Orientador: Maria Lucia Gomes Lourenço / Resumo: Ambulatorial electrocardiographic monitoring, or Holter method, has been shown to be an effective tool in veterinary medicine to detect early heart lesions, not only to monitor the electrical activity of the heart, but also to control the autonomic nervous system of this organ. It is also known that the main infectious diseases of dogs, such as canine distemper and canine monocytic ehrlichiosis (CME) cause considerable lesions in the heart, proven by histopathological examination. It has already been proven the occurrence of myocarditis in the CME, leading to frequent presence of changes in the generation and conduction of the cardiac electrical impulse. The present study analyzed the electrical activity of the heart during 24 hours, focusing on the prevalence of arrhythmias, heart rate variability study and the biomarkers concentration of dogs with chronic CME (sick group) compared to healthy animals (control group). Forty-five percent of the animals in the diseased group had a high frequency of arrhythmias during the study. The mean concentration of cardiac troponin I and creatinokinase MB (CK-MB) was significant (0.24 ng / mL ± 0.5; 229 ± 205 IU / mL) compared to the control group (0.042 ± 0.07 ng / ML, 126 ± 46.12 IU / mL). The standard deviation of the mean of all NN (SDNN) intervals and the percentage of adjacent RR intervals with a duration difference greater than 50 milliseconds (pnn50%) were also extremely significant (83 ± 65 and 14.56 ± 20) when compared to Healthy... (Resumo completo, clicar acesso eletrônico abaixo) / Mestre

Orientador: Maria Lucia Gomes Lourenço / Resumo: A modulação autonômica da frequência cardíaca reflete-se na variabilidade da frequência cárdiaca (VFC). Estudos em humanos hígidos mostraram que a VFC sofre redução com o avançar da idade e também que há uma imaturidade autonômica em neonatos, alterando esses índices. Esta análise apresenta perspectivas interesantes em cães, contudo, antes mesmo que possa ser utilizada, é pertinente que se estabeleça melhor compreensão sobre o comportamento fisiológico da modulação autonômica cardíaca. O objetivo desse estudo foi descrever um padrão característico de comportamento autonômico cardíaco em cães saudáveis em diferentes faixas etárias. Foi analisada a VFC no domínio do tempo e no domínio da frequência, utilizando o Holter e o frequencímetro em curto prazo em 87 cães. Observou-se que cães entre um e sete anos de idade, apresentaram maior VFC quando comparada a outras faixas etárias. Cães idosos (> 8 anos), exibiram tendência natural a diminuição dos marcadores parassimpáticos cardíacos da VFC, enquanto cães filhotes (< 1 ano), apresentaram maior predomínio simpático e consequentemente, menor VFC. Conclui-se que o balanço dos sistemas simpático e parassimpático, sofre influência da idade em cães, alterando os valores da VFC. Então é de extrema importância obter valores de referência, para futuras análises em diferentes afecções clínicas. Estas análises podem ser realizadas pelo Holter e frequencímetro cardíaco, mesmo apresentando limitações para cães, ambos os métodos avaliam a VFC. / Abstract: Autonomic heart rate modulation is reflected by heart rate variability (HRV). Studies in healthy human subjects show that the HRV is reduced with the advancing age and also, that there is an autonomic immaturity in neonates, which alters these parameters. This analysis presents interesting perspectives in dogs, however, even before it can be used, it is pertinent to establish a better understanding of the physiological behavior of cardiac autonomic modulation. The objective of this study was to describe a characteristic pattern of cardiac autonomic behavior in healthy dogs in different age groups. Time and frequency domain of HRV were analyzed using Holter and the short-term heart rate monitor in 87 dogs. It was observed that in dogs between one and seven years of age, they present higher HRV when compared to other age groups. Older dogs (> 8 years) had a natural tendency to decrease cardiac parasympathetic markers of HRV, while puppies (<1 year) had a upper sympathetic predominance and, consequently, lower HRV. It is concluded that the balance of the sympathetic and parasympathetic systems, is influenced by age in dogs, changing HRV values in the short term. Therefore, it is extremely important to obtain reference values for future analyzes in different diseases. These analyzes can be performed by the Holter and cardiac frequency meter, even with limitations for dogs, since both evaluate the heart rate variability. / Mestre

A circulação extracorpórea (CEC) é atualmente técnica amplamente utilizada na rotina da cirurgia cardíaca humana. Entretanto, na medicina veterinária, ainda não é utilizada rotineiramente devido a alta mortalidade que ocasiona. O presente experimento utilizou cinco cães machos, SRD, em condições satisfatórias para a realização de pesquisa médica. Esses animais foram submetidos a toracotomia intercostal direita convencional e realizadas as mensurações e coletas padrão pertinentes do experimento (M0). Após isso, os animais foram conectados a máquina de circulação extracorpórea, onde permaneceram por um período de duas horas (M1), sendo então desconectados da mesma, permanecendo por uma hora em processo de reperfusão pós CEC (M2) para após sofrer eutanásia. Foram avaliados os seguintes parâmetros: paO2 e pvO2 (oxigenação), paCO2 e pvCO2 (ventilação), pH e HCO3 (equilíbrio ácido-básico), Na, K e Ca ionizado (eletrólitos séricos), freqüência cardíaca, freqüência respiratória, temperatura retal, pressão arterial média, contagem de plaquetas, proteínas totais, glicose sérica, hematócrito, contagem de hemácias, avaliação anátomo-histopatológica do coração e pulmões. Foram observadas alterações significativas na oxigenação, ventilação, equilíbrio ácido-básico, eletrólito sérico potássio, freqüência cardíaca, temperatura retal, contagem de plaquetas, proteínas totais, glicose sérica, hematócrito, contagem de hemácias e no exame histológico do coração e pulmões. Fundamentado nos resultados verificados, concluiu-se que a circulação extracorpórea por duas horas com reperfusão durante 1 hora determina, em cães, alterações clínicas, modificações de parâmetros sanguíneos e induz processos patológicos no coração e pulmões / Actually cardiopulmonary bypass is frequently used in human cardiac surgery routine. However, in veterinary medicine, that does not happened because the high mortality produced. The present study was performed in five males mongrel dogs, in good health conditions for experimental purposes. These animals were submitted to a convencional right intercostal thoracotomy and it was collected the data and materials that concerns to the experiment (M0). Then the animals were connected to the cardiopulmonary bypass machine for a period of two hours (M1), disconnected of the machine and kept alive for a one hour period of reperfusion (M2) before the euthanasia. It was evaluated the paO2 e pvO2 (oxigenation), paCO2 e pvCO2 (ventilation), pH e HCO3 (acid-basic balance), Na, K e ionized Ca (serum electrolites), heart beats, respiratory movements, temperature, mean arterial pressure, platelets number, total protein dosage, serum glucose, hematocrit, red cells number, anatomic-histopathological evaluation of heart and lungs. It was observed significant alterations on the oxigenation, ventilation, acid-basic balance, potassium, heart beats, temperature, platelets number, total protein dosage, serum glucose, hematocrit, red cells number and at the anatomic-histhopathological exam of the heart and lungs. Evaluating the results, it was concluded that the cardiopulmonary bypass in dogs for two hours and a reperfusion period of one hour produced clinical alterations, blood parameters modifications and pathological process in the heart and lungs

Thesis advisor: Barabara Hazard / This randomized controlled trial (RCT) examined a discharge nursing intervention (DNI) aimed at promoting self-regulation of care for early discharge interventional cardiology patients. The purpose of this study was to compare medication adherence, patient satisfaction, use of urgent care, and illness perception in patients with cardiovascular disease (CVD) undergoing interventional revascularization procedures who receive usual care and those who receive a DNI. The Common Sense Model (CSM) of illness representation provided the theoretical foundation for this study. The CSM is a cognitive parallel processing model that draws relationships between illness representation, coping methods, and illness outcomes to help explain the process by which people make sense of their illness. Intervention research aimed at life style changes to reduce secondary events after treatment for CVD is needed to guide evidence based care. Treatment for CVD has shifted from surgical repair with prolonged hospitalizations to interventional procedures requiring shorter hospital stays. This trend reduces nursing time to monitor complications and provide education about medication management and lifestyle changes. Patients recover in short stay areas and return home within hours or one to two days of the procedure. Cardiac disease is then managed as a chronic, but often stable condition. With this change in the delivery of care, several trends have emerged that have implications for quality nursing care and patient outcomes: a) the burden of care shifts from the hospital setting to home, b) patients are discharged without extensive education about complications and disease management, c) the occurrence of secondary events and disease progression remain a valid threat, and d) nurses with expert practice are in a unique position to assist patients and families with CVD management. This study addressed the following questions. 1. Do patients receiving the nursing intervention differ significantly from those receiving usual care on medication adherence? 2. Do patients receiving the nursing intervention differ significantly from those receiving usual care on patient satisfaction? 3. Is there a significant difference in the utilization of urgent care between those patients receiving the nursing intervention when compared to those patients receiving usual care? 4. Does a difference exist between the patients receiving the nursing intervention and those patients receiving usual care on illness perception, as measured by seven components of the IPQ-R: time line (acute and chronic), consequence, personal control, treatment (cure) control, illness coherence, timeline (cyclical), and emotional representations? Purposive sampling was used to select a sample of patients admitted for interventional procedures at an academic teaching hospital. One hundred and fifty four patients were and randomized into control and experimental groups. Final analyses included data from 129 patients. Sixty-four participants in the experimental group received the DNI which included: 1) additional written information about taking medications, 2) a medication pocket card, 3) a list of 3 cardiac internet sites,and 4) a phone call, 24 hours post procedure, from an expert cardiac nurse to review discharge instructions. Sixty-five participants in the control group received usual care. Analyses on four outcome measures, medication adherence, use of urgent care, patient satisfaction, and illness perception, revealed one statistically significant result. Participants in the experimental group, receiving the DNI, scored significantly higher than the control group on one measure, the timeline (acute/chronic) component of illness perception (p = .006) indicating a greater appreciation of the chronicity of their disease. Otherwise, there were no significant group differences found. This study provides support for nursing intervention research guided by self-regulation theory that examines the patient's perception of illness. Patients with cardiac disease who received the DNI were statistically more likely to acknowledge that their illness would last a long time. This awareness, may improve adherence to a prescribed regimen of medication and lifestyle modification. Nursing interventions guided by an understanding of patients' belief that their cardiovascular disease is chronic will add to the body of knowledge that informs providers about decisions patients make concerning medication adherence and lifestyle modifications. However, the results underscore the limitations of adding additional discharge care to this population of patients to improve medication adherence, use of urgent care, and patient satisfaction. Future research should include a longitudinal study to examine how patients who perceive their disease to be chronic in nature managed their medications and care decisions at home. / Thesis (PhD) — Boston College, 2009. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Neste estudo, foi proposta a exploração de um banco de dados, com informações de exames de eletrocardiogramas (ECG), utilizado pelo sistema denominado Tele-ECG do Instituto Dante Pazzanese de Cardiologia, aplicando a técnica de data mining (mineração de dados) para encontrar padrões que colaborem, no futuro, para a aquisição de conhecimento na análise de eletrocardiograma. A metodologia proposta permite que, com a utilização de data mining, investiguem-se dados à procura de padrões sem a utilização do traçado do ECG. Três pacotes de software (Weka, Orange e R-Project) do tipo open source foram utilizados, contendo, cada um deles, um conjunto de implementações algorítmicas e de diversas técnicas de data mining, além de serem softwares de domínio público. Regras conhecidas foram encontradas (confirmadas pelo especialista médico em análise de eletrocardiograma), evidenciando a validade dessa metodologia. / In this study, the exploration of electrocardiograms (ECG) databases, obtained from a Tele-ECG System of Dante Pazzanese Institute of Cardiology, has been proposed, applying the technique of data mining to find patterns that could collaborate, in the future, for the acquisition of knowledge in the analysis of electrocardiograms. The proposed method was to investigate the data looking for patterns without the use of the ECG traces. Three Data-mining open source software packages (Weka, Orange and R - Project) were used, containing, each one, a set of algorithmic implementations and various data mining techniques, as well as being a public domain software. Known rules were found (confirmed by medical experts in electrocardiogram analysis), showing the validity of the methodology.

INTRODUÇÃO: A fadiga é freqüente em pessoas com insuficiência cardíaca e limita a manutenção de um estilo de vida compatível com senso desejável de autonomia e independência. O controle das limitações funcionais é prioridade no cuidado à pessoa com insuficiência cardíaca, mas não há estudos sobre fadiga em amostras de pacientes brasileiros. OBJETIVO: Caracterizar a fadiga em pacientes com insuficiência cardíaca e comparar sua freqüência e intensidade com voluntários sem doença. MÉTODO: Estudo descritivo-exploratório, com 300 pacientes ambulatoriais. (masculino=68,3%, idade média de 54,8(±11,5) anos, escolaridade média de 6,0(±4,1) anos; Classe Funcional I= 44,7%) e 64 voluntários sem doença, acompanhantes de pacientes ambulatoriais (masculino=34,4%, idade média de 33,3(±10,7) anos, escolaridade média de 10,2(±3,2) anos). Foi aplicado instrumento com as escalas de fadiga (Dutch Fatigue Scale - DUFS) de fadiga ao esforço (Dutch Exertion Fatigue Scale - DEFS), o Inventário de Depressão de Beck (IDB), instrumento de avaliação da atividade física (International Physical Activity Questionnaire) e itens para avaliação da dispnéia, tabagismo e terapia medicamentosa. As escalas DUFS e DEFS foram adaptadas para o Brasil e mostraram propriedades psicométricas adequadas (consistência interna, pelo alfa de Cronbach, na DUFS=0,848 e na DEFS=0,922 e solução fatorial que reproduziu suas estruturas originais). O IDB mostrou consistência interna adequada (alfa de Cronbach=0,873). Testes não paramétricos foram aplicados para analisar a associação entre fadiga e fadiga ao esforço (intensidade de fadiga - escore total DUFS; intensidade de fadiga ao esforço - escore total DEFS; freqüência de fadiga substancial - DUFS >=14,5; freqüência de fadiga substancial ao esforço - DEFS>=12,5) com variáveis selecionadas. RESULTADOS: O escore total médio da DUFS nos pacientes (19,4±8,2) foi mais elevado que o dos voluntários (16,8±6,1) (p=0,042); o mesmo ocorreu com a DEFS (pacientes=19,3±3,9; voluntários=12,6±3,9) (p<0,0001). A freqüência de DUFS>=14,5 foi semelhante entre os pacientes e voluntários (p=0,225) e da DEFS>=12,5 foi mais alta entre os pacientes que nos voluntários (p<0,0001). Nos pacientes observou-se maior intensidade de fadiga nas mulheres (p=0,014); na presença de dispnéia (p=0,000); uso de digitálicos (p=0,020); classes funcionais mais elevadas (p=0,000); nos sedentários (p=0,007), entre os com escores de depressão mais elevados (p=0,000) e com distúrbios do sono (p=0,000). A fadiga ao esforço foi mais elevada nos pacientes com dispnéia (p=0,000); que usavam digitálicos (p=0,021); em classe funcional mais elevada (p=0,000); sedentários (p=0,000); com escores de depressão mais elevados (p=0,000) e com distúrbio do sono (p=0,0001). A freqüência de DUFS>=14,5 foi mais elevada naqueles com dispnéia (p<0,0001); uso de betabloqueador (p=0,032); classe funcional mais elevada (p<0,0001); escores de depressão mais elevados (p<0,0001) e naqueles com distúrbio do sono (p<0,0001). Freqüências da DEFS>=12,5 foram mais elevadas na dispnéia (p<0,0001); classe funcional mais elevada (p<0,0001); nos sedentários (p=0,007); escores mais elevados de depressão (p<0,0001) e naqueles com distúrbio do sono (p<0,0001). Não se associaram com qualquer variável de fadiga as seguintes variáveis: índice de massa corporal, uso de inibidor de enzima conversora de angiotensina, idade e tabagismo. DISCUSSÃO: Esses resultados contribuem para o conhecimento sobre sintoma relevante para qualidade de vida e para o cuidado do paciente com insuficiência cardíaca / INTRODUCTION: Fatigue is a frequent symptom in heart failure patients that limits maintaining a life style compatible with a desirable sense of autonomy and independence. Although controlling functional limitations is a priority care goal of heart failure patients there are no studies on fatigue with Brazilian patient samples. OBJECTIVE: To characterize fatigue in heart failure patients and to compare their fatigue frequency and intensity with volunteers without heart failure. METHODS: Descriptive-exploratory study with 300 outpatients (male=68.3%, mean age=54.8(±11,5) years; mean schooling=6,0(±4,1) years; functional class I of heart failure = 44,7%), and 64 volunteers without heart failure, outpatients accompanying (male=34.4%, mean age=33.3(±10.7) years, mean schooling=10.2(±3.2) years). It was applied an instrument with fatigue (Dutch Fatigue Scale - DUFS) and exertion fatigue escales (Dutch Exertion Fatigue Scale - DEFS), Beck Depression Inventory (IDB), International Physical Activity Questionnaire and items to assess dyspnea, smoking and pharmacological treatment. DUFS and DEFS were adapted to Brazilian samples and their psychometric properties were adequate (Cronbach\'s alpha: DUFS=.848; DEFS=.922, and reproduction of the original structure by factor analysis). BDI presented good internal consistency (Cronbach\'s alpha=.873). Non-parametric tests were applied to test associations of fatigue, exertion fatigue (fatigue intensity - DUFS total score; exertion fatigue intensity - DEFS total score; frequency of substantial fatigue - DUFS >=14,5; frequency of substantial exertion fatigue - DEFS>=12,5). RESULTS: Patients mean DUFS total score (19.4±8.2) was higher than volunteers (16.8±6.1) (p=.042); the same occurred with DEFS (patients=19.3±3.9; volunteers=12.6±3.9) (p<.0001). The frequency of DUFS>=14,5 was not different between patients and volunteers (p=.225); frequency of DEFS>=12,5 was higher for patients than volunteers (p<.0001). In the patients group, fatigue intensity was higher for women (p=.014); and also in presence of dyspnea (p=.000); digoxin use (p=0,020); higher functional classes (p=.000); in sedentary patients (p=.007), higher IDB scores (p=.000), and sleep disturbance (p=.000). Exertion fatigue was higher in patients with dyspnea (p=.000); using digoxin (p=.021); in higher functional classes (p=.000); sedentary (p=.000); higher IDB scores (p=.000) and sleep disturbance (p=.0001). Frequency of DUFS>=14,5 was higher in patients with dyspnea (p<.0001); using betablockers (p=.032); higher functional classes (p<.0001); higher IDB scores (p<.0001) and sleep disturbance (p<.0001). Frequency of DEFS>=12,5 was higher in presence of dyspnea (p<.0001); higher functional classes (p<.0001); sedentary patients (p=.007); higher BDI scores (p<.0001) and sleep disturbance (p<.0001). There were no associations of fatigue variables with body mass index, users of angiotensin receptor blockers, age and smoking. DISCUSSION: This study results contribute to the knowledge concerning to a symptom relevant to the quality of life and nursing care of heart failure patients

A manutenção do RNI (Relação Normalizada Internacional), um exame específico feito em usuários de anticoagulantes orais, determinam os resultados individuais de quem se mantém na faixa terapêutica ou não. De acordo com as diretrizes Europeias (2015) e Americanas (2014), a faixa terapêutica recomendada para Fibrilação Atrial e demais eventos tromboembólicos é de 2 a 3, e para portadores de prótese valvar mecânicas, de 2,5 a 3,5. As complicações referentes ao exceder a faixa são classificadas em sangramentos, caso venha interferir e diminuir a faixa a possibilidade de ocorrer eventos trombóticos. As inferências relacionadas às complicações devidas à alteração do RNI estão associadas ao uso inadequado do medicamento, interações medicamentosas e alimentares, problemas de saúde, procedimentos invasivos e cirúrgicos, dentre outros fatores como estresse, atividade física, emagrecimento e aumento de peso. A intervenção baseada na educação em saúde por meio de um instrumento que estratifique e aponte com precisão os fatores de não permanência na faixa facilitará a adesão ao tratamento e, consequentemente, diminuirá os riscos de vida desta população. O presente objetivo principal foi avaliar e identificar os fatores que interferem na adesão de usuários de ACO (Anticoagulação Oral) e propor um escore de adesão aos usuários de Anticoagulante Oral para a manutenção na faixa terapêutica. Trata-se de um estudo analítico, observacional, transversal e abordagem quantitativa, realizado em um Centro de Anticoagulação Oral de um Hospital Público especializado em Cardiologia vinculado a Secretaria do Estado de São Paulo. Participaram deste estudo 607 usuários de ACO que atenderam aos critérios de inclusão: idade acima de 18 anos, alfabetizados e cadastrados no Sistema de ACO e que iniciaram o uso após duas semanas. Para o modelo de desenvolvimento, optou-se pelo desfecho o RNI alterado e as variáveis preditoras foram determinadas em manipulação do medicamento, interações medicamentosas e da dieta, atividade física, procedimentos e cirurgias, uso adequado do medicamento, problemas de saúde, outros fatores. A coleta de dados foi feita pelo pesquisador e foram realizadas, na parte I, questões relacionadas à caracterização e, na parte II, questões de perfil clínico. Antes, aplicou-se o TCLE após o consentimento e aprovação do usuário. Os dados do perfil sociodemográficos foram apresentados em absolutos e porcentagens, foram consideradas as variáveis que apresentaram nível de significância menor que 5% na análise exploratória ou que foram consideradas de relevância clínica, foram submetidas a um modelo de regressão logística múltipla. Participaram 607 usuários de ACO; o perfil sociodemográfico da população foi de 52% gênero feminino, 57% casados, faixa etária maior que 60 anos 62%, ensino fundamental incompleto 42%, provenientes de São Paulo 93%. As variáveis com nível de significância menor que 5% na análise multivariada: escolaridade, renda familiar, uso inadequado, interação medicamentosa, procedimentos invasivos, interações alimentar, atividade física, condições clínicas, outros fatores e complicações próprias do uso do ACO. Foram identificadas variáveis prognósticas: renda familiar, uso inadequado, procedimento invasivo, interação medicamentosa, hábitos alimentares, condições clínicas, outros fatores (estresse, emagrecimento, perda de peso). O C Statistic para o Escore de Adesão Simonetti & Mancussi foi de 0,94. Em usuários de Anticoagulante oral, o escore de adesão Simonetti & Mancussi mostrou-se de aplicabilidade fácil e exequível, com alto valor preditivo mediante os fatores intervenientes da adesão e permitiu o direcionamento para tomadas de decisões objetivas e direcionadas para o problema, facilitando a melhoria da adesão e manutenção na faixa ideal. / Maintaining the INR (International Normalized Ratio), a specific blood test performed in users of oral anticoagulants, determines the individual outcomes of those within or not the therapeutic range. According to the European (2015) and American (2014) guidelines, the therapeutic range recommended for atrial fibrillation and other thromboembolic events is 2 to 3. For those with mechanical valve prosthesis, the therapeutic range is 2.5 to 3.5. Bleeding can occur as a complication when the therapeutic range is exceeded whereas thrombotic events can occur when the therapeutic range is not reached. The inferences related to the complications due to changes in the INR are associated with inappropriate use of medication, drug and food interactions, health problems, invasive and surgical procedures, and other factors such as stress, physical activity, weight loss and weight gain. Interventions based on health education through instruments that stratify and accurately identify the factors keeping people out of the therapeutic INR range will facilitate adherence to treatment and consequently reduce the risks to life in this population. This main objective was to assess and identify the factors interfering in adherence to users of OAC (oral anticoagulants) and to propose an adherence score for users of OAC to maintain the therapeutic range. It is an observational, analytical, cross-sectional and quantitative study performed in a center of oral anticoagulation of a public hospital specialized in Cardiology associated with the Secretaria of the State of São Paulo. The study included 607 users of OAC that met the inclusion criteria: 18 years old or older, literate and registered in the OAC system and started using OAC two weeks later. For the development model the chosen outcome was altered INR and the predictor variables were medication handling, drug and food interactions, physical activity, surgeries and procedures, adequate use of medication, health issues, other factors. Data were collected by the researcher. Part I of the questionnaire contained questions related to characterization and Part II questioned the clinical profile. Before data collection, the users signed the informed consent form. Data on the sociodemographic profile were presented in absolute frequencies and percentages. Variables with a significance level less than 5% in the exploratory analysis or those considered clinically relevant were submitted to a multiple logistic regression model. Six hundred seven OAC users participated in the study. The sociodemographic profile of the population was: 52% female, 57% married, 62% over 60 years old, 42% with incomplete primary education, 93%from São Paulo. The variables with a significance level less than 5% in the multivariate analysis were: education, family income, inadequate use, drug interactions, invasive procedures, food interactions, physical activity, clinical conditions, other factors and OAC-associated complications themselves. The identified prognostic variables were: family income, inadequate use, invasive procedure, drug interactions, dietary habits, clinical conditions, other factors (stress, getting thinner, weight loss). The C statistic for the Adherence score Simonetti & Mancussi was 0.94. In users of OAC, the adherence score Simonetti & Mancussi proved to be of easy and practical applicability, with high predictive value given the factors intervening on adherence and allowed for objective and problem-focused decision making, thereby facilitating improvement of adherence and maintenance of the optimal range.

L’insuffisance rénale aiguë (IRA) représente une complication fréquente de lachirurgie cardiaque pédiatrique sous circulation extracorporelle (CEC). Son traitement resteessentiellement conservateur, visant à prévenir l’aggravation de l’atteinte rénale, ousubstitutif, par épuration extrarénale (EER). L’EER précoce améliore le pronostic des adultesen défaillance multiviscérale, mais ceci n’a pas été montré chez l’enfant après chirurgiecardiaque. Le diagnostic de l’IRA repose actuellement sur une diminution du débit defiltration glomérulaire (DFG), reflété par la hausse de la créatinine sérique (sCr), et laréduction de la diurèse. Ces critères traduisent une perte de la fonction glomérulaire ; orl’atteinte initiale dans l’IRA post-chirurgicale se situe au niveau tubulaire. Ces critères sontpeu spécifiques et tardifs, et risquent de retarder le diagnostic et la prise en charge de l’IRA.Des nouveaux biomarqueurs rénaux, traduisant la présence d’une lésion tubulaire, dont leNeutrophil Gelatinase-Associated Lipocaline urinaire (NGALu) est le plus populaire,permettraient un diagnostic plus précoce.Objectif. L’objectif de ce travail est triple : (i) explorer l’association entre le délai de la miseen route de l’EER et le pronostic à court et moyen terme chez le patient < 1an qui développeune IRA post-chirurgie cardiaque ; (ii) explorer les performances diagnostiques desvariations précoces de la sCr pour l’IRA sévère ; et (iii) explorer les performancesdiagnostiques de l’élévation de NGALu pour l’IRA sévère dans des populations similaires depatients < 1an.Méthode. Une cohorte monocentrique rétrospective de patients < 1an constituée sur 10 ansa servi pour étudier l’association entre le délai de la mise en route de l’EER et la survie àcourt et moyen terme. La technique de pondération inverse par le score de propension a étéutilisée afin de réduire le biais associé aux changements des pratiques inhérents à la longuepériode d’inclusion. Une deuxième cohorte monocentrique rétrospective de patients < 1anconstituée sur 3 ½ ans a servi pour étudier les performances diagnostiques des variationsprécoces de la sCr pour l’IRA sévère. Enfin, une troisième cohorte monocentriqueprospective de patients < 1an constituée sur 18 mois a servi pour étudier les performancesdiagnostiques de NGALu pour l’IRA sévère. Pour l’étude des deux biomarqueurs, sCr etNGALu, la méthodologie utilisée a été similaire : partition des trajectoires individuelles devariation, puis analyse de l’association avec un critère composite (recours à l’EER et/oudécès postopératoire) et définition du profil à faible risque d’IRA; enfin, utilisation de laméthodologie des courbes ROC et des tables de reclassification pour quantifier leursperformances diagnostiques respectives.Résultats. La mise en route de l’EER le jour de la chirurgie ou le lendemain a été associéeavec une augmentation d’environ 45% de la survie à 30 et 90 jours. La variation de la sCrdans les 2 jours suivant la chirurgie a été spécifique mais peu sensible et peu discriminantepour le diagnostic de l’IRA sévère ; le profil à faible risque, rencontré chez près de 50% despatients a été une diminution durable d’environ 25% de la sCr par rapport à la valeur basale.NGALu a été discriminant et prédictif pour le critère composite ; la concentration de NGALu aaugmenté dans les 2 heures suivant la chirurgie, et est restée élevée chez les patientsprésentant le critère composite.Discussion et conclusions. Si la prise en charge précoce par EER de l’IRA sévère est unepriorité en termes de pronostic chez le patient < 1an, alors il faut se munir de moyensdiagnostiques précoces et performants. La variation précoce de la sCr est peu sensible etpeu discriminante. En revanche, l’élévation précoce de l’NGALu présente d’excellentesperformances diagnostiques pour l’IRA sévère, faisant de NGALu un marqueur rénalprometteur dans la population < 1an bénéficiant d’une chirurgie cardiaque. / Acute kidney injury (AKI) is common following congenital cardiac surgery withcardiopulmonary bypass (CPB). To date, no prophylactic intervention has proved to beuseful for the prevention of postoperative AKI. When AKI occurs, treatment is mainlysupportive and, when severe, requires renal replacement therapy (RRT). Several reportshave shown better outcome with early RRT in adults with multiorgan failure. No such data isavailable in children undergoing cardiac surgery, and criteria for RRT vary among centres.The definition of AKI is a reduction in the glomerular filtration rate (GFR), and the diagnosis isbased on an increase in serum creatinine (sCr) and a reduction in urine output; these arefunctional criteria, translating the consequences of glomerular injury. However, it iscommonly admitted that the first pathophysiologic finding in AKI following cardiac surgery istubular injury. Besides, the functional criteria are late, are not specific, and may delay thediagnosis of AKI. Novel AKI biomarkers, specific of tubular injury are available nowadays,with urine Neutrophil Gelatinase-Associated Lipocaline (uNGAL) being the most popular –they may allow for an early diagnosis of AKI.Objectifs. The aim of this work was: (i) explore associations between the delay to RRT, earlyand mid-term outcome in patients younger than 1 year of age who develop AKI followingcardiac surgery; (ii) assess the accuracy of early sCr variations and (iii) of uNGAL for severeAKI in two similar populations aged < 1 year.Methods. A single centre retrospective cohort of patients aged < 1 year undergoing surgeryover 10 years was used to asses the association between the delay to RRT et short and midtermsurvival. Inverse probability of treatment weighting was used to reduce bias due tochanges in practices that occurred during the long study period. A second retrospectivecohort of patients aged < 1 year undergoing surgery over 3 ½ years was used to asses theaccuracy of early sCr variations for the diagnosis of severe AKI. Finally, a third prospectivecohort of patients aged < 1 year undergoing surgery over 18 month was used to asses theaccuracy of uNGAL for the diagnosis of severe AKI. The study of both sCr and uNGAL useda similar methodology: first clustering of all individual trajectories of variation, enablingassessment of the association with a composite outcome (need for RRT and/or death) andidentification of the « normally expected » postoperative evolution of both sCr an uNGAL,associated with the best outcome; second, use of ROC curves and reclassification tables toassess the accuracy of each biomarker for the diagnosis of AKI.Results. Early RRT, initiated on the day of surgery or on day 1 following surgery, wasassociated with a 45% increase in 30-days and 90-days survival. Early sCr variation, within 2days of surgery, had a good specificity but was lacking sensitivity and discrimination for thediagnosis of severe AKI; the « expected » sCr evolution was a persistent 25% postoperativereduction relative to baseline. uNGAL had good discrimination and predictive ability for thecomposite outcome; uNGAL concentration increased within 2 hours of surgery, andremained high in patients with the composite outcome.Discussion and conclusions. If early RRT improves outcome in patients aged < 1 yearswith AKI following cardiac surgery, then it becomes important to perform an early diagnosisof severe AKI. To date, diagnosis of AKI is based on early sCr variations, but such variationslack sensitivity and discrimination for the diagnosis of severe AK. On the other hand, theincrease in uNGAL within hours of surgery has excellent accuracy for the diagnosis of severeAKI, making uNGAL a promising AKI biomarker in patients aged < 1 year undergoing cardiacsurgery with cardiopulmonary bypass.

Orientador: Alessandra Melchert / Resumo: O presente estudo teve como objetivo avaliar a influência do escore corporal sobre parâmetros cardiovasculares (ecocardiográficos, eletrocardiográficos, tomográficos e radiográficos) em papagaios verdadeiros (Amazona aestiva) anestesiados e mantidos em cativeiro. Foram utilizadas 35 aves, sem distinção de sexo, agrupadas de acordo com a condição nutricional: Grupo Magro (n=11); Grupo Ideal (n=14); Grupo Obeso (n=10). Ao exame ecocardiográfico os papagaios obesos apresentaram menor o comprimento diastólico do VD em relação ao grupo magro. Os valores da fração de encurtamento (FE) do eixo transverso do ventrículo esquerdo (VE), FE do eixo longitudinal do VE e FE do eixo longitudinal do ventrículo direito (VD), para os papagaios obesos, apesar de não significativos, foram bastante inferiores aos dos animais em escore magro e normal. Na avaliação radiográfica e tomográfica, comparando as medidas dos diferentes grupos, não foram observadas diferenças significativas. No exame eletrocardiográfico foram determinados: frequência cardíaca (FC), ritmo cardíaco, duração e amplitude da onda P, duração do intervalo PR e complexo QRS (padrão rS), duração e amplitude da onda R, duração do intervalo RR e intervalo QT e QT corrigido (QTC), duração e amplitude da onda T, não se observando diferença significativa entre os grupos estudados. Concluiu-se que, assim como em mamíferos, alterações da condição nutricional em papagaios-verdadeiros (A. aestiva) acarretam em disfunções cardiovasculares, d... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The aim of this study was to evaluate the influence of the body condition score (BCS) on cardiovascular parameters (echocardiographic, electrocardiographic, tomographic and radiographic) in parrots (Amazona aestiva) anesthetized and kept in captivity. Thirty-five birds were evaluated, regardless of gender, grouped according to the nutritional condition: Lean group (n = 11); Ideal group (n = 14); Obese group (n = 10). On echocardiographic examination, obese parrots presented lower diastolic length of the right ventricle (RV) than the lean group. The fractional shortening (FS) values of the left ventricle (LV) in transverse axis, LV FS and RV FS in longitudinal axis for the obese parrots, although not significant, were lower than those of the lean and normal animals. In the radiographic and tomographic evaluation, comparing the measurements of the different groups, no significant differences were observed. Cardiac frequency (HR), heart rate, duration and amplitude of the P wave, duration of the PR interval and QRS complex (rS pattern), duration and amplitude of the R wave, duration of the RR interval, QT and correct QT (QTc) intervals, duration and amplitude of the T wave were determined in the electrocardiographic exam. No significant difference was observed between the studied groups. It was concluded that, as in mammals, changes in nutritional status in parrots (A. aestiva) lead to cardiovascular dysfunctions, however, detected only on echocardiographic examination. The prop... (Complete abstract click electronic access below) / Doutor

Thesis (Ph.D.)--Massachusetts Institute of Technology, Dept. of Electrical Engineering and Computer Science, 1981. / MICROFICHE COPY AVAILABLE IN ARCHIVES AND ENGINEERING. / Vita. / Bibliography: leaves 410-424. / by Paul Scott Schluter. / Ph.D.