Aneurysmal subarachnoid hemorrhage (SAH) is a devastating disease with mean age of 59 years. SAH accounts for 5% of all stroke and more than one quarter of potential life years lost through stroke. With the advanced neurosurgical methods of today two thirds of the patients survive. We know, however, that various cognitive, psychiatric and physical impairments are common that affect quality of life, social life, and the ability to work in the aftermath of SAH. The overall aim constituting this PhD dissertation is to better understand some of the challenges often faced by those surviving SAH. Two SAH patient cohorts have been studied. The first followed 96 consecutively included patients during the first year after ictus. Spasticity and cognitive impairment was assessed after 6 months and the Swedish stroke register follow-up form was used to investigate family support and the use of medical and social services. Return to work was assessed at 12 months. The second cohort assessed attention deficits using the test of variables of attention (T.O.V.A.) at 7 months after ictus in 19 patients with moderate to good recovery. Spasticity was just as common in our SAH patients as after other stroke, though it was rarely treated pharmacologically. By assessing cognitive impairment at 6 months after ictus using the Montreal cognitive assessment, 68% of the patients could be correctly predicted as having returned/not returned to work at 12 months. Seventeen percent of the patients had not had a follow-up appointment 6 months after ictus. These patients were older, more often living alone, had a lower quality of life, more depressive symptoms and more cognitive impairment compared to those having had a follow-up appointment. Twenty percent had had a follow-up in primary care. Seventy-eight percent of those with moderate to severe disability were living in their own accommodations. Fifty-eight percent of the patients had attention deficits. Challenges after SAH were common and often dealt with in the home environment of the patients. The results of this thesis highlight the importance of assisting the patients and their relatives in their struggle back to life after SAH.

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Les difficultés d’adaptation scolaire que peuvent développer les élèves dans une école secondaire entraînent bien souvent des conséquences. En effet, ces dernières peuvent mener au décrochage scolaire et parfois à l’adoption de comportements délinquants. L’instauration d’un suivi auprès d’élèves prend tout son sens lorsqu’il est question de difficultés d’adaptation. Ce suivi a été offert à cinq élèves présentant ces difficultés de l’école secondaire Honoré-Mercier de Montréal. Il y a deux objectifs à ce stage. Le premier vise une diminution des présences au local de retrait et le deuxième de diminuer les difficultés d’adaptation scolaire des élèves ciblés. L’atteinte de ces objectifs est considérée en fonction de données factuelles sur les présences au local de retrait, des résultats obtenus à un test standardisé, soit le Achenbach (Achenbach, 1991), mais également en fonction des perceptions des élèves et des professeurs sur le cheminement de l’élève. Les résultats illustrent que les élèves n’ont pas modifié significativement leur présence au local de retrait, que différentes problématiques définies dans le Achenbach ont été amplifiées tandis que d’autres ont été diminuées et que, finalement les élèves ont apprécié leur suivi puisque ce dernier les a amené à vivre des changements intrinsèques. Des conclusions découlent de l’analyse des résultats, soit concernant la durée des interventions et les problématiques présentes chez les élèves. Le rôle que peut assumer le criminologue dans le milieu scolaire est également abordé. Mots clés : adaptation, difficulté, scolaire, suivi, école, secondaire, adolescent / There can be many consequences when students have difficulties in adapting to the academic environment. They can lead to higher school dropout rates and to the adoption of delinquent behaviour. In the presence of adaptation difficulties, accompanying and monitoring the students is crucial. A monitoring program was offered to five Honoré-Mercier students presenting adaptation difficulties. The intervention program has two objectives. The first one is to decrease the number of classroom exclusions of those students. Another objective is to offer a place where they have the freedom to express their feelings openly. The results of the program are based on the number of classroom exclusion during the intervention. They are also measured on the results of an Achenbach test (Achenbach, 1991) and on the opinions of the students on their own progress. The results illustrate that the students did not significantly lower their number of classroom exclusion. They also show that some problems detected in the Achenbach test were amplified whereas types of problems decreased. Finally, the results show that students appreciated their follow-up because it allowed them to experience intrinsic changes. Based on these results, we can emit several hypotheses on the need to change the duration of the intervention or the problems experienced by the students. The potential contribution of a criminologist in an academic environment is also analyzed. Keywords: adaptation, difficulty, school, follow-up, secondary, teenager

Insomni och depression är två  psykiatriska tillstånd med hög prevalens. Prevalensen för insomni är ca 11% hos den svenska befolkningen och motsvarande siffror för depression är ca 5-8%. Komorbiditet mellan dessa två tillstånd är vanligt förekommande. Dessa två tillstånd är ofta teoretiskt sammankopplade med de två kognitiva processerna oro och ruminering. En behandlingsmetod som visat sig vara effektiv mot respektive tillstånd är kognitiv beteendeterapi (KBT). I föreliggande studie har internetbaserad KBT (iKBT) där båda tillstånden behandlas simultant studerats. Studiens huvudsakliga syfte var att undersöka skillnaden i utfall mellan en behandlingsmetod och en kontrollbehandling samt dess långtidseffekter. Totalt inkluderades 124 deltagare som randomiserades till antingen kombinationsbehandling mot komorbid insomni och depression (n=63), eller kontrollbehandling mot depression med desensibilisering som placebo mot insomni (n=61). Resultatet visar att behandlingsgruppen har en statistiskt signifikant större sänkning av insomnisymtom mellan före- och eftermätning jämfört med kontrollbehandling. Statistiskt signifikanta samband förekom gällande förändring i insomnisymtom, depressionssymtom, oro och ruminering mellan två mättillfällen. Förändring i oro mellan före- och eftermätning kunde predicera utfall i förändringsvärde för insomnisymtom mellan föremätning och FU36. Förändring i oro mellan före- och eftermätning kunde predicera nivå av depressionssymtom vid FU36. Studiens resultat stärker hypotesen att insomni är ett tillstånd som kräver specifik behandling och att det finns ett samband mellan insomni och depression samt de kognitiva processerna oro och ruminering men att detta samband bör undersökas ytterligare. / Insomnia and depression are two psychiatric conditions with high prevalence in the general population. Insomnia occurs among around 11% of the Swedish population and the equivalence for depression is around 5-8%. These conditions frequently appear comorbidly. There has found to be a theoretical link between these two conditions and the cognitive processes labeled anxious worry and rumination. One treatment method which has shown itself to be effective in treating these respective conditions is cognitive behavioral therapy (CBT). In the present study, internet-delivered CBT aiming to treat both conditions simultaneously have been studied with the purpose of evaluating two different methods and the long term effects of these methods. A total of 124 participants were included and randomized to either a combined treatment for insomnia or depression (n=63) or a control treatment consisting of treatment for depression and desensibilisation as placebo for insomnia (n=61). The results of the present study indicates a statistically significant effect on symptoms of insomnia between pre- and post measurements depending on treatment group. There was a statistically significant correlation between change in all the four domains, depression, insomnia, rumination and anxious worry between two separate measurements. A change in anxious worry between pre and post measurements was also found to predict the level of change in insomnia symptoms between pre and 36 month follow-up measurements. Change in anxious worry between pre and post measurements could also predict the level of depression observed at the measurement at the 36 month follow-up. The findings in this study corroborates the hypotheses that insomnia is a condition which require a specific treatment and that there is a relation between insomnia and depression and the cognitive processes anxious worry and rumination but that this relation needs to be further examined. / ClinicalTrials.gov Identifier: NCT01663844 New Clinical Applications for Internet-based Cognitive Behavior Therapy for Insomnia and Depression

OBK Sverige AB är en totalentreprenör från Örebro som bildades 2011. De har idag ca 65 anställda. De har inte kunnat arbeta in så mycket tid som de förväntat sig vid projektet Brf Vingen. Olika moment för projektet kommer att granskas och jämföras med ett av OBKs andra projekt, Kv. Sjukhuset. Enhetstiderna för momenten kommer jämföras med den gamla och den nya listan för enhetstider. Syftet med denna uppsats är att få svar på frågorna nedan.  • Hur stämmer vissa enhetstider som finns i den gamla listan i jämförelse med verkligheten? • Vad kan vara anledningen till att tiderna i vissa fall inte går att hålla? • Hur kommer den nya listan stämma överens med verkligheten? Enhetstiderna för momenten kommer jämföras med Nybyggnadslista 1999 och inte Ombyggnadslista 1999, då båda projekten är nybyggnationer. Dessa listor har getts ut av Byggnads, som är ett fackförbund, tillsammans med Sveriges Byggindustrier.  Litteraturstudier samt intervjuer har utförts för att ta fram information om vad enhetstider är. Intervjuer har gjorts för att få fram enhetstider och mängder för de granskade momenten. För att beräkna hur lång tid det tar att bygga en enhet av ett moment används enhetstider. Målning, gjutning och gipsning är exempel på olika moment och enheterna kan vara kvadratmeter, meter, styck osv. Enhetstiden varierar för olika moment och den multipliceras sedan med den totala mängden för momentet. Då får man fram hur lång tid det är beräknat att ett moment ska ta.  Momenten som granskats för båda projekten är betongstomme, taktäckning och gipsning av innerväggar. För projektet Brf Vingen har också fasadpartier av trä granskats. Resultatet i uppsatsen är att förutsättningen för inarbetning, när man arbetar efter nya listan, vid betongstommen för Brf Vingen ökar medan den för Kv. Sjukhuset minskar. Gipsning av innerväggar ökar, taktäckning minskar och fasadpartierna av trä minskar.  Beroende på olika faktorer i de projekt som granskats så stämmer enhetstiderna i den gamla listan olika bra med verkligheten. Anledningen till att vissa tider inte går att hålla är till exempel brant taklutning, små och trånga utrymmen samt byggnadens utformning. Den nya listan stämmer bättre överens med verkligheten för de granskade momenten. / OBK Sverige AB is a contractor company from Örebro that was established 2011. Today they have about 65 employees. They have not been able to save as much time as they where hoping for at one of their projects called Brf Vingen. We are going to view different stages of this project and compare to another of their projects called Kv. Sjukhuset. The unit times for the different stages will be compared to the old and the new list of unit times. The purpose with this essay is to answer these following questions. • How does some of the unit times from the old list come out compared to reality? • What can be the reason that the unit times in some cases can´t be kept? • How is the new list going to come out compared to reality? The unit times for the stages will be compared to Nybyggnadslistan 1999 an not to Ombyggnadslistan 1999 because the projects which are going to be viewed are constructions and not reconstructions. These lists have been published by Byggnads, which is trade union, with Sveriges Byggindustrier. Literature studies and interviews have been used to get the information about what unit times are. Interviews have also been used to get the unit times and amounts we needed for the viewed stages.  Unit times are being used to calculate how much time it takes to build one unit of a stage. Painting, foundry work and plastering is some examples of different stages and the units can be square meter, meter, piece etc. The unit time is different for different kinds of stages. This unit time is multiplied with the total amount of the stages.  The stages which has been selected to be viewed from both of the projects are the concrete frame, the roofing and the plastering of the interior walls. The wood panel at Brf Vingen has also been selected to be viewed. The result in this essay is that the time that has been saved, using the new list, for the concrete frame at Brf Vingen has increased and at Kv. Sjukhuset it has decreased. For the roofing it has decreased, for the plastering of the interior walls it has increased and for the wood panel it has de creased.  Depending on various factors in the viewed projects the unit times in the old list comes out differently well compared to reality. The reason that the unit times in some cases can´t be kept is for example that the roof slope is too steep, small and narrow spaces and also the construction design. The new list comes out better for the viewed stages compared to reality.

A diminuição da sobrevida registrada para pacientes com câncer de laringe nas últimas décadas pode estar relacionada a mudanças nos padrões de tratamento. Na literatura recente, há uma polëmica sobre o tratamento de tumores laríngeos em estádio clínico T3 devido ao emprego disseminado de estratégias de preservação de orgãos (Hoffman, 2006). Embora os critérios de inclusão para o grupo de preservação de órgãos tendam a selecionar tumores de \"baixo volume\", a escolha de uma determinada estratégia depende também da formação profissional do médico, da experiência e da infraestrutura do hospital e dos desejos dos pacientes. Essa consideração pressupõe uma distribuição homogênea dos pacientes entre os grupos de tratamento. No entanto, deve-se destacar o papel prognóstico das variáveis relacionadas ao tumor, ao paciente e à opção terapêutica na prática clínica. Objetivo: Avaliar as características clínicas, patológicas e a expressão de biomarcadores ativados pela via do EGFR em uma série de casos em relação à evolução e ao prognóstico. Metodologia: No presente estudo, 145 pacientes consecutivos com diagnóstico de carcinomas avançados de laringe cT3N0-3M0 foram analisados retrospectivamente. Foram incluídos casos de carcinoma epidermoide de supraglote, glote, subglote e transglotte, tratados em uma única instituição por quatro diferentes estratégias de tratamento (cirurgia exclusiva; cirurgia mais terapia adjuvante; radioterapia exclusiva, e radioquimioterapia). Os dados foram obtidos a partir do Registro de Câncer do Hospital A.C. Camargo, São Paulo (1990-2007). Uma série de variáveis clínicas e patológicas foi avaliada pelo métodos de Kaplan-Meier e de regressão de Cox. Opções de tratamento também foram avaliadas como fator prognóstico. Associações entre características clínico-patológicas do tumor e sobrevida, sobrevida livre de doença e risco de morte, foram investigadas. Resultados: Três variáveis clínicas, as variáveis terapêuticas e cinco variáveis patológicas, foram estatisticamente significativas na estimativa de sobrevida específica em 5 anos (CS-5a). A sobrevida foi influenciada negativamente pela invasão do tumor primário do espaço pré-epiglótico (45,5%, P = 0,003), pescoço clínico (cN) positivo (37,6%, P = 0,031), invasão da área retrocricóide (0,0%, P = 0,009) , invasão linfática (44,1%, P = 0,015), extravasamento capsular (43,1%, P = 0,003), pescoço patológico (pN) positivo (42,9%, P = 0,001), linfonodos positivos nos níveis cervicais IV-VI (33,3%, P = 0,008), margens cirúrgicas positivas (22,2%, P = 0,001). O tratamento teve impacto na sobrevida (CS-5a): a taxa foi de 51,6%, quando houve tratamento adjuvante (devido a achado patológico positivo na peça operatória), diminuiu até 41,5% no grupo de radioterapia exclusiva (P = 0,039). Cirurgia exclusiva e radioquimioterapia influenciaram a sobrevida de maneira semelhante (74,0% ; 77,5%). Considerando variáveis clínicas e terapêuticas, resultaram ser fatores prognósticos independentes: invasão do espaço paraglótico (RR multivariado 1,92; IC 1,02-3,61), pescoço clínico (cN) positivo (RR multivariado 2,24; IC 1,11-4,50), invasão do espaço pré-epiglótico (RR multivariado 2,65; IC 1,46-4,81) e tratamento radioterapico exclusivo (RR multivariado 2,88; IC 1,31-6,30); incluindo as variáveis patológicas, resultaram ser fatores prognósticos independentes achados patológicos de extravasamento capsular (RR multivariado 3,09; IC 1,56-6,12) e margens cirúrgicas comprometidas (RR multivariado 3,45; IC 1,11-10,75). A investigação de expressão imunoistoquímica de dez biomarcadores das vias de transdução de sinal ativadas pelo receptor tirosina quinase Erb B (EGFR, Erb B2, Erb B3, Erb B4, RAS, MEK, ERK, mTOR, PTEN, p53) mostrou associação entre expressão imunoistoquímica positiva de ErbB3 e ErbB4 e expressão de biomarcadores da via MAPKs e AKT-PI3K (MEK e mTOR). A positividade desses biomarcadores, ou seja, a desregulação da rede ErbB foi associada à invasão linfática, ponto de partida do acometimento linfonodal que resultou ser fator prognóstico independente entre as variáveis clínicas e patológicas (extravamento capsular). Conclusões: Entre as variáveis clínicas e terapêuticas, resultaram ser fatores prognósticos independentes: invasão do espaço paraglótico, pescoço clínico (cN) positivo, invasão do espaço pré-epiglótico e tratamento radioterápico exclusivo. Quando foram incluídas as variáveis patológicas, resultaram ser fatores prognósticos independentes achados patológicos de extravasamento capsular e margens cirúrgicas comprometidas. A positividade dos biomarcadores estudados (desregulação da rede ErbB), foi associada a invasão linfática. / The decreased survival recorded for patients with laryngeal cancer in the last decades may be related to changes in patterns of management; in literature a recent debate has been dedicated to the management of clinical stage T3 due to the disseminated use of organ preservation strategies (Hoffman, 2006). Although inclusion criteria for organ preservation group tends to select \"low volume\" tumors, in clinical practice the choice of a determined strategy depends also to medical and hospital experience and infrastructure and on patients\' wishes. This consideration may suppose an homogenous distribution of the patients among the treatment groups, however in clinical practice several clinico-pathological and therapeutic prognostic factors are considered for therapeutic decision. Objectives: Evaluate clinical and pathological characteristics and expression of biomarkers activated by the EGFR cascade in a case series and analise the association with outcomes and prognosis. Materials and method: In the present study 145 consecutive patients with diagnosis of laryngeal advanced carcinomas, cT3N0-3M0, were retrospectively analyzed, including cancer of the supraglottis, glottis, subglottis and trans-glottis, treated in a single institution by four different treatment strategies (exclusive surgery, surgery and adjuvant therapy, radiotherapy alone, and radiochemotherapy). Data was obtained from the Cancer Registry, Hospital AC Camargo, São Paulo (1990-2007). A set of clinical and pathological variables were assessed by Kaplan-Meier and Cox regression methods. Treatment option was also assessed as prognostic factor. Associations between clinical-pathological features of the tumor and survival, disease free-survival and risk of death, were investigated. Results: Three clinical variables, the therapeutic variable and five pathological variables, were statistically significant in estimating cancer specific survival at 5 years (CS-5y). Survival was negatively influenced by primary tumour spreading as filling of pre-epiglottic space (45.5%, P = 0.003), clinical neck (cN) positive (37.6%, P = 0.031), invasion of retrocricoid area (0.0%, P = 0.009), lymphatic invasion (44.1%, P = 0.015), extra-capsular nodal spread (43.1%, P = 0.003), pathological neck (pN) positive (42.9%, P = 0.001), positive IV-VI levels cervical nodes (33.3%, P = 0.008), positive surgical margins (22.2%, P = 0.001); treatment impacted on CS-5y, it decreases at 51.6% if adjuvant treatment (positive pathological finding on operative specimen), up to 41.5% in exclusive radiotherapy group (P = 0.039); exclusive surgery and radio-chemotherapy influenced survival similarly (74.0%; 77.5%). Among clinical e therapeutic variables, invasion of paraglottic space (HR adjusted 1.92; IC 1.02-3.61), positive clinical neck (cN) (HR adjusted 2,24; IC 1,11-4,50), invasion of pre-epiglottic space (HR adjusted 2,65; IC 1,46-4,81) and exclusive radiotheraphy (RR adjusted 2,88; IC 1,31-6,30) resulted to be independent prognostic factors; including pathological variables, extracapsular node invasion (HR adjusted 3,09; IC 1,56-6,12) and positive resection margins (HR adjusted 3,45; IC 1,11-10,75) were independent prognostic factors. Exploration of immunohistochemical expression of ten biomarkers of the signal transduction pathways activated by tyrosine kinases receptor Erb B (EGFR, Erb B2, Erb B3, Erb B4, RAS, MEK, ERK, mTOR, pTEN, p53) showed association between positive immunohistochemical expression of ErbB3 and ErbB4 and biomarkers of MAPKs and AKT-PI3K pathways (MEK and mTOR); the dysregulation of the Erb B network was associated with lymphatic invasion, starting point for lymph-nodes involvement that resulted to be clinical independent prognostic factors. Conclusion: Among clinical and therapeutic variables, the identified independent prognostic factors were: invasion of paraglotic space, clinically positive neck, invasion of pre-epiglotic space and radiotherapy alone. When pathologic variables were included, extracapsular spread and positive surgical margins were identified as independent prognostic factors. Positive results of the studied biomarkers (dysregulation of Erb B network) was associated with lymphatic invasion.

Estamos propondo um índice antropométrico para pectus excavatum correlacionando-o ao índice de Haller e ao índice vertebral inferior. Estudamos 20 pacientes com deformidade e 30 indivíduos normais. Os pacientes portadores do defeito torácico foram submetidos à correção cirúrgica. A correlação entre os índices foi alta, a acurácia semelhante e houve diferença significante entre o pré e pós-operatório estabelecida pelos índices. / We are proposing an anthropometric index for pectus excavatum correlating it to Haller's index and to the lower vertebral index. We have studied 20 patients with deformity and 30 normal patients. Patients carrying thoracic defect were submitted to surgical correction. The correlation between the indexes was high, the accuracy was similar and there was significant difference between the pre and post-operative established by the indexes.

INTRODUÇÃO: A lesão intraepitelial cervical de alto grau causada pelo HPV, precursora do câncer cervical, é facilmente diagnosticada e seu tratamento pode ser realizado de maneira ambulatorial, sem muitas complicações. Mesmo assim, o seguimento das pacientes tratadas deve ser feito de maneira criteriosa e sistemática para que a recorrência ou persistência da doença não passe despercebida. Conseguir identificar o grupo de pacientes com maior probabilidade de recorrência ou persistência da doença facilitaria sobremaneira esse seguimento, diminuindo o ônus econômico e psicológico que o seguimento generalizado produz. O objetivo deste trabalho é identificar marcadores que possam indicar o grupo de pacientes com maior possibilidade de recorrência da lesão intraepitelial cervical de alto grau. MÉTODOS: Neste estudo 114 mulheres com diagnóstico de lesão intraepitelial cervical de alto grau foram submetidas à conização cervical por cirurgia de alta frequência (CAF) no Setor de Patologia do Trato Genital Inferior (PTGI) da Divisão da Clínica Ginecológica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP) no período entre março de 2006 e maio de 2009. O seguimento foi realizado a cada seis meses durante o período de 24 meses. No seguimento foi coletada a citologia cervical, captura híbrida para HPV e realizada a colposcopia. Foram avaliados os testes de captura híbrida para HPV coletadas durante o seguimento, imuno-histoquímicos para oncoproteína viral E6 e proteína p16 na peça cirúrgica como possíveis marcadores de recorrência. RESULTADOS: A avaliação anatomopatológica da peça cirúrgica diagnosticou 85 (74,6%) casos de lesão intraepitelial cervical de alto grau e 29 (25,4%) casos de lesão intraepitelial de baixo grau. Nessas peças, 45 (39,5%) apresentaram expressão positiva para oncoproteína E6 e 69 (60,5%) apresentaram expressão negativa para E6; 74 (64,9%) apresentaram expressão positiva para p16 e 40 (35,1%) apresentaram expressão negativa para p16. A oncoproteína E6 não se associou com a apresentação mais grave da doença. Já a proteína p16 esteve positiva em 68 (80%) casos diagnosticados como lesão intraepitelial de alto grau e negativa em 23 (79,3%) casos com diagnóstico anatomopatológico de lesão intraepitelial de baixo grau ou cervicite crônica. A CH coletada no primeiro retorno apresentou sensibilidade de 83,3%, especificidade de 87,8%, VPP de 50% e VPN de 97,3%. Comparando a CH coletada no primeiro retorno com a citologia coletada após os 24 meses de seguimento, a CH apresentou sensibilidade de 75%, especificidade de 83,1%, VPP de 20% e VPN de 98,3%. CONCLUSÕES: A expressão das oncoproteína E6 e proteína p16 na peça cirúrgica não demonstraram ter valor para predizer recorrência no seguimento de pacientes tratadas por lesão intraepitelial cervical de alto grau, mesmo a p16 estando associada à presença de lesões mais graves. A CH pode ser usada como um teste preditivo de recorrência durante o seguimento de pacientes tratadas por lesão intraepitelial de alto grau. O VPN do teste é bastante alto e seu resultado negativo, seis meses após o tratamento indica uma taxa baixíssima de recorrência da doença / INTRODUCTION: The high grade cervical intraepithelial lesion caused by HPV, a pre-malignant condition, is easily diagnosed and its treatment can be done in outpatients without many complications. Nevertheless the patients follow-up must be done in a very systematic way to avoid any recurrence or persistence of the disease. To be able to identify the group of patients with higher rate of recurrence or persistence of the disease would make this follow-up much easier and decrease the economic and psychological burden of stressed outcome. The goal of our study is to identify markers that could indicate the group of patients more likely to recur. METHODS: In this study, 114 women diagnosed with high grade cervical intraepithelial lesion were treated with LLETZ at the Discipline of Gynecology, Faculty of Medicine, São Paulo University from March 2006 and May 2009. The follow-up visits after the treatment included Pap smear, HPV DNA test and colposcopy and occurred every 6 months for 24 months. The markers evaluated were the HPV DNA test collected during the follow-up and immunohistochemical tests performed on the surgical specimen: E6 oncoprotein and protein p16. RESULTS: We found 85 cases (74,6%) of HSIL and 29 cases (25,4%) of LSIL in the surgical specimen obtained with the LLETZ. The E6 oncoprotein was expressed in 45 (39,5%) and not expressed in 69 (60,5%) of the specimen; 74 (64,9%) expressed p16 and 40 (35,1%) didnt express p16. The E6 oncoprotein was not associated with severe presentation of the disease. The protein p16 was positive in 68 (80%) cases of diagnosed HSIL and negative in 23 (79,3%) cases with diagnosed LSIL or chronic cervicitis. The HPV DNA test collected at the first follow-up consult at 6 months presented a sensitivity of 83,3% specificity of 87,8%, positive predictive value (PPV) of 50% and negative predictive value (NPV) of 97,3%. Comparing the HPV DNA test collected at the first follow-up visit and the cervical cytology collected at the fourth and last follow-up visit at 24 months, the HPV DNA test presented a sensitivity of 75%, specificity of 83,1%, PPV of 20% and NPV of 98,3%. CONCLUSIONS: The E6 oncoprotein and protein p16 expression on the surgical specimen were not able to predict recurrence of the disease during the follow-up of the patients. The HPV DNA test can be used as a marker of the recurrence on the follow-up of patients treated for HSIL with LLETZ. The HPV DNA test negative result at the 6 month follow-up visit represents an extremely low recurrence rate

Com o objetivo de avaliar a sobrevida e os fatores prognósticos da cardiomiopatia hipertrófica estudamos, de forma prospectiva, 214 pacientes matriculados no ambulatório de Cardiopatias Gerais do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, entre 1980 e 1997. A idade variou de 3 a 76 anos, com média de 37±16; 102 pacientes eram do sexo masculino e 112 do sexo feminino. Os pacientes foram submetidos a eletrocardiografia, eletrocardiografia dinâmica de 24 horas, ecocardiografia e estudo hemodinâmico. A média do tempo de seguimento foi de 88±56 meses com variação de 13 a 299. Observamos 22 óbitos, sendo 14 (6%) relacionados à doença e destes, 11/14 (78%) faleceram subitamente. A probabilidade de sobrevida em cinco anos foi de 93,8%, 87,7% em dez anos e 76,4% em 15 anos. A taxa de mortalidade anual foi de 0,4%. A análise estatística univariada de cada uma das 23 variáveis clínicas e das 20 obtidas pelos exames complementares mostrou que apenas a forma familiar foi fator de risco de óbito. As variáveis forma familiar, idade menor que 20 anos, síncope e classe funcional foram selecionadas para análise multivariada pelo modelo de Cox e método stepwise. Novamente, a forma familiar foi identificada como fator . de risco independente de óbito. Podemos concluir, com base em nossos dados de casuística de centro de referência que, a longo prazo, a sobrevida dos pacientes portadores de cardiomiopatia hipertrófica foi benigna e que a forma familiar é fator de risco de óbito. / To evaluate the prognostic factors related to long-term survival in hypertrophic cardiomyopathy, 214 outpatients were prospectively studied from 1980 to 1997 at the Equipe de Cardiopatias Gerais do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. There were 102 male and 112 female patients, aged 37±16 years, ranging from 3 to 76 years. They underwent electrocardiography, 24-h ambulatory electrocardiographic recording, echocardiography and hemodynamic study. There were 22 deaths, 14 (6%) of them as a direct consequence of the disease, after a mean follow up of 88±56 months (13 - 299). Eleven of these deaths (78%) were sudden and unexpected. The cumulative survival rates were 93.8% in 5 years, 87.7% in 10 years and 76.4% in 15 years. The annual mortality rate was 0.4%. Univariate analysis was performed taking into account 23 clinical variables and 20 variables obtained from laboratory tests. Only family history was shown to be associated with cardiac mortality. In addition, four known adverse factors such as family history, young age, syncope, and functional class were chosen for entering a Cox's multivariate stepwise model. Again, only family history was identified as an independent risk factor for cardiac death. We concluded, based on this selected population from a referral center, that long-term survival of patients with hypertrophic cardiomyopathy is benign and related to family history.

Foram analisados retrospectivamente os prontuários de 97 pacientes portadores de carcinoma do esôfago quanto às complicações intra-operatórias, complicações pós-operatórias precoces, complicações pós-operatórias tardias, alterações digestivas e nutricionais, mortalidade pós-operatória, qualidade de vida e sobrevida até 24 meses, após a reconstrução do trânsito esofágico, comparando esofagocoloplastia versus esofagogastroplastia. Os pacientes foram divididos em dois grupos: A, reconstruídos com o colon (55 pacientes) e B, reconstruídos com o tubo gástrico (42 pacientes). A histologia foi carcinoma espinocelular nos grupos A e B em 96,4% e 92,9%, respectivamente, e adenocarcinoma nos grupos A e B em 3,6% e 4,8% respectivamente. A faixa etária média nos grupos A e B foi de 55,1anos e 58,1anos. As complicações intra-operatórias mais importantes foram a hemorragia nos grupos A e B respectivamente, (1,8% e 28,6%) com diferença significativa, e lesão do nervo recorrente laríngeo (grupos A e B 5,5% e 0%, respectivamente). As complicações pós-operatórias precoces mais freqüentes foram às fístulas cervicais com os seguintes percentuais: grupos A e B 36,4% e 50,0%, e as infecções com destaque para as broncopneumonias (nos grupos A e B 14,6% e 23,8%). Estenose de anastomose ocorreu nos grupos A e B em 14,6% e 14,3%, com boa resolução através da dilatação endoscópica. As complicações pós-operatórias precoces totais foram maiores nos pacientes do grupo B do que nos do grupo A, com significância estatística. A mortalidade pós-operatória nos grupos A e B foi de 9,1% e 14,3%. O ganho ponderal variou de 0 a 12kg nos 6 primeiros meses de pós-operatório, com média nos grupos A e B de 3,3kg e 3,2kg. A capacidade de deglutição foi definida como boa, quando o paciente não apresentasse nenhuma dificuldade em ingerir sólidos, pastosos e líquidos e verificou-se nos pacientes dos grupos A e B os seguintes dados: 54,6% e 42,9%, boa capacidade de ingestão. A satisfação com o procedimento, traduzindo assim uma melhor qualidade de vida em relação ao período pré-operatório, alcançou nos grupos A e B 54,6% e 42,9%. A sobrevida até 24 meses nos grupos A e B registrou 67,3% e 42,9%. Conclui-se que a esofagogastroplastia associou-se a maior sangramento intra-operatório, e maior taxa de complicações totais no pós-operatório precoce, cabendo a ressalva da diferença entre operações realizadas em um único e dois tempos cirúrgicos. Estenoses tardias ocorrem em ambos os grupos, as quais foram resolvidas facilmente através de dilatações endoscópicas com uma média de três para cada paciente, com intervalo entre uma e outra de três a quatro semanas. Ganho ponderal e alterações digestivas e nutricionais foram semelhantes nos dois grupos. A sobrevida até 24 meses foi maior entre os pacientes do grupo A, com significância estatística. A coloplastia foi superior a gastroplastia em relação a alguns aspectos pós-operatórios tardios, sendo que para a maioria das variáveis ambos os procedimentos se equipararam / Medical records of 97 patients with carcinoma of the esophagus were reviewed, retrospectively, to determine intra-operatory complications, as well as early and late post-operatory complications, digestive and nutritional changes, post-operatory mortality, quality of life and survival up to 24 months after the reconstruction of the esophageal transit, by comparing esophagocoloplasty and esophagogastroplasty. The patients were divided in two groups: Group A, those who had undergone colon reconstruction (55 patients) and Group B, those who had their gastric tube reconstructed (42 patients). Histology was consistent with spinocellular carcinoma in groups A and B, with 96.4% and 92.9% respectively, while adenocarcinoma was a finding in groups A and B for 3.6% and 4.8% individuals, respectively. The average age for group A and B patients was 55.1 and 58.1 years. The most important intra-operatory complications were hemorrhage in group A and B patients, representing, respectively, 1.8% and 28.6%, with a significant difference, and a lesion of the recurrent laryngeal nerve (the figures for groups A and B are 5.5% and 0%, respectively). The most frequent early post-operatory complications were cervical fistulas, with the following percentages for group A and B patients, 36,4% and 50.0%, followed by infections. The most prevalent of those were bronchopneumonias (which represented 14.6% and 23.8% in group A and B patients, respectively). Stenoses of the anastomosis were noticed in 14.6% and 14.3% patients of groups A and B, with good resolution through endoscopic dilation. Total early post-operatory complications were higher for group B patients than for group A patients, with statistical significance. Post-operatory mortality in groups A and B was of 9.1% and 14.3%. Weight gain varied between 0 to 12 kg, in the first 6 months after the procedure, and the average figures were 3.3 kg and 3.2kg, for group A and B patients. The ability to swallow was defined as good when the patient didn\'t have any problems ingesting solid, creamy and liquid food, and it was possible to observed the following percentages in the two groups: 54.6% and 42.9%. In groups A and B 70.9% and 64.3% of the patients were satisfied with the procedure, which would represent better quality of life. relative to the pre-operatory status. Survival up to 24 months in groups A and B was recorded as 67,3% and 42,9%. It is then possible to conclude that an esophagogastroplasty was associated with more intra-operatory bleeding and a higher rate of total complications during the early post-operatory phase. It is worthwhile pointing out, at this time, that there was an outcome difference between surgery being performed as one or two separate procedures. Late stenoses happened in both groups and were easily solved through endoscopic dilations, an average of 3 per patient, at three to four week intervals. Weight gain and digestive and nutritional changes were similar for both groups. Survival within 24 months was greater for group A patients, a fact which proved to be statistically significant. Coloplasty was considered a better procedure than gastroplasty with regards to some late post-operatory aspects, but for most of the variables, both procedures can be considered equivalent