Thesis (M. Med. Sc.)--University of Hong Kong, 2010. / Includes bibliographical references (p. 70-84).

published_or_final_version / Paediatrics and Adolescent Medicine / Master / Master of Medical Sciences

Thesis (Ph. D.)--University of Missouri-Columbia, 1996. / Typescript. Vita. Includes bibliographical references (leaves 86-95). Also available on the Internet.

Thesis (Ph. D.)--University of Missouri-Columbia, 1996. / Typescript. Vita. Includes bibliographical references (leaves 86-95). Also available on the Internet.

L’insuffisance rénale aiguë (IRA) représente une complication fréquente de lachirurgie cardiaque pédiatrique sous circulation extracorporelle (CEC). Son traitement resteessentiellement conservateur, visant à prévenir l’aggravation de l’atteinte rénale, ousubstitutif, par épuration extrarénale (EER). L’EER précoce améliore le pronostic des adultesen défaillance multiviscérale, mais ceci n’a pas été montré chez l’enfant après chirurgiecardiaque. Le diagnostic de l’IRA repose actuellement sur une diminution du débit defiltration glomérulaire (DFG), reflété par la hausse de la créatinine sérique (sCr), et laréduction de la diurèse. Ces critères traduisent une perte de la fonction glomérulaire ; orl’atteinte initiale dans l’IRA post-chirurgicale se situe au niveau tubulaire. Ces critères sontpeu spécifiques et tardifs, et risquent de retarder le diagnostic et la prise en charge de l’IRA.Des nouveaux biomarqueurs rénaux, traduisant la présence d’une lésion tubulaire, dont leNeutrophil Gelatinase-Associated Lipocaline urinaire (NGALu) est le plus populaire,permettraient un diagnostic plus précoce.Objectif. L’objectif de ce travail est triple : (i) explorer l’association entre le délai de la miseen route de l’EER et le pronostic à court et moyen terme chez le patient < 1an qui développeune IRA post-chirurgie cardiaque ; (ii) explorer les performances diagnostiques desvariations précoces de la sCr pour l’IRA sévère ; et (iii) explorer les performancesdiagnostiques de l’élévation de NGALu pour l’IRA sévère dans des populations similaires depatients < 1an.Méthode. Une cohorte monocentrique rétrospective de patients < 1an constituée sur 10 ansa servi pour étudier l’association entre le délai de la mise en route de l’EER et la survie àcourt et moyen terme. La technique de pondération inverse par le score de propension a étéutilisée afin de réduire le biais associé aux changements des pratiques inhérents à la longuepériode d’inclusion. Une deuxième cohorte monocentrique rétrospective de patients < 1anconstituée sur 3 ½ ans a servi pour étudier les performances diagnostiques des variationsprécoces de la sCr pour l’IRA sévère. Enfin, une troisième cohorte monocentriqueprospective de patients < 1an constituée sur 18 mois a servi pour étudier les performancesdiagnostiques de NGALu pour l’IRA sévère. Pour l’étude des deux biomarqueurs, sCr etNGALu, la méthodologie utilisée a été similaire : partition des trajectoires individuelles devariation, puis analyse de l’association avec un critère composite (recours à l’EER et/oudécès postopératoire) et définition du profil à faible risque d’IRA; enfin, utilisation de laméthodologie des courbes ROC et des tables de reclassification pour quantifier leursperformances diagnostiques respectives.Résultats. La mise en route de l’EER le jour de la chirurgie ou le lendemain a été associéeavec une augmentation d’environ 45% de la survie à 30 et 90 jours. La variation de la sCrdans les 2 jours suivant la chirurgie a été spécifique mais peu sensible et peu discriminantepour le diagnostic de l’IRA sévère ; le profil à faible risque, rencontré chez près de 50% despatients a été une diminution durable d’environ 25% de la sCr par rapport à la valeur basale.NGALu a été discriminant et prédictif pour le critère composite ; la concentration de NGALu aaugmenté dans les 2 heures suivant la chirurgie, et est restée élevée chez les patientsprésentant le critère composite.Discussion et conclusions. Si la prise en charge précoce par EER de l’IRA sévère est unepriorité en termes de pronostic chez le patient < 1an, alors il faut se munir de moyensdiagnostiques précoces et performants. La variation précoce de la sCr est peu sensible etpeu discriminante. En revanche, l’élévation précoce de l’NGALu présente d’excellentesperformances diagnostiques pour l’IRA sévère, faisant de NGALu un marqueur rénalprometteur dans la population < 1an bénéficiant d’une chirurgie cardiaque. / Acute kidney injury (AKI) is common following congenital cardiac surgery withcardiopulmonary bypass (CPB). To date, no prophylactic intervention has proved to beuseful for the prevention of postoperative AKI. When AKI occurs, treatment is mainlysupportive and, when severe, requires renal replacement therapy (RRT). Several reportshave shown better outcome with early RRT in adults with multiorgan failure. No such data isavailable in children undergoing cardiac surgery, and criteria for RRT vary among centres.The definition of AKI is a reduction in the glomerular filtration rate (GFR), and the diagnosis isbased on an increase in serum creatinine (sCr) and a reduction in urine output; these arefunctional criteria, translating the consequences of glomerular injury. However, it iscommonly admitted that the first pathophysiologic finding in AKI following cardiac surgery istubular injury. Besides, the functional criteria are late, are not specific, and may delay thediagnosis of AKI. Novel AKI biomarkers, specific of tubular injury are available nowadays,with urine Neutrophil Gelatinase-Associated Lipocaline (uNGAL) being the most popular –they may allow for an early diagnosis of AKI.Objectifs. The aim of this work was: (i) explore associations between the delay to RRT, earlyand mid-term outcome in patients younger than 1 year of age who develop AKI followingcardiac surgery; (ii) assess the accuracy of early sCr variations and (iii) of uNGAL for severeAKI in two similar populations aged < 1 year.Methods. A single centre retrospective cohort of patients aged < 1 year undergoing surgeryover 10 years was used to asses the association between the delay to RRT et short and midtermsurvival. Inverse probability of treatment weighting was used to reduce bias due tochanges in practices that occurred during the long study period. A second retrospectivecohort of patients aged < 1 year undergoing surgery over 3 ½ years was used to asses theaccuracy of early sCr variations for the diagnosis of severe AKI. Finally, a third prospectivecohort of patients aged < 1 year undergoing surgery over 18 month was used to asses theaccuracy of uNGAL for the diagnosis of severe AKI. The study of both sCr and uNGAL useda similar methodology: first clustering of all individual trajectories of variation, enablingassessment of the association with a composite outcome (need for RRT and/or death) andidentification of the « normally expected » postoperative evolution of both sCr an uNGAL,associated with the best outcome; second, use of ROC curves and reclassification tables toassess the accuracy of each biomarker for the diagnosis of AKI.Results. Early RRT, initiated on the day of surgery or on day 1 following surgery, wasassociated with a 45% increase in 30-days and 90-days survival. Early sCr variation, within 2days of surgery, had a good specificity but was lacking sensitivity and discrimination for thediagnosis of severe AKI; the « expected » sCr evolution was a persistent 25% postoperativereduction relative to baseline. uNGAL had good discrimination and predictive ability for thecomposite outcome; uNGAL concentration increased within 2 hours of surgery, andremained high in patients with the composite outcome.Discussion and conclusions. If early RRT improves outcome in patients aged < 1 yearswith AKI following cardiac surgery, then it becomes important to perform an early diagnosisof severe AKI. To date, diagnosis of AKI is based on early sCr variations, but such variationslack sensitivity and discrimination for the diagnosis of severe AK. On the other hand, theincrease in uNGAL within hours of surgery has excellent accuracy for the diagnosis of severeAKI, making uNGAL a promising AKI biomarker in patients aged < 1 year undergoing cardiacsurgery with cardiopulmonary bypass.

Submitted by Rosina Valeria Lanzellotti Mattiussi Teixeira (rosina.teixeira@unisantos.br) on 2017-06-09T17:39:16Z No. of bitstreams: 1 Bruno Leandro de Souza.pdf: 1656878 bytes, checksum: 18ca7a9e5002384728445b4498f2a549 (MD5) / Made available in DSpace on 2017-06-09T17:39:17Z (GMT). No. of bitstreams: 1 Bruno Leandro de Souza.pdf: 1656878 bytes, checksum: 18ca7a9e5002384728445b4498f2a549 (MD5) Previous issue date: 2017-03-21 / In Paraíba, until October 2011, there was no action directed at children with congenital heart disease. With the creation of the Pernambuco-Paraíba Pediatric Cardiology Network, the structuring of the pediatric cardiology service was started. Our objective in this study was to verify the impact of the implantation of the Pediatric Cardiology Network with the use of telemedicine in the care of children with congenital heart disease in the Arlinda Marques Pediatric Hospital from 2012. Method: This was a transversal in the Arlinda Marques Pediatric Hospital (CPAM), a reference hospital in the state of Paraíba for high complexity child care, located in the city of João Pessoa / PB. Clinical data (types of heart disease diagnosed and treated with surgical procedure, year of the procedure) and sociodemographic data (age group, sex, municipality of origin and characteristics of the municipality) were analyzed from records of children with congenital heart disease who performed CPAM surgery between 2010 and 2013. The data were analyzed by comparative tests between groups and tests of comparison of means that were defined after initial analysis of the data, considering that the value of "p" less than 0,05. Statistical analyzes were performed using software R. Results: Data from 260 patients were analyzed. There was an increase in the number of procedures after the implantation of the network from 99 to 163. 78% of the procedures were PCA, CIA, CIV and T4F, being statistically significant the increase after the implantation of the network for the procedures in patients with VSD (p = 0.03) and T4F (p = 0.04). The increase in procedures in the period 2012-2013 was statistically significant for children less than 1 years old (p = 0.01) and from the Sertão and Paraiba¿s Agreste (p <0.01). There was also a positive correlation between the period after the implementation of the program and assistance to children in municipalities with a lower percentage of urban area (p <0.001). Conclusion: The Network, which uses telemedicine as a fundamental tool to internalize and democratize health care, has had a positive impact on the care of children with congenital heart disease in the state of Paraíba, by increasing the number of services to children with congenital heart disease, especially In children under 1 year of age, and to expand the service coverage area, especially for the mesoregions of the hinterland and Agreste and municipalities with the highest percentage in the rural area. / Na Paraíba, não havia ações coordenadas para as crianças com cardiopatia congênita, até outubro de 2011. Com a criação da Rede de Cardiologia Pediátrica Pernambuco-Paraíba iniciou-se a estruturação do serviço de cardiologia pediátrica. O objetivo, neste estudo, foi analisar o impacto da implantação da Rede de Cardiologia Pediátrica com o uso da telemedicina no atendimento de crianças com cardiopatia congênita no Complexo de Pediatria Arlinda Marques a partir de 2012. Método: Tratou-se de um transversal no Complexo de Pediatria Arlinda Marques (CPAM), hospital referência no estado da Paraíba para atendimento infantil de alta complexidade, situado na cidade de João Pessoa/PB. Foram analisados dados clínicos (tipos de cardiopatia diagnosticada e tratada com procedimento cirúrgico, ano da realização do procedimento) e sociodemográficos (faixa etária, sexo, município de origem e características do município) a partir de registros de prontuários de crianças com cardiopatia congênita que realizaram cirurgia no CPAM entre os anos de 2010 e 2013. Os dados foram analisados por testes de comparação entre grupos antes da implantação (2010 e 2011) e depois (2012 e 2013). Para as análises estatísticas foi utilizado o programa software R. Resultados: Foram analisados os dados de 260 pacientes. Houve aumento do número de procedimentos após a implantação da rede de 99 para 163, sendo que 78% dos procedimentos foram de persistência do canal arterial, comunicação interatrial, comunicação interventricular e tetralogia de Fallot. Após a implantação da rede o aumento, dos procedimentos foi estatisticamente significante em pacientes com CIV (p = 0,03) e T4F (p = 0,04) e para crianças menores de 1 anos (p = 0,01), de pacientes procedentes do sertão e agreste paraibanos (p<0,01) e de assistência às crianças em municípios com menor percentual de zona urbana (p<0,001). Conclusão: A Rede de Cardiologia Pediátrica Pernambuco-Paraíba que o uso da telemedicina é uma ferramenta útil e importante para interiorizar e democratizar a assistência à saúde, pois trouxe impacto positivo para o atendimento às crianças com cardiopatias congênitas no estado da Paraíba ao ampliar o número de atendimentos a crianças com cardiopatia congênitas, sobretudo em menores de 01 ano, e ampliar a área de abrangência de atendimento, especialmente para as mesorregiões do sertão e do agreste e municípios da com maior percentual na zona rural.

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BACKGROUND: In India, an estimated 200,000 congenital heart defects are diagnosed each year but only 50 pediatric cardiac health centers exist with capacity to perform pediatric cardiac surgeries (PCS). Majority of the centers are private and have high cost of care. Hrudaya Foundation, a non-profit, was started to cover in-hospital costs of pediatric cardiac surgery for poor families. For the study, risk factors of post-operative infection (major outcome of PCS) were evaluated and gaps in care faced by Hrudaya Foundation patients were identified. METHODS: To identify risk factors associated with POI, retrospective cohort study was conducted. Medical records and foundation notes of 1028 interventional CATH and open heart surgery patients were examined. Chisq tests and logistic regressions on socio-economic and clinical factors were run to identify risk factors of POI for open heart surgery patients. The study also tested associations of patients’ community characteristics with pre-operative conditions and POI, like lack of access to improved latrines, distance to hospital, under & unemployment rate, and maternal illiteracy rates. To identify gaps in care, the study collected and analyzed interviews with 11 staff and 27 parents. The semi-structured interviews focused on care pathway from birth to post-discharge follow-up, financial obstacles, and an asset assessment. RESULTS: Pediatric open heart surgery patients had a 19% post-operative infection rate and a 5% mortality rate. Post-operative infections were significantly associated with age of 12 months and under, severely underweight, history of prior cardiac intervention, high risk surgery (RACHS-1 score 3 & 4), delayed sternal closure, and re-operation within same admission when the other risk factors were kept constant. POI did not have a statistically significant correlation with community level characteristics. The study found several gaps in care. Parents had difficulty getting a referral to affordable specialty cardiac care after diagnosis. Even after a referral to Hrudaya Foundation, parents still had to borrow large sums of money due to travel, lodging, and follow-up expenses. Financial constraints created barriers to maintain wellness before and after intervention. Most parents did not have consistent income and they were not aware of many assets in their communities. CONCLUSION: Patients with significant risk factors for POI should have more aggressive infection management. Though close to 41% of the sample were severely underweight, the risk factor was not recognized as actionable. Patients should get nutrition supplementation prior to surgery admission and parents should be notified of their child’s malnutrition status at discharge. Additionally, BPL parents need additional resource and system navigation assistance to reduce financial constraints and maintain their child’s follow-up care and nutrition. / 2021-05-12T00:00:00Z

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Ng, Mei. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2010. / Includes bibliographical references (leaves xvi-xlviii). / Abstracts in English and Chinese. / ACKNOWLEDGEMENTS --- p.i / ABSTRACT / In English --- p.ii / In Chinese --- p.iv / LIST OF TABLES --- p.vi / LIST OF FIGURE --- p.viii / ABBREVIATIONS / For Units --- p.ix / For Prefixes of the International System of Units --- p.ix / For Terms Commonly Used --- p.X / Chapter CHAPTER 1 --- Overview of Childhood Obstructive Sleep Apnoea Syndrome (OSAS) / Chapter 1.1 --- Prevalence --- p.1 / Chapter 1.2 --- Clinical Features --- p.3 / Chapter 1.3 --- Definitions and Cutoffs --- p.4 / Chapter 1.4 --- Pathophysiology --- p.6 / Chapter 1.5 --- Risk Factors / Chapter 1.5.1 --- Gender --- p.8 / Chapter 1.5.2 --- Obesity --- p.9 / Chapter 1.5.3 --- Adenotonsillar Hypertrophy --- p.10 / Chapter 1.5.4 --- Genetic --- p.11 / Chapter 1.5.5 --- Atopic Diseases --- p.12 / Chapter 1.6 --- Complications / Chapter 1.6.1 --- Neurobehavioural Deficits --- p.13 / Chapter 1.6.2 --- Growth Defects --- p.14 / Chapter 1.6.3 --- Metabolic Disorders --- p.16 / Chapter 1.6.4 --- Systemic inflammation --- p.17 / Chapter 1.6.5 --- Cardiovascular Consequences --- p.19 / Chapter 1.7 --- Diagnosis --- p.20 / Chapter 1.8 --- Treatment / Chapter 1.8.1 --- Surgical Treatment --- p.22 / Chapter 1.8.2 --- Continuous Positive Airway Pressure (CPAP) --- p.24 / Chapter 1.8.3 --- Corticosteroids --- p.24 / Chapter 1.8.4 --- Leukotriene Receptor Antagonist --- p.25 / Chapter 1.8.5 --- Oral Appliances --- p.26 / Chapter 1.8.6 --- Weight Control --- p.27 / Chapter CHAPTER 2 --- OSAS and Cardiovascular Complications in Adults / Chapter 2.1 --- Mechanism / Chapter 2.1.1 --- Acute Cardiovascular Responses --- p.28 / Chapter 2.1.2 --- Chronic Cardiovascular Responses --- p.29 / Chapter 2.2 --- Hypertension / Chapter 2.2.1 --- Epidemiological and Clinical Data --- p.31 / Chapter 2.2.2 --- Characteristics --- p.32 / Chapter 2.2.3 --- Mechanisms --- p.33 / Chapter 2.2.4 --- Treatment --- p.34 / Chapter 2.3 --- Heart Failure --- p.35 / Chapter 2.4 --- Stroke --- p.37 / Chapter 2.5 --- Cardiac Arrhythmias --- p.39 / Chapter 2.6 --- Myocardial Ischemia and Vascular Disease --- p.41 / Chapter 2.7 --- Pulmonary Hypertension --- p.43 / Chapter CHAPTER 3 --- OSAS and cardiovascular complication in children / Chapter 3.1 --- Blood Pressure --- p.45 / Chapter 3.2 --- Ventricular Hypertrophy and Dysfunctions --- p.48 / Chapter 3.3 --- Heart Rate Variability --- p.50 / Chapter 3.4 --- Arterial Tone --- p.51 / Chapter 3.5 --- Endothelial Function --- p.51 / Chapter CHAPTER 4 --- Longitudinal follow-up study of children with OSAS - a cardiovascular perspective / Chapter 4.1 --- Introduction --- p.53 / Chapter 4.2 --- Methods / Chapter 4.2.1 --- Subjects and Study Design --- p.57 / Chapter 4.2.2 --- Polysomnography --- p.59 / Chapter 4.2.3 --- Ambulatory Blood Pressure Measurement --- p.61 / Chapter 4.2.4 --- Statistical Analysis --- p.62 / Chapter 4.3 --- Results / Chapter 4.3.1 --- Subject Characteristics --- p.64 / Chapter 4.3.2 --- Blood Pressure During Wakefulness --- p.71 / Chapter 4.3.3 --- Blood Pressure During Sleep --- p.76 / Chapter 4.3.4 --- Nocturnal Blood Pressure Dipping --- p.83 / Chapter 4.3.5 --- Blood Profile --- p.86 / Chapter 4.4 --- Discussion --- p.87 / Chapter 4.5 --- Conclusion --- p.99 / Reference List --- p.xvi