Dans cette thèse, nous étudions les propriétés spectrales du Laplacien avec la condition de bord de Robin attractive sur des domaines du plan à coins. Notre but est de comprendre l’influence des coins convexes sur l’asymptotique des valeurs propres de cet opérateur lorsque le paramètre de Robin est grand. Nous montrons en particulier que l’asymptotique des premières valeurs propres de Robin sur des polygones curvilignes est déterminée par des opérateurs modèles : les Laplaciens agissant sur les secteurs tangents au domaine. Pour une certaine classe de polygones droits, nous montrons l’existence d’un opérateur effectif sur le bord du domaine qui détermine l’asymptotique des valeurs propres suivantes. Enfin, des asymptotiques de Weyl pour différents seuils dépendant du paramètre de Robin sont obtenues. / In this thesis, we are interested in the spectral properties of the Laplacian with the attractive Robin boundary condition on planar domains with corners. The aim is to understand the influence of the convex corners on the spectral properties of this operator when the Robin parameter is large. In particular, we show that the asymptotics of the first Robin eigenvalues on curvilinear polygons is determined by model operators: the Robin Laplacians acting on infinite sectors. For a particular class of polygons with straight edges, we prove the existence of an effective operator acting on the boundary of the domain and determining the asymptotics of the further eigenvalues. Finally, some Weyl-type asymptotics for different thresholds depending on the Robin parameter are obtained.

Prenant comme point de départ le rapport paradoxal qui existe entre le témoignage et la littérature (l’un étant considéré comme véridique et l’autre, comme fictive) le présent mémoire s’intéresse à l’utilisation de la fiction dans les récits autobiographiques et testimoniaux de Jorge Semprun, avec L’Écriture ou la vie (1994), et de Régine Robin, avec L’Immense fatigue des pierres (1996). L’étude de ces textes tente de vérifier l’hypothèse selon laquelle, en faisant de leur témoignage une œuvre littéraire qui assume sa part de fiction, les deux auteurs arriveraient à offrir un témoignage plus juste de leur expérience de la Shoah. Le premier chapitre constitue un panorama critique et historique des deux axes théoriques principaux sur lesquels s’appuie ce travail, d’une part les études sur l’écriture testimoniale et sur la littérature de la Shoah (Derrida, Bornand, Prstojevic) et d’autre part les travaux sur l’autobiographie (Lejeune, Robin, Viart et Vercier). Il s’interroge sur les liens qui les unissent tout en tentant de positionner Robin et Semprun à travers ce champ de pratiques littéraires. Les deuxièmes et troisièmes chapitres s’intéressent ensuite aux différents effets de fiction et de réel qui se trouvent dans les deux œuvres du corpus et analysent, dans un premier temps, la mise en scène d’un pacte de vérité ambiguë passant par la représentation littéraire de la figure auctoriale et de l’acte d’écriture et, dans un deuxième temps, la représentation littéraire du réel en étudiant les nombreuses références intertextuelles, la présence du topos de la visite au camp de concentration, ainsi que l’utilisation particulière de l’archive par Semprun et Robin. / Taking as a starting point the paradoxical link that exists between testimony and literature (one being considered veracious and the other, fictional), this master’s thesis explores the use of fiction in the autobiographical and testimonial works of Jorge Semprun, with L’Écriture ou la vie (1994), and Régine Robin, with L’Immense fatigue des pierres (1996). This study tries to confirm the assumption that, in making their testimony a literary work which assumes a fare share of fiction, the two authors succeed in offering a more accurate testimony of their experience of Holocaust. Chapter one consists in a critic and historic overview of the two approaches, which are this thesis foundations : the Holocaust studies and the testimonial writings (Derrida, Bornand, Prstojevic) on one hand, and the studies on autobiographical writings (Lejeune, Robin, Viart and Vercier) on the other. It focusses on finding what unifies them and tries to position Robin and Semprun in this large literary conventions spectrum. The next two chapters of this thesis are focussing on the various fictional effects as well as on the reality-occurencies in both novels of the corpus, first by studying the staging of this ambiguous truth pact through the literary representation of the auctorial figures and the act of writing, and then, by observing the literary representation of reality through the many intertextual references, the actual concentration camp visits descriptions (that have become a topos of Holocaust literature) and finally Semprun and Robin’s particular use of the archives.

Introduction : La croissance maxillo-mandibulaire des enfants avec une séquence de Pierre Robin (SPR) est controversée dans la littérature. Certains auteurs croient que la croissance mandibulaire est accélérée après la naissance, mais peu se sont penchés sur la croissance du maxillaire supérieur. Cette étude rétrospective sur dossier vise à analyser la croissance maxillo-mandibulaire des enfants atteints de la SPR. Dans un deuxième temps, nous aurions aimé évaluer la sévérité et l’évolution de l’apnée du sommeil en lien avec la croissance des maxillaires, mais un manque de données a empêché l’atteinte de cet objectif. Matériel et méthode : Les dossiers médicaux et orthodontiques de 93 patients (82 volet apnée et 40 volet croissance) du CHU Ste-Justine avec une SPR isolée ont été révisés puis comparés au groupe contrôle composé d’enfants normaux de l’Université du Michigan. L’analyse statistique de modèle mixte pour mesures répétées de même que celle de Brunner-Langer furent effectuées. Résultats : L’évaluation orthodontique a montré un changement statistiquement significatif pour la relation molaire droite, la présence de chevauchement et de diastème au maxillaire et le surplomb vertical. L’analyse des données céphalométriques nous montre que le maxillaire supérieur, la branche montante et le corps de la mandibule sont tous réduits par rapport à la normale. Ce dernier montre une diminution significative avec l’âge (p = 0,03). L’angle gonial, le SNA, SNB, ANB, l’angle de convexité faciale et l’inclinaison de l’incisive supérieure par rapport à FH sont tous normaux. Par contre, on remarque une augmentation statistiquement significative de cette dernière avec l’âge (p = 0,04). L’angle Y est augmenté tandis que les hauteurs faciales supérieure (HFS) et inférieure (HFI) sont diminuées bien que cette dernière montre une tendance à s’approcher de la normale avec l’âge (p ≤ 0,001). Discussion : Les dimensions des maxillaires sont similaires à plusieurs études. En ce qui concerne la mandibule, la croissance est soit plus lente, soit diminuée. Cette observation est plus marquée lorsque l’on s’approche du pic de croissance puisque l’écart par rapport à la normale s’agrandit. On voit une tendance à la croissance hyperdivergente qui pourrait expliquer l’augmentation de la HFI avec l’âge. Le fait que SNA et SNB soient dans la normale pourrait s’expliquer par une diminution de la longueur de la base crânienne. Conclusion : Il n’y a pas de rattrapage de croissance maxillaire et mandibulaire. Les maxillaires restent micrognathes quoique proportionnels l’un envers l’autre et le profil est convexe tout au long de la croissance. La comparaison des données céphalométriques et des traitements orthodontiques avec ceux des patients présentant une fente palatine isolée devrait se faire sous peu. Nous n’avons pas été en mesure d’atteindre nos objectifs concernant l’apnée du sommeil. Une étude prospective serait à prévoir pour y arriver. / Introduction: Maxillo-mandibular growth in children with Pierre Robin sequence (PRS) is controversial in the literature. Some authors believe that mandibular growth is accelerated after birth, but few have looked at the growth of the maxilla. This retrospective study aims to analyze the maxillo-mandibular growth in children with PRS. Secondly, we would have liked to assess the severity and evolution of sleep apnea related to the growth of the jaws, but a lack of data prevented the achievement of this objective. Materials and Methods: The medical and orthodontic records of 93 patients (82 apnea, 40 growth) of the CHU Ste-Justine with isolated PRS were reviewed and compared to the control group composed of normal children of the University of Michigan. The mixed model repeated measures statistical analysis as well as that of Brunner-Langer was performed. Results: Orthodontic evaluation showed a statistically significant change in the right molar relationship, the presence of crowding and diastema in the maxilla and the overbite. Analysis of cephalometric radiographs shows that the upper jaw, the ramus and body of the mandible are reduced compared to normal values. The latter shows a significant decrease with age (p = 0,03). The gonial angle, SNA, SNB, ANB, facial convexity angle and inclination of the upper incisor compared with FH are all normal. However, the latter is significantly increased with age (p = 0,04). The Y axis is increased while the upper and lower facial heights (UFH, LFH) are reduced although the latter shows a tendency to normalize with age (p ≤ 0,001). Discussion: Maxillary dimensions are similar to several studies. With regard to the mandible, the growth is either slower or decreased. This observation was more pronounced when approaching the peak of growth since the deviation from the normal enlarges. We see a growth trend hyperdivergent, which could explain the normalization of the LFH. The fact that SNA and SNB are in normal limits could be explained by a decrease in the length of the cranial base. Conclusion: There is no catch up growth either for the maxilla or the mandible. Both jaws remain smaller than normal and the profile stays convexe throughout growth. Comparison of cephalometric data and orthodontic treatments with patients presenting an isolated cleft palate should be done shortly. We have not been able to achieve our goals for sleep apnea. A prospective study would be expected to get there.

Motivée par deux problématiques liées aux plasmas de tokamak, cette thèse propose deux méthodes d'approximation numérique pour deux problèmes mathématiques s'y rattachant. D'une part, pour l'étude du transport turbulent de particules, une méthode numérique basée sur les schémas de subdivision est présentée pour la simulation de trajectoires de particules dans un champ de vitesse fortement variable. D'autre part, dans le cadre de la modélisation de l'interaction plasma-paroi, une méthode de pénalisation est proposée pour la prise en compte de conditions aux limites de type Neumann ou Robin. Analysées sur des problèmes modèles de complexité croissante, ces méthodes sont enfin appliquées dans des situations plus réalistes d'intérêt pratique dans l'étude du plasma de bord. / Motivated by two issues related to tokamak plasmas, this thesis proposes two numerical approximation methods for two mathematical problems associated with them. On the one hand, in order to study the turbulent transport of particles, a numerical method based on subdivision schemes is presented for the simulation of particle trajectories in a strongly varying velocity field. On the other hand, in the context of modeling the plasma-wall interaction, a penalization method is proposed to take into account Neumann or Robin boundary conditions. Analyzed on model problems of increasing complexity, these methods are finally applied in more realistic situations of practical interest in the study of the edge plasma.

Objetivo: Investigar a prevalência de disgenesias dentárias em indivíduos com síndrome Richieri-Costa-Pereira. Material e Métodos: 13 indivíduos, registrados no Hospital de Reabilitação de Anomalias Craniofaciais - Universidade de São Paulo (HRAC-USP), Bauru Brasil, com síndrome Richieri-Costa-Pereira, de ambos os gêneros, de etnia branca, acima de oito anos de idade e com pelo menos uma radiografia panorâmica disponível. As disgenesias dentárias foram avaliadas clinica e radiograficamente, por uma única examinadora, e foram classificadas como alterações hiperplasiantes, hipoplasiantes e heterotópicas e como alterações de forma, número, posição e estrutura, sendo as alterações de esmalte classificadas pelo índice de Defeitos de Desenvolvimento do Esmalte (DDE) e descritas com relação à face dentária afetada. Antes da coleta de dados, foi realizado estudo piloto para avaliação da concordância intra-examinador quanto à presença de agenesias dentárias e dentes supranumerários. Resultados: Todos os indivíduos (100%) apresentavam pelo menos uma disgenesia dentária, com predominância de alterações hipoplasiantes, principalmente representadas por agenesias dentárias dos incisivos e segundos pré-molares inferiores e opacidades de esmalte de coloração branco-creme, demarcada, afetando principalmente os pré-molares superiores seguidos dos molares inferiores, com predominância de alterações na face vestibular. Conclusão: Indivíduos com síndrome Richieri-Costa Pereira apresentam alta prevalência de agenesias dentárias, principalmente incisivos e pré-molares inferiores, bem como alta freqüência de opacidades de esmalte. Estes achados são compatíveis com a fissura mandibular presente em todos os indivíduos e refletem também a característica hipoplasiante da síndrome. / Objective: To investigate the prevalence of tooth abnormalities in individuals with Richieri-Costa-Pereira syndrome. Material and Methods: 13 individuals registered at the Hospital for Rehabilitation of Craniofacial Anomalies University of São Paulo (HRAC-USP), Bauru, Brazil, with Richieri-Costa-Pereira syndrome, of both genders, Caucasoid, aged more than eight years and with at least one panoramic radiograph available in the hospital files. The tooth abnormalities were evaluated clinically and radiographically by a single examiner and were classified as hyperplastic, hypoplastic or heterotopic alterations and as alterations of shape, number, position and structure. The enamel alterations were classified by the DDE index and described according to the tooth surface affected. Before data collection, a pilot study was conducted to evaluate the intraexaminer agreement as to the presence of tooth agenesis and supernumerary teeth. Results: All individuals (100%) presented at least one tooth abnormality, with predominance of hypoplastic disorders, mainly including agenesis of mandibular incisors and second premolars, as well as demarcated creamy-white enamel opacities, primarily affecting the maxillary premolars, followed by mandibular molars, mainly affecting the buccal surface. Conclusion: Individuals with Richieri-Costa Pereira syndrome present high prevalence of tooth agenesis, especially mandibular incisors and premolars, as well as high frequency of enamel opacities. These findings are compatible with the mandibular cleft observed in all individuals and also reflect the hypoplastic characteristic of the syndrome.

L’objectif que nous nous sommes fixés dans ce travail est la conception d’algorithmes d’ordonnancement temps réel en-ligne faisables optimisant l’utilisation de la plate-forme d’exécution et/ou des critères applicatifs de qualité de service propres à l’application. Nous avons en particulier étudié l’ordonnancement d’activités sur une ressource unique. Deux cas ont été analysés : le cas de tâches indépendantes périodiques s’exécutant sur un processeur et le cas de flux de messages indépendants périodiques sur un réseau de terrain avec accès au médium priorisé. Nos contributions reposent sur le “modèle classique” de l’ordonnancement temps réel où le système est représenté par un ensemble d’activités périodiques indépendantes et deux problématiques ont été abordées : • optimisation de l’utilisation de la plate-forme d’exécution : utiliser au mieux le potentiel de la plate-forme d’exécution tout en garantissant le respect des contraintes temporelles imposées au système ; ceci optimise le nombre de configurations faisables, • optimisation des critères applicatifs de qualité de service propres à l’application (i.e., pris en compte des performances de l’application autre que la faisabilité) : garantir les contraintes de temps tout en optimisant les performances de l’application. Nous avons donc proposé : • des méthodes de configurations permettant d’optimiser l’utilisation de la plate-forme d’exécution (i.e., maximiser faisabilité) en fixant les paramètres des politiques ou des systèmes considérés d’une manière appropriée. Deux études ont été conduites dans ce cadre : • allocation des “offsets” dans les systèmes “offset free”, • allocation de priorités, de politiques et de quantum dans les systèmes conformes au standard Posix 1003.1b, • une nouvelle classe de politiques d’ordonnancement permettant d’optimiser des critères de performances propres à l’application. De plus, une analyse d’ordonnancement générique pour cette classe a été proposée / Our goal is to come up with feasible (i.e., all required time constraints are met) on-line real-time scheduling algorithms. These algorithms have to optimise 1) the utilisation of the execution platform (i.e., meet time constraints and use platform at its fullest potential) and/or 2) optimise the application dependent performance criteria. We study two cases : the case of independent periodic tasks scheduled on a processor and the case of periodic traffic streams scheduled on a priority bus. To deal with these two problems, we propose : • Configuration methods to allow to optmlise the utilisation rate of the execution platform by setting the parameters of the policies or of the activities of the considered system. We perform two studies : the allocation of offsets in "Offset free" systems (I.E., offsets can be chosen off-line) and the priorities, policies and quantum allocations in systems compliant to the standard Posix 1003.1B, • A new class of scheduling policies to allow optimising application performance dependent criteria

Objetivos: verificar o impacto da promoção do autocuidado na carga de trabalho de enfermagem (CTE), em relação às crianças com Sequência de Robin Isolada e seus agentes de autocuidado; construir e validar um Tutorial referente à aplicação do Nursing Activities Score (NAS) em Unidade de Cuidado Semi-intensivo especializada; identificar e comparar a CTE em dois momentos distintos, compreendendo a 1ª internação (cuidadores não capacitados para o autocuidado) e a 2ª internação (cuidadores capacitados para o autocuidado); associar os itens NAS referentes à promoção do autocuidado (suporte e cuidado aos familiares) entre a 1ª e a 2ª internação; associar os aspectos sociodemográficos das crianças e dos agentes de autocuidado à CTE; identificar e comparar o dimensionamento de pessoal segundo as horas NAS na 1ª e 2ª internação à Resolução Cofen 293/04. Método: estudo prospectivo, desenvolvido na Unidade de Cuidado Semi-intensivo do Hospital de Reabilitação de Anomalias Craniofaciais, baseado no Referencial Teórico do Autocuidado de Dorothea Orem. A amostra constou de 31 lactentes com Sequência de Robin Isolada e seus respectivos agentes de autocuidado. Os participantes foram avaliados na 1ª e 2ª internação quanto à CTE. Para essa avaliação, utilizou-se o NAS, cujo Tutorial foi construído e validado para o presente estudo, considerando-se a especificidade da população. A coleta de dados ocorreu entre os meses de fevereiro a outubro de 2014. Utilizou-se para a análise estatística o Teste T-Student, a Análise de Variância e a Correlação de Pearson. Foram aceitas como diferenças significantes, os valores de p0,05 (5%). Resultados: Foram geradas 519 avaliações referentes à CTE. A média de duração da 1ª internação foi de 10,3 dias (±5,7), enquanto da 2ª foi de 6,4 dias (± 3,4). A média NAS na 1ª internação foi de 60,9% e na 2ª internação foi de 41,6%, ou seja, foram dispendidas 93,4 e 63,4 horas de enfermagem referente às 24 horas, respectivamente. A CTE no 1º dia de internação foi maior quando comparada ao último dia, tanto na 1ª (p<0,001) como na 2ª internação (p<0,001). A CTE foi maior no 1º (p<0,001) e último dia (p=0,025) na 1ª internação. A CTE na 1ª internação foi maior quando comparada com a 2ª internação (p<0,001). Os itens NAS referentes à capacitação do autocuidado influenciaram a CTE (p<0,001), enquanto que as características sociodemográficas das crianças e agentes de autocuidado, não influenciaram. O dimensionamento de pessoal segundo as horas NAS foi de 26 profissionais na 1ª internação e 18 profissionais na 2ª internação. Quanto à Resolução Cofen, foram necessárias 60,2 horas de enfermagem referentes às 24 horas, e o dimensionamento foi de 14 profissionais, ou seja, evidenciou-se um déficit de oito profissionais quando comparado com a 2ª internação, e de 12 profissionais quando comparado com a Resolução do Cofen 293/04. Conclusão: a CTE foi maior ao se promover o autocuidado e influenciou o quantitativo de profissionais de enfermagem, demonstrando a necessidade de se reconsiderar sobre o dimensionamento de pessoal referente a esse perfil de assistência / Objectives: to verify the impact of promoting self-care upon nursing workload, in relation to children with Isolated Robin Sequence and their self-care agents; to elaborate and validate a Tutorial referring to the application of the Nursing Activities Score (NAS) in a Specialized Semi-Intensive Care Unit; to identify and compare the nursing workload at two different periods, including the 1st hospitalization (untrained caregivers for self-care) and the 2nd hospitalization (caregivers trained for self-care); to associate NAS items related to the promotion of self-care (support and care concerning family members) between the 1st and the 2nd hospitalization; to associate the sociodemographic characteristics of children and the self-care agents to nursing workload; to identify and compare the staff dimensioning, according to NAS in the 1st and 2nd hospitalization, according to Cofen Resolution n° 293/04. Method: prospective study carried out at Specialized Semi-Intensive Care Unit of the Rehabilitation Hospital of Craniofacial Anomalies, based on the Self-Care Theoretical Framework of Dorothea Orem. The sample consisted of 31 infants with Isolated Robin Sequence and their respective self-care agents. Participants were evaluated on the 1st and 2nd hospitalization, regarding the nursing workload. For this evaluation, NAS was applied, whose Tutorial was developed and validated for this study, considering the specificity of the population. Data collection took place from February to October 2014. For the statistical analysis, the Student T-test, the analysis of variance and Pearson correlation were employed. Values for p=0.05 (5%) were accepted as significant difference. Results: a total of 519 assessments, related to nursing workload were generated. The average period of the 1st hospitalization consisted of 10.3 days (±5.7), while the 2nd consisted of 6.4 days (±3.4). NAS average in the 1st hospitalization was 60.9% and in the 2nd was 41.6%, that is, a total of 93.4 and 63.4 nursing hours, referring to 24 hours, respectively. The nursing workload on the 1st day of hospitalization was higher, when compared to the last day, either on the 1st (p<0.001) as on the 2nd hospitalization (p<0.001). Nursing workload was higher on the 1st (p<0.001) and last day (p=0.025) during the 1st hospitalization. Nursing workload in the 1st hospitalization was higher when compared to the 2nd hospitalization (p<0.001). NAS items related to self-care training influenced the nursing workload (p<0.001), while the socio-demographic characteristics of children and self-care agents, did not influence. The staff dimensioning according to NAS comprised 26 professionals in the 1st hospitalization and 18 professionals in the 2nd. As for Cofen Resolution, a total of 60.2 nursing hours were necessary, referring to 24 hours, and comprised 14 professionals, thus, it was evidenced, a deficit of eight professionals when compared to the 2nd hospitalization, and 12 professionals, when compared to Cofen Resolution 293/04. Conclusion: nursing workload was higher when promoted self-care and influenced the amount of nursing professionals, demonstrating the necessity for reconsidering the staff dimensioning, regarding this type of service

Introdução: Uma série de aspectos diagnósticos e terapêuticos relacionados à Sequência de Robin (SR) não possuem definição clara na literatura, conforme demonstrado em revisão sistemática presente nesta tese. Essas áreas de incerteza envolvem os métodos de classificação do grau de glossoptose por meio da endoscopia de via aérea (EVA), a associação com manifestações clínicas e a avaliação polissonográfica. Objetivos: Avaliar, a partir de um estudo transversal aninhado em uma coorte, a associação entre duas classificações de glossoptose e a severidade dos sintomas em pacientes com SR, além de determinar a acurácia dessas classificações na determinação de pacientes com maior gravidade clínica. Avaliar a associação entre parâmetros de polissonografia e graus de gravidade de manifestações clínicas. Métodos: Os pacientes com diagnóstico de SR tiveram suas manifestações clínicas classificadas conforme Cole et al. Foram submetidos à endoscopia do sono e as imagens foram classificadas de acordo com Yellon e De Sousa et al por pesquisador cegado. Os pacientes que não necessitavam de suporte ventilatório foram submetidos à polissonografia. Resultados: Os resultados obtidos foram apresentados em quatro trabalhos: Artigo 1, aceito para publicação: revisão sistemática; Artigo 2, publicado: Associação entre classificação endoscópica da glossoptose e manifestação clínica grave: neste trabalho, um total de 58 pacientes foram incluídos. A probabilidade de apresentar sintomas graves conforme classificado por Cole et al foi maior nos pacientes Yellon grau 3 (68,4%, P=0,012) e de Sousa et al moderado e grave (61,5% e 62,5%, respectivamente, P=0,015) do que nos graus mais leves de obstrução; Artigo 3, submetido: Performance diagnóstica das classificações endoscópicas: neste trabalho foram incluídos 80 pacientes. A sensibilidade (Y: 56.2% x S: 28.1%, P<0.001) e a especificidade (Y: 85.4% x S: 93.8%, P=0.038) na identificação de sintomas clínicos graves foram estatisticamente diferentes entre as classificações de Yellon e de Sousa et al. Calculou-se a Razão de Chances Diagnóstica para Yellon (RCD: 7,53 95%CI 4.15-10.90) e de Sousa (RCD: 5,87 95%CI 1.86-9.87). As diferenças encontradas não foram significativas (P=0,92); Artigo 4, submetido: Associação entre parâmetros polissonográficos e as manifestações clínicas conforme Cole et al. Determinou-se a Razão de Chances para cada variação nos seguintes parâmetros: índice de dessaturação (1.27; 1.07-1.51; R2=19.8%; P=0.006), índice de apneia e hipopneia (1.13; 1.01-1.26; R2=12.5%; P=0.02), média de saturação de oxigênio (0.16; 0.05-0.52; R2=22.6%; P=0.002), nadir de saturação (0.73; 0.56- 0.96; R2=10.0%; P=0.02), porcentagem de tempo com saturação menor que 90% (9.49; 1.63- 55.31, R2=37.6%; P=0.012) e porcentagem de tempo com obstrução (2.5; 1.31-4.76; R2=25.1%; P=0.006). Conclusões: As alterações na EVA estão associadas com a gravidade das manifestações clínicas. Ao se aprofundar a abordagem de análise sob uma perspectiva diagnóstica, demonstrou-se que as classificações de Yellon e de Sousa et al possuem uma baixa sensibilidade, porém uma alta especificidade. A porcentagem do tempo com saturação menor que 90%, porcentagem do tempo apresentando obstrução e média de saturação de oxigênio durante o sono foram os parâmetros polissonográficos com a maior associação com as manifestações clínicas. Assim, recomenda-se que a avaliação endoscópica da via aérea em pacientes portadores de SR seja realizada com intuito de estratificar a gravidade, mas não para triagem diagnóstica. Da mesma forma, recomenda-se que os parâmetros acima destacados da polissonografia, sejam especialmente considerados no acompanhamento desses pacientes. / Introduction: Several diagnostic and therapeutic aspects concerning Robin Sequence (RS) are not clearly defined in medical literature, as demonstrated in a systematic review included in this thesis. These areas of uncertainty comprehend methods of glossoptosis degree classification, its association with clinical manifestations and polysomnographic evaluation. Objectives: A cohort nested cross-sectional study was done to evaluate the association of two different glossoptosis classifications with symptom severity in RS patients, while determining its accuracy for the identification of severely symptomatic patients. The study also aimed to evaluate the association between polysomnographic parameters and clinical symptom severity. Methods: RS patients had their clinical manifestations classified according to Cole et al. They were also examined with flexible fiberoptic laryngoscopy (FFL) and recordings were classified according to Yellon and De Sousa et al classifications by a blinded researcher. Those patients not needing ventilator support underwent polysomnographic testing. Results: Overall results were divided into four distinct articles: Article 1, accepted for publication: systematic review; Article 2, published: Association between glossoptosis endoscopic classification and severe clinical manifestations: in this article, a total of 58 patients were enrolled. The probability of presenting severe clinical findings according to Cole et al classification was higher in patients classified as Yellon grade 3 (68.4%, P=0.012) and De Sousa et al moderate or severe levels (61.5% and 62.5%, respectively, P=0.015) than in milder degrees of obstruction. Article 3, submitted: Diagnostic performance of endoscopic classifications: in this article, additional 22 patients were enrolled, summing up 80 patients. The sensitivity (Y: 56.2% x S: 28.1%, P<0.001) and specificity (Y: 85.4% x S: 93.8%, P=0.038) in the identification of severe clinical symptoms were statistically different between classifications of Yellon and De Sousa et al. A Diagnostic Odds Ratio was computed for Yellon (DOR: 7.53 95%CI 4.15-10.90) and De Sousa et al (DOR: 5.87 95%CI 1.86-9.87). No relevant differences were found between them (P=0.92). Article 4: submitted: Association between polysomnographic parameters and obstructive airway symptoms: odds ratios for severe clinical findings were computed for the variation of polysomnographic parameters: Dessaturation Index (1.27; 1.07-1.51; R2=19.8%; P=0.006), Apnea/Hypopnea Index - AIH - (1.13; 1.01-1.26; R2=12.5%; P=0.02), Sleep Mean Oxygen Saturation (0.16; 0.05-0.52; R2=22.6%; P=0.002), Oxygen Saturation Nadir (0.73; 0.56-0.96; R2=10.0%; P=0.02), Percentage of time under oxygen saturation of 90% (9.49; 1.63-55.31, R2=37.6%; P=0.012) and Percentage of Time Presenting Obstruction (2.5; 1.31-4.76; R2=25.1%; P=0.006). Conclusions: FFL findings seem to have a fair association with the severity of clinical manifestations. However, this association was found to be probably a major influence of a high specificity, while observed sensitivity was less than would be desirable for diagnostic purposes. Percentage of time under 90% oxygen saturation, percentage of time with obstruction and mean oxygen saturation during sleep were the most associated parameters with clinical manifestations. Therefore, based on these findings, we would argue that airway endoscopic examination in RS patients should be approached aiming at clinical severity stratification, rather than for screening purposes. Also, we would recommend that those aforementioned parameters from polysomnography should be specifically addressed in the follow up of this peculiar group of patients.

Introdução: A sequência de Robin (SR) é definida por retromicrognatia e glossoptose que levam à dificuldade respiratória de deglutição, com ou sem fissura palatina. Com espectro etiológico amplo e associações sindrômicas diversas, a expressão clínica da SR se torna heterogênea. Há alta prevalência de síndrome da apneia obstrutiva do sono (SAOS), 40 a 60% nesta população. Conforme os protocolos atuais, o tratamento depende da gravidade dos sintomas e dos achados da endoscopia de via aérea superior (VFL). O momento ideal para o reparo cirúrgico do palato é controverso. Técnicas acessórias são fundamentais para o diagnóstico e avaliação prognóstica. No Hospital de Reabilitação de Anomalias Craniofaciais de Bauru (HRAC-USP) a palatoplastia é adiada em pacientes SR pelo conhecido risco para desenvolvimento de SAOS pós-operatória. Ainda há pouca informação na literatura quanto às interações entre o tipo de fissura palatina, os achados da VFL e polissonografia (PSG), com o risco de comprometimento tardio da via aérea superior (VAS) após a cirurgia palatina em crianças com SR isolada (SRI). Objetivos: Avaliar por meio de PSG o efeito da palatoplastia na SAOS em crianças com SRI. Correlacionar estes achados com os obtidos por VFL e exame físico do palato. Detectar a frequência de SAOS nesta população. Estabelecer a importância da PSG como parte de protocolo de tratamento da fissura palatina em crianças com SRI. Métodos: Estudo prospectivo longitudinal que, entre abril de 2011 e abril de 2013, analisou 53 pacientes com diagnostico de SR admitidos no HRAC-USP em fase de avaliação para correção cirúrgica da fissura palatina (entre 10 e 23 meses de idade). Equipe interdisciplinar inicialmente afastou associação de síndromes ou alterações genéticas na amostra, classificou a forma da fissura, realizou os exames de PSG e VFL previamente à palatoplastia; em seguida, a PSG foi repetida entre três a cinco meses após a cirurgia. Resultados: Vinte e uma crianças terminaram o protocolo de estudo adequadamente, quatorze meninas (66,6%), e sete meninos (33,3%). A fissura palatina foi classificada como em forma de \"V\" em onze casos (52,4%), e em forma de \"U\" em dez casos (47,6%). Dezenove pacientes apresentaram tipo I de obstrução da VAS (90,5%); dois pacientes apresentando o tipo II (9,5%), por meio da VFL. A PSG no momento pré-operatório identificou ausência de critérios mínimos para SAOS em oito crianças (38,1%), SAOS leve em oito (38,1%), SAOS moderada em três (14,3%), e SAOS grave em dois casos (9,5%). A PSG no momento pós-operatório identificou a ausência SAOS em quatorze crianças (66,7%), SAOS leve em três (14,3%), SAOS moderada em quatro (19%), e não identificou casos de SAOS grave. Conclusões: A prevalência SAOS encontrada foi de 61,9% no momento anterior à palatoplastia, e 33,3% no momento pós-operatório. Embora os dados não apresentem diferença significativa estatisticamente, a palatoplastia indicou resultado positivo em relação aos distúrbios respiratórios do sono, reduzindo tanto os índices de eventos respiratórios quanto a gravidade dos mesmos. Pacientes considerados mais graves, com IAH mais elevados, endoscopia tipo II, e fissura em \"U\" foram os maiores beneficiados. A PSG não apresentou valores preditivos significativos quanto às complicações cirúrgicas tardias / Introduction: The Robin sequence (RS) is defined as micrognathia and glossoptosis that lead to difficulty in breathing and swallowing, with or without cleft palate. With broad etiological spectrum and various syndromic associations, the clinical expression of RS becomes heterogeneous. There is a high prevalence of obstructive sleep apnea syndrome (OSAS), 40% to 60% in this population. As the current protocols, treatment depends on the severity of symptoms and the findings of the upper airway endoscopy (UAE). The ideal time for palate surgical repair is controversial. Ancillary techniques are essential for the diagnosis and prognostic assessment. At the Hospital for Rehabilitation of Craniofacial Anomalies of Bauru (HRAC-USP) palatoplasty is deferred in RS patients, once the risk for developing OSAS after surgery is well known. Still there is little information in the literature about the interactions of cleft palate morphology, UAE findings and polysomnography (PSG), with the risk of late upper airway (UA) compromise after palate repair in children with isolated Robin sequence (IRS). Objectives: To evaluate the effect of palatoplasty over OSAS in children with IRS as measured by PSG. To correlate these findings with those obtained by UAE and physical examination of the palate. To detect the frequency of OSAS in this population. To establish the importance of the PSG as part of treatment protocol in children with SRI. Methods: It is a longitudinal prospective study that, between April 2011 and April 2013, evaluated 53 patients with RS admitted in the HRAC-USP during the assessment phase for surgical correction of cleft palate (between 10 and 23 months of age). Interdisciplinary team first discarded genetic disorders among the sample, described the cleft anatomy, and conducted the PSG and UAE prior to palatoplasty; then, repeated the PSG between three to five months after surgery. Results: Twenty-one children finished the study protocol properly, fourteen girls (66.6%), and seven boys (33.3%). Cleft palate was classified as \"V\" shaped in eleven cases (52.4%), and \"U\" shaped in 10 cases (47.6%). Nineteen patients presented type I UAE obstruction (90.5%); two patients presented type II (9.5%). The pre-operative PSG identified the absence of criteria for OSAS in eight children (38.1%), mild OSAS in eight (38.1%), moderate OSA in three (14.3%), and severe OSA in two cases (9.5%). The post-operative PSG identified the absence OSAS in fourteen children (66.7%), mild OSA in three (14.3%), moderate OSAS in four (19%), and did not identify cases of severe OSA. Conclusions: The prevalence of OSA was 61.9% at the moment prior to the cleft palate repair and 33.3% at the post-operative moment. Although non statistically significant difference was found between the findings, palate surgery has indicated positive result in relation to OSAS, decreasing respiratory events indexes, as well as its severity. Patients considered more severe, with highest AHI, endoscopy type II, and \"U\" shaped clefts, were the ones with better results. The PSG did not demonstrate significant predictive values for long term surgical complications

In this thesis a multiscale mixed method aiming at the accurate approximation of velocity and pressure fields in heterogeneous porous media is proposed, the Multiscale Robin Coupled Method (MRCM). The procedure is based on a new domain decomposition method in which the local problems are subject to Robin boundary conditions. The method allows for the independent definition of interface spaces for pressure and flux over the skeleton of the decomposition that can be chosen with great flexibility to accommodate local features of the underlying permeability fields. Numerical simulations are presented aiming at illustrating several features of the new method. We illustrate the possibility to recover the multiscale solution of two wellknown methods of the literature, namely, the Multiscale Mortar Mixed Finite Element Method (MMMFEM) and the Multiscale Hybrid-Mixed (MHM) Finite Element Method by suitable choices of the parameter b in the Robin interface conditions. Results show that the accuracy of the MRCM depends on the choice of this algorithmic parameter as well as on the choice of the interface spaces. An extensive numerical assessment of the MRCM is conduct with two types of interface spaces, the usual piecewise polynomial spaces and the informed spaces, the latter obtained from sets of snapshots by dimensionality reduction. Different distributions of the unknowns between pressure and flux are explored. The results show that b, suitably nondimensionalized, can be fixed to unity to avoid any indeterminacy in the method. Further, with both types of spaces, it is observed that a balanced distribution of the interface unknowns between pressure and flux renders the MRCM quite attractive both in accuracy and in computational cost, competitive with other multiscale methods from the literature. The MRCM solutions are in general only global conservative. Two postprocessing procedures are proposed to recover local conservation of the multiscale velocity fields. We investigate the applicability of such methods in highly heterogeneous permeability fields in modeling the contaminant transport in the subsurface. These methods are compared to a standard procedure. Results indicate that the proposed methods have the potential to produce more accurate results than the standard method with similar or reduced computational cost. / Nesta tese é proposto um método misto multiescala visando a aproximação precisa de campos de velocidade e pressão em meios porosos altamente heterogêneos, o método Multiscale Robin Coupled Method (MRCM). Este procedimento é baseado em um novo método de decomposição de domínio no qual os problemas locais são definidos com condições de contorno de Robin. O método permite a definição independente de espaços de interface para pressão e fluxo sobre o esqueleto da decomposição que pode ser escolhida com grande flexibilidade para acomodar características locais dos campos de permeabilidade subjacentes. Simulações numéricas são apresentadas visando ilustrar várias características do novo método. Ilustramos a possibilidade de recuperar a solução multiescala de dois métodos bem conhecidos da literatura, a saber, o Multiscale Mortar Mixed Finite Element Method (MMMFEM) e o Multiscale Hybrid-Mixed (MHM) Finite Element Method por escolhas adequadas do parâmetro b nas condições da interface de Robin. Os resultados mostram que a precisão do MRCM depende da escolha deste parâmetro algorítmico, bem como da escolha dos espaços de interface. Uma extensa avaliação numérica do MRCM é conduzida com dois tipos de espaços de interface, os usuais espaços polinomiais por partes e os espaços informados, este último obtidos a partir da redução de dimensionalidade de conjutos de espaços de snapshots. Diferentes distribuições de incógnitas entre pressão e fluxo são exploradas. Os resultados mostram que b, adequadamente adimensionalizado, pode ser fixado em unidade para evitar qualquer indeterminação no método. Além disso, com ambos os tipos de espaços, observa-se que uma distribuição equilibrada de incógnita entre pressão e fluxo nas interfaces torna o MRCM bastante atraente tanto em precisão quanto em custo computacional, competitivo com outros métodos multiescala da literatura. As soluções MRCM são, em geral, apenas globalmente conservativas. Dois procedimentos de pós-processamento são propostos para recuperar a conservação local dos campos de velocidade multiescala. Investigamos a aplicabilidade de tais métodos em campos de permeabilidade altamente heterogêneos na modelagem do transporte de contaminantes na subsuperfície. Esses métodos são comparados a um procedimento padrão da literatura. Os resultados indicam que os métodos propostos têm o potencial de produzir resultados mais precisos do que o método padrão com custo computacional similar ou reduzido.