Orientador: Ana Lúcia dos Anjos Ferreira / Banca: Victor Zuniga Dourado / Banca: Luis Cuadrado Martin / Resumo: Apesar da fisioterapia respiratória aparentemente beneficiar pacientes sob ventilação mecânica, não há evidências suficientes para sua recomendação. Usando associação das manobras compressão torácica (CT) e hiperinsuflação manual (HM), prévio estudo de nosso grupo identificou significante redução no período de ventilação mecânica (VM), no período de internação e melhora da extensão de lesão pulmonar (Murray) em pacientes sob VM. Contudo, é desconhecido o papel isolado de cada manobra nos benefícios encontrados. Portanto, o objetivo deste estudo foi comparar prospectivamente o efeito isolado e associado das manobras CT e HM no período de internação e de VM em pacientes sob VM. O estudo foi conduzido por 13 meses na UTI (Pronto-Socorro do Hospital das Clínicas, UNESP, Botucatu, SP, Brasil) de um hospital universitário terciário. Foi também avaliada a interferência das manobras nos seguintes parâmetros: índice prognóstico (APACHE-II), Murray, oxigenação (PaO2/FiO2), mecânica respiratória, repercussões hemodinâmicas e saturação periférica de oxigênio (SpO2). A análise estatística utilizou o teste de Goodman para contrastes entre e dentro de populações multinomiais, qui-quadrado, análise de variância e análise de variância para o modelo de medidas repetidas em grupos independentes. Dos 204 pacientes que preencheram os critérios de inclusão e exclusão e foram admitidos no estudo, 20 pacientes foram alocados no grupo CT, 20 no grupo HM e 20 no grupo CT+HM de acordo com o processo de sistematização. Diversas causas levaram à exclusão de alguns pacientes durante o estudo e cada grupo passou a ser constituído por 15 pacientes. O grupo CT recebeu compressão torácica, o grupo HM recebeu hiperinsuflação manual e o grupo CT+HM recebeu a associação de ambas as manobras duas vezes ao dia durante cinco... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: There is no evidence to support the recommendation of chest physiotherapy on mechanically ventilated (MV) patients, although this procedure apparently improves those patients. Using association of thoracic compression (TC) and manual hyperinflation (MH), our previous study identified significant reduction in duration of weaning from ventilation, discharge from intensive care unit (ICU) and extent of lung damage index (Murray). However, it is unknown the individual role of each maneuver on those benefits. Therefore, the aim of the study was evaluate the isolated and associated effect of TC and MH on the mechanical ventilation period and length of stay in mechanically ventilated patients. Secondarily, outcomes of interest were the effect of physiotherapy on Murray, severity score and on hemodynamics, gas exchange, and respiratory mechanics. It was conducted at ICU of the Emergency Room (ER) at Hospital das Clínicas of São Paulo State University (UNESP-HC) (Botucatu, SP, Brazil) for 13 consecutive months. The significance of differences between groups was accessed by Goodman test, chi-squared analysis, ANOVA and a nonparametric repeated measures ANOVA. The present study was a three-group (TC, MH, and TC+MH), prospective and systematized clinical study lasting 5 days. Of the 204 patients who fulfilled all the inclusion criteria and were enrolled in the study, 20 patients were allocated into TC group, 20 into MH group or 20 into TC+HM group. The TC group received expiratory chest compression, the MH group received manual hyperinflation and the TC+HM received manual hyperinflation combined with expiratory chest compression twice a day for 5 days. Five patients from TC, 5 from MH and 5 from TC+HM were withdrawn during the study period due to several reasons and therefore, 15 patients remained in each group. The 3 groups... (Complete abstract click electronic access below) / Mestre

Introdução: Complicações respiratórias são comuns no pós-operatório de cirurgias abdominais. Identificar os fatores de risco para tal possibilita à equipe de saúde adotar medidas protetivas, a fim de reduzir a chance de complicações e suas implicações. Objetivo: Identificar fatores de risco para complicações respiratórias no pós-operatório de cirurgias abdominais. Metodologia: Estudo de coorte retrospectivo realizado por busca em prontuário eletrônico de indivíduos adultos submetidos à cirurgia abdominal no período de Janeiro a Julho de 2016. Os dados foram analisados através do software estatístico SPSS 20.0. Para teste de normalidade foi utilizado Shapiro-Wilk, para comparação entre grupos teste de X² e t-test, para cálculo de razão de chance foi utilizada regressão logística multivariada. Considerou-se significativo p<0,05. Resultados: No período estudado foram realizadas 1586 cirurgias, sendo os pacientes 55,7% do sexo feminino com idade média de 52,12±16,56 anos. Após a cirurgia, 17,7% dos pacientes apresentaram alguma complicação respiratória; sendo a mais prevalente atelectasia. Identificou-se como fator de risco independente para o surgimento de complicações respiratórias a realização de cirurgia aberta, cirurgia de emergência, presença de pneumopatia crônica, ASA≥3, incisão supraumbilical, IMC≤21kg/m², tabagismo, idade e tempo de cirurgia. Os indivíduos que apresentaram complicações respiratórias permaneceram mais tempo hospitalizados e apresentaram maior mortalidade. Conclusão: Cirurgias abdominais realizadas por laparoscopia estão relacionadas a um menor risco de complicações respiratórias, enquanto que a presença de pneumopatia crônica é o principal fator de risco entre comorbidades. Complicações respiratórias elevam o tempo de internação e a mortalidade. / Introduction: Postoperative respiratory complications are common after abdominal surgeries. Identify risk factors helps the health team to adopt protective measures in order to reduce the chance of complications and its implications. Objective: Identify risk factors for postoperative respiratory complications after abdominal surgeries. Methodology: A retrospective cohort study was carried out by searching electronic medical records of adult subjects submitted to abdominal surgery from January to July 2016. Data were analyzed using statistical software SPSS 20.0. For the normality test, Shapiro-Wilk was used to compare groups of categorical variables. X² test was used and for continuous variables, t test for independent variables and multivariate logistic regression was used to calculate odds ratios. Significant p<0.05 was considered. Results: During the study period, 1586 surgeries were performed, 55.7% female patients with a mean age of 52.12±16.56 years. After surgery, 17.7% of the patients presented one or more respiratory complications; the most common was atelectasis. Independent risk factors identified were open surgery, emergency surgery, chronic lung disease, ASA≥3, supraumbilical incision, BMI≤21kg/m², smoking, age and surgery time. Subjects with respiratory complications presented higher length of stay and mortality. Conclusion: Abdominal surgeries performed by laparoscopy are related to a lower risk of respiratory complications, while the presence of chronic lung disease is the main risk factor among comorbidities. Respiratory complications increase length of hospital stay and mortality.

Neutropenia febril (NF) constitui complicação frequente do tratamento quimioterápico do câncer e está associada a altas taxas de morbimortalidade. O reconhecimento dos principais fatores associados ao desenvolvimento de desfechos clínicos desfavoráveis na NF é fundamental, uma vez que estes podem ser utilizados como marcadores prognósticos ou alvos terapêuticos. Este estudo objetiva determinar os principais fatores associados com mortalidade, tempo de hospitalização, incidência de bacteremia por patógenos multirresistentes e incidência de choque séptico no início da febre em pacientes hospitalizados com NF secundária à quimioterapia citotóxica para o câncer. Na presente coorte prospectiva composta por 305 episódios consecutivos de NF (em 169 pacientes com câncer) realizada em um hospital terciário no período de outubro de 2009 a agosto de 2011, as seguintes questões de pesquisa foram avaliadas: impacto do tempo de início da antibioticoterapia na mortalidade em 28 dias; fatores relacionados com tempo de hospitalização; impacto dos fatores microbiológicos da bacteremia no desenvolvimento de choque séptico no início do episódio de NF; fatores de risco para bacteremia por patógenos multirresistentes; impacto da bacteremia por Staphylococcus coagulase-negativo na mortalidade em 28 dias. Em 5 publicações distintas, os seguintes resultados foram notados: o atraso do início da antibioticoterapia está associado a maiores taxas de mortalidade em 28 dias; neoplasia hematológica, regimes quimioterápicos de altas doses, duração da neutropenia e bacteremia por Gram-negativos multirresistentes estão associados com períodos prolongados de internação por NF; infecção de corrente sanguínea polimicrobiana, bacteremia por Escherichia coli e bacteremia por Streptococcus viridans estão associados a choque séptico no início do episódio de NF; idade avançada, duração da neutropenia e presença de cateter venoso central estão associados com bacteremia por patógenos multirresistentes; bacteremia por Staphylococcus coagulase-negativo está associada a menores taxas de mortalidade em 28 dias quando comparado à bacteremia por outros patógenos. / Febrile neutropenia (FN) is a common complication of cancer chemotherapy and is associated with high morbidity and mortality rates. Recognition of the main factors associated with the development of adverse clinical outcomes in FN is crucial, given that these factors can be used as prognostic markers or therapeutic targets. This study aims to determine the main factors associated with mortality, length of hospital stay, incidence of bacteremia by multidrug-resistant pathogens and incidence of septic shock at the onset of fever in hospitalized patients with FN secondary to cancer cytotoxic chemotherapy. In the present prospective cohort of 305 FN episodes (in 169 cancer patients) conducted at a tertiary hospital from October 2009 to August 2011, the following research questions were evaluated: impact of time to antibiotic administration on 28-day mortality; factors associated with length of hospital stay; impact of microbiological factors of bacteremia on the development of septic shock at the onset of FN; risk factors for bacteremia by multidrug-resistant pathogens; impact of coagulasenegative Staphylococcus bacteremia on 28-day mortality. In 5 distinct publications, the following results were noted: delay of antibiotic administration is associated with higher 28-day mortality rates; hematologic malignancy, high-dose chemotherapy regimens, duration of neutropenia and bacteremia by multidrug-resistant Gram-negative bacteria are associated with prolonged length of hospital stay; polymicrobial bloodstream infection, bacteremia by Escherichia coli, and bacteremia by viridans sreptococci are associated with septic shock at the onset of FN; advanced age, duration of neutropenia and presence of indwelling central venous catheters are associated with bacteremia by multidrug-resistant pathogens; coagulase-negative Staphylococcus bacteremia is associated with lower 28-day mortality rates compared with bacteremia by other pathogens.

Neutropenia febril (NF) constitui complicação frequente do tratamento quimioterápico do câncer e está associada a altas taxas de morbimortalidade. O reconhecimento dos principais fatores associados ao desenvolvimento de desfechos clínicos desfavoráveis na NF é fundamental, uma vez que estes podem ser utilizados como marcadores prognósticos ou alvos terapêuticos. Este estudo objetiva determinar os principais fatores associados com mortalidade, tempo de hospitalização, incidência de bacteremia por patógenos multirresistentes e incidência de choque séptico no início da febre em pacientes hospitalizados com NF secundária à quimioterapia citotóxica para o câncer. Na presente coorte prospectiva composta por 305 episódios consecutivos de NF (em 169 pacientes com câncer) realizada em um hospital terciário no período de outubro de 2009 a agosto de 2011, as seguintes questões de pesquisa foram avaliadas: impacto do tempo de início da antibioticoterapia na mortalidade em 28 dias; fatores relacionados com tempo de hospitalização; impacto dos fatores microbiológicos da bacteremia no desenvolvimento de choque séptico no início do episódio de NF; fatores de risco para bacteremia por patógenos multirresistentes; impacto da bacteremia por Staphylococcus coagulase-negativo na mortalidade em 28 dias. Em 5 publicações distintas, os seguintes resultados foram notados: o atraso do início da antibioticoterapia está associado a maiores taxas de mortalidade em 28 dias; neoplasia hematológica, regimes quimioterápicos de altas doses, duração da neutropenia e bacteremia por Gram-negativos multirresistentes estão associados com períodos prolongados de internação por NF; infecção de corrente sanguínea polimicrobiana, bacteremia por Escherichia coli e bacteremia por Streptococcus viridans estão associados a choque séptico no início do episódio de NF; idade avançada, duração da neutropenia e presença de cateter venoso central estão associados com bacteremia por patógenos multirresistentes; bacteremia por Staphylococcus coagulase-negativo está associada a menores taxas de mortalidade em 28 dias quando comparado à bacteremia por outros patógenos. / Febrile neutropenia (FN) is a common complication of cancer chemotherapy and is associated with high morbidity and mortality rates. Recognition of the main factors associated with the development of adverse clinical outcomes in FN is crucial, given that these factors can be used as prognostic markers or therapeutic targets. This study aims to determine the main factors associated with mortality, length of hospital stay, incidence of bacteremia by multidrug-resistant pathogens and incidence of septic shock at the onset of fever in hospitalized patients with FN secondary to cancer cytotoxic chemotherapy. In the present prospective cohort of 305 FN episodes (in 169 cancer patients) conducted at a tertiary hospital from October 2009 to August 2011, the following research questions were evaluated: impact of time to antibiotic administration on 28-day mortality; factors associated with length of hospital stay; impact of microbiological factors of bacteremia on the development of septic shock at the onset of FN; risk factors for bacteremia by multidrug-resistant pathogens; impact of coagulasenegative Staphylococcus bacteremia on 28-day mortality. In 5 distinct publications, the following results were noted: delay of antibiotic administration is associated with higher 28-day mortality rates; hematologic malignancy, high-dose chemotherapy regimens, duration of neutropenia and bacteremia by multidrug-resistant Gram-negative bacteria are associated with prolonged length of hospital stay; polymicrobial bloodstream infection, bacteremia by Escherichia coli, and bacteremia by viridans sreptococci are associated with septic shock at the onset of FN; advanced age, duration of neutropenia and presence of indwelling central venous catheters are associated with bacteremia by multidrug-resistant pathogens; coagulase-negative Staphylococcus bacteremia is associated with lower 28-day mortality rates compared with bacteremia by other pathogens.

INTRODUÇÃO: O sucesso do tratamento de dependentes de álcool e outras drogas numa comunidade terapêutica (CT) depende fundamentalmente da adesão ao tratamento, ou seja, o tempo de permanência na comunidade. Sabe-se que pacientes que permanecem em tratamento por um período de pelo menos três meses têm uma evolução melhor do que aqueles que abandonam o tratamento precocemente. O ambiente emocional familiar tem grande influência na adesão ao tratamento, e pode ser medido por meio da emoção expressa EE). MÉTODOS: Foram avaliados familiares de 31 dependentes de substâncias psicoativas e/ou de álcool, internados involuntariamente, por meio da versão abreviada e traduzida para o português da Entrevista Familiar de Camberwell (EFC). A partir de então, mediu-se a taxa de permanência na CT após seis, 12 e 18 meses. Foram avaliados os aspectos hostilidade, superenvolvimento e calor afetivo. A hostilidade foi abordada como ausente (pontuação igual a zero) ou presente (pontuação igual a 1, 2 ou 3). O superenvolvimento e o calor afetivo foram considerados de forma contínua (pontuação de zero a 5) e categorizada. Todos os possíveis pontos de corte foram estudados na procura de novas relações e significados dos componentes da EE para esta população específica e os achados da amostra. RESULTADOS: Foram considerados com alta EE para hostilidade 41,9% dos familiares entrevistados e 71% para superenvolvimento emocional; 25,8% destes familiares pontua ram para ambos os componentes da EE (hostilidade e superenvolvimento). Dos 31 pacientes, cinco (16,1%) desistiram do tratamento até os seis meses; dois pacientes desistiram entre o 6 o e o 12 o mês (25% de desistência em 12 meses) e quatro abandonaram o tratamento entre o 12 o e o 18 o mês (47,8% de abandono em 18 meses). Houve uma associação significativa entre a presença de hostilidade e o abandono do tratamento antes dos seis meses (p = 0,008, teste exato de Fischer). Houve diferença significativa na frequência de superenvolvimento familiar entre o grupo que permaneceu 18 meses e o grupo que abandonou o tratamento (p = 0,037, teste de Mann-Whitney). Os pacientes que permanceram em tratamento até os 18 meses tiveram uma freqüência maior de familiares com alto nível de superenvolvimento familiar (> 4) (p = 0,012; teste exato de Fisher). Não houve nenhuma associação entre o tempo de permanência e o calor afetivo. CONCLUSÕES: Alta EE tem influência significativa sobre o tempo de permanência do dependente químico ou de álcool na CT. A presença de hostilidade foi mais freqüente no grupo com o abandono prematuro do tratamento, enquanto o alto superenvolvimento do familiar foi mais freqüente no grupo de pacientes que permaneceu em tratamento até os 18 meses. Estudos com uma população maior são necessários para apoiar esses achados. / BACKGROUND: The success of treatment for alcohol and other substance dependence in a therapeutic community (TC) depends greatly on the treatment adherence, i.e., the length of stay at the TC. It is well known that subjects who stay on treatment for ate least three months have a better outcome, compared with those who early withdraw. The family emotional environment can be measured through expressed emotion (EE) and has great influence on treatment adherence. METHODS: 31 key-relatives of alcoholics and other substance dependents, who involuntarily began a treatment in a TC, were assessed through the Camberwell Family Interview (CFI) (shorter translated to Portuguese version). The proportion of subjects who remained on treatment in the TC was then measured after six, 12 and 18 months. Evaluated aspects included hostility, overinvolvement and warmth. Hostility was assessed as absent (score = 0) or present (score = 1, 2 or 3). Overinvolvement and warmth were considered as continuous and categorized values (scores 0 to 5). Every possible cutoff points were studied, in order to find new associations and meanings of EE components of this specific population and the length pf stay in a TC. RESULTS: 41.9% of the relatives were considered as having high EE for hostility and 71% for overinvolvement; among those relatives with high EE, 25.8% had presence for both hostility and overinvolvement. Among the 31 patients, five (16.1%) abandoned treatment up to 6 months; 2 patients abandoned treatment between 6th and 12th month (25% treatment abandon in 12 months) and four abandoned the treatment between 12th and 18th month (47.8% treatment abandon at 18 months). There was a significant higher frequency of presence of hostility in the group that abandoned before six months (p = 0.008, Fischer exact test). A significant difference of familiar overinvolvement was found between the group who remained in the treatment up to 18 months and the group that abandoned treatment earlier (p = 0.037, Mann-Whitney test). Families with score = 4 for overinvolvement were more frequent in the group that remained on treatment up to 18 months (p = 0.0012; Fischer exact test). No correlation was found between warmth and length of stay at TC. CONCLUSIONS: High EE has a significant influence over the length of stay of the alcoholic or other substance dependent in a TC. The presence of hostility is more frequent among families of patients who prematurely abandon treatment, while higher score of overinvolvement was more frequent in the families of the group that completed 18 months of treatment in the TC. Further studies with larger population are needed to support those findings.

In 2007, the Canadian Paediatric Society (CPS) released a guideline aimed at preventing complications of neonatal jaundice through universal screening and guidelines for follow-up and treatment. This thesis investigates the impact of implementation of the CPS guideline on health services utilization at a population level in Ontario. First, we surveyed all Ontario hospitals providing maternal-newborn services to determine if and when they had implemented universal bilirubin screening, and to gather information about the organization of services to provide follow-up and treatment, and about the factors that influenced screening implementation. Then we conducted two population-based cohort studies using linked administrative health data to evaluate the association between 1) the implementation of universal bilirubin screening and phototherapy use (during and following birth hospitalization) length of stay (LOS), jaundice-related emergency department (ED) visits and readmissions; and 2) universal bilirubin screening implementation and access to recommended follow-up care by socio-economic status (SES). By 2012, the majority of Ontario hospitals had implemented universal bilirubin screening. There is heterogeneity in how hospitals organize services, but a notable trend towards hospital-based post-discharge care. Screening was associated with an increase in phototherapy during hospitalization at birth (relative risk (RR) 1.32, 95% confidence interval (CI) 1.09-1.59), and a decrease in jaundice-related ED visits (RR 0.79, 95% CI 0.64-0.96), but no statistically significant difference in phototherapy after discharge, length of stay, or jaundice-related readmissions after accounting for pre-existing temporal trends in healthcare service use and other patient socio-demographic and hospital characteristics. Implementation of the universal bilirubin screening in Ontario was associated with a modest increase in rates of early follow-up (adjusted RR 1.11, CI 1.0014-1.22, p=0.0468), but most babies were not seen within the recommended timeframe. Babies of lowest SES were least likely to receive recommended follow-up, and disparities in follow-up increased following universal bilirubin screening implementation. En 2007, la Société canadienne de pédiatrie (SCP) a publié une directive visant à la prévention des complications de l'ictère néonatal par le dépistage universel et des lignes directrices pour le suivi et le traitement. Cette thèse étudie l'impact de la mise en œuvre de la directive SCP sur l'utilisation des services de santé à niveau de population de l'Ontario. Tout d'abord, nous avons interrogé tous les hôpitaux de l'Ontario offrant des services de santé maternelle-nouveau-né afin de déterminer si et quand ils avaient mis en œuvre le dépistage universel de la bilirubine, et à recueillir des informations sur l'organisation des services pour assurer un suivi et de traitement, et sur les facteurs qui ont influencé la mise en œuvre de dépistage. Ensuite, nous avons mené deux études de cohorte basée sur la population à partir de données administratives sur la santé pour évaluer 1 ) l'association entre la mise en œuvre du dépistage de la bilirubine universel et la photothérapie utilisation lors de l'hospitalisation à la naissance, la photothérapie après avoir sortie de l'hôpital, la durée du séjour, le service des urgences liées à la jaunisse et des réadmissions liées à la jaunisse; et 2 ) l'association entre la mise en œuvre du dépistage universel et l'accès aux soins de suivi recommandés et si cela différait entre les quintiles de statut socioéconomique. En 2012, la majorité des hôpitaux de l'Ontario a mis en œuvre le dépistage universel de la bilirubine. Il existe une hétérogénéité de la façon dont les hôpitaux organisent des services, mais une tendance notable vers les soins post-décharge en milieu hospitalier. Le dépistage a été associé à une augmentation de la photothérapie pendant l'hospitalisation à la naissance (risque relatif (RR) de 1,32, intervalle de confiance 95 % (IC 95 %) de 1,09 à 1,59), et une diminution des visites à l'urgence liées à la jaunisse (RR 0,79, IC 95 % 0,64 à 0,96), mais aucune différence statistiquement significative dans la photothérapie après la sortie , la durée du séjour , ou réadmissions liées jaunisse - après comptabilisation des tendances temporelles pré- existants dans l'utilisation des services de soins de santé et d'autres caractéristiques socio- démographiques des patients et caractéristiques de l'hôpital. La mise en œuvre de le dépistage universel en Ontario a été associée à une légère augmentation des taux de suivi précoce (RR ajusté 1,11; IC de 1,0014 à 1,22; p = 0,0468), mais la plupart des bébés n'ont pas été vues dans les délais recommandés. Les bébés de statut socioéconomique faibles étaient moins susceptibles de recevoir de soins de suivi recommandés et les disparités dans le suivi ont augmenté suite à la mise en œuvre du dépistage universel de la bilirubine.

Introdução: Complicações respiratórias são comuns no pós-operatório de cirurgias abdominais. Identificar os fatores de risco para tal possibilita à equipe de saúde adotar medidas protetivas, a fim de reduzir a chance de complicações e suas implicações. Objetivo: Identificar fatores de risco para complicações respiratórias no pós-operatório de cirurgias abdominais. Metodologia: Estudo de coorte retrospectivo realizado por busca em prontuário eletrônico de indivíduos adultos submetidos à cirurgia abdominal no período de Janeiro a Julho de 2016. Os dados foram analisados através do software estatístico SPSS 20.0. Para teste de normalidade foi utilizado Shapiro-Wilk, para comparação entre grupos teste de X² e t-test, para cálculo de razão de chance foi utilizada regressão logística multivariada. Considerou-se significativo p<0,05. Resultados: No período estudado foram realizadas 1586 cirurgias, sendo os pacientes 55,7% do sexo feminino com idade média de 52,12±16,56 anos. Após a cirurgia, 17,7% dos pacientes apresentaram alguma complicação respiratória; sendo a mais prevalente atelectasia. Identificou-se como fator de risco independente para o surgimento de complicações respiratórias a realização de cirurgia aberta, cirurgia de emergência, presença de pneumopatia crônica, ASA≥3, incisão supraumbilical, IMC≤21kg/m², tabagismo, idade e tempo de cirurgia. Os indivíduos que apresentaram complicações respiratórias permaneceram mais tempo hospitalizados e apresentaram maior mortalidade. Conclusão: Cirurgias abdominais realizadas por laparoscopia estão relacionadas a um menor risco de complicações respiratórias, enquanto que a presença de pneumopatia crônica é o principal fator de risco entre comorbidades. Complicações respiratórias elevam o tempo de internação e a mortalidade. / Introduction: Postoperative respiratory complications are common after abdominal surgeries. Identify risk factors helps the health team to adopt protective measures in order to reduce the chance of complications and its implications. Objective: Identify risk factors for postoperative respiratory complications after abdominal surgeries. Methodology: A retrospective cohort study was carried out by searching electronic medical records of adult subjects submitted to abdominal surgery from January to July 2016. Data were analyzed using statistical software SPSS 20.0. For the normality test, Shapiro-Wilk was used to compare groups of categorical variables. X² test was used and for continuous variables, t test for independent variables and multivariate logistic regression was used to calculate odds ratios. Significant p<0.05 was considered. Results: During the study period, 1586 surgeries were performed, 55.7% female patients with a mean age of 52.12±16.56 years. After surgery, 17.7% of the patients presented one or more respiratory complications; the most common was atelectasis. Independent risk factors identified were open surgery, emergency surgery, chronic lung disease, ASA≥3, supraumbilical incision, BMI≤21kg/m², smoking, age and surgery time. Subjects with respiratory complications presented higher length of stay and mortality. Conclusion: Abdominal surgeries performed by laparoscopy are related to a lower risk of respiratory complications, while the presence of chronic lung disease is the main risk factor among comorbidities. Respiratory complications increase length of hospital stay and mortality.

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Having a newborn can be a big change for families, especially for first-time parents. At hospital discharge, parents are often provided with a lot of information, which can be difficult to retain. Due to shortened postnatal lengths of stay, nurses typically have less time to educate parents, which often results in families feeling overwhelmed. After hospital discharge, it is recommended for families to see a health care provider (i.e., physician, nurse practitioner, or registered midwife) within 72 hours for a follow-up appointment. This follow-up appointment is meant to assess both the mother and newborn to ensure they are both in good health and to provide any needed support. Unfortunately, completing the appointment within this timeframe may not be possible for every family or they may not be aware of its importance. Depending on the family’s model of care, completing the follow-up appointment within 72 hours after hospital discharge can be challenging. Families that have a physician as their health care provider may experience delays in scheduling the follow-up appointment. This can be due to the physician’s lack of availability, as there is a physician shortage in most communities. Furthermore, some families do not have access to a health care provider and, therefore, do not see a care provider after hospital discharge. Completing the follow-up appointment later than when it is recommended, or not at all, can result in negative health consequences for the mother and newborn and can also increase re-admission hospital rates and related costs (Cargill et al., 2007). At the moment, postnatal lengths of stay are shortening but the service delivery has not changed to accommodate this trend (Lemyre et al., 2018). This means that the services typically provided to families in the hospital now need to be provided in the community. The follow-up appointment after hospital discharge is an opportunity to provide these services; however, timely access to a health care provider, specifically a physician, can be challenging. Thus, this thesis explores the development of a general design methodology for a postpartum nurse practitioner-led clinic. The aim of the clinic is to provide timely access to any family that needs to complete the necessary postpartum services after hospital discharge within a community. An analytical model was developed to explore the characteristics of a postpartum nurse practitioner-led clinic and how it would operate (i.e., what services would be offered, the amount of time needed for these services, what is needed to offer these services, etc.). The model conducts a simulation of the appointment scheduling process based on the input values entered into it and evaluates a number of performance metrics (e.g., number of diversions, patient wait times, resource idle time, clinic overtime, number of appointments provided within 72 hours and number of appointments provided beyond 72 hours). The findings from the model can support the potential implementation of a postpartum nurse practitioner-led clinic in any community. Implementing such clinics could increase awareness, further educate parents and increase access to postpartum services.

Essential hypertension (HTN) has been and continues to be a serious public health problem across the globe, particularly among Black races, with an estimated morbidity rate of over 1 billion people and an estimated mortality rate of 9.4 million people worldwide. Essential HTN can lead to a host of chronic diseases including cardiovascular disease (CVD), stroke, myocardial infarction, brain damage, kidney failure, and retinopathy. The main purpose of this quantitative, descriptive, nonexperimental study was to investigate the association of physical inactivity, length of stay in the United States, immigrants' health status, and food security as risk indicators in the development of essential HTN among African-born immigrants after accounting for age and education. The conceptual framework for this study was the socioecological model of health (SEMH). A secondary dataset from the National Health Interview Survey (NHIS), for the year 2014, was used for this study, including data for Africa-born immigrants over the age of 40 who participated in the survey. Logistic regression was used for statistical analyses. The results of the study revealed that length of stay or years in spent in the United States have a significant association with the development of essential HTN. Results from this study could be used to promote positive social change by identifying and assessing challenges in implementing intervention programs meant to assist in controlling essential HTN among African-born immigrants and Black populations who are disproportionately affected by this condition.