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Orientador: Jesse de Paula Neves Jorge / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-06T03:51:59Z (GMT). No. of bitstreams: 1 Prota_FranciscoEduardo_D.pdf: 271190 bytes, checksum: 7a4b25298004f37adb6a487471a8a999 (MD5) Previous issue date: 2006 / Resumo: Introdução: A histerectomia por via vaginal se constitui no procedimento de melhor desempenho para retirada do útero, segundo vários fatores avaliados, quando comparada àquela por via abdominal ou mesmo a laparoscópica. Apesar destas vantagens, em nosso meio a maioria dos serviços a praticam em pacientes portadoras de distopias, sendo poucos os que indicam em pacientes sem prolapso uterino. Objetivo: Avaliar os parâmetros pré, intra e pós-operatórios de mulheres submetidas à histerectomia vaginal na ausência de prolapso uterino. Sujeitos e métodos: Foi realizado estudo retrospectivo através da revisão de prontuários de 190 mulheres submetidas à histerectomia vaginal na ausência de prolapso uterino operadas no Hospital e Maternidade Celso Pierro da PUC-Campinas e no Hospital Penido Burnier no período de março de 2000 a setembro de 2005. Foram avaliados parâmetros pré-operatórios como idade, índice de massa corpórea, número de gestações, vias de parto, indicação da cirurgia, volume uterino pela ultrassonografia, antecedentes clínicos e antecedentes de cirurgias pélvicas. Quanto aos procedimentos intra-operatórios foram avaliados o tipo de anestesia, tempo operatório, quantidade de sangramento, técnica empregada na retirada da peça cirúrgica, cirurgias associadas e complicações. Os parâmetros pós-operatórios avaliados foram o tempo de permanência hospitalar, peso do útero e complicações. A análise estatística dos dados foi realizada através de medidas de freqüência, médias e desvio padrão. Para o desenvolvimento destes procedimentos estatísticos foi utilizado o pacote SAS Versão 8.2. Resultados: A média etária de mulheres avaliadas nessa casuística foi de 44,6 anos, com índice IMC médio de 26,4kg/m2; 91% delas com uma ou mais gestações e 72,7% referindo antecedente de pelo menos um parto via abdominal. A indicação cirúrgica mais freqüente foi a miomatose uterina em 45,3% dos casos, seguida por diagnóstico de sangramento uterino anormal em 43,7%. A anestesia mais utilizada foi o bloqueio espinhal e a quantidade do sangramento maior ou igual a 300ml ocorreu em 11,6% dos casos. A duração da cirurgia em 58,9% dos casos não excedeu 75 minutos. Houve distribuição semelhante quanto ao uso ou não de técnicas de redução do volume uterino. As freqüências de complicações intra e pós-operatórias foram baixas 3,6% e 15,8% respectivamente. O tempo de hospitalização foi inferior a 48 horas em 87,4% dos casos sendo o tempo médio de hospitalização de 31,5 horas. Conclusões: A taxa de complicação, o tempo de cirurgia, a quantidade de sangramento e o tempo de internação foram baixos, mostrando que a histerectomia por via vaginal na ausência de prolapso é um procedimento cirúrgico seguro e vantajoso para muitas mulheres / Abstract: Introduction: Vaginal hysterectomy represents the best performance procedure to the removal of the uterus, based on many evaluated factors, when compared to abdominal hysterectomy or even laparoscopic hysterectomy. Despite many well known advantages of vaginal hysterectomy, most surgeons among us only indicate it to women with prolapsed uterus, being very few those who indicate it to women with non prolapsed uterus. Objective: Evaluate pre, intra and post operative parameters from women eligible to vaginal hysterectomy with non prolapsed uterus Patients and Methods: This is retrospective study in which 190 medical records of women who underwent vaginal hysterectomy with non prolapsed uterus at Hospital e Maternidade Celso Pierro da PUC-Campinas and at the Hospital Penido Burnier during the period from march 2000 to september 2005 were reviewed. Women¿s age, body mass index, parity, frequency of vaginal delivery, indication of hysterectomy, uterine volume through ultrasound, clinical history and previous pelvic surgeries were analyzed. In respect to the intra operatory procedures, types of anesthesia, surgical time, blood loss, technique used to remove the uterus, associated surgeries and complications were analyzed. The postoperative parameters analyzed were hospitalization period, histologic analysis of the removed organ, uterus weight and complications. Statistical analysis were done with frequency, means and standard deviation, using SAS version 8.2. Results: The mean age of women evaluated in this study was 44,6 years, with a mean body mass index of 26,4kg/m2; 91% of them with one or more gestation and 72.7% referred at least one cesarean section. The most frequent surgical indication was fibroid uterus 45.3% of the cases, followed by the diagnosis of dysfunctional uterine bleeding in 43.7%. The most frequent anesthesia was spinal and the amount of blood loss equal or greater than 300ml occurred in 11.6% of the cases. Operation time did not exceed 75 minutes in 58.9% of the cases. The distribution of techniques to reduce the uterine volume were similar. The frequency of intra and postoperative complications were low, 3.6% and 15.8%, respectively. The hospitalization time was less than 48 hours in 87.4% of the cases, and the mean hospital stay was 31.5 hours. Conclusions Complication rate, mean operation time, the amount of blood loss and the hospitalization period were low, which show that vaginal hysterectomy in non prolapsed uterus is a safe and advantageous procedure to many women / Doutorado / Tocoginecologia / Doutor em Tocoginecologia

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Balloon dilatation of the stenosed mitral valve, in an attempt to relieve symptoms, was developed to replace the surgical procedure of closed mitral valvotomy. This procedure, whereby a balloon tipped catheter is introduced from the femoral vein and directed across the mitral valve after an atrial septal puncture, was developed in 1982. The procedure was first performed at Groote Schuur Hospital in 1988. Two types of dilating balloon (Inoue and Bifoil types) have been used. The aim of this retrospective study was to analyze the results of balloon mitral valvuloplasty procedures performed from 1988 until November 1992. In addition a detailed analysis was made of all complications of the procedure. 118 patients (mean age 30.7 years) underwent 124 attempted procedures. 93 % of attempts were successfully completed and an optimal result was achieved in 76% of patients. Mitral valve area increased from 0.9cm² to 2.0cm². Equivalent results have been achieved with both balloon types. Death occurred in 1.6 % of patients. 2.4 % of patients had severe mitral regurgitation as a complication. 4% of procedures resulted in cardiac chamber perforation. The experience at Groote Schuur has been similar to other centres treating young patients with rheumatic mitral stenosis.

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第21701号 / 社医博第92号 / 新制||社医||10(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 平井 豊博, 教授 小西 靖彦, 教授 伊達 洋至 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

Introduktion: Träning och rörelse är viktigt för alla människor oavsett ålder eller kön, och kan förhindra flera olika sjukdomar. Tidigare har rekommendationer kring träning under graviditet varit restriktiva och givits med försiktighet för att inte riskera säkerheten för barn och mamma. Tidigare studier tyder dock på att träning under graviditet medför positiva effekter, med förutsättning att graviditeten är komplikationsfri. Som fysioterapeut är det viktigt att både veta risker med träning under graviditet, men även vilka positiva effekter det kan ha på både barn och mamma. Syfte: Syftet med litteraturstudien var att sammanställa vilka effekter träning har på den gravida kvinnan och hennes ofödda barn. Metod: Olika sökkombinationer som fokuserar på de olika delarna av graviditeten samt träning har använts i databaserna PEDro, PubMed, Cinahl och Amed. Genom syfte, PICO-modellen samt inklusions- och exklusionskriterier kunde studier exkluderas via titel, abstrakt samt när studierna lästes i full text. Totalt inkluderades 17 studier i litteraturstudien. Resultat: Flera positiva effekter på både barn och mamma har dokumenterats och inga negativa effekter har påvisats under litteratursammanställningen. Träning under graviditet påverkar flera olika faktorer, som exempelvis glukosvärden, lägre vilopuls och självuppskattat välmående hos mamman och även barnet i magen påverkas positivt av mammans träning. Konklusion: Träning bör rekommenderas under komplikationsfria graviditeter, då det enligt studier medför antingen inga effekter eller positiva effekter för både mamma och barn.

The prevalence of post-bariatric complications and post-bariatric leaks has dramatically increased over the last two decades, in line with the pandemic of morbid obesity and the growing number of bariatric surgeries. For bariatric leaks, re-operation with drainage, and possibly an attempt at surgical closure, has, for a long time, been considered as the only possible treatment.In the early 2000s, our team started to be involved in post bariatric complications management and, with the experience we acquired in other diseases associated with upper gastrointestinal leakages, endotherapy became logically a good theoretical option to treat these leaks. It offers a potentially less invasive alternative to an unsatisfactory surgical management.Insertion of a self-expandable stent to cover the leak and facilitate its closure was our initial treatment strategy. Our retrospectives studies in this field, in addition to demonstrating good results, helped to identify major clinical factors associated with treatment success, such as early endoscopic management after leakage diagnosis. We promoted the use of partially covered stents which helps to reduce the risk of migration, probably increases watertightness, and can be efficiently extracted after the insertion of a fully covered stent.However, post bariatric leaks is a serious and difficult clinical situation and we experienced disappointing results with stent treatment alone in several patients. This led us to develop complementary techniques, such as fistula plug insertion or internal drainage with double pig tail stents, which provided additional positive results. Internal drainage even appears to be effective as an isolated strategy in selected patients.The present work illustrates the evolution of this new clinical modality and demonstrates, based on our published results, how endotherapy has become a first-line option that now plays a pivotal role in the multimodal approach to post-bariatric leakage. We show that, in the hands of an experienced team and with treatment tailored to the variety of clinical presentations, endotherapy can reach almost 90% success. Based on our results and on our current experience, we propose a treatment algorithm for management of post bariatric leaks and fistulas in which deployment of intraluminal self-expandable stents remains the cornerstone.As prospective and comparative study for management of this life-threatening complication are lacking, we also propose several direction for future clinical researches in this area which could help to standardize the multimodal treatment of post-bariatric leaks. / Doctorat en Sciences médicales (Médecine) / info:eu-repo/semantics/nonPublished

Objective:Iatrogenic acute limb ischaemia in paediatric patients is a well-recognised complication of vascular access. This retrospective review of a paediatric intensive care unit identified patients who developed iatrogenic acute limb ischaemia between January 2008 and July 2013. Methods: The medical records of inpatients diagnosed with acute limb ischaemia during the study period were reviewed. Patients with other causes of acute limb ischaemia were excluded. A descriptive analysis of demographics, primary diagnosis, type of vascular access used, affected anatomical region, clinical presentation, type of therapy, type of block, response to intervention used and outcomes was conducted. Results:A total of 28 patients presented with signs of acute limb ischaemia, of whom 28.6% were aged <30 days, 46.4 % were between one and 12 months and 25% were between one and five years old; 78.6% of the affected limbs were lower limbs. Four patients had resolution of ischaemia upon removal of the vascular access devices. 23 patients received various forms of pharmacological sympathectomy, in addition to conservative therapy. One patient had missing data on the type of sympathectomy that was done. The response to the sympathectomies was: 60.9% good, 8.7% moderate, 8.7% poor and in 21.7% no responses. Documented tissue loss related to the ischaemia occurred in six (21.4%) of the 28 patients. Conclusions: Iatrogenic acute limb ischaemia in children are usually managed without surgical intervention. Pharmacological sympathectomies lead to increased blood flow to the affected limb via vasodilatation of collateral vessels, with an added advantage of reducing ischemic pain. The improved blood flow is postulated to avoid and/or minimise the amount of tissue loss. Pharmacological sympathectomies may, thus, have a role to play in th e management of iatrogenic acute limb ischaemia in the paediatric population.

Hintergrund: Für eine fortlaufende, standardisierte und systematische Erfassung von Komplikationen nach Ohroperationen existieren aktuell keine Vorgaben. Die Detektion, Dokumentation und Auswertung von komplikationsbehafteten postoperativen Verläufen dient dem Ausbau einer hohen Behandlungsqualität. Fragestellung: Das Ziel der vorliegenden Arbeit war die Etablierung einer fortlaufenden, standardisierten und systematischen Erfassung von unerwünschten Verläufen nach Ohroperationen. Aus diesen Verläufen sollten Parameter herauskristallisiert werden, die sich zur Charakterisierung und Beschreibung von Komplikationen und der Behandlungsqualität eignen. Dabei wurden Komplikationen nicht dichotom als vorhanden oder abwesend betrachtet, sondern auch deren zeitlicher Verlauf erfasst. Dieser prospektive Ansatz in der Erfassung von Verläufen findet sich in der aktuellen ohrchirurgischen Forschungslage nicht. Die Darstellung der Daten sollte in einer Weise erfolgen, dass zeitsparend und überblicksartig der tagesaktuelle Stand der vorhandenen Komplikationen, die Entwicklung der länger zurückliegenden Ereignisse sowie der Verlauf einer Komplikation verfolgt werden kann. Methode: Es erfolgte eine prospektive Erfassung aller Ohroperationen am HNO-Universitätsklinikum Dresden. Ohrspezifische Komplikationen wurden mittels Melderegister angezeigt. Eine Kontrolle der erfassten Daten erfolgte durch retrospektive Sichtung aller Verläufe (min. 6 bis max. 12 Monate postoperativ). Zur Detektion eines komplikationsbehafteten Verlaufes wurden Daten aus OP-Bericht, Anästhesieprotokoll und ärztlicher Verlaufsdokumentation erhoben. Neben einer qualitativ-deskriptiven Auswertung erfolgte die statistische Analyse des dynamischen Komplikationsverlaufes mittels Komplikationspersistenzfunktion (KPF) und anhand der medianen Persistenzzeit (MPZ). Ergebnisse Es konnten 525 Mittelohroperationen und 130 (24%) unterschiedliche Komplikationen analysiert werden. Am häufigsten trat ein postoperativer Knochenleitungsabfall (n=69 (13%)) auf. Das minimal erforderliche Nachbeobachtungs-intervall wurde durch den Eintritt in die Plateauphase (PP) der KPF bestimmt. Nach Eintritt in die PP kann die Wahrscheinlichkeit für Langzeitresiduen einer Komplikation anhand der Persistenzrate (PR) angegeben werden. Am Beispiel eines Knochenleitungsabfalles betragen diese Parameter 144 Tage (PP) mit einer PR von 27%. Die mediane Persistenzzeit eines KL-Abfalls betrug 79 Tage. Der zeitliche Aufwand für die Erfassung und Analyse der Daten lag im Durchschnitt bei 300-360min/Woche. Davon etwa 60±10min für einen komplikationsbehafteten und 10±4min für einen erwarteten Verlauf. Dies entspricht ca. 400h für die Auswertung eines Jahres bei 700 OPs/Jahr. Schlussfolgerung: Zur Routineerfassung von komplikationsbehafteten Verläufen sind standardisierte Prozesse und dynamische Analysen unerlässlich. Ermöglicht wird das durch den Kaplan-Meier-Schätzer als Komplikationspersistenzfunktion mit Hilfe der medianen Persistenzzeit (MPZ) und der Wahrscheinlichkeit für Langzeitresiduen einer Komplikation (=Persistenzrate (PR)). Das Pflegen eines Komplikationsregisters ist nur mit einem erheblichen Zeitaufwand und hohem Ressourcenverbauch in die klinische Routine integrierbar. Nichtsdestotrotz ist die Bedeutung und der Beitrag für die Qualitätsentwicklung und -beschreibung in der Ohrchirurgie enorm.:Abkürzungsverzeichnis IV 1. Einleitung 1 1.1 Qualität definieren 1 1.1.1 Deutsche Industrienorm DIN 2 1.1.2 Institute of Medicine (IOM) 2 1.1.3 Institut für Qualität und Transparenz im Gesundheitswesen (IQTIG) 3 1.1.4 Qualität als dynamischer Begriff in der Mittelohrchirurgie 3 1.1.4.1 Strukturqualität 4 1.1.4.2 Prozessqualität 4 1.1.4.3 Ergebnisqualität 4 1.1.5 Die Abwesenheit von Komplikationen als Ergebnisqualität 5 1.1.5.1 Unterscheidung zwischen Komplikation, Behandlungsmisserfolg und Fehler 5 1.1.5.2 Spezifische Komplikationen nach Mittelohroperationen 6 1.2 Mittelohrchirurgische Indikationen und Eingriffe 8 1.2.1 Sanierende Mittelohroperationen 8 1.2.1.1 Mastoidektomie 8 1.2.1.2 Radikaloperation 8 1.2.2.1 Myringoplastik 9 1.2.2.2 Ossikuloplastik 9 1.2.2.3. SAMEO-ATO 10 1.2.2 Tumorchirurgie des Felsenbeins 10 1.3 Frage- und Zielstellung der Arbeit 12 2. Methode 13 2.1 Studiendesign 13 2.2 Studienteilnehmer:innen 13 2.3 Zielgrößen 13 2.4 Datenquellen 14 2.4.1 HNO- Verlaufsdokumentation 14 2.4.2 Anästhesiologisches Protokoll 14 2.4.3 OP-Bericht und Arztbrief 14 2.4.4 Audiologische Daten 14 2.5 Klassifikation von Merkmalen 16 2.6 Statistische Methoden 16 2.6.1 Exkurs Kaplan-Meier-Schätzer (KM) 16 3. Ergebnisse 18 3.1 Erfassung der Komplikationen 18 3.2 Patient:innenkollektiv 19 3.3 Deskriptive Daten 20 3.3.1 Charakteristik der Fälle 20 3.3.2 Operationen 20 3.3.3 Komplikationen 22 3.3.3.1 Frühe Komplikationen 22 3.3.3.2 Späte Komplikationen 24 3.4 Struktur des inferenzstatistischen Ergebnisteils 25 3.5 Knochenleitungs-Abfälle 26 3.5.1 Charakteristik der Patientinnen mit KL-Abfall 26 3.5.2 Zeitliches Auftreten der KL-Abfälle 27 3.5.3 Zeitlicher Verlauf von KL-Abfällen 28 3.5.3.1 Stratifiziert nach frühen KL-Abfällen 30 3.5.3.2 Stratifiziert nach späten KL-Abfällen 31 3.5.3.3 Stratifiziert nach frühen und späten KL Abfällen32 3.5.3.4 Stratifiziert nach KL-Abfall und anderen Komplikationen 33 3.5.3.5 Stratifiziert nach Eingriffsart 34 3.6 Fazialisparesen 37 3.6.1 Charakteristik der Patient:innen mit Fazialisparese 37 3.6.2 Zeitlicher Verlauf von Fazialisparesen 38 3.7 Nachbeobachtungszeiten einzelner Komplikationen 39 3.7.1 Gehörgangsstenose 39 3.7.2 Wundheilungsstörungen (WHS) 40 3.7.3 Tinnitus 40 3.7.4 Schwindel (mit Reiz-/Ausfallnystagmen) 40 3.8 KPF nach intraoperativem Fräsen des Knochens 41 3.8.1 Alle Komplikationen 41 3.8.2 Stratifiziert nach Eingriffsart 42 3.8.3 Stratifiziert nach KL-Abfall 43 3.8.3.1 Frühe und späte KL-Abfälle 44 3.8.4 Fazialisparese 46 3.9 KPF nach Mastoidektomie, Radikalhöhlenanlage oder Gehörgangserweiterung 46 3.10 Zusammenfassung der medianen Persistenzzeiten und der Persistenzraten 47 3.11 Hörergebnisse 48 3.11.1 Hörergebnisse stratifiziert nach Eingriffsart 49 3.11.1.1 Tympanoplastik Typ 149 3.11.1.2 Tympanoplastik Typ 3 50 3.11.1.3 Cholesteatom OP 50 3.11.1.4 Stapesplastik 51 3.11.1.5 Sonstige Mittelohr-Operationen 51 3.11.2 Hörergebnisse stratifiziert nach KL-Abfall 52 3.11.2.1 Ohne KL-Abfall 52 3.11.2.2 Frühe KL-Abfälle 54 3.11.2.3 Späte KL-Abfälle 55 4. Diskussion 56 4.1 Studiendesign 57 4.2 Patient:innenkollektiv 57 4.3 Komplikationen nach Mittelohroperationen 57 4.3.1 Postoperativer Knochenleitungsabfall 59 4.3.2 Auswirkungen auf den zeitlichen Verlauf eines KL-Abfalls 60 4.3.3 Fazialisparese 62 4.4 Weitere registrierte Komplikationen 63 4.4.1 Gehörgangsstenose 63 4.4.2 Wundheilungsstörungen 64 4.4.3 Tinnitus 64 4.4.4 Schwindel 64 4.5 Hörergebnisse 66 4.5.1 Nach Tympanoplastik Typ 1 67 4.5.2 Nach Tympanoplastik Typ 3 68 4.5.3 Nach Cholesteatom Operation 68 4.5.4 Nach Stapesplastik 68 4.5.5 Nach sonstigen Mittelohroperationen 69 4.6 Hörergebnisse stratifiziert nach KL-Abfall 69 4.7 Schlussfolgerung 70 Zusammenfassung VI Summary VIII Tabellenverzeichnis X Abbildungsverzeichnis XI Literaturverzeichnis XII Danksagung XVII Ehrenwörtliche Erklärung XVIII

Introduction: The aim of this study was to determine the types and prevalence of complications following MARPE protocol at University of the Pacific and to investigate the complication of asymmetry using CBCT analysis. Methods: In the first portion of this study, 97 patients who started treatment prior to July 2020 and who had MARPE expander treatment at the University of the Pacific were included. Chart review and evaluation of progress clinical photographs were used to report the following complications: inflammation, pain, appliance malfunction, broken microscrew, and pulpitis. In the second portion of this study, 77 patients from a private practice orthodontist who started treatment prior to January 2021 were included in this study. The complication of asymmetry was measured using CBCT measurements from T1 (prior to treatment start) and T2 (immediately following MARPE expansion). The change in U6 molar angulation changes was also assessed. Results: It was determined in the first portion of this study that the most common complication was inflammation around the MARPE site, with 82% of the study population exhibiting any severity of inflammation. 3 patients exhibited severe inflammation requiring removal of MARPE. 18% reported pain in the MARPE area. 9 patients exhibited appliance malfunction, 1 patient exhibited broken microscrew, and 1 patient exhibited pulpitis. It was determined in the second portion of this study that 47% of patients exhibited asymmetry greater than 1 mm and the average asymmetry at ANS was 1.47 mm. No correlation was exhibited between amount of asymmetric expansion and the following measures: age, molar inclination, palatal thickness, posterior screw expansion and palatal vault height. 3 Conclusions: Inflammation of the MARPE is the most common complication that can result in early removal of the expander. Other complications such as asymmetry and pain are common as well.