Plataforma de apoio à decisão nos cuidados de ginecologia e obstetrícia

Dissertação de mestrado integrado em Engenharia Biomédica (área de especialização em Informática Médica)

Contributos dos ambientes digitais online para a aprendizagem em contexto de atividades de apoio extraescolar

Dissertação de mestrado em Ciências da Educação (área de especialização em Tecnologia Educativa)

Mediastinitis after cardiac transplantation

OBJECTIVE: Assessment of incidence and behavior of mediastinitis after cardiac transplantation. METHODS: From 1985 to 1999, 214 cardiac transplantations were performed, 12 (5.6%) of the transplanted patients developed confirmed mediastinitis. Patient's ages ranged from 42 to 66 years (mean of 52.3±10.0 years) and 10 (83.3%) patients were males. Seven (58.3%) patients showed sternal stability on palpation, 4 (33.3%) patients had pleural empyema, and 2 (16.7%) patients did not show purulent secretion draining through the wound. RESULTS: Staphylococcus aureus was the infectious agent identified in the wound secretion or in the mediastinum, or both, in 8 (66.7%) patients. Staphylococcus epidermidis was identified in 2 (16.7%) patients, Enterococcus faecalis in 1 (8.3%) patient, and the cause of mediastinitis could not be determined in 1 (8.3%) patient. Surgical treatment was performed on an emergency basis, and the extension of the débridement varied with local conditions. In 2 (16.7%) patients, we chose to leave the surgical wound open and performed daily dressings with granulated sugar. Total sternal resection was performed in only 1 (8.3%) patient. Out of this series, 5 (41.7%) patients died, and the causes of death were related to the infection. Autopsy revealed persistence of mediastinitis in 1 (8.3%) patient. CONCLUSION: Promptness in diagnosing mediastinitis and precocious surgical drainage have changed the natural evolution of this disease. Nevertheless, observance of the basic precepts of prophylaxis of infection is still the best way to treat mediastinitis.

The use of primary stenting or balloon percutaneous transluminal coronary angioplasty for the treatment of acutely occluded saphenous vein grafts. Results from the Brazilian National Registry - CENIC

OBJECTIVE: We conducted a comparative analysis of the in-hospital outcomes of patients who underwent primary percutaneous transluminal angioplasty (PTCA) or stent implantation because of an acute myocardial infarction (AMI) related to an acute vein graft occlusion. METHODS: Since 1991 the Brazilian Society of Hemodynamic and Interventional Cardiology has maintained a large database (CENIC). From these, we selected all consecutive patients, who underwent primary PTCA or stenting in the first 24 hours of AMI, with the target vessel being an occluded vein graft. Immediate results and major coronary events occurring up until hospital discharge were analyzed. RESULTS: During this period, 5,932 patients underwent primary PTCA or stenting; 158 (3%) of the procedures were performed because of an acute vein graft occlusion. Stenting was performed in 74 (47%) patients. Patients treated with stents had a higher success rate and lower mean residual stenosis compared with those who underwent primary balloon PTCA. The incidence of reinfarction and death were similar for stenting and balloon PTCA. CONCLUSION: Primary percutaneous treatment of AMI related to acute vein graft occlusion is still an uncommon practice. Primary stenting improved luminal diameter and offered higher rates of success; however, this strategy did not reduce the in-hospital reinfarction and death rate, compared with that occurring with PTCA treatment.

Sommes-nous prêts à prescrire une polypill à nos patients [Are we ready to prescribe a polypill to our patients?].

The all-in-one pill combination (Polypill) of several active components used in primary prevention of cardiovascular disease was a decade ago purposed to reduce the cardiovascular burden by more than 80%. This Polypill could be approved before 2013 in United States. Although controversed, it could answer to the worried situation even observed in Switzerland: the adherence to secondary prevention treatments is clearly insufficient and the cardiovascular events remain in the first row of death's causes. This abstract summarize the results from interventional studies who tried to valid this concept as well as the main stakes to be assessed on the medical side before to consider such a similar approach in Switzerland.

Primary isolated aortic valve surgery in octogenarians.

We reviewed our surgery registry, to identify predictive risk factors for operative results, and to analyse the long-term survival outcome in octogenarians operated for primary isolated aortic valve replacement (AVR). A total of 124 consecutive octogenarians underwent open AVR from January 1990 to December 2005. Combined procedures and redo surgery were excluded. Selected variables were studied as risk factors for hospital mortality and early neurological events. A follow-up (FU; mean FU time: 77 months) was obtained (90% complete), and Kaplan-Meier plots were used to determine survival rates. The mean age was 82+/-2.2 (range: 80-90 years; 63% females). Of the group, four patients (3%) required urgent procedures, 10 (8%) had a previous myocardial infarction, six (5%) had a previous coronary angioplasty and stenting, 13 patients (10%) suffered from angina and 59 (48%) were in the New York Heart Association (NYHA) class III-IV. We identified 114 (92%) degenerative stenosis, six (5%) post-rheumatic stenosis and four (3%) active endocarditis. The predicted mortality calculated by logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 12.6+/-5.7%, and the observed hospital mortality was 5.6%. Causes of death included severe cardiac failure (four patients), multi-organ failure (two) and sepsis (one). Complications were transitory neurological events in three patients (2%), short-term haemodialysis in three (2%), atrial fibrillation in 60 (48%) and six patients were re-operated for bleeding. Atrio-ventricular block, myocardial infarction or permanent stroke was not detected. The age at surgery and the postoperative renal failure were predictors for hospital mortality (p value <0.05), whereas we did not find predictors for neurological events. The mean FU time was 77 months (6.5 years) and the mean age of surviving patients was 87+/-4 years (81-95 years). The actuarial survival estimates at 5 and 10 years were 88% and 50%, respectively. Our experience shows good short-term results after primary isolated standard AVR in patients more than 80 years of age. The FU suggests that aortic valve surgery in octogenarians guarantees satisfactory long-term survival rates and a good quality of life, free from cardiac re-operations. In the era of catheter-based aortic valve implantation, open-heart surgery for AVR remains the standard of care for healthy octogenarians.

Augment de la resolució en la reconstrucció de les temperatures de l'aigua i de l'aire del llac Baikal (Sibèria) dels últims 60.000 anys

Aquest estudi consisteix en l’augment de la resolució en la reconstrucció de la temperatura de l’aigua i l’aire del llac Baikal durant els últims 60.000 anys mitjançant l’ús de les proxies de reconstrucció de la temperatura TEX86 i MAAT, i la d’aportació de matèria orgànica d’origen terrestre, el BIT. L’objectiu general d’aquesta investigació és incrementar la resolució temporal en el mostreig del testimoni CON-01-603-02 per tal de millorar el registre de dades obtingudes i d’aquesta manera poder contrastar la hipòtesi de la interconnexió climàtica global, així com identificar esdeveniments climàtics sobtats, tals com els Heinrich events i els esdeveniments D-O. Un cop obtinguts els resultats s’ha realitzat l’anàlisi de la qualitat i fiabilitat de les dades a les resolucions de 5, 10 i 20 Kanys, i es conclou que existeixen diferències globals estadísticament significatives amb els resultats realitzats per Escala et al., (r.n.p [resultats no publicats]), la resolució dels quals es volia augmentar. S’han tractat d’anular aquestes diferències restant o bé sumant la diferència mitjana obtinguda entre les dues mostres en cada un dels intervals de 5 Kanys en què s’han donat aquestes. Els resultats integrats d’Escala et al.,(r.n.p) i els d’aquest estudi, aporten dades que recolzen l’hipòtesi de la interconnexió climàtica global, ja que al comparar-los amb els registres climàtics de Grenlàndia (GRIP2) i l’Antàrtica (Vostok) mostren respostes similars tant per les forces de Milankovitch com per les de subMilankovitch.

Índexos indicadors de l'estat de l'ecosistema costaner: influència dels factors físoco-químics en l'ecologia del plàncton

La tesi en projecte aborda l’estudi multiescala de la relació entre la variabilitat de la turbulència i els nutrients, i l’estructura i la dinàmica de l’ecosistema costaner en el Mediterrani noroccidental. A partir d’experiments al laboratori i de diferents campanyes al mar, es pretén generar indicadors de funcionament de l’ecosistema planctònic sensibles a variacions hidrodinàmiques. L’efecte conjunt de la turbulència i els nutrients es preveu condicionat no únicament per la magnitud d’ambdues variables, sino també per la relació temporal entre els episodis de turbulència i els aports de nutrients. Per tal de tenir una casuística més àmplia de validació dels indicadors, s’han seleccionat tres àrees d’estudi properes a les desembocadures de rius amb aports de nutrients de concentracions relatives molt variables. La finalitat última del treball és millorar la comprensió del funcionament de l’ecosistema costaner en la interfase terra-mar per a una gestió més eficaç dels recursos.

Estudi exploratori per a la reconstrucció de temperatures de l'aigua i de l'aire en la conca central del llac Baikal (Sibèria) en els últims 40000 anys

Aquest estudi consisteix en un anàlisi exploratori que té per objectiu principal la realització d’una reconstrucció de la temperatura de l’aigua i l’aire del llac Baikal durant els últims 40.000 anys. El treball s’ha dut a terme mitjançant l’ús de les proxys de reconstrucció de la temperatura y la utilització dels mètodes TEX86, MAAT, i la d’aportació de matèria orgànica d’origen terrestre, el BIT, aplicant-les a la mostra VER93-2 st GC-24, extreta pel Baikal Drilling Project a la conca central, amb l’objectiu de fer una aportació de dades paleoclimàtiques per tal d’aconseguir una millora en les interpretacions de futurs esdeveniments climàtics, i d’identificar esdeveniments climàtics sobtats, tals com els Heinrich events i els Youngers Dryas. Abans de la realització de l’anàlisi de les mostres s’ha dut a terme una extrapolació de l’edat en el testimoni, degut a que l’edat del core BDP VER93-2.st.GC-24 havia estat extrapolada fins a 277,5 cm de profunditat i en el present estudi s’ha ampliat l’anàlisi fins als 460 cm. de profunditat. Un cop obtinguts els resultats s’ha realitzat un càlcul de precisió i reproductibilitat per tal de conèixer una estimació quantitativa de la variabilitat de les dades obtingudes en les diferents proxys, en el qual ha estat demostrat una baixa variabilitat de les dades, exceptuant la variabilitat del TEX86 i la precisió del MAAT. Per a la localització dels diferents esdeveniments climàtics donats durant l’Holocè i el Plistocè s’han realitzat anàlisis gràfics dels propis resultats, juntament i en comparació dels resultats realitzats per Escala et al. (r.n.p [resultats no publicats]) en la conca sud, i de l’estudi publicat per Prokopenko et al., en el que s’analitza la presència de diatomees i matèria orgànica l’Atlàntic Nord. Els resultats integrats d’Escala et al.,(r.n.p) i els d’aquest estudi coincideixen en la datació dels diferents esdeveniments, amb alguna variació hipotèticament produïda per l’extrapolació d’edat realitzada en el present estudi i la gran aportació de matèria orgànica en el lloc d’extracció del testimoni per part del riu Selenga. Aquests resultats mostren una possible relació entre els esdeveniments climàtics i la variació de la temperatura de l’aigua.

Genotoxic effect of alkaloids

Because of the increase use of alkaloids in general medical practice in recent years, it is of interest to determine genotoxic, mutagenic and recombinogenic response to different groups of alkaloids in prokaryotic and eucaryotic organisms. Reserpine, boldine and chelerythrine did not show genotoxicity response in the SOS-Chromotest whereas skimmianine showed genotixicity in the presence of a metabolic activation mixture. Voacristine isolated fromthe leaves of Ervatamia coronaria shows in vivo cytostatic and mutagenic effects in Saccharomyces cerevisiae hapioids cells. The Rauwolfia alkaloid (reserpine) was not able to induce reverse mutation and recombinational mitotic events (crossing-over and gene conversion) in yeast diploid strain XS2316.

Objectifying psychomental stress in the workplace--an example.

BACKGROUND: Psychomental stress is a major source of illness and reduced productivity. Data objectifying physiological stress responses are scarce. We studied salivary cortisol levels in a highly stressful environment, the pediatric critical care unit. The aim was to identify targets for organizational changes, to implement these changes and to assess their impact on cortisol levels. DESIGN: Repeated measurements observational cohort study (before and after intervention). SUBJECTS: 84 nurses working in two independent teams (A and B) in a 19 bed pediatric intensive care unit. Between study periods team A experienced a major exchange of experienced staff while the turnover rate in team B remained average. MEASUREMENTS AND INTERVENTIONS: Salivary cortisol samples were collected every 2 h and after stressful events. Nurses in study period I showed elevated cortisol levels at the beginning of the late shift, interpreted as an anticipatory stress reaction. To ease conditions during the early part of the late shift (conflicting tasks, noise and crowding), we postponed the afternoon ward round, limited non-urgent procedures and introduced a change in visiting hours. The early shift, which was not affected by the intervention, served as control. MAIN RESULTS: Both crude and adjusted analysis revealed a decrease of cortisol levels at the beginning of the late shift in team B (p = 0.0009), but not in team A (p = 0.464). The control situation showed no difference between teams and study periods. INTERPRETATION: We demonstrated reduced cortisol secretions in one team following organizational changes, which was probably overridden by the disruption of social coherence in the second team.

Sistemes lidar (radar laser) d'ona contínua i baixa potència per a la detecció i mesura de concentració de gasos amb resolució espacial

The present project has performed the study and development of a new technique for the detection of gases with range resolution. This technique called FMCW-lidar is a technique that evolves from the FMCW-radar technique to be applied to lidar systems. Moreover, it takes advantage of the appearance of spectral absorption lines because of the interaction between light and gases to tune the light wavelength of a laser emitter with one of this spectral lines and then detects the backscattered light and analyzes it in order to obtain gas concentration measurements. The first part of the project consisted in the analysis of the WMS technique which is a technique for the in-situ measurement of gases. A complete theoretical analysis has been performed and some experiments have been carried out in order to test the technique and to validate its application to an FMCW-modulated system for the detection of gases. The second part of the project consisted in the analysis of the lidar FMCW technique for solid target detection and its extension to continuous media. The classical form of this technique has been analyzed for a distributed medium and a filtering effect has been found which prevents the accurate acquisition of the medium response. A modification of the technique has been proposed and a validation via simulations and some experiments has been carried on. After performing these tests, a novel system is proposed to be developed and tested in order to perform the indicated gas detection with range resolution.

Mycobacteriosis in the compromised host

The studies of rare genetic defects, the preliminary results of population-based studies, being validated by the experimental immunocompromised animal models and the current observations accumulated in immunocompromised patients with mycobacterial diseases provide us with insights into the importance of the macrophage activation pathway in controlling human infection with pathogenic and non pathogenic intracellular multiplying mycobacteria. Initial cytokine production by infected macrophages and/or dendritic cells could be crucial in the overall regulation of self cure, acquired protection or immunopathological sequelae expressing the disease. Knowledge of molecular and genetic cross-talks between phagocytic and specialized antigen presenting cells and different mycobacterial products associated with persistence or replication of the intracellular bacteria, could provide further informations on the global immune regulation of the early host responses to infection and the following events. It seems likely that the development of mycobacterial infections in humans will turn out to be as much dependent on the genetic make up of the host as or the virulence of the bacteria.

Vascular-endothelial-growth-factor (VEGF) targeting therapies for endocrine refractory or resistant metastatic breast cancer.

BACKGROUND: Vascular-endothelial-growth-factor (VEGF) is a key mediator of angiogenesis. VEGF-targeting therapies have shown significant benefits and been successfully integrated in routine clinical practice for other types of cancer, such as metastatic colorectal cancer. By contrast, individual trial results in metastatic breast cancer (MBC) are highly variable and their value is controversial. OBJECTIVES: To evaluate the benefits (in progression-free survival (PFS) and overall survival (OS)) and harms (toxicity) of VEGF-targeting therapies in patients with hormone-refractory or hormone-receptor negative metastatic breast cancer. SEARCH METHODS: Searches of CENTRAL, MEDLINE, EMBASE, the Cochrane Breast Cancer Group's Specialised Register, registers of ongoing trials and proceedings of conferences were conducted in January and September 2011, starting in 2000. Reference lists were scanned and members of the Cochrane Breast Cancer Group, experts and manufacturers of relevant drug were contacted to obtain further information. No language restrictions were applied. SELECTION CRITERIA: Randomised controlled trials (RCTs) to evaluate treatment benefit and non-randomised studies in the routine oncology practice setting to evaluate treatment harms. DATA COLLECTION AND ANALYSIS: We performed data collection and analysis according to the published protocol. Individual patient data was sought but not provided. Therefore, the meta-analysis had to be based on published data. Summary statistics for the primary endpoint (PFS) were hazard ratios (HRs). MAIN RESULTS: We identified seven RCTs, one register, and five ongoing trials from a total of 347 references. The published trials for VEGF-targeting drugs in MBC were limited to bevacizumab. Four trials, including a total of 2886 patients, were available for the comparison of first-line chemotherapy, with versus without bevacizumab. PFS (HR 0.67; 95% confidence interval (CI) 0.61 to 0.73) and response rate were significantly better for patients treated with bevacizumab, with moderate heterogeneity regarding the magnitude of the effect on PFS. For second-line chemotherapy, a smaller, but still significant benefit in terms of PFS could be demonstrated for patients treated with bevacizumab (HR 0.85; 95% CI 0.73 to 0.98), as well as a benefit in tumour response. However, OS did not differ significantly, neither in first- (HR 0.93; 95% CI 0.84 to 1.04), nor second-line therapy (HR 0.98; 95% CI 0.83 to 1.16). Quality of life (QoL) was evaluated in four trials but results were published for only two of these with no relevant impact. Subgroup analysis stated a significant greater benefit for patients with previous (taxane) chemotherapy and patients with hormone-receptor negative status. Regarding toxicity, data from RCTs and registry data were consistent and in line with the known toxicity profile of bevacizumab. While significantly higher rates of adverse events (AEs) grade III/IV (odds ratio (OR) 1.77; 95% CI 1.44 to 2.18) and serious adverse events (SAEs) (OR 1.41; 95% CI 1.13 to 1.75) were observed in patients treated with bevacizumab, rates of treatment-related deaths were lower in patients treated with bevacizumab (OR 0.60; 95% CI 0.36 to 0.99). AUTHORS' CONCLUSIONS: The overall patient benefit from adding bevacizumab to first- and second-line chemotherapy in metastatic breast cancer can at best be considered as modest. It is dependent on the type of chemotherapy used and limited to a prolongation of PFS and response rates in both first- and second-line therapy, both surrogate parameters. In contrast, bevacizumab has no significant impact on the patient-related secondary outcomes of OS or QoL, which indicate a direct patient benefit. For this reason, the clinical value of bevacizumab for metastatic breast cancer remains controversial.

Party drug use in techno nights: a field survey among French-speaking Swiss attendees.

This study was designed to investigate the lifestyle and substance use habits of dance music event attendees together with their attitudes toward prevention of substance misuse, harm reduction measures and health-care resources. A total of 302 attendees aged 16-46 years (mean=22.70, S.D.=4.65) were randomly recruited as they entered dance music events. Rates for lifetime and current use (last 30 days) were particularly high for alcohol (95.3% and 86.6%, respectively), cannabis (68.8% and 53.8%, respectively), ecstasy (40.4% and 22.7%, respectively) and cocaine (35.9% and 20.7%, respectively). Several patterns of substance use could be identified: 52% were alcohol and/or cannabis only users, 42% were occasional poly-drug users and 6% were daily poly-drug users. No significant difference was observed between substance use patterns according to gender. Pure techno and open-air events attracted heavier drug users. Psychological problems (such as depressed mood, sleeping problems and anxiety attacks), social problems, dental disorders, accidents and emergency treatment episodes were strongly related to party drug use. Party drug users appeared to be particularly receptive to harm reduction measures, such as on-site emergency staff, pill testing and the availability of cool water, and to prevention of drug use provided via counseling. The greater the involvement in party drug use, the greater the need for prevention personnel to be available for counseling. General practitioners appeared to be key professionals for accessing health-care resources.