Darbo tikslas: nustatyti veiksnius, susijusius su arterioveninių jung¬čių (AVJ) dializuojamiems pacientams funkcionavimo trukme bei įvertinti jungčių funkcijos monitoravimo naudą jų funkcionavimo trukmei prail-ginti. Darbo uždaviniai: 1. Įvertinti AVJ funkcijos monitoravimo naudą jos funkcionavimo trukmei prailginti. 2. Nustatyti pirmosios hemodializės procedūros atlikimo būdo ryšį su paciento stacionarizavimo trukme. 3. Nustatyti veiksnius, susijusius su AVJ funkcionavimo trukme. 4. Nustatyti centrinės venos kateterio buvimo ir lokalizacijos reikšmę AVJ funkcionavimo trukmei. 5. Įvertinti AVJ „brandinimo“ trukmės ryšį su AVJ funkcionavimo trukme. 6. Įvertinti priešoperacinio kraujagyslių ultragarsinio ištyrimo reikšmę pirminių jungties disfunkcijų išsivystymui bei AVJ funkcionavimo trukmei. DARBO METODIKA Tyrimas atliktas Lietuvos sveikatos mokslų universiteto Nefrologijos klinikoje, gavus Kauno regioninio tyrimų etikos komiteto leidimą Nr. BE 2-20. Dalis duomenų buvo renkama retrospektyviai, naudojant medicinos dokumentaciją, kita dalis informacijos apie pacientų laboratorinių tyrimų duomenis bei HD procedūros parametrus buvo renkama viso tyrimo ei¬goje. Visos AVJ pagal buvo suskirstytos į tris grupes: 1. Istorinė grupė – monitoravimas taikytas nebuvo (187 pacientai, 260 AVJ); 2. Monitoruota grupė – AVJ buvo monitoruojamos nuo pirmosios per ją atliktos HD (29 pacientai, 31 AVJ); 3. Dalinai monitoruota grupė – AVJ naudojamos HD iki 2008 m. gruo-džio 31 d., o vėliau... [toliau žr. visą tekstą] / Patients to be treated with chronic hemodialysis (HD) must have blood vessel connection. There are three types of blood vessel connections: native arteriovenous fistula (AVF), synthetic prosthesis and permanent central venous catheter. Each connection has its strengths and weaknesses. Primary AVF dysfunction occurs in 7.5% of the whole population of patients receiving HD, and in up to 80% of high risk patients (those with diabetes, elderly patients, and women) [Mann et al 2005]. Compared to other blood vessel connections (permanent central venous catheter or synthetic prosthesis) function of properly formed AVF is the longest, and incurs the lowest incidence of infectious and thrombotic complications. All international guidelines on HD procedures recommend native AVF as the method of choice. Formation of blood vessel junctions and treatment of their complications account for up to 20% of all hospitalizations of patients with end stage renal failure in USA [Allon et al 2002], up to 30% in Canada [Mann et al 2005], and up to 25% in Europe [Pissoni et al 2002]. It should be stated that formation of AVF and treatment of their complications are very expensive, and therefore determining the causes of the development of AVF complications and their timely diagnosis and correction are extremely important. Various methods of monitoring of AVF function are used in many European and USA HD centers; however, the most important criterion of early diagnosis of AVF complications has not... [to full text]

Orientador: Marcone Lima Sobreira / Resumo: A insuficiência renal crônica (IRC) é uma desordem metabólica de instalação lenta e irreversível muito prevalente. Estima-se que existam cerca de 1,2 a 1,5 milhão de pacientes no Brasil. Condições clínicas como: diabetes mellitus, hipertensão arterial sistêmica, lúpus, infecções, traumas são os principais causadores da IRC. Para a realização da hemodiálise são utilizados acessos temporários como os cateteres, ou confeccionada um acesso definitivo que são as fístulas arteriovenosas (FAVs), que podem apresentar complicações como trombose, hipertensão venosa, roubo de fluxo ou infecções, as quais podem contribuir para a perda do acesso. Para análise da condição funcional da FAV, pode-se utilizar o conhecimento da pressão intra-acesso (PIA) venosa e arterial, que podem ser correlacionadas com parâmetros hemodinâmicos como pressão venosa (PV) e o fluxo de sangue (QB) fornecidos durante a hemodiálise pela máquina. Neste estudo prospectivo, serão aferidas as PIAs dos pacientes do setor de hemodiálise do Hospital das Clínicas da Faculdade de Medicina de Botucatu/UNESP que possuem FAV com o objetivo de se identificar sinais indicativos de estenose subclínica, correlacionando-os com os parâmetros ultrassonográficos (velocidade de pico sistólico, velocidade diastólica final e volume de fluxo). O método utilizado baseia-se no isolamento da pressão do sistema e do dialisador visando aferir a pressão estática e coleta dos valores de PV e do QB. Esses dados serão colocados em planilha Excel... (Resumo completo, clicar acesso eletrônico abaixo) / Mestre

Made available in DSpace on 2014-12-17T14:13:57Z (GMT). No. of bitstreams: 1 TertulianoAN.pdf: 232411 bytes, checksum: a161cb11c2dc4f0938a8a590c218ab3d (MD5) Previous issue date: 2005-04-12 / Conselho Nacional de Desenvolvimento Cient?fico e Tecnol?gico / Enterocutaneous fistulas are associated with prolonged hospital stay, high morbidity/mortality, and increase in hospital costs. This study aims to describe the use of a vacuum system and normal oral diet in dealing with this problem. Methods: Seventy-four consecutive patients with recent and defined external postoperative fistulas were analyzed. Abdominal imaging was used to exclude abscess and distal obstruction. The fistula tract was sealed with Foley catheter, connected to a negative pressure flask, changed daily for 5, 10 or 15 days, as necessary. Normal oral diet was permitted. Results: No patient died. Serum albumin and transferrin showed significantly higher levels at the end of treatment than at the beginning. The moderate and low-output fistulas had the best results (97% closed). Forty-eight (65%) fistulas closed after five days, 16(22%) after 10 days and 4(5%) after 15 days. Treatment failed in 6(8%) patients, who subsequently underwent surgery. Only one patient with low-output did not close her fistula. The cost of the treatment was US$ 41.75/day and it was considered cost effective. Conclusions: The vacuum system demonstrated good results in the treatment of fistulas. It included simplicity, low cost, short hospital stay, absence of skin breakdown, normal eating, good nutrition and activity patterns / As f?stulas enterocut?neas s?o associadas com hospitaliza??o prolongada, alta morbidez e mortalidade, e aumento dos custos hospitalares. Foi realizado estudo com o objetivo de analisar o uso de um sistema a v?cuo e dieta oral normal para o tratamento dessas f?stulas. M?todos: Foram analisados setenta e quatro pacientes consecutivos portadores de f?stulas enterocut?neas p?s-operat?rias, recentes e bem definidas. Exames abdominais por imagem foram usados para excluir abscesso e obstru??o intestinal distal. O trajeto fistuloso foi fechado com sonda de Foley conectada a um frasco de press?o negativa, que era trocado diariamente por 5, 10 ou 15 dias, conforme necess?rio. Foi permitida dieta oral normal a todos os pacientes. Resultados: Nenhum paciente morreu. Os n?veis de albumina e transferrina s?rica mostraram-se significativamente mais elevados no final do tratamento, quanto comparado com seu in?cio. As fstulas de d?bitos baixo e moderado atingiram os melhores resultados e 97% delas fecharam. Quarenta e oito (65%) f?stulas fecharam ap?s 5 dias, 16(22%) ap?s 10 dias e 4(5%) ap?s 15 dias de tratamento. O sistema falhou em 6(8%) pacientes, que subseq?entemente foram submetidos a interven??o cir?rgica. Apenas em um paciente com fi?stula de baixo d?bito n?o se conseguiu resultado satisfat?rio. O tratamento teve o custo di?rio de R$ 108,55 e foi considerado baixo e efetivo. Conclus?es: O sistema a v?cuo utilizado demonstrou bons resultados no tratamento das f?stulas. Caracterizou-se por simplicidade na execu??o, baixo custo, curto per?odo de hospitaliza??o, aus?ncia de les?es cut?neas, dieta normal, bom estado nutricional, mobilidade e atividades normais dos pacientes

Recentemente demonstramos o desenvolvimento de fibrose na região subendocárdica (SE) do ventrículo esquerdo (VE) em resposta a sobrecarga de volume na fístula aorto-cava (FAC) crônica. A pressão de perfusão coronariana (PPC) associou-se com fibrose SE e com disfunção do VE subsequentes, sugerindo ser o hipofluxo um dos mecanismos envolvidos no remodelamento ventricular.O remodelamento agudo do VE após FAC ainda é desconhecido. O objetivo deste estudo foi investigar a perfusão e o remodelamento cardíaco nas fases agudas após FAC e as possíveis implicações resultantes sobre a função do VE. Ratos Wistar foram submetidos a cirurgia fictícia (sham) ou a FAC e examinados em 3 períodos de seguimento: 1, 3 e 7 dias. Medidas hemodinâmicas sistêmicas e do VE foram realizadas para calcular a PPC e determinar a função do VE. Cortes teciduais do coração foram submetidos à coloração com HE e Sirius red. A necrose de miócitos, o infiltrado leucocitário e a fração de volume de colágeno foram determinados. O fluxo miocárdico, estimado por microesferas coloridas, a atividade de mieloperoxidase (MPO), a expressão de citocinas e a atividade de metaloproteinase-2 (MMP-2) foram determinados ao final de cada seguimento, todos examinados em duas regiões distintas do VE: SE e não SE. Comparados a sham, os grupos FAC apresentaram (média ± desvio-padrão, P <0,05) menores pressões sistêmicas no dia 1 (PAS: 116±6 vs. 88±17; PAD: 84±13 vs. 51±19 mm Hg/s), no dia 3 (PAS: 121±4 vs. 83±28; PAD: 92±5 vs. 46±21 mm Hg/s) e no dia 7 (PAS: 122±6 vs. 96±21; PAD: 93±6 vs. 66±21 mm Hg/s); maior pressão diastólica final do VE no dia 1 (7±3 vs. 15±6 mm Hg/s), no dia 3 (7±3 vs. 18±3 mm Hg/s) e no dia 7 (7±3 vs. 18±5 mmHg/s); menor PPC no dia 1 (77±14 vs. 37±18 mmHg/s), no dia 3 (86±5 vs. 29±20 mmHg/s) e no dia 7 (86±6 vs. 48±19 mmHg/s). Menor função sistólica e diastólica do VE no dia 1 (+dP/dt: 7898±4045 vs. 5828±2262; -dP/dt:. 6626±1717 vs 4728±863 mmHg/s) e no dia 7 (+dP/dt: 7924±2317 vs. 4564±2044; -dP/dt: 6435±1302 vs. 4750±1442 mmHg/s). Houve maior necrose de miócitos no dia 1 no SE (114±5 vs. 208±8) e no não SE (27±3 vs. 42±10) e no dia 3 no SE (82±12 vs. 148±31) e no não SE (21±3 vs. 31±6); maior infiltrado leucocitário no dia 1 no SE (48±5 vs. 84±13) e no não SE (33±4 vs. 40±6), no dia 3 no SE (48±10 vs. 117±13) e no não SE (41±6 vs. 65±8) e no dia 7 no SE (33±5 vs. 50±6) e no não SE (27±6 vs. 38±7); maior fibroplasia no dia 3 no SE (11± 2,6 vs 26±10) e no dia 7 no SE (11±2,3 vs 47±11); maior fibrose no dia 1 no não SE (1,2±0,2 vs. 1,7±0,5), no dia 3 no SE (1,7±0,3 vs. 5,4±0,1) e no não SE (1,4±0,3 vs. 1,8±0,3) e no dia 7 no SE (1,8±0,4 vs. 10,3±2,3) e no não SE (1,7±0,1 vs. 2,8±0,7). O fluxo miocárdico total no dia 7 foi menor, mais intensamente no SE do que no não SE (6.7±1.2 vs. 2.7±1.6 e 7.5±1.3 vs. 4.8±2.6 mL/min/g). Houve maiores níveis de IL-1 no SE e não SE no dia 1 (1050±145 vs. 4225±792 e 1070±138 vs. 4084±359 pg/mg); de TNF- no SE no dia 3 (1415±447 vs. 2037±200 e 1387±279 vs. 1412±301 pg/mg) e IL-6 no SE no dia 7 (3499±397 vs. 4955±429 e 3653±331 vs. 4297±743 pg/mg). No grupo FAC, os animais com PPC <60 mmHg comparados àqueles com PPC >60 mmHg apresentaram maior atividade de MMP-2 no SE e no não SE no dia 1 (69.1±7 e 66.1±7.0 vs. 13.2±4.0 e 11.2±3.4 %), no SE no dia 3 (104.7±39.5 e 22.3±9.0 vs. 26.3±11.3 e 11.5±2.7 %) e no SE do dia 7 (60.5±12.7 e 48.7±4.2 vs. 29.2±8.0 e 6.7±5.8 %). A PPC apresentou correlação direta e significativa com o fluxo do SE (R=0,65), e com o fluxo do não SE (R= 0,62). O fluxo do SE, porém não o do não SE, apresentou correlação direta e significativa tanto com a +dP/dt (R=0,62) quanto com a dP/dt (R=0,67). A PPC apresentou correlação inversa e significativa com a MMP-2 no dia 1 (R=0,86), no dia 3 (R=0,88) e no dia 7 (R=0,93). O remodelamento cardíaco após FAC aguda caracteriza-se por dano isquêmico no SE, resultante da queda da perfusão e implica em disfunção precoce do VE. / Recently, we have demonstrated that fibrosis develops within the subendocardial region (SE) of the left ventricle (LV) in response to chronic volume overload following aortocaval fistula (ACF). Initially low coronary driving pressure (CDP) was associated with subsequent SE fibrosis and LV dysfunction, suggesting that prior low myocardial perfusion may be one of the mechanisms involved in LV remodeling. This study aimed at investigating the role of myocardial blood flow (MBF) in the development of LV remodeling, particularly within SE, during the acute phases of ACF. Wistar rats were submitted to sham (SH) or ACF operations and examined after 1, 3, and 7 days. Apart from haemodynamics, histology (HE- and Sirius red-stained tissue sections), microsphere MBF, and biochemical studies were undertaken in two different LV myocardial regions: SE and non-SE. Compared with SH, ACF showed (mean±S.D.) lower systemic and higher LV end-diastolic pressures resulting in lower CDP at days 1 (77±14 vs. 37±18 mmHg/s), 3 (86±5 vs. 29±20 mmHg/s), and 7 (86±6 vs. 48±19 mmHg/s) with lower systolic and diastolic LV function at days 1 (+dP/dt: 7898±4045 vs. 5828±2262; -dP/dt:. 6626±1717 vs 4728±863 mmHg/s), and 7 (+dP/dt: 7924±2317 vs. 4564±2044; -dP/dt: 6435±1302 vs. 4750±1442 mmHg/s). There was a higher number of myocyte necrotic cells (cells/mm2) within SE (114±5 vs. 208±8) and non-SE (27±3 vs. 42±10) at day 1, and within SE (82±12 vs. 148±31) and non-SE (21±3 vs. 31±6) at day 3; a higher number of leukocyte cells within SE (48±5 vs. 84±13) and non-SE (33±4 vs. 40±6) at day 1, within SE (48±10 vs. 117±13) and non-SE (41±6 vs. 65±8) at day 3, and within SE (33±5 vs. 50±6) and non-SE (27±6 vs. 38±7) at day 7; a greater fibroplasia within SE (11± 2,6 vs 26±10) at day 3, and within SE (11±2,3 vs 47±11) at day 7; a greater fibrosis deposition within SE (1,7±0,3 vs. 5,4±0,1%) and non-SE (1,4±0,3 vs. 1,8±0,3%) at day 3, and within SE (1,8±0,4 vs. 10,3±2,3%) and non-SE (1,7±0,1 vs. 2,8±0,7%) at day 7. Compared with controls, ACF showed increased IL-1 levels within SE and non-SE at day 1 (1050±145 vs. 4225±792 and 1070±138 vs. 4084±359 pg/mg); increased TNF- levels within SE at day 3 (1415±447 vs. 2037±200 pg/mg); increased IL-6 levels within SE at day 7 (3499±397 vs. 4955±429 pg/mg). Compared with ACF rats with CDP >60 mmHg, MMP-2 activity was increased in rats with CDP 60 mmHg within SE and non-SE at day 1 (13.2±4.0 vs. 69.1±7.6 and 11.2±3.4 vs. 66.1±7.0%), and within SE at day 3 (26.3±11.3 vs. 104.7±39.5 and 11.5±2.7 vs. 22.3±9.0%l). At day 7, MBF was more pronouncedly reduced within SE than within non-SE (6.7±1.2 vs. 2.7±1.6 and 7.5±1.3 vs. 4.8±2.6 mL/min/g). CDP was positively and significantly related to MBF in both SE (R=0.65) and non-SE (R= 0.62). MBF within SE was directly and significantly related to both +dP/dt (R= 0,61) and dP/dt (R=0,67). CDP showed negative and significant correlations with SE MMP-2 at days 1 (R=0.86), 3 (R=0.88), and 7 (R=0.93). LV remodeling during the acute phases of ACF occurs within the SE predominantly, results from low perfusion pressure, and contributes to early LV dysfunction.

Objetivo: Identificar a frequência das fístulas após a palatoplastia primária dos pacientes com fissura transforame unilateral do Estudo Clínico Randomizado (ECR) - Projeto Flórida (PF), de acordo com dados registrados pelos profissionais de Cirurgia plástica (CP) e Fonoaudiologia (FGA); descrever a terminologia utilizada pelos profissionais ao reportar a localização das fístulas e descrever o tamanho, a sintomatologia e o gerenciamento destas complicações; e verificar a concordância entre as áreas da CP e FGA quanto às informações sobre presença e localização das fístulas em relação ao forame incisivo (pré ou pós-forame incisivo). Métodos: Foram analisados 466 prontuários de pacientes com fissura transforame unilateral não sindrômica e operada. Os dados quanto a presença de fístula, a localização, o tamanho e a sintomatologia, foram compilados e analisados, de modo descritivo, em duas janelas de tempo. O primeiro tempo abrangeu todos os registros datados até três anos após a realização da palatoplastia primária e o segundo tempo abrangeu os registros durante e após a expansão rápida da maxila (ERM). Comparou-se os achados com uma classificação Padrão Ouro das fístulas no ECR-PF, verificando o nível de concordância entre as informações registradas pela CP e FGA (Estatística Kappa). Resultados: A área da CP reportou um total de 117 (25,1%) fístulas, enquanto a FGA reportou 171 (36,7%), comparados às 164 (35,2%) fístulas identificadas na classificação Padrão Ouro. Combinando as duas áreas, obteve-se um total de 184 (39,5%) casos de fístulas, sendo que 104 (56,5%) foram registradas por ambas as áreas, 67 (36,4%) foram identificadas apenas nas documentações da FGA e 13 (7,1%) somente nos registros da CP. Quanto ao tamanho, dos 104 casos com esta informação, a maioria foi classificada como fístula de tamanho pequeno (N=50; 48%). A sintomatologia mais reportada nos 184 casos foi o refluxo nasal de alimentos em 125 (68%), seguido do escape de ar nasal em 62 (33,6%) e hipernasalidade em 56 (30,4%). Durante a análise do segundo tempo deste estudo (ERM), observou-se um total de 50 (14%) casos de fístulas em 359 pacientes que realizaram esse tratamento ortopédico, sendo que 39 (78%) destas fístulas foram localizadas em região pré-forame incisivo. Quanto ao tamanho, a maioria foi classificada como fístula de tamanho pequeno (N=25; 50%) e a sintomatologia mais encontrada foi o escape de ar nasal em 29 (58%). Tanto no primeiro, quanto no segundo tempo de análise, observou-se o uso de terminologia variada entre as duas áreas, aspecto este que dificultou a classificação da localização das fístulas em relação forame incisivo. Obteve-se uma concordância moderada entre a classificação Padrão Ouro e os dados reportados no prontuário pelo CP (Kappa = 0,32) e uma concordância substancial entre a classificação Padrão Ouro e os dados reportados no prontuário pela FGA (Kappa = 0,63). Conclusão: Com base no levantamento dos registros cirúrgicos e fonoaudiológicos, os dados encontrados indicaram uma concordância moderada e substancial entre as áreas em relação ao Padrão Ouro. Dessa forma, fica claro a necessidade de se estabelecer e validar um protocolo para a utilização em rotina clínica e multiprofissional. / Purpose: To identify the frequency of fistulas after primary palatoplasty of patients with unilateral cleft lip and palate at a Randomized Clinical Trial (RCT) - Florida Project (FP), according to the data registered in patients records by the areas of Plastic surgery (PS) and Speech-language pathology (SLP); to describe the terminology used by this professionals to record the location of the fistulas, as well as to describe the size, symptoms and management of these complications; and to verify the agreement between the areas of PS and SLP regarding the presence and location of fistula in relation with the incisive foramen (pre- or post-foramen). Methods: A total of 466 medical records of patients with unilateral, nonsyndromic and operated cleft lip and palate were analyzed. The data about presence of fistula, location, size and symptoms, were compiled and analyzed descriptively considering two time-windows regarding the primary palatoplasty. The first window included all data registered up to three years after the primary palatoplasty, and the second window included data registered during and after rapid maxillary expansion (RME). The findings were compared to a Gold Standard classification of fistula from the RCT, with the verification of the level of agreement (Kappa Statistics) between the information recorded by the two areas. Results: A total of 117 (25,1%) fistulas were reported by the PS while 171 (36,7%) were reported by the SLP area compared to 164 (35,2%) fistulas identified with the RCT-Gold Standard classification. A total of 184 (39,5%) cases of fistula was indicated, and 104 (56,5%) were recorded in both areas, 67 (36,4%) were recorded only in the SP and 13 (7,1%) were identified only in CP records. Considering the 104 cases with information regarding fistula size, most were classified as small (N=50, 48%). The most common symptom reported for the 184 cases with fistula was nasal regurgitation in 125 cases (68%), followed by nasal air escape in 62 (33,6%) and hypernasality in 56 (30,4%). A total of 50 (14%) fistulas were identified for the 359 patients who received rapid maxillary expansion (RME), and 39 (78,0%) fistulas were located prior to the incisive foramen. The most of fistulas were classified as small (N=25, 50%) and the most common symptom reported was nasal air escape in 29 cases (58%). On the first and second time-window, a large variation was found regarding terminology used by both areas to refer to fistula, making it very difficult to classify the location regarding to the incisive foramen. The agreement between the Gold Standard classification of fistula and the findings reported by the PS was moderate (Kappa = 0,32) while it was substantial for the SLP (Kappa = 0,63). Conclusion: Based on the survey of surgical and speech records, the data found indicated a moderate and substantial agreement between the findings regarding fistula occurrence reported by the areas of PS and SLP when compared to the Gold Standard classification for the RCT-FP. Thereby, it is clear the need to establish and validate a protocol for use in clinical and multidisciplinary routine.

Abstract Children born with a cleft lip and or palate face numerous difficulties during the course of their lives. Their families must respond to the challenge of a high level of burden of care required by these patients. The studies listed in this thesis benchmark the characteristics of cleft lip and palate in a cohort of patients living in Northern Finland. These studies strived to consider epidemiologic aspects, speech results, palatal fistula rates and hearing outcome. Records of a total of 214 patients treated between 1998-2011 at the Oulu Cleft Lip and Palate Center were assessed on a retrospective basis. Cleft palate (68.7%) was most frequent followed by cleft lip and palate (18.7%) and cleft lip with or without alveolus (12.6%). Cleft palate occurred more frequently in females (63%) and cleft lip and palate was more frequent in males (62.5%) most commonly affecting the left side (82%). The overall frequency of speech operations following primary palatoplasty was 21%. This was significantly higher for girls (27%) than for boys (13%). Patients with cleft lip and palate were more likely to require speech improvement surgery (24%) than patients with isolated soft or soft and hard palate clefts (20%). The overall frequency of postoperative fistulas following primary palatoplasty was (9.6%). Patients with cleft lip and palate were more likely to develop postoperative palatal fistulas (20%) than patients with cleft palate (6.6%). The severity of the cleft, the surgical technique used to repair the palate, hearing outcome, and the need for ventilation tube placement were determined retrospectively. At least mild hearing loss was found in 3.3% of cleft patients. Neither the surgical technique used to repair the cleft palate nor the severity of the cleft were found to be significant factors related to hearing loss or to the number of ventilation tubes required. Hearing improved significantly with increasing age over a span of 6 years. / Tiivistelmä Halkiopotilaat kohtaavat elämänsä aikana monenlaisia haasteita samoin kuin heidän vanhempansa. Tämä retrospektiivinen tutkimus esittelee huuli- ja suulakihalkiopotilaisiin liittyviä näkökohtia Pohjois-Suomen alueella käsitellen epidemiologiaa, puheenparannusleikkauksen tarvetta, postoperatiivisten fisteleiden määrää sekä kuulotuloksia. Tutkimusmateriaali koostui 214 halkiopotilaasta, jotka olivat hoidossa Oulun yliopistollisessa sairaalassa vuosina 1998–2011. Tutkimusaineistossa suulakihalkio (68.7&#160;%) oli yleisin halkiotyyppi, huulisuulakihalkio (18.7&#160;%) oli toiseksi yleisin ja huulihalkioita oli vähiten (12.6&#160;%). Suulakihalkio todettiin useammin tytöillä (63&#160;%) ja huulisuulakihalkio (62.5&#160;%) pojilla. Huulisuulakihalkio oli useimmiten vasemmalla puolella (82&#160;%). Puheenparannusleikkauksen tarvitsi 21&#160;% suulakihalkiopotilaista. Leikkauksen tarve oli merkittävästi yleisempi tytöillä (27&#160;%) kuin pojilla (13&#160;%). Huulisuulakihalkiopotilaat (24&#160;%) tarvitsivat puheenparannusleikkausta todennäköisemmin kuin potilaat, joilla oli pehmeän tai kovan suulaen halkio (20&#160;%). Suulaen primaarisulun jälkeen postoperatiivisten fisteleiden ilmaantuvuus oli 9.6&#160;%. Huulisuulakihalkiopotilaille kehittyi todennäköisemmin postoperatiivinen fisteli (20&#160;%) kuin suulakihalkiopotilaille (6.6&#160;%). Suulakihalkion vaikeusaste, suulaen kirurginen sulkutekniikka, kuulotulos sekä välikorvan ilmastointiputkien laitto selvitettiin potilastiedoista. Vähintään vähäinen kuulonalenema todettiin 3.3 prosentilla halkiopotilaista. Sulkutekniikan eikä halkion vaikeusasteen todettu merkittävästi vaikuttavan kuulonalenemaan tai välikorvan ilmastointiputkien laittotiheyteen. Kuulon todettiin paranevan iän myötä.

Les anévrysmes se développant au niveau des fistules artério-veineuses (FAV), représentent une complication rare mais potentiellement mortelle dont la physiopathologie reste inexplorée. Jusqu’à présent la pratique courante était de les remplacer par un segment prothétique. Nous avons proposé un nouveau traitement chirurgical consistant en une anévrysmorraphie veineuse renforcée extérieurement par une exoprothèse. Notre premier objectif a été de rapporter les résultats à un an de cette nouvelle technique. Dans un second temps nous avons perfusé ex vivo des veines saphènes humaines renforcées par la même exoprothèse dans des conditions hémodynamiques de shear stress (SS) artériel en faisant varier la pression. L’analyse morphologique a montré le développement d’une hyperplasie intimale dans la veine sans et avec exoprothèse à haute pression. L’analyse des gènes et des protéines impliqués dans le remodelage vasculaire n’a pas montré de différence entre la veine nue et la veine renforcée mais nous a permis de mieux caractériser le rôle du SS et de la pression dans le mécanisme de l’artérialisation veineuse. Notre troisième objectif a été de décrire le remodelage anévrysmal des FAV. A partir d’une tissuthèque constituée d’échantillons de veines prélevées chez les patients opérés, nous avons comparé la veine artérialisée anévrysmale à la veine non artérialisée non anévrysmale. Les métalloprotéinases et leurs inhibiteurs participent activement à ce remodelage. Les anévrysmes régulièrement ponctionnés ont un profil inflammatoire qui influence la nature de ce remodelage. / Aneurysm complicating arteriovenous fistula (AVF) is a rare but potentially life-threatening complication. To date, its pathobiology remains unexplored and prosthetic replacement constitutes the conventionnal treatment. We have proposed a new surgical technique consisting in a venous aneurysmorraphy reinforced by an exoprosthesis. Our first goal was to evaluate the one-year results in terms of patency and aneurysm recurrence. Secondly, we have studied the impact of the exoprosthesis on human saphenous veins perfused ex vivo and submitted to different flow conditions consisting in an arterial shear stress (SS) in association with a low or a high pressure setting. Morphological analysis revealed an intimal hyperplasia in veins with and without exoprosthesis under high pressure. Analysis of the proteins and genes involved in the vascular remodeling did not showed an exoprosthesis effect but allowed us to better decipher the selective role played by SS and pressure in the arterialization process. Thirdly, we have collected tissue samples from patients operated and compared aneurysmal arterialized veins to non-aneurysmal non-arterialized veins. Metalloproteinases and their inhibitors actively participate in the remodeling. In aneurysms frequently cannulated inflammation influence the remodeling process.

Bakgrund: Pankreatikoduodenektomi är den enda kurativa behandlingen av pankreascancer och pankreasanastomosläckage (PAL) är en mycket allvarlig postoperativ komplikation. Metoder för att identifiera detta i ett tidigt skede behöver förbättras. Den postoperativa övervakningen består till stor del av vitalparametrar men sjuksköterskan observerar även andra tecken på försämring. Metod: 32 patienter som genomgått pankreatikoduodenektomi inkluderades i studie. Ett bedömningsformulär innehållande 14 parametrar togs fram och användes för att identifiera vad i sjuksköterskans observationer som kan identifiera tidiga tecken på PAL. Studien hade kvantitativ ansats. Syfte: Att identifiera tidiga tecken på PAL efter pankreatikoduodenektomi med hjälp av ett bedömningsformulär. Resultat: Bedömningsformuläret identifierade normalförloppet efter pankreatikoduodenektomi. Vid jämförelse mellan patienterna som drabbats av PAL och normalförloppet urskildes tre signifikanta skillnader. Patienterna med PAL hade innan det diagnostiserades ökat syrgasbehov, sjuksköterskan bedömde deras allmäntillstånd som dåligt istället för ganska gott och patienternas egenbedömning av allmäntillståndet visade att de mådde sämre för varje dag istället för bättre. Slutsatser: Studien indikerar att ökat syrgasbehov samt sjuksköterskans bedömning och patientens egenbedömning av allmäntillståndet är vägledande för upptäckten av pankreasanastomosläckage. / Background: Pancreaticoduodenectomy is the only curative treatment of pancreaticcancer and postoperative pancreatic fistula (POPF) is a very serious complication. Methods to identify this in an early stage must be improved. The postoperative monitoring is largely composed of vital signs, but the nurse also observes other signs of deterioration. Method: 32 patients how underwent pancreaticoduodenectomy were included in the study. An assessment form containing 14 parameters was used to identify what in the nurse's observation that can identify early signs of POPF. The study had a quantitative approach. Objective: To identify early signs of POPF after pancreaticoduodenectomy using anassessment form. Results: The assessment form identified the normal process after pancreaticoduodenectomy. In the comparison between the patients affected by POPF and the normal process, three significant differences were distinguished. The patients with POPF had before it occurred increased oxygen needs, the nurse assessed the general health as poor rather than pretty good and the patients self-assessed the general health worse by the day instead of better. Conclusions: This study indicates that increased oxygen needs and the nurse's assessment and the patient's self-assessment of general health can be indicative for the discovery of POPF.

Women’s rights have been recognized by national, regional and international human rights instruments. In Africa particularly, both the African Charter and the African Women Protocol provide for the right to health. However, the continent offers the highest rate of women suffering from fistula. This paper aims to answer the question whether the current level of governments’ response to the plight of victims of obstetric fistula, complies with the requirements of international human rights law. It looks at whether the consideration of victims of fistula from a right-based approach will contribute to affordability and free access to treatment for women suffering from the disease / Thesis (LLM (Human Rights and Democratisation in Africa)) -- University of Pretoria, 2008. / A Dissertation submitted to the Faculty of Law University of Pretoria, in partial fulfilment of the requirements for the degree Masters of Law (LLM in Human Rights and Democratisation in Africa). Prepared under the supervision of Prof. Doutor Gilles Cistac, of the faculty of law, Universidade Eduardo Mondlane, Mozambique / http://www.chr.up.ac.za/ / Centre for Human Rights / LLM

Le 17 novembre 2016 a eu lieu la 3ème journée mondiale de lutte contre le cancer du pancréas.Cette prise en considération tardive rend compte de la dualité entre une incidence faible et un pronostic redoutable. Sa réputation de cancer rapidement mortel est attestée par un ratio incidence/mortalité proche de 1. Au 10ème rang en termes de localisations de cancers, il se hisse au 4ème rang en termes de mortalité par cancer et devrait devenir, en 2020, la 2ème cause de décès par cancer devant le cancer du côlon et juste après le cancer du poumon. Le taux de survie à 5 ans, tous stades confondus, est de 5% aux USA et en Europe.L’adénocarcinome canalaire pancréatique représente la tumeur la plus fréquente (80% des tumeurs pancréatiques exocrines). Sa localisation dans la glande pancréatique est céphalique dans 2/3 des cas.A ce jour, le traitement chirurgical reste le seul traitement potentiellement curatif. Celui-ci ne s’adresse qu’à une faible proportion de patients. En effet, seul 20% des patients présentant un adénocarcinome pancréatique céphalique sont effectivement résécables permettant d’obtenir un taux de survie globale à 5 ans d'environ 10 à 20% si la résection est suivie de chimiothérapie adjuvante ou non. Ces résultats modestes sont en outre à pondérer par la morbi-mortalité des résections pancréatiques céphaliques. Dans la série de l’Association Française de Chirurgie, reprenant les résections pancréatiques céphaliques réalisées en France entre 2004 et 2010, la mortalité était de 3,8% et la morbidité de 54%. Parmi les complications post-opératoires, la fistule pancréatique représente la principale complication en termes de mortalité (15 à 25%), génératrice de coût important dans les soins et d’une augmentation significative de la durée de séjour. La fistule pancréatique demeure la pierre angulaire de l’amélioration du pronostic des patients.L’objectif de ce travail sur l’adénocarcinome canalaire pancréatique céphalique traité chirurgicalement était d’analyser certains facteurs influençant la morbi-mortalité au trois temps de sa prise en charge :- Avant l’intervention, avec l’étude d’un facteur pronostic préopératoire, sur une cohorte de patients, pouvant influencer la survenue d’une fistule pancréatique et la mortalité- Pendant l’intervention, avec la réalisation d’une méta-analyse sur le type de reconstruction pancréatique et son influence sur la survenue d’une fistule pancréatique- Après l’intervention, avec l’étude de l’influence de la survenue d’une complication sévère sur la survie et la survie sans récidive.Au cours de cette thèse nous avons vu, que la réduction du taux de fistule pancréatique, par le seul biais de techniques peropératoires semble difficilement réalisable au regard de la multiplicité des techniques et de la difficulté à réaliser des études randomisées contrôlées méthodologiquement satisfaisantes. En revanche, la recherche des facteurs liés aux patients, prédisposant à la survenue d’une fistule pancréatique semble l’approche à privilégier. Ceci est d’autant plus primordial dès lors que nous avons mis en évidence un lien entre la survenue d’une complication sévère et la survie ou la récidive chez les patients réséqués. Ce travail souligne l’importance d’être capable d’identifier, dès la consultation, les patients à haut risque de complications sévères et de fistule post-opératoire d’une part, pour sélectionner les bons candidats à la chirurgie et d’autre part, pour être capable de leur apporter une information franche et loyale indispensable éthiquement au consentement éclairé. / The third World Day on pancreatic cancer took place the 17th November 2016. This late consideration is due to the duality between his relative scarcity and a dreadful prognosis.Its aggressiveness is underlined by a mortality rate equal to its incidence. Ranked 10th on cancer-related localization and 4th on cancer-related mortality, he will become the second cause of cancer-related deaths in 2020 just behind pulmonary cancer and before colorectal cancer. 5-yr survival rate is 5% irrespective of the stage.Pancreatic ductal adenocarcinoma is the most frequent form (80% of exocrine pancreatic tumors). He is localized in cephalic pancreas in 2/3 of cases.Although pancreatic resection provides the only chance of long-term survival, no more than 20% of patients will be eligible for surgery in curative intent leading to a 5-yr survival rate of 10 to 20%. Pancreaticoduodenectomy for pancreatic head, neck and uncinated process is still a challenging procedure. In the study of the French Surgery Association, mortality and morbidity rate were respectively 3.8% and 54%. Postoperative pancreatic fistula is considered as the Achilles’ heel of pancreaticoduodenectomy and is associated with increased post-operative mortality. Postoperative pancreatic fistula generates significant costs and prolonged hospital stay. Thus postoperative pancreatic fistula is the corner stone of patient’s prognosis improvement.The aim of this study on operated pancreatic ductal adenocarcinoma was to analyze several factors influencing morbidity and mortality.- Before surgery, by testing the impact of body surface area in a cohort of patients.- During surgery, by conducting a meta-analysis on reconstruction methods for pancreatic anastomosis.- After surgery, by evaluating the influence of severe complications on survival and recurrence.We show that the use of various surgical refinements, such as type of pancreatic anastomoses, are equivocal to decrease postoperative pancreatic fistula rate and that performing randomized controlled trials will be difficult. In contrast, the search for patient’s factors leading to postoperative pancreatic fistula seems to be the promising approach. This is of major concern as we demonstrated the causal link between the occurrence of severe postoperative complications and survival or recurrence. This work highlights the need for surgeons to distinguish during preoperative consultation high-risk patients in order to select the best candidates suitable for surgery as well as to give them a full and frank information ethically necessary for free and informed consent.