágeno no gânglio simpático / Introduction: Primary hyperhidrosis consists of excessive sweating in small areas of the body. The video-assisted thoracic sympathectomy is one of the suggested treatments for primary palmar hyperhidrosis, which combines high therapeutic success with low risk. The pathophysiology of primary hyperhidrosis is not fully understood yet. Objectives: Analyzing the morphometric characteristics of the thoracic sympathetic ganglion (G3) surgically removed from patients with palmar hyperhidrosis. The sympathetic ganglion removed at the same level (G3) from patients who are organ donors after brain death and who did not have hyperhidrosis were used as control. Stereology and cellular apoptosis, as well as the fibers of the collagen/elastin system of the extracellular matrix were subjected to scrutiny. Methods: Cross-sectional study, which included 40 thoracic sympathetic ganglion (G3) removed from the left hemithorax of patients who have palmar hyperhidrosis (Group I) and underwent video-assisted thoracoscopic sympathectomy, and also 14 sympathetic ganglion from control patients who did not have hyperhidrosis (Group II), which were removed with median sternotomy. Results: In regards to gender , the proportion of women to men was 30:10 in Group I and 7:7 in Group II, with p = 0.103. The age Group I ranged from 10 to 42 years, with an average of 23.73 (+ 7.51) years and in Group II, from to 17 to 68 years, with an average of 37.57 (+ 16.65) years, with p = 0.009. The average of ganglion cells in Group I was 14.25 (+ 3.81) and in Group II, 10.65 (+ 4.93) with p = 0.007. The average ganglion cells stained by Caspase (apoptosis) in Group I was 2.37 (+0.79) and in Group II, 0.77 (+ 0.28) with p = 0.001. The median collagen area by Picrosirius in Group I was 0.80 IQ (0.08-1.87) and in Group II, 2.36 IQ (0.49-5.98) with p = 0.061. Conclusions: Patients with primary palmar hyperhidrosis have an increased number of ganglion cells in the sympathetic ganglion in comparison to the control group. There are a higher number of sympathetic ganglion cells in apoptosis in hyperhidrosis. Patients with hyperhidrosis have less collagen in sympathetic ganglion

Le principe de la radiothérapie est de délivrer le maximum de dose de rayons X à la tumeur en épargnant au mieux les tissus sains environnants. Dans le cas du cancer du poumon, les mouvements respiratoires représentent une difficulté majeure. L’imagerie tomodensitométrique (TDM) 4D fournit des informations de mouvement spécifique à chaque patient qui peuvent servir de base pour la construction de modèles de mouvement respiratoire. La disponibilité dans les salles de traitement d’imageurs tomographiques embarqués sur les accélérateurs linéaires permet une estimation direct du mouvement et offre des informations plus précises. Un tel système d’imagerie permet entre-autre d’acquérir des images fluoroscopiques : ensemble de projections radiographiques 2D acquises au cours du temps et sous le même angle de vue. Notre approche s’intègre dans des systèmes de synchronisation de l’irradiation avec la respiration. Actuellement, cette technique existe en utilisant pour signal de synchronisation soit un signal externe, soit un signal interne issu du mouvement de marqueurs implantés autour de la tumeur. Notre approche permet d’obtenir un signal de synchronisation obtenu à partir de données internes sans marqueurs implantés. Dans ce cadre, nous avons expérimenté, développé puis évalué 3 méthodes de détection du mouvement à partir de séquences fluoroscopiques. Ces méthodes sont basées respectivement sur la variation de l’intensité, l’extraction de la hauteur du diaphragme et le suivi de blocst. A partir d’un algorithme de mise en correspondance de blocs, nous avons étudié l’homogénéité du mouvement apparent et déterminé, sans a priori géométrique, des régions où le mouvement est uniforme. Nous avons ensuite étudié la corrélation entre le signal interne extrait sur des séquences fluoroscopiques, et un signal extrait d’une vidéo-caméra synchronisée aux séquences fluoroscopiques assimilable à un signal externe. Dans une dernière partie, nous proposons d’estimer le mouvement 3D de la tumeur à partir d’un modèle de mouvement a priori élaboré dans une étape de pré-traitement à l’aide d’images TDM 4D et du signal respiratoire acquis dans la salle de traitement. L’intérêt de notre approche est qu’elle ne nécessite pas de marqueurs implantés ce qui la rend moins invasive que de nombreuses autres techniques. D’autre part, nous proposons un suivi 2D donc potentiellement rapide, mais basé sur un modèle 3D sous-jacent permettant ainsi de retrouver le maximum d’information. Cliniquement, notre approche permettrait de réaliser une adaptation quotidienne aux mouvements inter-sessions. Une des limites de notre approche est qu’elle nécessite une prise d’images ionisantes en continue. Un système hybride basée sur la combinaison d’un signal interne et d’un signal externe permettrait de limiter la dose additionnelle. Des efforts supplémentaires sur la réduction du temps de calcul sont encore nécessaires pour espérer guider un traitement par une telle approche. / Radiotherapy consist of locally exposing target tumor cells to ionizing radiation with the aim of causing irreparable damage to their DNA. Respiratory motion introduces uncertainties in radiation therapy fo lung cancer treatment. The main risks are an over-irradiation of soft tissue and under-irradiation of tumor. The principal aim of this work is to provide a contribution to the extraction of quantitative motion parameters which can help to improve treatment planning. Recent developments have led to the routine acquisition of four-dimensional computed tomography (4DCT) and cone-beam computed tomography (CBCT) for the planning and delivery of certain treatment strategies. The availability of these images over the course of treatment make them particularly suited for providing patient-specific motion information and deriving motion models. Cone-beam is mainly use for its 3D capacity with the rotation system. But it can also acquire fluoroscopic sequences : a set of 2D projections acquired during time and under the same angle of projection. Our approach take place in the gating category treatment where the dose delivery is synchronized with respiration. For lung cancer treatment with gated radiotherapy, tracking apparent respiratory motion in fluoroscopic images is an important step. It is frequently realize using implanted marker next to the tumor. The first purpose of this study is to extract respiratory motion during treatment delivery from fluoroscopy images without implanted markers. We developed 3 methods inspired from literature and compared them. These methods are respectively based on variation intensity in the lung, diaphragm motion extraction and block matching. For each method, we obtain a signal correlated to the respiratory motion. In a second part, we study the spatial variation of the motion in the lung. We try to determine regions where the extracted apparent motion is homogeneous and reliable. Using an adapted block-matching algorithm on fluoroscopic sequences, we extracted individual point trajectories in region of interest corresponding to the lung and classified them using the k-means++ clustering algorithm. We then studied the apparent motion separately in each determined region. As a result, we obtained regions with homogeneous motion. In a third part, we are interested in the correlation of internal and external motion. Finally, in the last section, we propose to estimate 3D motion tumor from an a priori motion model obtained with the planning 4DCT and the respiratory signal extracted in the treatment room.

La circulation extracorporelle compte parmi les progrès techniques majeurs associés à la chirurgie cardiaque. Elle constitue aussi l’une des causes de complications principales car responsable d’une réponse inflammatoire généralisée qui résulte de la conjugaison des effets du stress oxydant et des cytokines libérés, contribuerait à la dysfonction multi-organe aboutissant aux complications myocardiques et rénales survenant au cours des périodes per- et postopératoires. La première partie de notre travail avait pour objectif d’explorer l’évolution des taux circulants du GDF-15, cytokine associée au stress oxydant et à l’inflammation, dans ce contexte de chirurgie cardiaque. Notre étude prospective a démontré pour la première fois que cette procédure est accompagnée de l’augmentation du GDF-15 dont les taux plasmatiques sont associés aux lésions postopératoires cardiaques et rénales.L’évaluation du risque opératoire repose sur un ensemble de scores dont le calcul est basé essentiellement sur des caractéristiques cliniques. Ces scores présentent toutefois un certaines limitations. Chez les patients « médicaux » atteints de pathologies cardiovasculaires la stratification du risque est définie en associant des caractéristiques cliniques à l’évaluation des taux circulants de biomarqueurs. L’objectif de cette seconde partie a donc été de mettre en évidence le pouvoir prédictif du GDF-15 en tant que biomarqueur circulant dans la survenue de complications rénales au cours de la chirurgie cardiaque sous CEC. Nous avons mis en évidence que les patients présentant des taux préopératoires élevés de GDF-15 sont à risque de développer une insuffisance rénale aigue postopératoire. / Ischemic cardiac diseases are the most frequent and deleterious pathologies leading to important cardiovascular-related mortality worldwide. One of the alternative therapies consists to treat these patients using cardiac surgery. Cardiopulmonary bypass was developed to greatly improve this surgical procedure. However, some adverse effects can occur during cardiac surgery associated with cardiopulmonary bypass due to the inflammatory response. This phenomenon is the result of various mechanisms including oxidative stress and inflammatory cytokines which lead to multi-organ failure and then to myocardial and renal injuries occurring during the peri- and post-operative periods.The first part of this work was designed to evaluate in the context of cardiac surgery the kinetics of plasma GDF-15 levels, an oxidative stress and inflammation related cytokine. Our prospective study demonstrated for the first time the kinetic increase in plasma GDF-15 levels which were associated to postoperative cardiac and renal injuries.Currently, operative risk evaluation is based on score calculation including clinical criteria. These risk scores present some limitations. Concerning other cardiac patients out of surgical fields, the risk assessment is defined using clinical parameters and biomarkers evaluation (cardiac troponin, BNP, Nt-proBNP). Thus, we aimed to determine whether pre-operative GDF-15 as plasma biomarker could help to identify patients at high risk of renal injuries. We found that patients with the highest pre-operative plasma GDF-15 levels are at risk for post-operative acute kidney injury.

Thoracic surgical procedures require partial or complete airway separation and the opportunity to exclude one lung from ventilation (one-lung ventilation, OLV). OLV is commonly associated with profound pathophysiological changes that may affect the postoperative outcome. It is injurious in terms of increased mechanical stress including alveolar cell stretch and overdistension, shear forces secondary to repeated tidal collapse and reopening of alveolar units and compression of alveolar vessels. Ventilation and perfusion distribution may thus be affected during and after OLV. The present studies investigated the influence of OLV on ventilation and perfusion distribution, on the gas/tissue distribution and on the lung histomorphology in a pig model of thoracic surgery. Anaesthetised and mechanically ventilated piglets were examined. The ventilation and perfusion distribution within the lungs was assessed by single photon emission computed tomography. Computed tomography was used to establish the effects of OLV on dependent lung gas/tissue distribution. The pulmonary histopathology of pigs undergoing OLV and thoracic surgery was compared with that of two-lung ventilation (TLV) and spontaneous breathing. OLV induced hyperperfusion and significant V/Q mismatch in the ventilated lung persistent in the postoperative course. It increased cyclic tidal recruitment that was associated with a persistent increase of gas content in the ventilated lung. OLV and thoracic surgery as well resulted in alveolar damage.  In the present model of OLV and thoracic surgery, alveolar recruitment manoeuvre (ARM) and protective ventilation approach using low tidal volume preserved the ventilated lung density distribution and did not aggravate cyclic recruitment of alveoli in the ventilated lung. In conclusion, the present model established significant alveolar damage in response to OLV and thoracic surgery. Lung injury could be related to the profound pathophysiological consequences of OLV including hyperperfusion, ventilation/perfusion mismatch and increased tidal recruitment of lung tissue in the dependent, ventilated lung.  These mechanisms may contribute to the increased susceptibility for respiratory complications in patients undergoing thoracic surgery. A protective approach including sufficient ARM, application of PEEP, and the use of lower tidal volumes may prevent the ventilated lung from deleterious consequences of OLV.

L’association lésionnelle d’une contusion pulmonaire et d’un état de choc hémorragique est fréquente et constitue un réel chalenge thérapeutique. La prise en charge de ce choc va nécessiter une réanimation hémodynamique dans laquelle le remplissage vasculaire tient une place centrale. Mais dans ce contexte de poumon contus, il devra être raisonné car délétère sur le plan pulmonaire, notamment en terme d'oedème et d'altération de la compliance. Ce remplissage devra donc être titré, basé sur des objectifs tensionnels clairs et un monitorage hémodynamique fiable. L'utilisation de solutés à haut pouvoir d'expansion volémique (sérum salé hypertonique, colloïdes) présente un intérêt, de même que l'introduction précoce de vasopresseurs. Le monitorage hémodynamique permettra de conduire cette réanimation sur des objectifs de pression artérielle, sur des indices de précharge dépendance et sur la mesure de l'eau pulmonaire extravasculaire. Notre travail, basé sur des études expérimentales et cliniques, a pour objectif de caractériser les modalités actuelles de prise en charge d’une contusion pulmonaire, sur les plans hémodynamiques et respiratoires. / Pulmonary contusion is often associated with hemorrhagic shock, constituting a challenge in trauma care. For patients who have sustained lung contusions, fluid resuscitation should be carefully performed, because injured lungs are particularly vulnerable to massive fluid infusions with an increased risk of pulmonary edema and compliance impairment. Fluid administration should be included in an optimized and goal directed resuscitation, based on blood pressure objectives and hemodynamical monitoring. The use of fluids with high volume-expanding capacities (hypertonic saline, colloids) is probably interesting, as well as early introduction of vasopressors. Hemodynamic monitoring will allow to conduct resuscitation on blood pressure objectives, on preload parameters and on extravascular lung water measurement.Our work, based on experimental and clinical studies, objective to characterize the current modalities of ventilatory and hemodynamical aspect of pulmonary contusion care.

O registro eletrônico do paciente (REP) está sendo gradativamente implantado no meio médico hospitalar. Grande parte das informações essenciais do REP está armazenada na forma de texto narrativo livre, dificultando operações de procura, análise e comparação de dados. O processamento de linguagem natural (PLN) refere-se a um conjunto de técnicas computacionais, cujo objetivo é a análise de texto através de conhecimentos léxicos, gramaticais e semânticos. O presente projeto propõe a criação de uma ferramenta computacional de investigação clínicoepidemiológica aplicada a textos narrativos médicos. Como metodologia propomos a utilização do processador de linguagem natural especializado em medicina MEDLEE desenvolvido para textos em Inglês. Para que seu uso seja possível textos médicos em Português são traduzidos ao Inglês automaticamente. A tradução automatizada (TA) é realizada utilizando o aplicativo baseado em regras SYSTRAN especialmente configurado para processar textos médicos através da incorporação de terminologias especializadas. O resultado desta seqüência de TA e PLN são informações conceituais que serão investigadas à procura de achados clínicos pré-definidos, atrvés de inferência lógica sobre uma ontologia. O objetivo experimental desta tese foi conduzir um estudo de recuperação de informações em um conjunto de 12.869 relatórios de radiografias torácicas à procura de vinte e dois achados clínicos e radiológicas. A sensibilidade e especificidade médias obtidas em comparação com referência formada pela opinião de três médicos radiologistas foram de 0,91 e 0,99 respectivamente. Os resultados obtidos indicam a viabilidade da procura de achados clínicos em relatórios de radiografias torácicas através desta metodologia de acoplamento da TA e PLN. Conseqüentemente em trabalhos futuros poderá ser ampliado o número de achados investigados, estendida a metodologia para textos de outras modalidades, bem como de outros idiomas / The Electronic Medical Record (EMR) is gradually replacing paper storage on clinical care settings. Most of essential information contained on EMR is stored as free narrative text, imposing several difficulties on automated data extraction and retrieval. Natural language processing (NLP) refers to computational linguistics tools, whose main objective is text analysis using lexical, grammatical and semantic knowledge. This project describes the creation of a computational tool for clinical and epidemiologic queries on narrative medical texts. The proposed methodology uses the specialized natural language processor MEDLEE developed for English language. To use this processor on Portuguese medical texts chest x-ray reports were Machine Translated into English. The machine translation (MT) was performed by SYSTRAN software, a rule based system customized with a specialized lexicon developed for this project. The result of serial coupling of MT an NLP is tagged text which needs further investigation for extracting clinical findings, whish was done by logical inference upon an ontolgy. The experimental objective of this thesis project was to investigate twenty-two clinical and radiological findings on 12.869 chest x-rays reports. Estimated sensitivity and specificity were 0.91 and 0.99 respectively. The gold standard reference was formed by the opinion of three radiologists. The obtained results indicate the viability of extracting clinical findings from chest x-ray reports using the proposed methodology through coupling MT and NLP. Consequently on future works the number of investigated conditions could be expanded. It is also possible to use this methodology on other medical texts, and on texts of other languages

INTRODUÇÃO: Para os pacientes portadores de transposição das grandes artérias que perderam a chance da cirurgia de Jatene nas primeiras semanas de vida, indica-se realizar o preparo ventricular através da bandagem do tronco pulmonar (BTP), objetivando causar aumento na massa miocárdica. Entretanto, com o tempo, a câmara hipertrofiada pode apresentar disfunção contrátil; portanto, é importante conhecer a qualidade do tecido preparado, uma vez que já se sabe que tanto os miocardiócitos (MCD) quanto as células do interstício e vasos (I/V) são capazes de proliferar após o período neonatal. Baseando-se no condicionamento físico de atletas e considerando-se que os músculos cardíaco e esquelético são ambos estriados, postula-se a hipótese de que o tipo de preparo ventricular possa influenciar nas características do miocárdio treinado. OBJETIVOS: Identificar o tipo de mecanismo adaptativo (hipertrofia/hiperplasia) envolvido no preparo rápido do ventrículo pulmonar submetido à sobrecarga de pressão por meio de BTP, através da análise dos MCD e células do I/V, verificando se existem diferenças em relação ao tipo de treinamento (contínuo x intermitente) em comparação com os controles. MÉTODOS: Foram estudados experimentalmente 21 cabritos após o período neonatal, divididos em três grupos (C = grupo controle, n = 7, sem procedimento cirúrgico; EC = grupo de estimulação contínua, n = 7, com bandagem progressiva e permanente do tronco pulmonar durante 96 horas; EI = grupo de estimulação intermitente, n = 7, com bandagem progressiva, 12 horas ao dia, totalizando 48 horas). Todos foram submetidos a estudo ecocardiográfico basal e aqueles dos grupos EC e EI a ecocardiogramas diários para verificar a aquisição de massa muscular do ventrículo direito (VD). Após o estudo, os animais foram sacrificados, os corações retirados e cortes histológicos do VD, ventrículo esquerdo (VE) e septo interventricular (S) fixados em formalina e processados para análise. Foram estudados a porcentagem de área de colágeno através do Picro-sirius, o diâmetro dos MCD e seus respectivos núcleos e o número de MCD e células do I/V marcadas com Ki-67. As células marcadas foram avaliadas por campo microscópico e por índice (número de células Ki-67+/2000 células). O nível de significância considerado foi de 0,05. RESULTADOS: Ambos os grupos estimulados apresentaram ganho significativo de massa muscular do VD (p < 0,05). Não houve aumento na porcentagem de colágeno do VD nos grupos treinados (p = 0,403). Considerando-se o VD, os grupos EC e EI apresentaram diâmetro dos MCD maior que o grupo controle (p < 0,001), ocorrendo o mesmo com os respectivos núcleos (EI x C: p < 0,001 e EC x C: p = 0,005). O número de MCD marcados com Ki-67 foi maior no VD dos grupos estimulados comparado com o VE (p = 0,009, índice de proliferação; p = 0,001, contagem por campo), bem como para as células do I/V (p < 0,001, contagem por campo e índice). CONCLUSÕES: Tanto hipertrofia quanto hiperplasia celular estão envolvidas na adaptação do ventrículo pulmonar submetido à sobrecarga sistólica através da BTP. Ambos os tipos de condicionamento (contínuo e intermitente) provocaram hipertrofia e hiperplasia dos MCD, induziram também à mitose das células do I/V, sem deposição de colágeno intersticial ao final do experimento. / INTRODUCTION: Rapid ventricular conditioning induced by pulmonary artery banding (PAB) has been indicated to those patients with transposition of the great arteries (TGA) who have lost the chance for arterial switch operation ? Jatene?s procedure ? aiming at induce myocardial mass increase. However, with time, hypertrophied chamber may exhibit contractile dysfunction, so that, it is important to assess quality of the prepared tissue, once it is of knowledge that both cardiomyocytes (CMC) and interstitial/vessel (I/V) cells are capable of proliferating after neonatal period. Based on fitness of athletes and considering that cardiac and skeletal muscles are both striated, there is the hypothesis that the type of ventricular prepare may influence the characteristics of the training myocardium. OBJECTIVES: Through CMC and I/V cells analysis, identifies the type of adaptive mechanism (hypertrophy/ hyperplasia) involved in rapid prepare of subpulmonary ventricle submitted to pressure overload by PAB, and verifies if there are differences in relation to the kind of training (continuous x intermittent), comparing them to the controls. METHODS: Twenty-one goats, beyond neonatal period, were experimentally studied. They were divided in three groups: C (control group, n = 7, with no surgical procedure); CS (continuous stimulation group, n = 7, with progressive and permanent PAB, during 96 hours); IS (intermittent stimulation group, n = 7, with progressive PAB, 12 hours/day, totalizing 48 hours). All the animals were submitted to basal echocardiograms and those from CS and IS groups to diary echocardiograms to verify right ventricular (RV) muscular mass acquisition. After the study, goats were killed, hearts excised and histological sections from RV, left ventricle (LV) and ventricular septum (VS) were formalin fixed and histologically processed. Collagen area fraction (through Picro-sirius red staining), CMC and respective nuclei diameter, and number of CMC and I/V cells Ki-67 positive were studied. Marked cells were analysed per high-power fields and by index (Ki-67 positive cells/2000 cells). The statistical significant level was set at 5%. RESULTS: Both stimulated groups presented significant RV muscular mass increase (p < 0.05). There were no augmentation in RV collagen area fraction in training groups (p = 0.403). Considering the RV, CS and IS groups showed an increase in CMC diameter compared to the control group (p < 0.01), occurring the same to respective nuclei (EI x C: p < 0.001 e EC x C: p = 0.005). Number of CMC marked with Ki-67 was greater in RV from stimulated groups in relation to LV (p = 0.009, proliferation index; p = 0.001, number/high-power fields); the same occurred to I/V cells (proliferation index and number/high-power fields: p < 0.001). CONCLUSIONS: Both cell hypertrophy and hyperplasia are involved in adaptation of the pulmonary ventricle submitted to pressure overload through PAB. Both types of conditioning (continuous and intermittent) caused CMC hypertrophy and hyperplasia, besides induced I/V cells mitosis, without interstitial collagen deposition at the end of experiment.