Background: Adverse birth outcomes present a difficult and chronic challenge in Ontario, in Canada and in developed countries in general. Increasing proportions of preterm births, significant regional disparities and the high cost of treating all adverse birth outcomes have focused attention on explaining them and developing effective treatments. Methods: Birth outcomes and maternal characteristics for approximately 626,000 births, about 90% of births in 2005–2009, were linked to small geographic areas throughout Ontario. For each of four adverse outcomes: late preterm, moderate to very preterm, small for gestation age and still births, proportions of total births were calculated for the full province and for each small geographic area. Geographic hotspots of elevated rates were identified for each of the different adverse birth outcomes using the local Moran’s I statistic. Data for nine known ecologic and individual risk factors were then linked to the areas. Hierarchical regression analysis was used to model each of the outcomes for the full province and for dispersed local areas. The resulting models for the different outcomes were contrasted. Results: Significant geographic hotspots exist for each of the four outcomes. Hotspots for the different outcomes were found to be largely spatially exclusive. For like outcomes, predictive models differed markedly between local areas (i.e. local groups of hotspots) as well as between full-province and local areas. Ecologic level variables played a strong role in all models; the influence of individual level risk factors was consistently modified by ecologic risk factors except for small for gestational births. Conclusions: The finding of significant hotspots for different adverse birth outcomes indicates that certain geographic areas have aetiologies or patterns of predictors sufficient to create significantly elevated levels of particular outcomes. The finding that hotspots for the different adverse outcomes are largely exclusive implies that the aetiologies are specific; i.e., those that are sufficient to create significantly higher levels for one outcome do not also create significantly higher levels of others. The consistently strong role of ecologic level risk factors in modifying individual level risk factors implies that contextual characteristics are an important part of the aetiology of adverse birth outcomes. Differences in local area models suggest the existence of location-specific (rather than universal) aetiologies. The findings support the need for more careful attention to local context when explaining birth outcomes.

No description available.

Objectifs : Etablir des corrélations dose-volume effet entre les paramètres dosimétriques proposés par le GEC-ESTRO et la probabilité de survenue d’événements tels que le contrôle tumoral ou une toxicité radio-induite.Matériel et méthodes : Les données cliniques et dosimétriques de cohortes de patientes traitées à Gustave Roussy et dans différents centres ont été confrontées. Dans un premier temps les paramètres dosimétriques de la curiethérapie 3D ont été comparés à ceux de la curiethérapie classique. Dans un second temps, la topographie des zones les plus exposées des organes à risque, ainsi que l’impact des mouvements de la vessie, du rectum, et du colon sigmoïde sur l’évaluation de la dose délivrée, ont été étudiés. Enfin, des analyses dose-volume effets ont été réalisées.Résultats : Les valeurs des paramètres dosimétriques volumétriques (D2cm3) de la vessie et du rectum se sont révélées faiblement corrélées et significativement supérieures aux doses évaluées aux points de l’ICRU ou à un point vésical alternatif. Les zones les plus exposées de la vessie et du rectum sont apparues situées au-dessus des points de l’ICRU. Les mouvements des organes autour de l’implant pendant la délivrance du traitement sont apparus marginaux pour la vessie et sigmoïde, en dehors de variations individuelles. En revanche, la dose délivrée au rectum étaient en moyenne plus élevée que le dose planifiée. Les analyses dose-volume effets ont montré des corrélations significatives entre D0.1cm3 et D2cm3 et la probabilité de survenue d’une morbidité tardive urinaire ou rectale. De la même manière, des corrélations significatives ont été établies entre la D90 des CTV à haut risque et à risque intermédiaire et la probabilité d’obtention du contrôle local. Divers caractéristiques tumorales (largeur au diagnostic, volume du CTV-HR, stade FIGO), impactent ces relations, de même que l’étalement total du traitement.Conclusion : Des corrélations dose-volume effets ont été établies entre les paramètres dosimétriques modernes et la probabilité d’obtenir le contrôle local ou d’entraîner une morbidité tardive. En ce qui concerne le contrôle tumoral, les objectifs de prescription doivent être personnalisés en fonction de critères carcinologiques. Pour les organes à risque, de contraintes de dose basées sur l’expérience de la curiethérapie 3D peuvent être établies, mais doivent être affinées dans de futures études en fonction de cofacteurs tels que les comorbidités. Les points gardent un intérêt en recherche clinique, pour l’étude de la morbidité vésicale ou vaginale.Ce travail a l'objet de 6 publications dans des revues internationales à comité de lecture. La septième est présentée sous forme de manuscrit. / Objectives: To establish dose-volume effects correlations between volumetric dosimetric parameters proposed by the GEC-ESTRO and the probability of occurrence of events such as tumor control or radiation-induced toxicity.Methods: Clinical and dosimetric data of patients treated at Gustave Roussy and in different centers have been reviewed. At first step, dosimetric parameters of image-guided brachytherapy were compared with those of conventional brachytherapy. Secondly, the topography of the most exposed areas of the organs at risk, and the impact of the movements of the bladder, rectum, and sigmoid colon on the assessment of the delivered dose, were studied. Finally, analyzes dose-volume effects were performed.Results: The values of volumetric dosimetric parameters (D2cm3) of the bladder and rectum appeared weakly correlated and significantly higher than the doses evaluated at ICRU points of bladder and rectum , an even in an alternative bladder point. The most exposed areas of the bladder and rectum appeared located above the points of the ICRU. The movements of the organs around the implant during the delivery of the treatment appeared marginal for the bladder and sigmoid, apart from individual variations. However, the mean delivered dose to the rectum was higher than the planned dose. Dose-volume effects correlations showed significant correlations between D0.1cm3 and D2cm3 and the probability of occurrence of urinary or rectal late morbidity. Similarly, significant correlations have been established between the D90 of the high risk, intermediate risk-CTV and the probability of achieving local control. Various tumor characteristics (width, HR-CTV volume, FIGO stage) impact these relationships, as well as the treatment time.Conclusion: Dose-volume effects correlations have been established between modern dosimetric parameters and the probability of achieving local control or cause late morbidity. Regarding tumor control, prescription aims must be customized according to oncologic criteria. For organs at risk, new dose constraints based on 3D brachytherapy experience can be established but should be refined in future studies based on cofactors such as comorbidities. The points retain an interest in clinical research for the study of bladder or vaginal morbidity.

Im Rahmen dieser Arbeit wurden die Kinderskelete der frühbronzezeitlichen Mad'arovce-Kultur aus Jelšovce / Slowakei auf Erkrankungen untersucht. Diese Ergebnisse helfen die Lebensbedingungen der in der Frühbronzezeit in Mitteleuropa lebenden Menschen zu beschreiben. Es zeigt sich, dass schon in der Bronzezeit die Gesundheit der Menschen durch klimatische und geographische Faktoren stark beeinflusst wurde. Zu Vergleichszwecken wurden frühbronzezeitliche Populationen aus Niederösterreich und Anatolien, sowie mittelalterliche und neolithische Kinderpopulationen herangezogen. Im Laufe der Frühbronzezeit nimmt die Erkrankungshäufigkeit fast aller Krankheiten zu. Die Kinder der Mad'arovce-Kultur sind überdurchschnittlich häufig betroffen. Eine interessante Vergleichsmöglichkeit ergibt sich durch die frühbronzezeitlichen Populationen der Nitra-, und Aunjetitz-Kultur, die ebenfalls vom Gräberfeld in Jelšocve stammen, allerdings zeitlich früher datiert werden. Die diachrone Untersuchung der drei Kinderpopulationen von Jelšovce zeigt, einen Häufigkeitsanstieg der Infektions-, Zahn- und, mit Ausnahmen, auch der Mangelerkrankungen im Verlauf der Frühbronzezeit in Jelšovce, bei annähernd gleichem Krankheitsspektrum. Dies spricht für ein sehr ähnliches Biotop über den gesamten frühbronzezeitlichen Siedlungszeitraum hinweg. Für die dort lebenden Menschen waren die gleichen positiven wie negativen Aspekte relevant, wie sich in der annähernden Übereinstimmung des Krankheitsspektrums zeigt. Der beobachtete Unterschied in den Krankheitshäufigkeiten wurde sehr wahrscheinlich durch eine Erschöpfung der Ressourcen sowie die Zunahme der Populationsgröße verursacht. Ursachen für die beobachteten Unterschiede zwischen den weiteren bronzezeitlichen Populationen sind in den unterschiedlichen Biotopen sowie den sich im Verlauf der Frühbronzezeit deutlich ändernden klimatischen Bedingungen zu suchen. Sich wandelnde kulturelle und gesellschaftliche Grundlagen spielen offenbar ebenfalls eine Rolle. Auch die Größe der Populationen und deren materieller Reichtum und die damit verbundenen notwendigen Ressourcen beeinflussten die Lebensbedingungen der bronzezeitlichen Menschen. Obwohl es sich bei der Population der Mad’arovce-Kultur um eine relativ reiche Population handelt, sind ihre Kinder häufig von Erkrankungen betroffen. Dies zeigt, dass das Biotop in der Vergangenheit einen größeren Einfluss auf die Gesundheit der Menschen und das Auftreten von Erkrankungen hat als bisher angenommen wurde. Der Skorbut wird in dieser Arbeit bevorzugt behandelt, da zum einen ein System zur Diagnose von kindlichem Skorbut vorgestellt wird, welches eine Diagnosefindung erleichtern soll. Zum anderen treten in der Mad'arovce-Kultur in Jelšocve relativ viele Fälle von Skorbut auf, so dass sich hier eine genauere Betrachtung anbietet. Außerdem kann ein Skorbut als möglicher Cofaktor die hohe Prävalenz an entzündlichen Erkrankungen in der Mad'arovce-Kultur mit erklären. Spuren einer Kauterisation an einem Kinderschädel weisen auf einen Behandlungsversuch im frühbronzezeitlichen Jelšovce hin. In einem anderen Fall wurde ein ossärer Tumor nachgewiesen. Bei zwei Kindern konnten Erkrankungen der Knochen festgestellt werden, die es in dieser Form heute offenbar nicht mehr gibt. Somit liefert die Untersuchung der Kinderskelete von Jelšovce auch medizinhistorisch interessante Befunde.

Background:There is controversial evidence with regard to the significance of peripheral arterial disease (PAD) as an indicator for future stroke risk. We aimed to quantify the risk increase for mortality and morbidity associated with PAD. Methods:In an open, prospective, noninterventional cohort study in the primary care setting, a total of 6,880 unselected patients ≧65 years were categorized according to the presence or absence of PAD and followed up for vascular events or deaths over 5 years. PAD was defined as ankle-brachial index (ABI) <0.9 or history of previous peripheral revascularization and/or limb amputation and/or intermittent claudication. Associations between known cardiovascular risk factors including PAD and cerebrovascular mortality/events were analyzed in a multivariate Cox regression model. Results:During the 5-year follow-up [29,915 patient-years (PY)], 183 patients had a stroke (incidence per 1,000 PY: 6.1 cases). In patients with PAD (n = 1,429) compared to those without PAD (n = 5,392), the incidence of all stroke types standardized per 1,000 PY, with the exception of hemorrhagic stroke, was about doubled (for fatal stroke tripled). The corresponding adjusted hazard ratios were 1.6 (95% confidence interval, CI, 1.1–2.2) for total stroke, 1.7 (95% CI 1.2–2.5) for ischemic stroke, 0.7 (95% CI 0.2–2.2) for hemorrhagic stroke, 2.5 (95% CI 1.2–5.2) for fatal stroke and 1.4 (95% CI 0.9–2.1) for nonfatal stroke. Lower ABI categories were associated with higher stroke rates. Besides high age, previous stroke and diabetes mellitus, PAD was a significant independent predictor for ischemic stroke. Conclusions:The risk of stroke is substantially increased in PAD patients, and PAD is a strong independent predictor for stroke. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

La fibrillation auriculaire postopératoire (FAPO) est une complication fréquente de la chirurgie cardiaque et est associée à une morbidité et des coûts accrus. Bien que de nombreuses méthodes prophylactiques aient été évaluées, aucune n’est actuellement universellement employée compte tenu du risque de complications, de contre-indications et du manque de données probantes. Ce mémoire tente d’examiner la contribution du sang intra-péricardique à la genèse de fibrillation auriculaire après une chirurgie cardiaque et d’évaluer son potentiel en tant que cible prophylactique. Trois études furent réalisées dans le cadre de ce travail. Dans un premier temps, une revue de la littérature fut pilotée afin d’éclaircir les éléments pathophysiologiques et cliniques unissant l’accumulation de sang dans le sac péricardique à la FAPO. Ensuite, un projet rétrospectif avec analyse par score de propension et un essai clinique randomisés furent menés afin d’évaluer l’effet d’un protocole de drainage thoracique adoptant un dispositif de dégagement actif des drains [active tube clearance (ATC)], visant à prévenir la formation de caillots intraluminaux, sur l’incidence de FAPO. La première étude conclut que la présence de sang intra-péricardique, via l’activation de processus inflammatoire et oxydatif local, est un facteur périopératoire contribuant à la survenue de FAPO. La seconde étude identifia l’utilisation de l’ATC en tant que facteur protecteur indépendant contre la FAPO. Finalement, la dernière étude démontra une diminution non-significative du risque relatif de FAPO de 18% associée à l’ATC. En somme, un drainage efficace du péricarde pourrait réduire l’incidence de FAPO, or les modalités optimales demeurent à être spécifiées. / Postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery that is associated with increased morbidity and costs. Although numerous prophylactic measures have been evaluated, none have been universally implemented considering the risk of complications, contraindications and lack of evidence. The aim of this thesis is to examine the role of intrapericardial blood in the development of POAF after cardiac surgery and evaluate its potential as a target for prophylaxis. For this thesis, a total of three studies were carried out. To begin, a literature review was conducted to elucidate the pathophysiological and clinical elements connecting the accumulation of shed blood within the pericardial sac to POAF. Afterwards, both a retrospective study with propensity score analysis and a randomized controlled trial were carried out to evaluate the incidence of POAF after implementing a universal postoperative chest drainage protocol using an active tube clearance (ATC) device, designed to prevent intraluminal clogging and improve drainage. The first study concluded that the presence of intra-pericardial blood, through the activation of local and oxidative processes, is a perioperative factor triggering POAF in susceptible individuals. The second study identified the use of ATC as an independent protective factor against POAF. Finally, the last study demonstrated a 15% non-significant relative risk reduction of POAF associated with ATC. In conclusion, an efficient pericardial drainage could reduce the incidence of POAF after cardiac surgery. However, the optimal strategy has yet to be determined.

Il est généralement reconnu, par la communauté́ scientifique, que le risque de morbidité́ augmente lors des vagues de chaleur. On retrouve néanmoins des différences importantes en ce qui a trait à la vulnérabilité́ des populations au stress thermique. L'effet de la température sur la morbidité́ diffère selon plusieurs facteurs, dont l’âge. Pour des raisons physiologiques et comportementales, les enfants sont l’un des groupes les plus vulnérables aux vagues de chaleur (Hutter et al., 2007; Thompson et al., 2012). La présente étude vise à analyser l’influence de la vulnérabilité́ différentielle face aux problèmes de santé chez les enfants lors des vagues de chaleur à Ouagadougou. L’analyse de la vulnérabilité́ aux risques environnementaux rend compte des conditions de fragilité́ des individus pouvant mener à des expériences de souffrance et de dépendance à autrui. Ceci influence conséquemment la capacité à faire face aux catastrophes et à se rétablir (Becerra, 2012; Muttarak et al., 2015). Les données utilisées ont été́ recueillies par l’Observatoire de Population de Ouagadougou (OPO) de mars à mai 2017 lors d’une enquête sur la vulnérabilité́ et la capacité d'adaptation de la population de l'OPO aux vagues de chaleur. Ces données transversales regroupent un sous-échantillon aléatoire de 332 enfants de cinq ans et moins, habitant dans cinq quartiers de la périphérie nord de Ouagadougou. Nous les analysons tout d’abord à l’aide de tableaux croisés, de tests de chi-2 et d’une analyse factorielle. Des régressions logistiques ordinales permettent ensuite d’étudier la force et la significativité des associations entre la prévalence des symptômes lors des vagues de chaleur et les variables associées à la vulnérabilité climatique. L’analyse permet de relever des associations inattendues entre la prévalence de certains symptômes chez l’enfant lors des vagues de chaleur et plusieurs variables indépendantes. Par exemple, lorsque nous étudions les effets bruts des variables indépendantes sur la variable dépendante, nous constatons que les enfants dont la mère n’a pas tendance à apporter de l’aide supplémentaire aux très jeunes enfants lors des périodes de très forte chaleur sont plus susceptibles de ne pas présenter de symptôme(s) que de présenter des symptômes (OR = 0,60* (0,36 ; 1,01), à la limite du significatif de 10%), comparativement aux enfants ayant une mère apportant de l’aide supplémentaire. Nous notons également que les enfants dont le toit de chambre est isolé ou construit avec du ciment / béton (dalle) sont plus susceptibles de manifester des symptômes lors des vagues de chaleur que de ne pas en manifester (OR = 1,68* (0,97 ; 2,91), à la limite du significatif de 10%), en comparaison aux enfants dont le toit de chambre est fait de tôle galvanisée / métal / fer-blanc / zinc. Néanmoins, ces résultats sont très faiblement significatifs (seuil de 10%) à partir d’un échantillon de petite taille. Ainsi, le fait que les résultats sont à la limite du significatif à 10% nous amène à interpréter de manière prudente l’existence des liens entre ces variables. Dans l’explication de ces résultats, nous soupçonnons la présence de biais dans l’auto-déclaration des symptômes. Les limites des données incluent l’auto-déclaration des symptômes, la petite taille de l’échantillon, la nature transversale des données ainsi que la présence de biais de rappel liée aux problèmes de mémoire. Compte tenu de ces limites méthodologiques, il serait nécessaire de confirmer les résultats obtenus dans de futures recherches. Néanmoins, ces résultats pourront contribuer à orienter de futures recherches sur l’effet des vagues de chaleur chez les enfants au Sahel. / It is generally recognized by the scientific community that the risk of morbidity increases during heatwaves. However, there are important differences in regard to the vulnerability of populations to increased temperatures. The effect of temperature on morbidity differs depending on several factors, including age. Children are one of the most vulnerable groups when it comes to heatwaves due to physiological and behavioral reasons (Hutter et al., 2007; Thompson et al., 2012). This study aims to analyze the influence of differential vulnerability on children’s health during heatwaves in Ouagadougou. The analysis of vulnerability on environmental risks takes into account the fragile conditions of individuals that can lead to experiences of suffering and dependence on others. Consequently, it influences the capacity to cope with and recover from disasters (Becerra, 2012; Muttarak et al., 2015). The data used were collected by the Ouagadougou Population Observatory (OPO) from March to May 2017 during a survey on the vulnerability and adaptability of the OPO population to heatwaves. The cross-sectional data brings together a random subsample of 332 children aged five and under, living in five neighborhoods in the northern outskirts of Ouagadougou. We first analyze them using crosstabs, chi-2 tests and factor analysis. Ordinal logistic regressions are then performed to study the strength and significance of the associations between the prevalence of symptoms during heatwaves and the variables associated with climatic vulnerability. Descriptive analysis reveals unexpected associations between the prevalence of certain symptoms in children during heatwaves and several independent variables. An in-depth analysis carried out with the use of ordinal logistic regressions shows that the results do not support our initial hypotheses. For example, when we study the gross effects of the independent variables on the dependent variable, we found that children with mothers who do not tend to provide extra help to very young children during intense periods of heat are more likely to be symptom-free than to have symptoms (OR = 0.60 * (0,36 ; 1,01), at the significant limit of 10%), compared to children with mothers who provide extra help. We also note that children whose room roof is insulated or built with cement / concrete (slab) are more likely to show symptoms during heat waves than to not show symptoms (OR = 1.68 * (0,97 ; 2,91), at the significant limit of 10%), compared to children whose room roof is made of galvanized sheet metal / metal / tinplate / zinc. Nevertheless, these results are very weakly significant (10% threshold) from a small sample size. Thus, the fact that the results are at the limit of significance at 10% leads us to interpret the existence of links between these variables cautiously. In an attempt to explain these results, we suspect that there is a bias in the self-reported symptoms. Data limitations include self-reporting of symptoms, small sample size, the cross-sectional nature of the data, and the presence of recall bias related to memory problems. Given these methodological limitations, it would be necessary to confirm our results with those obtained in future research. However, the results obtained may help guide future research about the effect of heatwaves on children’s health in Sahel.

Introducción: El presente proyecto de intervención en salud se realizó en el asentamiento humano Pacífico Villa parte alta, ubicado en el distrito de Chorrillos, donde la prevalencia y mortalidad por enfermedades respiratorias en niños menores de 5 años es alta y representa un problema en salud. Objetivos: El proyecto tuvo el objetivo de mejorar el conocimiento de la población sobre la prevención de enfermedades respiratorias agudas en niños menores de 5 años. Para lograr esto se incidió en las principales 3 causas encontradas que eran los inadecuados hábitos de higiene en niños y cuidadores involucrados, la baja cobertura de vacunación en los niños menores de 5 años y la malnutrición en los niños que los predispone a padecer todo tipo de enfermedades. Metodología: Se siguió la metodología del marco lógico, se realizó en primer lugar una priorización de problemas y el análisis de involucrados, se esquematizó el árbol de problemas y árbol de objetivos, a continuación, se analizaron las alternativas de solución y se graficó la estructura analítica del proyecto, luego se realizó la matriz del marco lógico y finalmente se plantearon las actividades y tareas resumidas en la matriz de programación. Actividades: Se realizaron 2 actividades principales que consistieron en la realización de afiches y videos para presentar a la comunidad vía online debido a la coyuntura actual de la pandemia por Sars-CoV-2. Resultados: Los resultados del proyecto a corto plazo se midieron por encuestas de conocimiento respondidas por la comunidad, una antes de la intervención y otra después, siendo el logro final la mejora de conocimiento de la comunidad en materia de prevención de enfermedades respiratorias, reconocimiento de sus signos de alarma, importancia de la vacunación, alimentación saludable, métodos de higiene, lactancia materna, entre otros. / Introduction: This health intervention project was carried out in the Pacific Villa upper part human settlement, located in the district of Chorrillos, where the prevalence and mortality from respiratory diseases in children under 5 years of age is high and represents a health problem. Objectives: The project had the objective of improving the population’s knowledge about prevention of acute respiratory diseases in children under 5 years of age. To achieve this, the main 3 causes found were involved, which were inadequate hygiene habits in children and their caregivers, low vaccination coverage in children under 5 years of age and malnutrition in children that predisposes them to suffer all kinds of diseases. Methodology: The logical framework approach was followed, first a prioritization of problems and the analysis of those involved were carried out, the tree of problems and tree of objectives were outlined, then the solution alternatives were analyzed and the analytical structure of the project, then the logical framework matrix was made and finally the activities and tasks summarized in the programming matrix were proposed. Activities: Two main activities were carried out, which consisted of making posters and videos to present to the community online due to the current situation of the Sars-CoV-2 pandemic. Results: The results of the short-term project were measured by knowledge surveys answered by the community, one before the intervention and another after, the final achievement being the improvement of the community's knowledge in the prevention of respiratory diseases, recognition of its warning signs, the importance of vaccination, healthy eating, hygiene methods, breastfeeding, among others. / Tesis

Objectives: To study the effects of prenatal zinc and vitamin A supplementation on birthsize, neonatal morbidity, infant mortality, and growth in children up to two years of age. Subjects and Methods: From September 1995 to December 1999 pregnant women inPurworejo District, Central Java, Indonesia with gestational age &lt;17 weeks (n=2173) wererecruited to and participated in a community-based, individually randomized, placebo controlled,double blinded study aiming to evaluate the impact of supplementation (vitamin A,zinc, vitamin A + zinc) during pregnancy on maternal morbidity and pregnancy outcomes. Weanalyzed secondary data from that study regarding birth size, neonatal morbidity and infantmortality of the 1956 infants born alive. A subsample of infants (n=343) was followed until 2years of age concerning growth, feeding practices and morbidity. Outcomes were tested usingthe chi-square test, ANOVA, ANCOVA, and Cox’s proportional hazard function. Results: Birth weights in the zinc [mean ±Standard deviation (SD): 3.16 ± 0.52 kg], vitaminA (3.08 ± 0.46 kg) or the combined vitamin A and zinc (3.10 ± 0.59) groups did not differ fromplacebo (3.09 ± 0.50 kg) after adjustment for maternal pre-pregnancy weight, weight gainduring pregnancy, and parity (P=0.70). Birth lengths of infants born to mothers supplementedwith zinc or vitamin A were in average 0.3 cm and 0.2 cm longer than those in the placebogroup after adjustment for maternal height, pre-pregnancy weight, weight gain during pregnancy,and parity (P=0.04). The impact of prenatal supplementation on infant mortality andneonatal morbidity was not significant. There was a small effect of prenatal vitamin A supplementationon postnatal growth in height-for-age z-score (HAZ). The absolute differencesbetween the vitamin A only and vitamin A + zinc groups at 3 and 9 months were 0.34 SD and0.37 SD, respectively, and the absolute difference between the vitamin A only and zinc onlygroups at 18 months was 0.31 SD. Defining growth faltering as downward crossing of ≥2 majorpercentile lines, 50-75% of the children were faltering within 9 months of age, whereas 17%and 8% were &lt;-2 SD for growth in weight-for-age z-score (WAZ) and HAZ, respectively.Prenatal supplementation did not reduce the prevalence of growth faltering. Conclusions: Prenatal vitamin A and zinc demonstrates a small but significant impact onbirth length, but it does not have any protective effect on infant mortality and neonatal morbidity.Prenatal vitamin A supplementation had a small but significant effect on postnatallength growth until 18 months of age, but no effect on weight gain, growth rate and it did notreduce the prevalence of growth faltering. / Tujuan: meneliti pengaruh suplementasi zink dan vitamin A pada masa prenatal terhadapukuran tubuh bayi baru lahir, morbiditas neonatal, kematian bayi, dan pertumbuhan anaksampai dengan umur dua tahun Subjek dan Metode: Dari bulan September 1995 sampai dengan Desember 1999 ibu hamildi Kabupaten Purworejo, Jawa Tengah, Indonesia dengan umur kehamilan &lt;17 minggu(n=2173) diikutsertakan ke dalam penelitian berbasis komunitas, teracak, menggunakankontrol plasebo dan buta ganda yang bertujuan mengevaluasi pengaruh suplementasi vitaminA, zink, dan kombinasi vitamin A dan zink selama kehamilan terhadap morbididitas ibu danhasil kehamilan. Kami menganalisis data sekunder dari penelitian ini dan mengevaluasi ukurantubuh bayi waktu lahir, morbiditas neonatal, dan kematian bayi dari 1956 bayi yang lahirhidup. Sebagian dari subjek (n=343) diikuti sampai dengan umur dua tahun untuk mengetahuipertumbuhan, cara pemberian makan, dan morbiditasnya. Data dianalisis dengan chi-squaretest, ANOVA, ANCOVA, dan Cox’s proportional hazard function. Hasil: Berat badan lahir pada kelompok zink [mean ±standar deviasi (SD): 3.16 ± 0.52 kg],vitamin A (3.08 ± 0.46 kg) atau kombinasi vitamin A dan zink (3.10 ± 0.59) tidak berbedasecara bermakna dibandingkan dengan plasebo (3.09 ± 0.50 kg) setelah dikontrol oleh beratbadan ibu sebelum hamil, pertambahan berat badan selama hamil, dan paritas (P=0,70).Panjang lahir dari kelompok ibu yang disuplementasi dengan vitamin A atau zink 0,2 cm danrata-rata 0,3 cm lebih panjang dibanding kelompok plasebo setelah dikontrol oleh tinggi badanibu, berat badan ibu sebelum hamil, pertambahan berat selama hamil, dan paritas (P=0,04). Pengaruh suplementasi selama masa prenatal terhadap kematian bayi dan morbiditas neonataltidak bermakna. Suplementasi masa prenatal mempunyai efek yang lemah terhadap pertumbuhanyang diukur dengan indikator tinggi badan menurut umur (HAZ). Perbedaan absolutpanjang badan anak antara kelompok vitamin A dan kombinasi vitamin A dan zink pada umur3 dan 9 bulan adalah 0,34 SD dan 0,37 SD; dan perbedaan absolut antara kelompok vitaminA dengan zink pada umur 18 bulan adalah 0,31 SD. Dengan menggunakan kriteria growthfaltering sebagai penurunan garis pertumbuhan memotong ≥ 2 persentil major, 50-75% anakmengalami growth faltering pada umur 9 bulan, dan hanya 17% dan 8% yang terdeksi mengalamigrowth faltering bila digunakan kriteria WAZ dan HAZ &lt;- 2SD. Suplementasi vitaminA dan zink pada masa prenatal tidak menurunkan prevalensi growth faltering. Kesimpulan: Suplementasi vitamin A dan zink pada masa prenatal menunjukkan adanyapengaruh lemah tetapi bermakna terhadap panjang lahir, tetapi tidak menunjukkan efekprotektif terhadap kematian bayi dan morbiditas neonatal. Suplementasi vitamin A pada masaprenatal mempunyai efek lemah tetapi bermakna terhadap pertumbuhan panjang badansampai dengan umur 18 bulan, tetapi tidak disertai pengaruh terhadap kenaikan berat badan,laju pertumbuhan dan tidak menurunkan prevalensi growth faltering.

Introdução: Estima-se que ocorram 2,5 milhões de mortes por ano relacionadas a cirurgias não cardíacas e cinco vezes este valor para morbidade, com limitações funcionais e redução na sobrevida em longo prazo. Pacientes que deverão ser submetidos à cirurgia vascular são considerados de risco aumentado para eventos adversos cardiovasculares no pós-operatório. Há, ainda, muitas dúvidas em como fazer uma avaliação pré-operatória mais acurada desses pacientes. Objetivo: Em pacientes submetidos à cirurgia vascular arterial eletiva, avaliar a incidência e preditores de complicações cardiovasculares e/ou óbito total, e calcular a performance dos modelos de estratificação de risco mais utilizados. Métodos: Em pacientes adultos, consecutivos, operados em hospital terciário, determinou-se a incidência de complicações cardiovasculares e óbitos, em 30 dias e em um ano. Comparações univariadas e regressão logística avaliaram os fatores de risco associados com os desfechos e a curva ROC (receiver operating characteristic) examinou a capacidade discriminatória do Índice de Risco Cardíaco Revisado (RCRI) e do Índice de Risco Cardíaco do Grupo de Cirurgia Vascular da New England (VSG-CRI). Resultados: Um total de 141 pacientes (idade média 66 anos, 65% homens) realizou cirurgia de: carótida 15 (10,6%), membros inferiores 65 (46,1%), aorta abdominal 56 (39,7%) e outras (3,5%). Complicações cardiovasculares e óbito ocorreram, respectivamente, em 28 (19,9%) e em 20 (14,2%), em até 30 dias, e em 20 (16,8%) e 10 (8,4%), de 30 dias a um ano. Complicações combinadas ocorreram em 39 (27,7%) pacientes em até 30 dias e em 21 (17,6%) de 30 dias a um ano da cirurgia. Para eventos em até 30 dias, os preditores de risco encontrados foram: idade, obesidade, acidente vascular cerebral, capacidade funcional ruim, cintilografia com hipocaptação transitória, cirurgia aberta, cirurgia de aorta e troponina alterada. Os escores Índice de Risco Cardíaco Revisado (RCRI) e Índice de Risco Cardíaco do Grupo de Estudo Vascular da New England (VSG-CRI) obtiveram AUC (area under curve) de 0,635 e 0,639 para complicações cardiovasculares precoces e 0,562 e 0,610 para óbito em 30 dias, respectivamente. Com base nas variáveis preditoras aqui encontradas, testou-se um novo escore pré-operatório que obteve AUC de 0,747, para complicações cardiovasculares precoces, e um escore intraoperatório que apresentou AUC de 0,840, para óbito em até 30 dias. Para eventos tardios (de 30 dias a 1 ano), os preditores encontrados foram: capacidade funcional ruim, pressão arterial sistólica, cintilografia com hipocaptação transitória, ASA (American Society of Anesthesiologists Physical Status) classe > II, RCRI (AUC 0,726) e troponina alterada. Conclusões: Nesse grupo pequeno e selecionado de pacientes de elevada complexidade clínica, submetidos à cirurgia vascular arterial, a incidência de eventos adversos foi elevada. Para complicações em até 30 dias, mostramos que os índices de avaliação de risco mais utilizados até o momento (RCRI e VSG-CRI) não apresentaram boa performance em nossa amostra. A capacidade preditiva de um escore mais amplo pré-operatório, e uma análise de risco em dois tempos: no pré-operatório e no pós-operatório imediato, como o que simulamos, poderá ser mais efetiva em estimar o risco de complicações / Introduction: Approximately 2.5 million deaths are caused by non-cardiac surgeries per year, while morbidity, represented by functional impairment and a decline in long-term survival, accounts for five times this value. Patients who require a vascular surgery are considered at an increased risk for adverse cardiovascular events in the postoperative period. However, the method for obtaining a more accurate preoperative evaluation in these patients has not yet been determined. Objective: In patients undergoing elective arterial vascular surgery, the incidence and predictors of cardiovascular complications and/or total death were determined and the performance of risk stratification models was assessed. Methods: The incidence of cardiovascular complications and death within 30 days and 1 year after vascular surgery was determined in consecutive adult patients operated in a tertiary hospital. Univariate comparison and logistic regression analysis were used to evaluate risk factors associated with the outcome, and the receiver operating characteristic (ROC) curve determined the discriminatory capacity of the Revised Cardiac Risk Index (RCRI) and the Cardiac Risk Index of the New England Vascular Surgery Group (VSG-CRI). Results: In all, 141 patients (mean age, 66 years; 65% men) underwent vascular surgery, namely for the carotid arteries (15 [10.6%]), inferior limbs (65 [46.1%]), abdominal aorta (56 [39.7%]), and others (5 [3.5%]). Cardiovascular complications and death occurred in 28 (19.9%) and 20 (14.2%) patients, respectively, within 30 days after surgery, and in 20 (16.8%) and 10 (8.4%) patients, respectively, between 30 days and 1 year after the surgical procedure. Combined complications occurred in 39 patients (27.7%) within 30 days and in 21 patients (17.6%) between 30 days and 1 year after surgery. The risk predictors for cardiovascular events that occurred within 30 days were age, obesity, stroke, poor functional capacity, transitory myocardial hypocaptation on scintigraphy, open surgery, aortic surgery, and abnormal troponin levels. The RCRI and VSG-CRI showed an under the curve area of 0.635 and 0.639 for early cardiovascular complications as well as of 0.562 and 0.610 for death within 30 days, respectively. Based on the predictors found in this study, a new preoperative score was proposed, based on an AUC of 0.747 obtained for early cardiovascular complications and an intraoperative score that presented an AUC of 0.840 for death within 30 days. For late events (between 30 days and 1 year), the predictors were poor functional capacity, systolic blood pressure, presence of transitory myocardial hypocaptation on scintigraphy, class > II American Society of Anesthesiologists Physical Status score, RCRI (AUC= 0.726), and abnormal troponin levels. Conclusions: In this small group of patients with increased clinical complexity who underwent arterial surgery, the incidence of adverse events was high. In our series, we found that RCRI and VSG-CRI do not reasonably predict the risk of cardiovascular complications. The predictive capacity of a modified preoperative score and evaluating the risk preoperatively and early postoperatively, such as that simulated in this study, may be more effective in determining the risk of complications