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  • About
  • The Global ETD Search service is a free service for researchers to find electronic theses and dissertations. This service is provided by the Networked Digital Library of Theses and Dissertations.
    Our metadata is collected from universities around the world. If you manage a university/consortium/country archive and want to be added, details can be found on the NDLTD website.
231

Kardijalni biomarkeri u predviđanju operativnog rizika kardiohirurških bolesnika sa oslabljenom sistolnom funkcijom leve komore / Cardiac surgery operative risk assessment in patients with impaired systolic left ventricular function using cardial biomarkers

Radišić Bosić Jasna 29 June 2017 (has links)
<p>Kardijalni biomarkeri u predviđanju operativnog rizika kardiohirur&scaron;kih bolesnika sa oslabljenom sistolnom funkcijom leve komore Evaluacija rezultata u kardiohirurgiji podrazumeva praćenje ishoda operativnog lečenja u određenom vremenskom periodu. Najče&scaron;će je to interval od 30 dana od datuma intervencije. Najče&scaron;ći kriterijumi za praćenje su stopa mortaliteta i morbiditeta, dužina boravka u jedinici intenzivnog lečenja, ukupna dužina hospitalizacije i tro&scaron;kovi lečenja. Stratifikacija rizika podrazumeva da se bolesnici mogu podeliti u grupe u zavisnosti od broja i važnosti preoperativno utvrđenih faktora rizika, odnosno da se pre operacije može predvideti ishod hirur&scaron;ke intervencije kod svakog od njih pojedinačno. U Evropi je, u periodu između 1995. i 1999. godine, na osnovu multicentrične studije u 8 evropskih zemalja i 128 kardiohirur&scaron;kih centara u kojima je operisano 19.030 odraslih bolesnika, kreiran EvroSKOR - EuroSCORE (European System for Cardiac Operative Risk Evaluation) model za stratifikaciju rizika u kardiohirurgiji. Međutim, neminovne promene i napredak u operativnom lečenju doveli su do toga da je neophodno ažurirati postojeći sistem stratifikacije. Tako je 2012. godine u rutinsku upotrebu uveden novi sistem Euroscore II. Na Klinici za kardiohirurgiju Instituta za kardiovaskularne bolesti Vojvodine (IKVBV), EuroSCORE model uveden je u rutinsku upotrebu od početka 2001. godine. Analizom rezultata, posle dvogodi&scaron;nje primene, pokazalo se da je model bio precizan, odnosno da nije postojala značajna razlika između očekivanog (3,7%) i stvarnog mortaliteta (3,47%). U poslednjih nekoliko godina, kod bolesnika kojima sledi kardiohirur&scaron;ka intervencija, u smislu razmatranja njihove prediktivne vrednosti, sve vi&scaron;e pažnje se poklanja kardijalnim biomarkerima. Najznačajniji biomarkeri u kardiovaskularnoj medicini su: Troponin, Kreatin kinaza MB izoenzim (CKMB), N-terminalni pro B-tip natriuretski peptid (NT-proBNP), C-reaktivni protein (CRP), Laktat dehidrogenaza (LDH), Mokraćna kiselina (Acidum uricum). Ciljevi ovog rada su bili da se kreira model za predviđanje preoperativnog rizika kardiohirur&scaron;kih bolesnika sa oslabljenom sistolnom funkcijom leve komore na osnovu preoperativnih vrednosti određenih biomarkera i da se kreira novi model sa kombinacijom prethodnog modela i već postojećeg modela EuroSCORE II. Ispitana su 704 bolesnika sa oslabljenom sistolnom funkcijom leve komore, ejekcione frakcije manje ili jednake 50%. Bolesnici su operisani na Institutu za kardiovaskularne bolesti Vojvodine, od 20. januara 2014. do 20. aprila 2016. Kod bolesnika su urađene tri vrste operacija: revaskularizacija miokarda-koronarna hirurgija, hirurgija stečenih srčanih mana - valvularna hirurgija i kombinovane operacije. Od biohemijskih analiza, 24 sata pre operacije, urađene su sledeće analize: troponin I, kreatin kinaza, kreatin kinaza MB izoenzim, masena kreatin kinaza, laktat dehidrogenaza, C-reaktivni protein, NT-proBNP i mokraćna kiselina. Praćen je postoperativni mortalitet, postoperativni infarkt miokarda i postoperativni cerebrovaskularni incident i njihova povezanost sa preoperativnim vrednostima nabrojanih biomarkera. U studiju su bili uključeni svi bolesnici sa stečenim bolestima srca, stariji od 18 godina, kod kojih je ejekciona frakcija leve komore bila manja ili jednaka 50% i kod kojih su izvr&scaron;ene sledeće vrste operacija: revaskularizacija miokarda - koronarna hirurgija, hirurgija stečenih srčanih mana - valvularna hirurgija i kombinovane operacije - koronarna i valvularna hirurgija. Rezultati su pokazali da je postoperativni mortalitet bio 3,13%, da je postoperativni infarkt miokarda imalo 7,95% a postoperativni cerebrovaskularni incident 9,23% od ukupnog broja ispitanika. 1. Povezanost vrednosti biomarkera sa postoperativnim infarktom miokarda kod bolesnika sa oslabljenom ejekcionom frakcijom leve komore: povi&scaron;ene preoperativne vrednosti troponina I su bile povezane sa postoperativnim infarktom miokarda. Povezanost preoperativnih vrednosti biomarkera sa postoperativnim cerebrovaskularnim incidentom kod bolesnika sa oslabljenom ejekcionom frakcijom leve komore: povi&scaron;ene preoperativne vrednosti troponina I i CRP-a su bile povezane sa postoperativnim cerebrovaskularnim incidentom. 2. Analiziran je uticaj preoperativnog nivoa svih biomarkera, pojedinačno, na značajne neželjene kardijalne i cerebrovaskularne događaje - Major Adverse Cardiac and Cerebrovascular Events (MACCE) kao ishod posle operacije na srcu, kod bolesnika sa oslabljenom ejekcionom frakcijom leve komore. Dobijeni su sledeći rezultati: Preoperativna vrednost nivoa troponina I veća od 0,01&mu;g/L i MACCE bili su povezani. Povećane preoperativne vrednosti nivoa C-reaktivnog proteina (CRP) i postoperativni MACCE bili su povezani. Povećane preoperativne vrednosti nivoa laktat dehidrogenaze (LDH) i MACCE bili su povezani. Zaključci ove teze su: 1. Nezavisni prediktor postoperativnog infarkta miokarda i značajnih neželjenih kardijalnih i cerebrovaskularnih događaja, kod kardiohirur&scaron;kih bolesnika sa oslabljenom sistolnom funkcijom leve komore, ejekcionom frakcijom manjom ili jednakom 50%, jeste povi&scaron;ena preoperativna vrednost troponina I. 2.Vrednost preoperativnog troponina I je slab marker za predviđanje postoperativnog infarkta miokarda i značajnih neželjenih kardijalnih i cerebrovaskularnih događaja, kod kardiohirur&scaron;kih bolesnika sa oslabljenom sistolnom funkcijom leve komore, ejekcionom frakcijom manjom ili jednakom 50%. 3. Na pojavu postoperativnog cerebrovaskularnog incidenta, kod kardiohirur&scaron;kih bolesnika sa oslabljenom sistolnom funkcijom leve komore, ejekcionom frakcijom manjom ili jednakom 50%, ne utiče nijedna od ispitivanih varijabli. 4. Nezavisni prediktori postoperativnog mortaliteta kod kardiohirur&scaron;kih bolesnika sa oslabljenom sistolnom funkcijom leve komore, ejekcionom frakcijom manjom ili jednakom 50%, na osnovu kojih je moguće kreirati prediktivni Model su godine starosti i povi&scaron;ene preoperativne vrednosti NT-proBNP. 5. Kreirani Model je dobar marker za predikciju ishoda posle operacije na srcu, kod kardiohirur&scaron;kih bolesnika sa oslabljenom sistolnom funkcijom leve komore, ejekcionom frakcijom manjom ili jednakom 50%. 6. Povi&scaron;ena preoperativna vrednost NT- proBNP može da bude dobar marker u predikciji smrtnog ishoda posle operacije na srcu kod bolesnika sa oslabljenom sistolnom funkcijom leve komore, ejekcionom frakcijom manjom ili jednakom 50%. 7. Model EuroSCORE II se pokazao kao slabiji marker za predikciju ishoda posle operacije na srcu kod kardiohirur&scaron;kih bolesnika sa oslabljenom sistolnom funkcijom leve komore, ejekcionom frakcijom manjom ili jednakom 50%. 8. Testiranjem kreiranog modela, podelom na manje rizične i vi&scaron;e rizične bolesnike, u odnosu na visinu ejekcione frakcije leve komore, pokazalo se da je model dobar marker za predviđanje smrtnog ishoda posle operacije na srcu, u obe grupe.</p> / <p>Cardiac surgery operative risk assessment in patients with imapired systolic left ventricular function using cardial biomarkers Evaluation of results in cardiac surgery involves monitoring the outcomes of operative treatment in a given time period. Typically, this interval includes 30 days from the date of operation. The most common criteria used for monitoring are the rate of mortality and morbidity, length of stay in the intensive care unit, the total length of hospitalization and medical costs. Risk stratification means that patients can be divided into groups depending on the number and importance of preoperatively identified risk factors, and that the outcome of surgery for each of the patients can be predicted preoperatively. In Europe, in the period of 1995-1999 on the basis of a multi-center study in 8 European countries and 128 cardiac centers in which 19,030 adult patients were operated on, EuroSCORE (European System for Cardiac Operative Risk Evaluation) model for risk stratification in cardiac surgery was developed. However, the inevitable changes and progress in the surgical treatment rendered the EuroSCORE model obsolete warranting updated system. It was in 2012 when a new system EuroSCORE II was introduced into practice At the Clinic for Cardiac Surgery of the Institute of Cardiovascular Diseases, EuroSCORE model was introduced in routine clinical use since the beginning of 2001. By analyzing the results, two years after application, it was shown that the model was accurate, and that there was no significant difference between the expected (3.7%) and the actual mortality (3.47%) In recent years, in patients who are candidates for cardiac surgery, more attention is paid to cardiac biomarkers in terms of evaluating their predictive power. The most significant biomarkers in cardiovascular medicine are: Troponin, creatine kinase MB isoenzyme (CKMB), N-terminal pro B-type natriuretic peptide (NT-proBNP), C-reactive protein (CRP), Lactate dehydrogenase (LDH), and uric acid (Uric uricum). The objectives of this study were to create a model to predict preoperative risk for cardiac surgery patients with impaired systolic left ventricular function on the basis of preoperative levels of certain biomarkers and to create a new model with a combination of the previous model and already existing EuroSCORE II model. The study included 704 patients with impaired systolic left ventricular function, ejection fraction less than or equal to 50%. All patients underwent cardiac surgery at the Institute of Cardiovascular Diseases, from January 20th 2014 until 20th April 2016. Patients were submitted to three types of operations: revascularization - coronary surgery, surgery of acquired heart defects - valvular surgery and combined operations. Following biochemical analyses were performed 24 hours prior to surgery: troponin I, creatine kinase, creatine kinase MB isoenzyme, mass creatine kinase, lactate dehydrogenase, C-reactive protein, NT-proBNP and uric acid. Postoperative mortality, postoperative onset of myocardial infarction and occurence of cerebrovascular accident and their correlation with preoperative values of listed biomarkers were registered. The study included all patients with acquired heart disease, older than 18 years, with the left ventricular ejection fraction less than or equal to 50% who were submitted to the following types of operations: revascularization - coronary surgery, surgery of acquired heart diseases - valvular surgery and combined operations - coronary and valvular surgery. The results showed that the postoperative mortality was 3.13%, new onset of postoperative myocardial infarction was detected in 7.95% of the patients and postoperative cerebrovascular accident developed in 9.23% of patients. Correlation of preoperative biomarkers values with postoperative myocardial infarction in patients with impaired left ventricular ejection fraction - elevated preoperative troponin I were associated with postoperative myocardial infarction. Correlation of preoperative biomarkers values with postoperative cerebrovascular incident occurence in patients with impaired left ventricular ejection fraction - elevated preoperative troponin I and CRP were associated with postoperative cerebrovascular incident. The influence of preoperative levels of all biomarkers, separetly, on the rate of significant adverse cardiac and cerebrovascular events - Major Adverse Cardiac and Cerebrovascular Events (MACCE) as the heart surgery outcome, in patients with impaired left ventricular ejection fraction. The following results were obtained: Increased preoperative levels of C-reactive protein (CRP) and postoperative MACCE were related. Increased preoperative levels of lactate dehydrogenase (LDH) and MACCE were related. The conclusions of this thesis are: 1. Independent predictor of postoperative myocardial infarction onset and significant adverse cardiac and cerebrovascular events in cardiac surgery patients with impaired systolic left ventricular function (ejection fraction less than or equal to 50%) is elevated preoperative value of troponin I. 2. Preoperative Troponin I value was poor marker for predicting postoperative myocardial infarction and significant adverse cardiac and cerebrovascular events in cardiac surgery patients with impaired systolic left ventricular function (ejection fraction less than or equal to 50%). 3. None of the studied variables showed influence on the postoperative cerebrovascular accident occurence, in cardiac surgery patients with impaired systolic left ventricular function (ejection fraction less than or equal to 50%). 4. Independent predictors of postoperative mortality in cardiac surgery patients with impaired systolic left ventricular function (ejection fraction less than or equal to 50%), that could be used to create a predictive model are: age and elevated preoperative value of NT-proBNP. 5. Developed model showed satisfactory results for predicting outcome after heart surgery in cardiac surgery patients with impaired systolic left ventricular function (ejection fraction less than or equal to 50%). 6. Elevated preoperative value of NT-proBNP may be a good marker for mortality prediction after the cardiac surgery in patients with impaired systolic left ventricular function (ejection fraction less than or equal to 50%). 7. EuroSCORE II model showed poor performance when predicting outcomes after cardiac surgery in patients with impaired systolic left ventricular function (ejection fraction less than or equal to 50%). 8. Validation of the newly-created model, considering low and medium risk patients, based on the value of left ventricular ejection fraction, showed that the model is a good marker for the mortality prediction in both groups.</p>
232

[pt] ASPECTOS ATÍPICOS NO ENVELHECIMENTO: AVALIAÇÃO NEUROPSICOLÓGICA EXTENSA NO ENVELHECIMENTO NORMAL COMPROMETIMENTO COGNITIVO LEVE E DOENÇA DE ALZHEIMER / [en] ATYPICAL ASPECTS IN AGING: EXTENSIVE NEUROPSYCHOLOGICAL ASSESSMENT IN NORMAL AGING, MILD COGNITIVE IMPAIRMENT AND ALZHEIMER S DISEASE

MARINA MARTORELLI PINHO 29 January 2020 (has links)
[pt] O envelhecimento em todo o mundo é um dos maiores desafios da saúde. Nesse contexto, condições clínicas como demências e Comprometimento Cognitivo Leve (CCL) também aumentam suas prevalências. A causa de demência mais frequente e estudada é demência de Alzheimer (DA). Tradicionalmente, DA é caracterizada pelo déficit precoce na memória episódica. Entretanto, estudos atuais mostram que a DA apresenta heterogeneidade neuropsicológica e alguns pacientes apresentam déficits cognitivos precoces não-amnésticos. Essas apresentações são chamadas por alguns autores de DA atípica. Dessa forma, a primeira parte dessa tese dedicou-se a estudar a heterogeneidade neuropsicológica na DA através de dois estudos: uma revisão sistemática sobre heterogeneidade neuropsicológica na DA (publicado) e um estudo de casos sobre perfis típico e atípico na DA (publicado). A revisão sistemática tornou-se necessária já que foi a primeira revisão sistemática publicada sobre o tema. Os achados dos dois estudos mostraram que aspectos atípicos na DA precisam ser mais explorados, já que DA não é uma condição homogênea. Compreender esses perfis cognitivos na DA irá interferir nos métodos diagnósticos e intervenções terapêuticas, seja farmacológica ou comportamental. A segunda parte dessa tese explora esses aspectos atípicos em três amostras: envelhecimento normal, CCL e AD. Assim, um estudo transversal foi realizado para comparar medidas de velocidade de processamento (VP), controle inibitório e automonitoramento nas três amostras. Os resultados desse estudo mostram que medidas de VP podem ser indicadores precoces do declínio cognitivo envelhecimento. Ao comparar CCL com o grupo de envelhecimento saudável, os dados mostram diferença nas medidas de VP e erros cometidos nos testes de VP. Entretanto, as duas amostras não apresentaram diferenças nas medidas de funções executivas (FEs) e nas medidas de funcionalidade. CCL versus AD mostraram diferenças nas medidas de VP, funções executivas e funcionalidade. Dessa forma, esse estudo traz resultados relevantes para o diagnóstico precoce de CCL e novas diretrizes para o cenário clínico e pesquisa. Além disso, na segunda parte desta tese foi realizado um artigo sobre acurácia diagnóstica das medidas de VP nos casos de CCL e AD. A literatura mostra falta de estudos sobre diferenças nas medidas de VP no envelhecimento e parâmetros diagnósticos dos instrumentos de VP. Esse estudo mostrou que medidas de VP apresentam habilidades discriminativas, para DA e CCL. Esses dados são necessários, já que apresentamos um cenário de escassez de instrumentos com elevados parâmetros diagnósticos para medidas de VP no envelhecimento. Esse cenário torna-se ainda mais drástico, quando falamos de Brasil. / [en] Aging is a major healthcare challenge worldwide. With aging, the prevalence of conditions such as dementia and Mild Cognitive Impairment increase. The most frequent and studied cause of dementia is Alzheimer s dementia (AD). Traditionally, AD is characterized by early deficit in episodic memory. However, current studies show that AD presents heterogeneity in clinical manifestations, especially cognitive manifestations. Thus, some patients present a non-amnestic cognitive profile. These profiles are called by some authors as atypical AD. The first part of this thesis was aimed at studying the neuropsychological heterogeneity in AD by means of 2 studies: a systematic review on neuropsychological heterogeneity in AD (published) and cases of study with typical and atypical AD patients (published). The systematic review was necessary, as it was the first published review about the topic. The findings of the two studies show that atypical aspects in AD need to be further explored, since AD is not a homogeneous condition. Understanding these cognitive profiles in AD will interfere in diagnostic methods and therapeutic interventions, either pharmacological or behavioral ones. The second part of this thesis explores atypical aspects in three samples: normal aging, MCI and AD. Thus, a cross-sectional study was conducted to compare measures of processing speed (PS), inhibitory control, working memory and cognitive flexibility in the three samples. The results of this study showed that PS measures may be early indicators of cognition decline in aging. MCI versus normal aging showed differences in PS measures and errors in tests of PS. However, these samples did not show differences in executive function measures (EFs) and functional measures. Nevertheless, MCI versus AD show differences in PS measures, executive functions and functionality. Thus, this study showed relevant results for the diagnosis process of MCI and new guidelines for clinical settings and research. In addition, in the second part of this thesis an article was written on diagnostic accuracy of the PS measures used in cases of MCI and AD. The literature shows a lack of studies on differences in PS measures in aging and diagnostic parameters of PS instruments. This study showed that PS measures present discriminative abilities in AD and MCI. These data are important, as there is a lack of diagnostic tools for PS in aging, especially in the Brazilian scenario.

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