Background: Celiac disease (CD) is an autoimmune disorder that affects genetically susceptible individuals and is induced by dietary gluten. Treatment consists of a lifelong gluten-free diet. CD is common and affects about 1% of the general population. The classic symptoms include diarrhea and malabsorption, but many patients have only mild symptoms or no symptoms at all. The proportion of individuals presenting with atypical symptoms or discovered only when investigating an associated condition of CD is increasing. Aims: The aim of this thesis was to investigate the risk of possible associated disorders through Swedish population-based registers. The objective was to gain more information on the consequences of having CD and to identify high risk groups where screening may be considered. Materials and methods: We used the Swedish hospital discharge register to examine the risk of liver disease, autoimmune heart disease, Addison’s disease and thyroid disorders in a cohort of about 14,000 individuals with CD and an age and sex matched reference population of 70,000 individuals. In the last study we used all regional pathology registers and the cancer registry to examine the risk of hematopoietic cancer, including lymphoma in three different cohorts: I) 28,810 individuals with CD; II) 12,681 individuals with small intestinal mucosal inflammation but without villous atrophy; and III) 3552 individuals with latent CD (a positive serology test for CD with a normal small intestinal biopsy). Results: CD is statistically significantly associated with an increased risk of liver disease, Addison’s disease, thyroid disease and lymphoma. We also found an increased risk of lymphoma in individuals with small intestinal mucosal inflammation. There was no statistically significant association between autoimmune heart disease or leukemia and CD. Latent CD was not associated with any hematopoietic cancers. Conclusion: This thesis found a positive association between CD and a number of autoimmune and inflammatory disorders. Clinicians need to have a high awareness of this association and to test for these conditions when symptoms appear.

The diagnostic accuracy attained with the use of transbronchial fine needle aspiration biopsy, aspiration of bronchial secretion, bronchial washing, brush biopsy and forceps biopsy via a flexible fiberoptic bronchoscope was compared in patients with carcinoma of the lung. In endoscopic visible tumours the sensitivity of forceps biopsy was higher than that of the other methods. When forceps biopsy was combined with bronchial washing the overall diagnostic accuracy was significantly higher than that of any of the single methods, while no appreciable increase was obtained by adding additional methods. Selective brush biopsy from every segment bronchus has been established as a method in the search for occult bronchial carcinoma. The extent of respiratory mucosal damage and wound healing after brush biopsy was therefore studied in rabbits. Large differences in the extension and depth of the damage was observed. The basement membrane was often penetrated. Regeneration started during the first day after brush biopsy and a normal ciliated epithelium was restored within three weeks. To determine if the bronchoscope itself damaged the respiratory epithelium, bronchial mucosa was studied in the pig after examination with a flexible fiberoptic bronchoscope. The columnar epithelial cells were torn off in areas where the bronchoscope had rubbed against the airway wall but the basement membrane was not damaged. Since the function of the respiratory epithelium is to remove inhaled particles from the airways, mucociliary clearance was studied in man after fiberoptic bronchoscopy. The study suggests that the tracheobronchial clearance system has a large reserve for mechanical trauma. Mucociliary clearance can however be decreased after fiberoptic bronchoscopy in some patients. An increasing number of patients with impaired cardiopulmonary function are today subjected to examination with flexible fiberoptic broncoscopy. The haemodynamic effects of fiberoptic bronchoscopy performed under topical anaesthesia were therefore studied in patients with restrictive lung disease. The procedure induced marked haemodynamic changes during passage of the larynx and during suctioning. A slight fall in arterial oxygen tension was observed during bronchial suctioning and in the post-bronchoscopic period. Three of ten patients developed ST-T-segment changes during bronchial suctioning. / <p>S. 1-48: sammanfattning, s. 49-126: 5 uppsatser</p> / digitalisering@umu.se

Abstract Magnetic resonance imaging (MRI) is a well-established imaging modality for disorders of the musculoskeletal system. The distinguishing advantages of MRI are absence of ionizing radiation, excellent tissue contrast and the ability to use any arbitrary imaging plane. MRI can also be used as a guidance method for various percutaneous procedures. The purpose of this study was to evaluate the feasibility of MRI guidance for musculoskeletal biopsies and therapeutic bone drillings. A 0.23 tesla open configuration MRI scanner with an interventional optical guidance system was used. 172 percutaneous biopsies performed using MRI guidance were reviewed to define the safety and accuracy of the guidance method. The value of fine needle aspiration biopsy (FNAB) as a supplementary diagnostic procedure for core biopsy was also evaluated. The overall diagnostic accuracy of MRI-guided biopsy was 0.95, sensitivity 0.91, and specificity 0.98. The diagnostic accuracy of histological biopsy alone was 0.93, sensitivity 0.89, and specificity 0.98, and accuracy for FNAB alone was 0.85, sensitivity 0.80, and specificity 0.90. MRI guidance was deemed feasible and accurate and fine needle biopsy a useful supplement. The feasibility and safety of MRI-guided retrograde drilling of osteochondritis dissecans of the knee were evaluated by analysing ten procedures. All the lesions were successfully located and reached without complications. All patients experienced pain alleviation and follow-up MRI showed ossification in all. The feasibility and safety of MRI-guided retrograde drilling of osteochondritis dissecans of the talus were assessed by evaluating four procedures. Technical success was achieved in all cases and no complications were reported. All patients experienced some clinical benefit, although the changes in the pathological imaging findings were subtle. The feasibility and safety of MRI-guided core decompression for avascular necrosis of the femoral head were assessed by analysing twelve such procedures. The patients quantified their symptoms before and after the procedure. All procedures were successful without complications. All patients with low-stage disease benefited from the procedure. MRI guidance seems accurate, safe and technically feasible for the therapeutic bone drillings studied. / Tiivistelmä Magneettikuvaus (MK) on vakiintunut tuki- ja liikuntaelimistön sairauksien kuvantamismenetelmä. Sen erityispiirteitä ovat ionisoivan säteilyn puuttuminen, erinomainen kudoskontrasti sekä mahdollisuus saada kuvia mielivaltaisesta leiketasosta. Magneettikuvausta voidaan myös käyttää ohjausmenetelmänä useiden perkutaanisten toimenpiteiden yhteydessä. Tämän tutkimuksen tarkoitus oli selvittää MK-ohjauksen käyttökelpoisuus tuki- ja liikuntaelimistön neulanäytteenottojen ja hoidollisten luuporausten ohjausmenetelmänä. Tutkimuksessa käytettiin 0.23 teslan avomagneettia, jossa oli lisäksi optinen ohjausjärjestelmä. MK-ohjauksen turvallisuuden ja tarkkuuden selvittämiseksi tutkittiin 172 perkutaanista MK-ohjattua neulanäytteenottoa. Myös paksuneulanäyteen yhteydessä otetun ohutneulanäytteen antama lisäarvo arvioitiin. MK-ohjatun neulanäytteenoton kokonaistarkkuus oli 0.95, herkkyys 0.91 ja spesifisyys 0.98. Pelkän histologisen näytteenoton vastaavat tunnusluvut olivat 0.93, 0.89 ja 0.90 ja pelkän ohutneulanäytteen tunnusluvut olivat 0.85, 0.80 ja 0.90. Magneettikuvaus todettiin käyttökelpoiseksi ja tarkaksi ohjausmenetelmäksi ja ohutneulanäyte hyödylliseksi lisätoimenpiteeksi. MK-ohjauksen turvallisuutta ja soveltuvuutta polven osteokondriitin poraushoitoon arvioitiin kymmenen toimenpiteen perusteella. Kaikkiin kohteisiin osuttiin, eikä komplikaatioita ilmennyt. Kaikkien potilaiden kipu helpottui ja seurantakuvauksissa nähtiin luutumista. MK-ohjauksen turvallisuutta ja soveltuvuutta telaluun osteokondriitin poraushoitoon arvioitiin neljän toimenpiteen perusteella. Toimenpide onnistui teknisesti kaikissa tapauksissa, eikä komplikaatioita esiintynyt. Kaikki potilaat hyötyivät jonkin verran, mutta poikkeava kuvalöydös muuttui vain vähän. MK-ohjatun reisiluun pään avaskulaarisen nekroosin poraushoidon turvallisuutta ja soveltuvuutta arvioitiin kahdentoista toimenpiteen perusteella. Potilaat määrittivät oireensa numeerisesti ennen ja jälkeen toimenpiteen. Kaikki toimenpiteet onnistuivat, eikä komplikaatioita esiintynyt. Toimenpiteestä hyötyivät kaikki potilaat, joilla oli varhaisvaiheen tauti. Magneettikuvaus vaikuttaa tarkalta, turvalliselta ja teknisesti soveltuvalta ohjausmenetelmältä tutkittujen terapeuttisten luuporausten yhteydessä.

Abstract Food hypersensitivities are becoming increasingly common worldwide. Previous studies indicate that cell mediated immunity has a role in delayed paediatric gastrointestinal food hypersensitivities, but the exact pathogenetic mechanisms are unknown. Cytotoxic activation of T-lymphocytes is known to play an important role in the pathogenesis of celiac disease (CD). The pathogenetic mechanisms of cow's milk protein sensitive enteropathy (CMSE) are largely unknown. CMSE is a non-IgE related type of food hypersensitivity with variable gastrointestinal symptoms but no visible mucosal abnormalities on light microscopy. The diagnosis is based on an open or blinded elimination/challenge test, as the endoscopic, histological and laboratory findings are generally non-specific. This thesis aims to characterize the role of lymphocyte cytotoxicity in the pathogenesis and diagnosis of CMSE in preschool and school aged children, including comparison with CD where the pathogenetic significance of cytotoxicity is well established. The study cohort consisted of 151 children, including 57 with untreated CMSE, 18 with treated CMSE, 24 with CD, and 52 controls. Using immunohistochemistry, the mucosal expressions of cytotoxic T cell-restricted intracellular antigen type 1 (TIA-1), perforin, granzyme A and B were analysed in the duodenal bulb and descending duodenum. Intraepithelial T-lymphocytes were labelled with CD3, alpha/beta and gamma/delta T cell receptor antigens. To determine the rates of overall and epithelial apoptosis as well as proliferation, the immunohistochemical TUNEL technique, M30 and Ki-67 antibodies were used. Serum levels of granzymes, CD30 and soluble Fas were studied using ELISA method. The number of intraepithelial lymphocytes with TIA-1, perforin and granzyme A containing granules was increased in CMSE. This increase was related to antigen challenge and not a constitutional abnormality. The cytotoxic reaction in CMSE differed from that in CD by being of lesser magnitude, concerning predominantly the descending duodenum and not showing signs of cytotoxicity related epithelial destruction. The serum levels of GrA, GrB and CD30 were increased in both CMSE and CD, correlating with the number of duodenal CD3+, alpha/beta and gamma/delta+ intraepithelial lymphocytes. The results strongly support the role of cell-mediated immunity in the pathogenesis of CMSE. Mucosal cytotoxic activation seems to be manifested by the release of cytoxicity related proteins in serum. This provides a new approach to the monitoring of intestinal immune activation which could help in diagnosis and in objectively monitored treatment response.

Introducción El sistema Bethesda se utiliza para clasificar los resultados de la prueba de Papanicolaou. Entre los resultados se tienen a las células ASC-US (células escamosas atípicas de significancia indeterminada) y ASC-H (células escamosas atípicas que no pueden descartar lesión intraepitelial). Se ha relacionado a estas células con neoplasia de cuello uterino; sin embargo, su asociación no ha sido muy estudiada en Perú. Objetivos Calcular la probabilidad de displasia severa, carcinoma in situ y cáncer de células escamosas, en mujeres con hallazgo citológico de ASC-H y ASC-US. Métodos Estudio observacional, transversal realizado en un hospital nivel IV en Lima-Perú, entre el 2012 y 2013, en el cual se evaluaron a 1060 pacientes con resultado de la prueba de Papanicolaou, Se realizó análisis bivariado y regresión logística binomial múltiple para evaluar la asociación. Se usó Chi cuadrado y se consideró el valor de p <0,05 como significativo. Resultados Se analizaron 1060 pruebas de Papanicolaou. La edad media fue 46,4 (DE: 13,2) años y 64,9% fueron menores de 50 años. La prevalencia de ASC-US fue 3,45% y la de ASC-H 0,32%. De 175 biopsias, el 22,9% presentó displasia moderada a severa o carcinoma escamoso. Se encontró asociación entre el hallazgo de ASC- H y la presencia de displasia moderada/severa (NIC 2/3), carcinoma in situ y carcinoma de células escamosas, en el estudio histopatológico (PR=2,39; IC(95%):1,49-3,81). Conclusión Dada la asociación encontrada, las mujeres con hallazgo de ASC-H, deben ser estudiadas de manera más profunda, con el fin de buscar displasia moderada/severa (NIC 2/3) o carcinoma de células escamosas. / Background The Bethesda system is used to classify Pap smear results. Some of the results are ASC-US (atypical squamous cells of undetermined significance) and ASC- H cells (atypical squamous cells cannot exclude intraepithelial lesion). It has been found an association between these results with cervical neoplasia; however they have not been well studied in Peru. Objectives To calculate the probability of severe dysplasia in situ or squamous cell cancer in women with cytology results of ASC-H and ASC-US. Methods An observational, cross-sectional study was carried out in a reference higher complexity health establishment in Lima, Peru (4th level), from 2012 to 2013, in which 1060 data of patients was analyzed. Bivariate and multiple binomial logistic regression analysis were performed. Chi square test was used and p-value < 0.05 was considered as significant. Results 1060 Pap smears were evaluated. Mean age was 46,4 (SD: 13,2) years and 64,9% were under 50 years old. ASC-US prevalence was 3,45% and ASC-H 0,32%. Out of 175 biopsies, 22,9% had moderate to severe dysplasia, carcinoma in situ or squamous carcinoma. There was an association between ASC-H finding and the presence of moderate/severe dysplasia (CIN 2/3), carcinoma in situ and squamous cell carcinoma (PR=2,39; CI(95%):1,49-3,81). Conclusion Given the association found, women with ASC-H findings should be further and thoroughly studied in order to look for moderate/severe dysplasia (CIN2/3) or squamous cell carcinoma.

Introdução: o carcinoma de endométrio é uma das neoplasias ginecológicas mais comuns nos países industrializados. O tratamento desta doença é primariamente cirúrgico. Segundo a normatização da Federação Internacional de Ginecologia e Obstetrícia (FIGO), a cirurgia ideal consiste na realização de histerectomia total, anexectomia bilateral, linfadenectomia retroperitonial e coleta de citologia peritoneal. No entanto, a realização sistemática da linfadenectomia tem sido contestada. Alguns centros de referência acreditam que deva ser realizada apenas em um grupo de pacientes com alto risco para disseminação linfática da doença. O desafio é encontrar marcadores pré-operatórios que possam ser preditivos da presença de doença linfonodal e, assim , virem a ser utilizados para a definição da necessidade da linfadenectomia. Objetivos: verificar se a expressão imuno-histoquímica (IMH) positiva da p53 na amostra endometrial diagnóstica e, se o valor sérico do CA 125 obtido no tempo pré-operatório, podem ser efetivos para prever a presença de doença linfonodal. Métodos: um estudo transversal restrospectivo foi realizado. Foram incluídas 111 pacientes com carcinoma de endométrio submetidas a histerectomia com anexectomia bilateral e linfadenectomia com ou sem citologia peritoneal. Noventa pacientes apresentavam CA 125 pré-operatório e 73, a avaliação da p53. Cinquenta e quatro pacientes apresentavam as duas variáveis em combinação. Foram estabelecidas as associações entre o valor de CA 125 e da expressão IMH da p53 com o envolvimento linfonodal. Uma curva ROC foi construída para identificar o valor de CA 125 com melhor Sensibilidade (S) e Especificidade (E) para doença linfonodal. / Introduction: endometrial carcinoma is one of the most common gynecological malignancies in industrialized countries. The treatment of this disease is primarily surgical. According to the International Federation of Gynecology and Obstetrics surgery ideal consists in performing total hysterectomy, bilateral adnexectomy, retroperitoneal lymphadenectomy and peritoneal cytology. However, the systematic lymphadenectomy has been disputed, and should only be performed in a group of patients at high risk of lymphatic spread of the disease. The challenge is to find preoperative markers that may be predictive of the presence of lymph node disease and thus come to be used to determine the necessity of lymphadenectomy. Objectives: to determine whether the positive immunohistochemical expression (IMH) of p53 in diagnostic endometrial sample and, if the value of serum CA 125, obtained during pre-operative, can be effective to predict the presence of lymph node disease. Methods: a cross-sectional study was conducted. The final sample consisted of 111 patients with endometrial carcinoma undergoing hysterectomy with bilateral adnexectomy and lymphadenectomy with or without peritoneal cytology. Ninety two patients had preoperative CA 125 and 73, evaluation of p53. Fifty four patients had both variables in combination. Associations have been established between the value of CA 125 and IMH expression of p53 with lymph node involvement. A ROC curve was constructed to identify the value of CA 125 with better sensitivity (S) and specificity (E) for lymph node disease.

Orientador: Miriam Dambros Lorenzetti / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-28T00:11:28Z (GMT). No. of bitstreams: 1 Souza_FelipeGoncalvesSchrodere_M.pdf: 1431848 bytes, checksum: df85a182625e0c75b33faa908d302d6c (MD5) Previous issue date: 2015 / Resumo: Introdução: A neoplasia de próstata é a segunda mais prevalente entre os homens, com estimativa de cerca de 68 mil casos novos no Brasil em 2014. Além disso, é a segunda causa de morte no sexo masculino por neoplasias. O câncer de próstata raramente causa sintomas em seus estágios iniciais, por isso existe a necessidade do diagnóstico precoce. Atualmente a forma de rastreamento desta neoplasia ainda é controverso, porém quando realizado, baseia-se em exame digital retal da próstata e na mensuração sérica dos níveis do PSA. Estudos de rastreamento populacional mostraram uma diminuição de 41% no casos de neoplasia avançada de próstata e risco de diagnóstico de câncer 46% maior, quando comparados a grupos não submetidos a rastreamento. O PSA não é câncer específico, então, os refinamentos do PSA (relação do PSA livre/total, densidade do PSA e velocidade do PSA) aparecem como métodos para melhorar sua especificidade, na tentativa de diminuir o número de biópsias desnecessárias. Quando existe suspeita diagnóstica, é indicada uma biópsia guiada por ultrassonografia transretal, procedimento que não é isento de complicações, principalmente as infecciosas. Objetivos: Avaliar a positividade para adenocarcinoma de próstata em biópsias guiadas por ultrassonografia transretal, e estratificá-la de acordo com a idade, com o valor do PSA total, com a densidade do PSA e com a relação entre a fração livre do PSA e o PSA total. Materiais e Métodos: Analisamos retrospectivamente os resultados obtidos no serviço de urologia do Hospital Municipal Dr. Mário Gatti com relação à positividade das biópsias estratificadas pela idade, PSA total, percentual da fração livre do PSA e densidade do PSA, comparando-os com os dados descritos na literatura. Resultados: Foram realizadas 314 biópsias no período de janeiro de 2011 à novembro de 2012. A média de idade dos pacientes foi de 65,2 (± 8,32) anos e a positividade foi de 44,9%. A positividade das biópsias foi maior com o aumento da idade (p<0,001), com o aumento do PSA (p<0,001), com o aumento da densidade (p<0,001) e com a diminuição da relação do PSA (p=0,002) Conclusão: A neoplasia prostática correlacionou-se significativamente com o aumento da idade, do PSA total, da densidade do PSA, e com a diminuição da relação entre o PSA livre sobre o PSA total / Abstract: Introduction: Prostate neoplasia is the second most prevalent neoplasia in men and about 68 thousand new cases were estimated in 2014 in Brazil. In addition, it is the second most common cause of cancer related death in men. Prostate cancer rarely causes symptoms at an early stage, hence the need of an early diagnosis. Although there is still no consensus about how to screen this neoplasia, it is done through digital rectal examination and measurement of PSA levels. Population screening trials showed a decrease of 41% in new cases of advanced prostate neoplasia. The risk of a cancer diagnosis increased 46% when compared to the group who was not screened. PSA is not cancer specific. Therefore, PSA features (relation between free PSA and total PSA, PSA density, PSA velocity) are used to increase its specificity, attempting to reduce the number of unnecessary biopsies. Once there is a cancer suspicion, a biopsy guided by transrectal ultrasonography is indicated, which is not a complication free procedure, mainly infection. Objective: to assess the positiveness of prostatic adenocarcinoma in transrectal ultrasonography guided biopsies and to evaluate it according to age, total PSA value, PSA density, and the relation between free PSA and total PSA. Materials and Methods: This is a retrospective study with patients who underwent prostatic biopsy guided by transrectal ultrasonography done by the urology team from Hospital Municipal Dr. Mário Gatti. Collected data included patient¿s age, total PSA value, PSA density and the relation between free PSA and total PSA. Results: 314 prostatic biopsies guided by transrectal ultrasonography were analyzed between January 2011 and November 2012. Patient¿s mean age was 65.2 (+/-8.32) years. A positive biopsy to adenocarcinoma was found in 44.9% of the patients. The number of positive biopsies was higher among older patients (p<0.001). It was also higher the higher the PSA (p<0.001) and the higher the PSA density (p<0.001). It was inversely related to PSA relation (p=0.002). Conclusion: There is a direct correlation between prostatic neoplasia and age, value of PSA and PSA density. Additionally, prostatic neoplasia is inversely proportional to the relation of free PSA over total PSA / Mestrado / Fisiopatologia Cirúrgica / Mestre em Ciências da Cirurgia

INTRODUÇÃO: A utilização da ultra-sonografia (USG) como método de diagnóstico por imagem na avaliação das afecções abdominais, em particular para o acompanhamento de pacientes portadores de hepatite C crônica, vem sendo rotineiramente empregada. Neste trabalho, avaliamos a contribuição da USG na avaliação das alterações histopatológicas encontradas neste grupo de doentes, com ênfase para a esteatose hepática (EH), afecção bastante freqüente na hepatite causada pelo vírus C. MÉTODO: Comparamos os achados ultra-sonográficos de 192 pacientes consecutivos, portadores de hepatite crônica pelo vírus C, submetidos à biópsia hepática, com os achados histopatológicos dos fragmentos hepáticos obtidos. Todos os pacientes foram biopsiados sob orientação USG, sendo a ultra-sonografia assim como a biópsia hepática realizadas cada qual por um médico especialista e sempre o mesmo. Todos os exames ultra-sonográficos obedeceram a um mesmo protocolo, sendo analisados os seguintes parâmetros ultra-sonográficos: 1) com relação às características ecográficas do parênquima: ecogenicidade, ecotextura e atenuação; 2) com relação à utilização da USG para o diagnóstico da EH: biometria da parede abdominal, dimensões e contornos hepáticos. Posteriormente os pacientes estudados foram agrupados em: A) grupo com alterações ultra-sonográficas e B) sem alterações ultra-sonográficas, e comparados com as alterações histopatológicas presentes. Foram realizados também cálculos de regressão logística com os parâmetros USG avaliados para a avaliação da acurácia deste método de imagem para o diagnóstico da EH. RESULTADOS: Entre as alterações histopatológicas presentes, a alteração arquitetural e a EH apresentaram diferença estatística significante entre os grupos A (com alterações USG) e B (sem alterações USG). Observou-se também diferença estatística significante entre: a) espessura da parede abdominal e as dimensões hepáticas com relação à presença de EH, b) contornos hepáticos irregulares e a presença de EH. E dentre os componentes ultra-sonográficos avaliados, a atenuação foi o que apresentou melhor correlação com a EH. A utilização das variáveis idade, sexo, atenuação, espessura da parede abdominal e dimensões hepáticas, foram as que apresentaram melhores resultados nos cálculos de regressão logística, com sensibilidade de 60,5% e especificidade de 83,9% em diagnosticar EH. CONCLUSÕES: Neste trabalho, o estudo ultra-sonográfico do fígado de pacientes com hepatite C crônica apresentou correlação com as alterações arquiteturais e com a EH encontradas na histopatologia. A utilização da USG para o diagnóstico da EH apresentou relação estatística com a espessura da parede abdominal, dimensões e contornos hepáticos, e a atenuação foi o melhor componente ultra-sonográfico para o diagnóstico da EH. / INTRODUCTION: Ultrasonography is consistently utilized as the method of diagnostic imaging while evaluating abdominal infections particularly in patients with chronic hepatitis C. We studied the contribution of the ultrasonography in the evaluation of histopathologic alterations in this group of patients with emphasis in hepatic steatosis (HS), sufficiently frequent in hepatitis caused by the C virus. METHODS: We compared the findings from the ultrasounds of 192 carrying patients of chronic hepatitis C virus, who had undergone hepatic biopsy, with the histopathogical findings of the hepatic fragments obtained. All patients who have undergone liver biopsy guided by ultrasonography were always evaluated by the same medical specialist for both sonogram or hepatic biopsy. All ultrasound examinations followed the same protocol, analyzing the following parameters: 1) regarding to the echographic characteristics of parenchyma: echogenicity, echotexture and attenuation; 2) regarding to the use of the sonography for the diagnosis of the HS: biometry of the abdominal wall, hepatic dimensions and contours. Post results, patients had been grouped in: A) altered ultrasound group and B) ultrasound group without ultrasound alterations, both compared with present histopathological alterations. Calculations of logistic regression with ultrasonography parameters had also been performed to determine the accuracy of this method for the HS diagnosis. RESULTS: Of the histopathological alterations present, the architectural alteration and the HS had presented significant statistical difference between the groups (altered ultrasound group) and the B (without ultrasound alterations). We also noted significant statistical difference between: a) thickness of the abdominal wall and the hepatic dimensions with regard to presence of HS, b) irregular hepatic contours and the presence of HS. Amongst the evaluated ultrasound components, attenuation presented better correlation with the HS. The variables age, sex, attenuation, thickness of the abdominal wall and hepatic dimensions of the right lobe, presented better results in the calculations of logistic regression, with 60,5% sensitivity and specificity of 83,9% in diagnosing HS. CONCLUSIONS: In this research, the hepatic ultrasonography of patients with chronic hepatitis C presented correlation with the architectural alterations and the HS found at the histopathology. The utilization of the ultrasonography for the diagnosis of the HS presented statistical relationship with the thickness of the abdominal wall, hepatic dimensions and contours, and the sonographic attenuation was the best component for the diagnosis of ES.

Introdução: A história natural da insuficiência mitral associa-se a décadas de remodelação ventricular esquerda com fibrose intersticial. A fronteira entre o processo adaptativo e a miocardiopatia dilatada demanda avaliação clínico-histológica. Atualmente, sabe-se que o melhor método empregado para quantificar as alterações decorrentes do remodelamento que acomete o ventrículo esquerdo é a biópsia miocárdica, que analisa a doença, somente após a cirurgia ou no post mortem. O presente estudo visa avaliar a fibrose miocárdica associada à insuficiência mitral crônica, através de estudo pela Ressonância Magnética, de maneira não invasiva, precoce e rápida. Objetivos: Avaliar a capacidade e a aplicabilidade da ressonância magnética cardíaca de detectar a fibrose miocárdica na insuficiência mitral crônica importante, tendo como referência a biópsia miocárdica. Métodos: Foram selecionados 52 pacientes portadores de IM crônica pura ou associada a estenose mitral leve, com PVM e DR, e com indicação cirúrgica. Todos os pacientes foram reavaliados pelo EcoDopplercardiograma e realizaram ressonância magnética cardíaca para avaliação da função ventricular, volumes e índice de massa ventricular esquerda, através da cine-ressonância e pela técnica do realce tardio miocárdico, com injeção de 0,2 mmol/kg de contraste gadolínio para a detecção de FM, sendo submetidos a cirurgia de plástica ou troca de válvula mitral com bióspsias miocárdicas, retiradas de locais padrão, na parede lateral do ventrículo esquerdo. Todas foram coradas pela técnica do hematoxilinaeosina, e as positivas para FM, confirmadas pelo corante picrossirius, que cora colágeno, e quantificadas pelo aparelho do quantimet. Resultados: Os pacientes foram divididos em quatro grupos, conforme a RM e a biópsia. A RM diagnosticou FM em 18 pacientes, concordantes com a BM (RMC/BM +). A RM foi negativa para FM em 33 pacientes, sendo 28 concordantes com a BM (RMC/BM -). Observou-se discordância de RM com a BM, em 7 casos falsos negativos (RMC-/BM +). A sensibilidade da RMC à fibrose foi de 72%, especificidade de 100%, e acurácia de 86,3%. Nos grupos distintos estudados, a sensibilidade, especificidade e acurácia foram de 64,7%, 100% e 82,4%, respectivamente, na PVM, e de 97,5%, 100% e 92,9%, respectivamente, na DR. O índice Kappa foi de 0,724 (p<0,001) para o grupo total; 0,665 (p<0,001) para PVM e 0,857(p<0,001) na DR. VDF, VSF e IMVE tiveram correlação positiva e significativa com a porcentagem de fibrose, sendo que, quanto maiores esses valores, maior a porcentagem de fibrose. Conclusão: RMC teve boa concordância com a BM, em relação aos achados de FM / Introduction: The natural history of mitral insufficiency (MI) is associated to decades of left ventricular remodelation with intersticial fibrosis. The frontier between adaptative process and dilatade miocardiopaty needs clinic and histologic evaluation. Now a days , we know that the best method to quantify the alterations of remodelation in left ventricule is myocardial biopsies which analyses the illness only after surgery or post morten. This actual study aims to evaluate myocardial fibrosis associated with cronic MI, through the study with magnetic resonance (MR), in a not invasive, early and quickly way. Objectives: Evaluate capacity and applicability of the magnetic resonance in detection of myocardial fibrosis in chronic important mitral insufficiency in reference with myocardial biopsis. Methods: It was selected 52 patients with pure chronic MI or associated with mild mitral stenosis, with cirurgical indication. All of the patients were reevaluated by EcoDopplercardiogram and it was done cardiac MR to evaluate ventricular function, volumes and left ventricular mass rate through MR cine and myocardial late realce techinique with 0,2 mmol/Kg with gadoline contrast and myocardial fibrosis (MF) detection and being undergone plastic or mitral valvular changes surgery with myocardial biopsis (MB) were taken from the left ventricular lateral wall. All of them were colored with hematoxilin eosine and the positives were confirmated with picrossirius and quantified with quantimet device. Results: Patients were divided in four groups according to MR and biopsies. MR diagnosticated MF in 18 patients agreed with MB (MR / MB +). MR was negative for MF in 33 patients where 28 agreed with MB (MR / MB -). We observated discordance with MR and MB in 7 cases false negatives (MR- /MB+). The sensibility of MR to fibrosis was 72%, specificity was 100% and acurace was 86,3%. In the distinct groups studied, we see sensibility, specifity and acure were 64,7%, 100 % and 82,4% respectivity in PVM and 97,5%, 100% and 92,9% respectivity in reumathic disease. The Kappa indice is 0,714 (p<0,001) for the total group; 0,665 (p<0,001) for PMV and 0,857 (p<0,001) in RD. There is a positive correlation and significative between fibroses percentage with VDF, VSF, IMVE of the MR. So the higher the values, higher the fibrosis percentage. Conclusion: MR had a good concordance with MB in relation to found the MF in IMC

INTRODUÇÃO: A rejeição constitui-se em uma das principais causas de mortalidade após o transplante cardíaco pediátrico. O peptídeo natriurético tipo B (BNP), tem sido estudado como método no diagnóstico de rejeição aguda principalmente em pacientes adultos submetidos ao transplante cardíaco. OBJETIVOS: Avaliar o peptídeo natriurético tipo B no diagnóstico de rejeição aguda em crianças submetidas ao transplante cardíaco ortotópico, avaliar o papel do BNP como método adicional não invasivo na elucidação diagnóstica da doença coronariana após transplante e comparar parâmetros clínicos, ecocardiográficos e hemodinâmicos em relação à biópsia endomiocárdica no diagnóstico de rejeição cardíaca aguda. MÉTODOS: Foram coletadas 50 amostras de BNP de 33 crianças em pós-operatório de transplante cardíaco e analisados dados de idade, sexo, cor, grupo sangüíneo, painel imunológico, tempo de evolução após o transplante, sintomatologia, imunossupressão utilizada, número de rejeições, dados ecocardiográficos e parâmetros hemodinâmicos. Os grupos foram divididos em pacientes com rejeição e pacientes sem rejeição. RESULTADOS: Foram analisadas 50 amostras consecutivas de 33 crianças, durante período de 17 meses. A idade mediana foi de 10,1 anos, com predomínio do sexo feminino (54%) e da cor branca (85%). No momento da dosagem de BNP o tempo médio pós-transplante foi 4,3 anos. A biópsia endomiocárdica diagnosticou nove rejeições em oito pacientes (27%), sendo três com grau 3 A, cinco com grau 2 e um com rejeição humoral. No momento da biópsia, a maioria dos pacientes encontrava-se assintomática. O nível sérico de BNP teve mediana de 77,2 pg/ml, sendo 144,2 pg/ml no grupo com rejeição e 62,5 pg/ml no grupo sem rejeição, com p = 0,02. Análise de curva ROC mostra que níveis sangüíneos de BNP maiores que 38 pg/ml apresentam sensibilidade de 100% e especificidade de 56% na detecção de rejeição cardíaca. Os níveis de BNP foram maiores que 100 pg/ml nos pacientes com doença coronariana, com mediana de 167,5 pg/ml, em relação à 15 mediana de 40,5 pg/ml dos pacientes que não apresentaram doença coronariana. A curva ROC mostra ponto de corte de 90 pg/ml como ideal para diagnóstico de doença coronariana, com p = 0,01. Os parâmetros hemodinâmicos não foram diferentes entre os grupos com rejeição e sem rejeição. A sensibilidade do ecocardiograma para detecção de rejeição foi de 44% e especificidade de 90%, com p= 0,02. CONCLUSÕES: Pacientes podem apresentar-se assintomáticos durante episódio de rejeição aguda. O nível sérico de BNP apresentou diferença estatisticamente significante no grupo com rejeição, podendo ser método adicional no diagnóstico de rejeição cardíaca. A doença coronariana esteve associada com níveis elevados de BNP, independente da presença de rejeição aguda. O ecocardiograma mostrou baixa sensibilidade para o diagnóstico de rejeição cardíaca, mas alta especificidade. A avaliação dos parâmetros hemodinâmicos não apresentou neste estudo correlação com os resultados de biópsia. / INTRODUCTION: The rejection is one of the main causes of mortality after pediatric heart transplant. B natriuretic peptide has been used as a diagnostic method for rejection mainly in adult patients after heart transplantation. OBJECTIVE: To correlate BNP levels collected at the moment of endomyocardial biopsy with rejection, to evaluate BNP as an additional method for coronary artery disease and to compare clinical, echocardiograph assessment and hemodynamic parameters with endomyocardial biopsy findings. METHODS: There were 50 BNP blood samples from 33 children submitted to orthotopic cardiac transplantation. Analyzed parameters included: age, gender, race, blood type, reactive panel, functional class, immunosuppressive regimens, number of rejection episodes, echocardiography findings and hemodynamic parameters. The patients were divided in two groups: with rejection and without rejection. RESULTS: Thirty three children with a median age of 10.3 years (54% female) were studied at median time of 4.2 years after heart transplantation. Endomyocardial biopsy diagnosed nine rejection episodes (27%): three were grade 3A; five were grade 2 and one was humoral rejection. At the moment of biopsy most patients were asymptomatic. Average BNP level was 77.2 pg/ml (144.2 pg/ml in the patients with rejection and 65.8 pg/ml in the group without rejection, p=0.02). BNP level was increased in humoral rejection and in patients with coronary artery disease. ROC curve demonstrates BNP levels over 38 pg/ml to present 100% sensibility and 56% specificity to detect acute rejection. The levels of BNP were higher than 100 pg/ml in most of the patients with coronary artery disease (median of 167.5 pg/ml compared with a 40.5 pg/ml in patients without coronary artery disease). The curve ROC shows a critical cut off value for the diagnosis of coronary artery disease at the level of 90 pg/ml in, with p = 0.01. The hemodynamic parameters did not show significant differences between the patients with rejection and the group without rejection. The echocardiogram presented 44% sensibility and a 17 90% specificity to detect the rejection episode (p = 0.02). CONCLUSIONS: Children could be asymptomatic at allograft rejection episodes. BNP level was significantly elevated in children with the allograft rejection episode and may add a valuable information for the rejection assessment. Also, the higher BNP levels associated with coronary artery disease may contribute for its surveillance. Although the echocardiography presented low sensibility to screen for acute rejection episodes, its high specificity enhances its role to structural and functional alterations. The hemodynamic parameters did not contribute for the diagnosis nor presented correlation with the biopsy findings.