INTRODUÇÃO: Os tomógrafos multidetectores (TCMD) aumentaram a sensibilidade na detecção do tromboembolismo pulmonar (TEP). Observa-se, no entanto, um substancial aumento no número de imagens e, conseqüentemente, no tempo de análise pelo radiologista. Uma possível solução, para este problema, é a realização de reconstruções em projeção de intensidade máxima (MIP) que reduz o número de imagens para análise. Existe ainda uma nova modalidade de imagem utilizando reconstrução MIP em planos rotacionais sobre um eixo horizontal ao nível dos hilos pulmonares (reformatação em pás de roda moinho, PRM), que tem demonstrado melhor a continuidade dos ramos arteriais que irradiam dos hilos. No entanto, estudos são necessários para determinar se o uso de reformatações MIP pode reduzir o número de imagens a serem analisadas, sem perda significativa de informações, e se a adição de reformatação PRM pode melhorar o diagnóstico de TEP. OBJETIVOS: Testar a hipótese de que imagens utilizando reconstruções em projeção de intensidade máxima de 2,0 mm e 4,0 mm de espessura, multiplanares, têm o mesmo valor diagnóstico para detecção de TEP nas grandes e pequenas artérias pulmonares, quando comparadas a imagens multiplanares de 1 mm, realizadas em TCMD de 10 e 16 fileiras de detectores. Avaliar se há influência no valor diagnóstico de TEP o acréscimo de reformatações PRM, nas imagens reconstruídas em MIP de 2 mm. CASUÍSTICA E MÉTODOS: Cinqüenta pacientes com suspeita diagnóstica de TEP (30 com TEP positivo e 20 com TEP negativo, detectados no exame tomográfico), realizaram tomografia computadorizada do tórax para avaliação das artérias pulmonares em TCMD com 16 e 10 fileiras de detectores (120 kV, 200 mAs e 1 mm de colimação). Cada exame foi reconstruído em 4 tipos de séries de imagens multiplanares: imagens multiplanares (MPR) de 1 mm e 3 tipos de reconstrução MIP, com espessuras de 2 mm, 4 mm e 2 mm acrescidas de reformatação PRM. Dois observadores avaliaram, independentemente, em estação de trabalho, a presença ou ausência de êmbolos nas artérias principais, lobares, segmentares e subsegmentares dos 50 pacientes em cada uma das reconstruções MIP, as quais foram comparadas usando-se a reformatação MPR de 1 mm como padrão de referência. RESULTADOS: As reconstruções MIP de 2 mm tiveram melhor acurácia, estatisticamente significativa, em relação a MIP de 4 mm, com valores de sensibilidade 100,0 e 100.0 para as artérias principais e lobares; 92,6 e 85,5 para as segmentares e 94,3 e 86,8 para as subsegmentares. Utilizando as imagens multiplanares de 1 mm como referência padrão. Todos pacientes com TEP foram detectados com imagens em MIP de 2 mm. Dois pacientes com TEP não foram diagnosticados com imagens em MIP de 4 mm. Não houve diferença estatisticamente significativa entre a reformatação MIP de 2 mm e 2 mm + PRM na detecção de êmbolos. CONCLUSÃO: Com um número de imagens equivalente a metade da reconstrução MPR de 1 mm, a reconstrução em MIP de 2 mm conseguiu detectar todos os pacientes com TEP positivo que foram diagnosticados pelas imagens multiplanares de 1 mm, com sensibilidade de 100,0 e 100,0 nas artérias principais e lobares, de 92,6 e 85,5 para as artérias segmentares e 94,3 e 86,8 para as artérias subsegmentares. O acréscimo de reformatações PRM às imagens em MIP de 2 mm não aumentou a acurácia na detecção de êmbolos, mas melhorou a visualização da continuidade dos êmbolos, principalmente, nas artérias centrais. / INTRODUCTION: Multidetector computed tomography (MDCT) has been making possible the increase of the sensibility in the detection of the pulmonary embolism (PE). It is observed, however, that there is a substantial increase in the number of images and, consequently, in the time of analysis for the radiologist. A possible solution to this problem is accomplishing a maximum intensity projection reconstruction (MIP) that reduces the number of images for analysis. Still, there is a new image modality using MIP reconstructions in rotational plans that pivot on a central horizontal axis between the lung hila (paddlewheel reformations, PDW). It provides a continuous display of branching arteries that radiate from both hila. However, studies are necessary to determine if the use of multiplan MIP reformation can reduce the number of images to be analyzed, without significant loss of information; and, if the addition of PDW reformation can improve the diagnosis of PE. OBJECTIVE: To test the hypothesis that images using maximum intensity projection reconstructions of 2,0 mm and 4,0 mm of thickness, multiplan, have the same diagnosis value for detection of pulmonary embolism in the big and small pulmonary arteries, when compared to multiplan images of 1 mm collimation, accomplished in 16 and 10 slice MDTC; and to evaluate if there is influence on the diagnosis value of PE the increment of PDW reformation, in the images rebuilt in MIP of 2 mm. CASUISTIC AND METHODS: Fifty patients suspected of having an acute PE (30 with positive PE and 20 with negative PE, detected during the tomography exam) accomplished computerized tomography of the thorax for evaluation of the pulmonary arteries by 16 and 10 slice MDTC (120 kV, 200 mAs and 1 mm collimation). Four kind of images series (1 mm thick multiplan images and 3 kinds of reconstructed images using the MIP tecnhnique with slab thicknesses of 2 mm, 4 mm and 2 mm added of PDW reformation) were obtained from each exam. Two observers independently evaluated, in work station, the presence or absence of emboli in the main and lobar, segmental and subsegmental arteries in the 50 patients in each one of the reconstructions in MIP, which they were compared using the reformation of 1 mm of thickness as reference pattern. RESULTS: The reconstructions in MIP of 2 mm had better accuracy than MIP of 4 mm, statistically significant with values of sensibility 100,0 and 100,0 for the main and lobar pulmonary arteries; 92,6 and 85,5 for the segmental and 94,3 and 86,8 for the subsegmental. The images in MPR of 1 mm were used as a reference pattern. All patients with PE were detected with images in MIP of 2 mm; two patients with PE were not diagnosed with images in MIP of 4 mm. There was not difference statisticament significant among reformation in MIP of 2 mm and 2 mm plus PDW in the detection of emboli. CONCLUSION: Reconstruction in MIP of 2 mm reduced the number of images for the half and it detected all patients with positive PE that were diagnosed by the multiplans images of 1 mm, with sensibility of 100,0 and 100,0 in the main and lobar arteries, of 92,6 and 85,5 and 79,2 for the segmental arteries and 94,3 and 86,8 for the subsegmental arteries. The increment of PDW reformation to the images in MIP of 2 mm didn\'t increase the accuracy in the detection of emboli, but it improved the visualization of the continuity of the emboli, mainly, in the central arteries.

Every year about half a million women die from complications of pregnancy, parturition and puerperium, most of which are preventable. The purpose of this thesis was to chart the distribution and decline in maternal mortality in Sweden between 1751 and 1980, and furthermore to characterize positive (predisposing) factors and negative (protective) factors of maternal mortality. Maternal mortality declined from 900 to 6.6 per 100,000 live births in these 230 years. Maternal deaths accounted for 10070 of all female deaths in the reproductive ages between 1781 and 1785, but only 0.2.0/0 between 1976 and 1980. However, in the 19th century 40-450/0 of the female deaths in the most active childbearing ages were maternal deaths. The children left motherless had an extremely high mortality. Indirect maternal deaths and puerperal sepsis accounted for the bulk of maternal deaths in the rural areas. Only a minority of maternal deaths occurred in lying-in hospitals. Midwifery services in rural areas and antiseptic techniques were most effective in preventing maternal deaths during the late 19th century. The changing distribution ofage and parity amongst the parturients had a definite impact on the mortality decline, enhanced by time, contributing to 500/0 of the mortality decline over the last 15 years. The expontential decline of cause-specific mortality and case fatality rates during the last 40 years is furthermore explained by the emergence ofmodern medicine - antibiotics, antenatal and obstetric care. The earlier serious problem of illegal abortions was eradicated by legislation and changes in hospital practice. The maternal mortality decline has levelled out during the 1970s, the relative importance of embolism as a cause of death is increasing. Advanced age and intercurrent disease are the most difficult risk factors to overcome. To conclude, this study indicates that the reason why maternal mortality has declined faster than otherhealth indices is that the major part of the maternal deaths can be prevented by medical technology, including family planning, antenatal and obstetric care. This experience should be of interest to developing countries where high rates of maternal mortality prevails.

No description available.

INTRODUÇÃO: Os tomógrafos multidetectores (TCMD) aumentaram a sensibilidade na detecção do tromboembolismo pulmonar (TEP). Observa-se, no entanto, um substancial aumento no número de imagens e, conseqüentemente, no tempo de análise pelo radiologista. Uma possível solução, para este problema, é a realização de reconstruções em projeção de intensidade máxima (MIP) que reduz o número de imagens para análise. Existe ainda uma nova modalidade de imagem utilizando reconstrução MIP em planos rotacionais sobre um eixo horizontal ao nível dos hilos pulmonares (reformatação em pás de roda moinho, PRM), que tem demonstrado melhor a continuidade dos ramos arteriais que irradiam dos hilos. No entanto, estudos são necessários para determinar se o uso de reformatações MIP pode reduzir o número de imagens a serem analisadas, sem perda significativa de informações, e se a adição de reformatação PRM pode melhorar o diagnóstico de TEP. OBJETIVOS: Testar a hipótese de que imagens utilizando reconstruções em projeção de intensidade máxima de 2,0 mm e 4,0 mm de espessura, multiplanares, têm o mesmo valor diagnóstico para detecção de TEP nas grandes e pequenas artérias pulmonares, quando comparadas a imagens multiplanares de 1 mm, realizadas em TCMD de 10 e 16 fileiras de detectores. Avaliar se há influência no valor diagnóstico de TEP o acréscimo de reformatações PRM, nas imagens reconstruídas em MIP de 2 mm. CASUÍSTICA E MÉTODOS: Cinqüenta pacientes com suspeita diagnóstica de TEP (30 com TEP positivo e 20 com TEP negativo, detectados no exame tomográfico), realizaram tomografia computadorizada do tórax para avaliação das artérias pulmonares em TCMD com 16 e 10 fileiras de detectores (120 kV, 200 mAs e 1 mm de colimação). Cada exame foi reconstruído em 4 tipos de séries de imagens multiplanares: imagens multiplanares (MPR) de 1 mm e 3 tipos de reconstrução MIP, com espessuras de 2 mm, 4 mm e 2 mm acrescidas de reformatação PRM. Dois observadores avaliaram, independentemente, em estação de trabalho, a presença ou ausência de êmbolos nas artérias principais, lobares, segmentares e subsegmentares dos 50 pacientes em cada uma das reconstruções MIP, as quais foram comparadas usando-se a reformatação MPR de 1 mm como padrão de referência. RESULTADOS: As reconstruções MIP de 2 mm tiveram melhor acurácia, estatisticamente significativa, em relação a MIP de 4 mm, com valores de sensibilidade 100,0 e 100.0 para as artérias principais e lobares; 92,6 e 85,5 para as segmentares e 94,3 e 86,8 para as subsegmentares. Utilizando as imagens multiplanares de 1 mm como referência padrão. Todos pacientes com TEP foram detectados com imagens em MIP de 2 mm. Dois pacientes com TEP não foram diagnosticados com imagens em MIP de 4 mm. Não houve diferença estatisticamente significativa entre a reformatação MIP de 2 mm e 2 mm + PRM na detecção de êmbolos. CONCLUSÃO: Com um número de imagens equivalente a metade da reconstrução MPR de 1 mm, a reconstrução em MIP de 2 mm conseguiu detectar todos os pacientes com TEP positivo que foram diagnosticados pelas imagens multiplanares de 1 mm, com sensibilidade de 100,0 e 100,0 nas artérias principais e lobares, de 92,6 e 85,5 para as artérias segmentares e 94,3 e 86,8 para as artérias subsegmentares. O acréscimo de reformatações PRM às imagens em MIP de 2 mm não aumentou a acurácia na detecção de êmbolos, mas melhorou a visualização da continuidade dos êmbolos, principalmente, nas artérias centrais. / INTRODUCTION: Multidetector computed tomography (MDCT) has been making possible the increase of the sensibility in the detection of the pulmonary embolism (PE). It is observed, however, that there is a substantial increase in the number of images and, consequently, in the time of analysis for the radiologist. A possible solution to this problem is accomplishing a maximum intensity projection reconstruction (MIP) that reduces the number of images for analysis. Still, there is a new image modality using MIP reconstructions in rotational plans that pivot on a central horizontal axis between the lung hila (paddlewheel reformations, PDW). It provides a continuous display of branching arteries that radiate from both hila. However, studies are necessary to determine if the use of multiplan MIP reformation can reduce the number of images to be analyzed, without significant loss of information; and, if the addition of PDW reformation can improve the diagnosis of PE. OBJECTIVE: To test the hypothesis that images using maximum intensity projection reconstructions of 2,0 mm and 4,0 mm of thickness, multiplan, have the same diagnosis value for detection of pulmonary embolism in the big and small pulmonary arteries, when compared to multiplan images of 1 mm collimation, accomplished in 16 and 10 slice MDTC; and to evaluate if there is influence on the diagnosis value of PE the increment of PDW reformation, in the images rebuilt in MIP of 2 mm. CASUISTIC AND METHODS: Fifty patients suspected of having an acute PE (30 with positive PE and 20 with negative PE, detected during the tomography exam) accomplished computerized tomography of the thorax for evaluation of the pulmonary arteries by 16 and 10 slice MDTC (120 kV, 200 mAs and 1 mm collimation). Four kind of images series (1 mm thick multiplan images and 3 kinds of reconstructed images using the MIP tecnhnique with slab thicknesses of 2 mm, 4 mm and 2 mm added of PDW reformation) were obtained from each exam. Two observers independently evaluated, in work station, the presence or absence of emboli in the main and lobar, segmental and subsegmental arteries in the 50 patients in each one of the reconstructions in MIP, which they were compared using the reformation of 1 mm of thickness as reference pattern. RESULTS: The reconstructions in MIP of 2 mm had better accuracy than MIP of 4 mm, statistically significant with values of sensibility 100,0 and 100,0 for the main and lobar pulmonary arteries; 92,6 and 85,5 for the segmental and 94,3 and 86,8 for the subsegmental. The images in MPR of 1 mm were used as a reference pattern. All patients with PE were detected with images in MIP of 2 mm; two patients with PE were not diagnosed with images in MIP of 4 mm. There was not difference statisticament significant among reformation in MIP of 2 mm and 2 mm plus PDW in the detection of emboli. CONCLUSION: Reconstruction in MIP of 2 mm reduced the number of images for the half and it detected all patients with positive PE that were diagnosed by the multiplans images of 1 mm, with sensibility of 100,0 and 100,0 in the main and lobar arteries, of 92,6 and 85,5 and 79,2 for the segmental arteries and 94,3 and 86,8 for the subsegmental arteries. The increment of PDW reformation to the images in MIP of 2 mm didn\'t increase the accuracy in the detection of emboli, but it improved the visualization of the continuity of the emboli, mainly, in the central arteries.

Introdução: O termo tromboembolismo venoso (TEV) engloba trombose venosa profunda (TVP) e/ou tromboembolismo pulmonar (TEP). TEV tem sido considerado incomum após cirurgia de revascularização miocárdica (CRM), e Diretrizes recomendam profilaxia mecânica para todos os pacientes e acrescentar profilaxia com heparina apenas se o tempo de internação hospitalar for prolongado por complicações não hemorrágicas (Grau 2C). Objetivo: Pesquisar o diagnóstico de TEV no pós-operatório de CRM, independente de suspeita clínica, e analisar se os resultados podem contribuir para melhor definição das características clínicas de TEV após CRM. Métodos: Em estudo observacional, prospectivo, unicêntrico, 100 pacientes com doença arterial coronariana crônica realizaram tomografia computadorizada da artéria pulmonar (multidetectores-64) e ultrassonografia compressiva dos membros inferiores após CRM eletiva. Pacientes com alto risco para TEV foram excluídos. Resultados: Por livre escolha dos cirurgiões, 83 cirurgias foram realizadas com circulação extracorpórea e 17 sem extracorpórea. Em média, tomografia e ultrassonografia foram realizadas 7 ± 3 dias após a cirurgia. TEP isolada foi observada em 13/100 (13%), TEP e TVP simultâneos em 8/100 (8%), e TVP isolada em 4/100 (4%) pacientes, totalizando 25/100 (25%) TEVs. Entre as 21 TEPs, 3/21 (14%) envolveram artérias subsegmentares, 15/21 (71%) artérias segmentares, 1/21 (5%) artéria lobar e 2/21 (10%) artérias pulmonares centrais (tronco da artéria pulmonar e/ou seus ramos principais). Das 12 TVPs, todas foram distais (abaixo da veia poplítea) e 2/12 (17%) foram também proximais; 5/12 (42%) foram unilaterais, das quais 3/5 (60%) acometeram a perna contralateral à safenectomia. Nenhum TEV causou instabilidade hemodinâmica e nenhum deles foi clinicamente suspeitado. Conclusões: TEV é frequente e subdiagnosticado após CRM, talvez porque a maioria tenha localização distal e porque os procedimentos habituais desta cirurgia dificultam a suspeita diagnóstica. Os resultados enfatizam a recomendação de recentes Diretrizes que sugerem profilaxia mecânica para todos os pacientes, e ressaltam a necessidade de estudos randomizados para avaliar a relação de benefícios e os riscos de profilaxia farmacológica / Background: Venous thromboembolism (VTE) includes deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Currently, VTE has been considered uncommon after coronary artery bypass grafting (CABG) and Guidelines suggest mechanical prophylaxis and adding prophylactic heparin if hospital course is prolonged by nonhemorrhagic complications (Grade2C). Objective: To search VTE after CABG, independent of clinical suspicion, and to analyze whether the results can aid in better defining the clinical characteristics of VTE after CABG. Methods: In a prospective, observational, single-center study, 100 patients with coronary artery disease underwent computed tomographic pulmonary angiography (multidetector-64) and lower-extremity venous compressive ultrasound after elective CABG. Patients at high risk for VTE were excluded. Results: At the discretion of surgeons, 83 surgeries were on-pump and 17 off-pump. On average, tomography and ultrasound were performed 7 ± 3 days after CABG. Isolated PE was observed in 13/100 (13%) patients, simultaneous PE and DVT in 8/100 (8%), and isolated DVT in 4/100 (4%), totaling 25/100 (25%) VTEs. Of the PEs 3/21 (14%) involved subsegmental, 15/21 (71%) segmental, 1/21 (5%) lobar and 2/21 (10%) central pulmonary arteries. Of the 12 DVTs all were distal (below the popliteal vein) and 2/12 (17%) were also proximal; 5/12 (42%) were unilateral, of which 3/5 (60%) on the contralateral vein saphenous harvested leg. No VTE caused hemodynamic instability and none was clinically suspected. Conclusions: VTE is frequent and underdiagnosed perhaps because the majority is distally localized and because the ordinary procedures of GABG conceal the diagnostic suspicion. The results emphasize the current guidelines\' recommendation suggesting mechanical prophylaxis for all patients and highlight the necessity of randomized studies to assess the risk/benefit ratio of pharmacological prophylaxis

Le but de notre travail a été d’évaluer l’effet de la réduction de la dose d’irradiation en TDM multibarrette quant à la performance diagnostique, la confiance de l’observateur dans le diagnostic proposé, la capacité à suggérer un diagnostic alternatif dans quelques pathologies courantes et/ou caractérisées par des situations de faibles contrastes entre les structures anatomiques normales ou pathologiques. Nous avons donc comparé ces paramètres entre des TDM à doses réduites et à doses standard telles que couramment rapportées dans la littérature dans les circonstances suivantes :<p><p>•\ / Doctorat en sciences médicales / info:eu-repo/semantics/nonPublished

Abstract Cardiac surgery with cardiopulmonary bypass (CPB) results in hemodilution, systemic inflammatory response, activation of coagulation and fibrinolysis, and microembolisation, which may all contribute to postoperative organ dysfunction. As an attempt to attenuate these side effects, the use of minimized cardiopulmonary bypass (MCPB) systems has increased. Compared to conventional CPB (CCPB), they are characterized with reduced artificial surface area and blood-air interface. The goal of these alterations has been to reduce systemic inflammation, preserve coagulation function and minimize the need for blood tranfusions. This study was aimed at determining whether or not MCPB attenuates the adverse effects of CPB. In study I, the safety, feasibility and effect on transfusion requirements of MCPB was investigated in unselected coronary artery bypass surgery (CABG) patients. In studies II and III, the incidence of retinal microembolism after CABG and aortic valve replacement (AVR) surgery with MCPB was compared to that of CCPB by means of fluorescein angiography. Furthermore, in studies II and III, the effect of MCPB on systemic inflammation, coagulation, endothelial activation and injury, as well as on platelet activity, was compared to those of CCPB. In study IV, the effect of MCPB on intestinal mucosal damage following CPB was compared to CCPB in a porcine model of prolonged CPB. MCPB appeared as safe and feasible as CCPB in unselected CABG patients (Study I). MCPB was associated with decreased retinal microembolism compared to CCPB in CABG patients (Study II). Conversely, the difference in retinal microembolism in AVR patients was not statistically significant (Study III). MCPB was associated with a decrease in neutrophil activation in CABG and AVR patients as compared to CCPB. However, there were no differences in coagulation, endothelial activation and injury, or in platelet activity (Studies II, III). There were no differences in markers of intestinal mucosal damage between MCPB and CCPB following prolonged CPB in the experimental model (Study IV). The results of this study suggest that MCPB may be used safely with CABG patients, with beneficial effects on hematocrit, and attenuated neutrophil activation. In CABG patients, MCPB is associated with reduced retinal microembolism, suggesting a decreased embolic load to the brain. The clinical feasibility of MCBP requires further technical evolution in the management of valve surgery. The results of the animal model support previous concerns regarding intestinal mucosal damage during CPB. / Tiivistelmä Sydänkeuhkokoneen käyttö aiheuttaa elimistössä hemodiluution, yleistyneen tulehdusvasteen ja hyytymisjärjestelmän aktivoitumisen sekä mikroembolisaatiota. Ilmiöt ovat yleensä lieviä ja ohimeneviä, mutta voivat johtaa elintoimintahäiriöihin ja pitkittyneeseen toipumiseen sydänleikkauksen jälkeen. Haittojen lievittämiseksi sydänkeuhkokonetta on pyritty kehittämään fysiologisemmaksi. Miniperfuusiolaitteistoissa kiertävän veren kontakti pintamateriaalien ja ilman kanssa jää pienemmäksi ja veren laimenemista tapahtuu vähemmän. Tutkimuksen tavoitteena oli selvittää voidaanko miniperfuusiolla lievittää sydänkeuhkokoneen haittoja. Ensimmäisessä osatyössä selvitettiin miniperfuusion käyttökelpoisuutta ja vaikutusta verensiirtotarpeeseen ohitusleikkauspotilailla valikoimattomassa aineistossa. Toisessa ja kolmannessa osatyössä selvitettiin silmänpohjan mikroembolioiden ilmaantuvuutta miniperfuusion ja perinteisen sydänkeuhkokoneen käytön jälkeen ohitusleikkauspotilailla ja aorttaläppäleikkauspotilailla. Toisessa ja kolmannessa osatyössä selvitettiin lisäksi miniperfuusion vaikutuksia yleistyneen tulehdusvasteen voimakkuuteen, hyytymisjärjestelmään sekä endoteelin aktivaatioon perinteiseen sydänkeuhkokoneeseen verrattuna. Neljännessä osatyössä verrattiin kokeellisessa mallissa miniperfuusion ja perinteisen sydänkeuhkokoneen vaikutuksia suoliston limakalvon eheyteen. Miniperfuusio ilmeni yhtä käyttökelpoiseksi kuin perinteinen sydänkeuhkokone ohitusleikkauspotilaiden hoidossa. Ohitusleikkauspotilailla ilmeni vähemmän silmänpohjan mikroembolioita miniperfuusion jälkeen, mutta aorttaläppäleikkauspotilailla ero ei ollut tilastollisesti merkitsevä. Miniperfuusion käyttöön liittyi vähemmän neutrofiilien aktivaatiota. Tekniikoiden välillä ei ilmennyt eroa hyytymisjärjestelmän eikä endoteelin aktivaatiota osoittavissa merkkiaineissa. Sydänkeuhkokoneen käyttö aiheutti saman tasoisen suoliston limakalvon vaurion miniperfuusiolla ja perinteisellä sydänkeuhkokoneella. Tutkimuksen perusteella miniperfuusiotekniikkaa voidaan käyttää turvallisesti ohitusleikkauspotilaiden hoidossa ja sen käyttö vähentää hemodiluutiota ja neutrofiilien aktivaatiota verrattuna perinteiseen sydänkeuhkokoneeseen. Miniperfuusiolla voidaan vähentää sydänkeuhkokoneen käytön aiheuttamaa silmänpohjan mikroembolisaatiota, joka saattaa viitata vähäisempään aivoverenkierron mikroembolisaatioon. Miniperfuusiotekniikoiden tulee edelleen kehittyä hyödyttämään enemmän myös aorttaläppäleikkauspotilaita. Löydökset koskien sydänkeuhkokoneen aiheuttamia suoliston limakalvovaurioita vahvistavat aiempaa olettamusta suoliston haavoittuvuudesta sydänleikkauksen jälkeen.

Background: Patent Foramen Ovale (PFO), a remnant of the foetal circulation, is emerging as a new cause of disease. It has been found to be associated with cryptogenic stroke in young adults, peripheral arterial embolism and neurological decompression sickness in divers. The detection of PFO remains a diagnostic challenge; transoesophageal echocardiogram being currently considered the ‘gold standard’. The development of a non-invasive technique is crucial for the identification of a venous-to-arterial shunt (v-aCS) which may permit paradoxical embolism. Little is known about the genetic basis of PFO and our limited knowledge is based on animal studies and gene mutations detected in patients with other cardiac septal defects. Methods: Study 1: PFO Detection and Evaluation: This study was designed to evaluate transcranial Doppler (TCD), transthoracic echocardiogram (TTE) and transoesophageal echocardiogram (TOE) with administration of contrast via arm and femoral veins. We then developed a standardized protocol for PFO detection and quantification using TCD. Study 2: PFO and Migraine: The PFO detection protocol developed from the first study formed the diagnostic technique to detect v-aCS in an adequately powered matched case control study to explore the association between PFO and migraine. Study 3: The Genetic basis of PFO: This study was designed to explore the genetic basis of a PFO using a candidate gene approach. Results: Study 1 - PFO Detection Study: When compared with TOE with femoral vein contrast injection as the ‘gold standard’, TCD with arm vein contrast was 100% sensitive and 97.4% specific for detecting a PFO. We defined a PFO positive (+ve) study on TCD as > 15 microbubbles entering the cerebral circulation, on TCD following arm vein injection and >16 microbubbles with a femoral contrast injection. A ‘major’ PFO+ve v-aCS was defined as >35 microbubbles with arm vein injection or >90 microbubbles with femoral vein injection. We then developed a new diagnostic pathway for PFO detection in clinical practice. Study 2 - PFO Migraine study: A significant difference in prevalence of v-aCS between migraine with aura M+A) and their matched controls was demonstrated with adjusted OR=3.72 (1.48-9.38) p=0.005 for a PFO+ve v-aCS, and a highly significant difference between M+A and controls for a ‘major’ PFO+ve v-aCS with adjusted OR = 6.38 (1.89 – 21.48) p = 0.003. There was significant association with APC resistance and migraine on thrombophilia screen. Study 3 - The PFO Genetics Study: This study detected mutations of GATA4 and NKX2-5 in both PFO+ve cases and PFO-ve controls. Two novel non synonymous mutations of GATA4, c.461T>A and c.994G>A were found only in PFO positive individuals and may be associated with a PFO. All the PFO+ve cases with a GATA4 gene mutation had a major PFO+ve v-aCSConclusion:TCD detects PFO with a sensitivity of 100% and specificity of 92.3% and is the most reliable non-invasive technique for PFO detection. When arm vein injections are used both cough and valsalva provocation is essential. There was a highly significant association between PFO+ve v- aCS and M+A, especially with a ‘major’ PFO+ve v-aCS. GATA 4 mutations though infrequent were found PFO+ve cases and all had major v-aCS.

Os objetivos do estudo foram avaliar as características clínicas das embolias arteriais sistêmicas no curso da endocardite infecciosa, a distribuição temporal, os fatores de risco de embolia e a influência prognóstica da embolia no curso da doença. Foram estudados 629 episódios de endocardite infecciosa. A idade dos pacientes variou de 2 meses a 83 anos (média 37,9 anos; desvio padrão 17,3). Ocorreram 396 (63%) episódios em homens e 233 (47%) em mulheres. Em 538 (85%) episódios, os pacientes eram portadores de doença cardíaca prévia, 272 (43%) com valvopatia, 224 (36%) portadores de prótese valvar cardíaca, 29 (5%) com doença cardíaca congênita, 13 (2%) com outras cardiopatias e 91 (14%) pacientes não apresentavam evidência de cardiopatia prévia. Os agentes etiológicos foram os estreptococos em 297 (47%) pacientes, os enterococos em 51 (8%), os Staphylococcus aureus em 77 (12,6%), os Staphylococcus epidermidis em 56 (9%), as bactérias gram-negativas em 33 (5%), os fungos em nove (1,4%), e outros microorganismos em 27 (4%). Em 79 (13%) pacientes as hemoculturas foram negativas. Os pacientes receberam tratamento clínico em 376 (60%) episódios e cirúrgico em 253 (40%). Para a análise estatística foram utilizados além da estatística descritiva, o método de Kaplan-Meier para avaliar a sobrevida livre de embolia e o prognóstico, comparadas com os testes de Log-rank e Breslow. Em seguida para a estimativa de riscos, foi ajustado o modelo de riscos proporcionais de Cox. As embolias arteriais ocorreram em 133 (21%) pacientes, cerebrais em 63 (47%), extracerebrais em 57 (43%) e cerebrais a extracerebrais em 13 (10%) pacientes. A distribuição temporal das embolias foi decrescente após o início dos sintomas. O risco de embolia não revelou diferença significativa quanto a idade, a sexo, o estado cardíaco, presença e número de vegetações identificadas no ecocardiograma e a modalidade de tratamento clínico ou cirúrgico. Os pacientes com endocardite causada por Staphylococcus aureus apresentaram risco de ocorrência de embolia 2,9 vezes maior do que os pacientes com endocardite causada por outros agentes etiológicos. Nos pacientes com endocardite infecciosa em prótese mitral e aórtica com vegetação identificada no ecocardiograma, o risco de embolia foi respectivamente 2,4 e 3,3 vezes maior relação aos pacientes com endocardite em valva natural ou em prótese sem vegetação. O risco de embolia foi menor a medida que o tempo decorrido entre o início dos sintomas e o tratamento aumentou. O risco de óbito nos pacientes que sofreram embolia duplicou em relação aos pacientes que não sofreram embolia. / The objectives of the study were to evaluate the clinical characteristics of systemic arterial embolism at infective endocarditis courses, the time related distribution of emboli, risk predictors and prognostic influence of emboli during active disease. So far, we studied 629 episodes of left-sided endocarditis. The patients were aged 37.9 ± 17.3 years; 396 (63%) episodes occurred in men; 233 (47%) in women; 538 (85%) episodes occurred in patients with heart disease: 272 (43%) had valvular heart disease, 224 (36%) had prosthetic heart valves, 29 (5%) had congenital heart disease, 13 (2%) had others cardiac diseases and 91 (14%) had no known heart disease. The causative microorganisms were streptococci in 297 (47%) patients, enterococci in 51 (8%), Staphylococcus aureus in 77 (1 2.6%), Sfaphylococcus epidermidis in 56 (9%), gram-negative bacteria in 33 (5%), fungi in nine (1.4%), and other microorganisms in 27 (4%); 79 (13%) patients had negative blood cultures. The treatment was medical in 376 (60%) and surgical in 253 (40%) episodes. Statistical analysis was pet-formed with descriptive analysis, with Kaplan-Meier methods to evaluate survival free of emboli and prognosis, and Cox proportional hazards model for risk analysis; 133 (21%) patients had an embolic event; 63 (47%) were cerebral emboli and 57 (43%) were extracerebral emboli and 13 (10%) were cerebral and extracerebral. The time-related distribution showed decrease in the incidence after beginning of symptoms. The risk for emboli was not significantly different relative to age, sex, cardiac status, presence or number of vegetations at echocardiogram, and medical or surgical treatment. The risk of emboli was 2.97 times higher in patients with Staphylacoccus aureus endocarditis. The risk of embolism in patients with infective endocarditis in mitral and aortic prosthetic valve with vegetations were 2.4 and 3.3 times higher. The risk of embolism decrease as the time elapsed between beginning of symptoms and treatment increased, suggesting a lower risk in less acute disease. Risk of death was 2.01 times higher in patients with embolism.

Orientador: Carmen Maria Casquel Monti Juliani / Resumo: Objetivos: caracterizar o risco de tromboembolismo venoso e o uso de profilaxia em pacientes clínicos e cirúrgicos, avaliando a conformidade ou não-conformidade da prescrição de profilaxia medicamentosa e desvelar a percepção dos enfermeiros frente ao uso do protocolo de profilaxia de tromboembolismo venoso. Métodos: Estudo descritivo, com abordagem multimétodos ou método misto, utilizando técnicas quantitativas (estudo transversal) e qualitativas (fenomenologia), com a finalidade de realizar a interação entre os métodos, fornecendo melhores possibilidades analíticas. Resultados: A taxa global de profilaxia de tromboembolismo venoso foi 70% e os pacientes clínicos apresentaram maior conformidade de prescrição de profilaxia em relação ao protocolo e a quantidade de fatores de risco/pacientes foi maior em pacientes clínicos em relação aos cirúrgicos. Os enfermeiros costumam preencher o protocolo no momento da admissão do paciente e, quando não conseguem, informam a necessidade durante passagem do plantão. Há um consenso entre os enfermeiros que médicos fixos nos setores prescrevem mais adequadamente a medicação profilática em relação aos rotativos. Conclusão: Para que todos os usuários se beneficiem da profilaxia, é necessária educação permanente/continuada associada a estratégias para envolvimento da equipe multiprofissional, além de divulgação maciça do protocolo de profilaxia de tromboembolismo venoso, a fim de diminuir as lacunas do conhecimento e instrumentalizar as equipe... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Objectives: To characterize the risk of venous thromboembolism and the use of prophylaxis in clinical and surgical patients, to evaluate a measure or non-compliance of prescribing medication prophylaxis and to develop nurses' perceptions regarding the use of venous prophylaxis protocol. Methods: Descriptive study with a multimedia approach or method, using quantitative (cross-sectional) and qualitative (phenomenology) techniques, using an interaction between methods, providing better analytical alternatives. Results: An overall rate of venous thromboembolism prophylaxis was 70% and clinical patients with a higher prevalence of prophylaxis prescription compared to the protocol and a number of risk factors / patients were the highest in clinical patients compared to physicians. Nurses usually complete the protocol at the time of patient admission and, when unable to do so, provide the necessary information during the passage of planting. There is a consensus among nurses that doctors fix in the prescribed sectors more that use prophylactic medication in relation to rotary ones. Conclusion: For all users who benefit from prophylaxis, it is mandatory / continued associated with multiprofessional team participation strategies, in addition to the massive dissemination of venous thromboembolism prophylaxis protocol, an end of loss as knowledge gaps and to instrumentalize as teams with the specific practice in using. / Doutor