Дисертації з теми "Risk factors for HCC recurrence"

Hepatocellular carcinoma (HCC) is the most frequent primary liver tumor, with annual worldwide incidence of over one million cases, accounting for at least 500,000 deaths per year. The majority of cases of HCC occur in the setting of liver cirrhosis. Liver transplantation (LT) is a curative treatment modality for HCC. However the recurrence of HCC after LT is the main obstacle to the success of this treatment. The aim of this study was to evaluate the risk factors for recurrence of hepatocellular carcinoma after conducting LT. In this retrospective, descriptive and analytical study, between May 2002 and April 2012, were conducted 664 liver transplantations (LT) at HUWC â UFC, among which 140 LT were performed in patients with HCC. The risk factors of HCC recurrence after liver transplantation were analysed. The variables analyzed were: sex, age, blood type, etiology of cirrhosis, alpha-fetoprotein level, diagnostic imaging, Milan criteria, time from diagnosis of HCC and the realization of LT, time on the waiting list for the LT and pathological tumor characteristics in explant. The tumor was more frequent in men with an average age of 56 years, infected with hepatitis C virus. The rate of HCC recurrence after LT was 8, 57 % and occurred more often in the first two years after transplantation, with the liver graft being the most common site. In conclusion, independent risk factors for carcinoma hepatocellular recurrence after liver transplantation were: time in the LT waiting list above 7,8 months, liver number nodules over 3.5 nodules, tumors exceeding the Milan criteria, level of alphafetoprotein above 1000 ng/ml and presence of micro-vascular invasion.
O carcinoma hepatocelular (CHC) à o mais frequente tumor primÃrio maligno do fÃgado, com incidÃncia mundial anual de mais de um milhÃo de casos, sendo responsÃvel por pelo menos 500.000 mortes por ano. Em torno de 90 % a 95 % dos tumores estÃo associados à cirrose. O transplante hepÃtico (TH) à uma modalidade de tratamento curativo para o CHC. Entretanto, a recorrÃncia do CHC apÃs o TH à o principal obstÃculo ao sucesso deste tratamento. O objetivo deste estudo foi avaliar os fatores de risco para recorrÃncia de carcinoma hepatocelular apÃs a realizaÃÃo de TH. Foram realizados 664 transplantes de fÃgado entre maio de 2002 e abril de 2012, no Hospital UniversitÃrio Walter CantÃdio, da Universidade Federal do Cearà (HUWC â UFC), dos quais 140 casos em pacientes com diagnÃstico de CHC. Foi realizado um estudo analÃtico, descritivo, retrospectivo e longitudinal deste grupo de pacientes, analisando os fatores de risco para a recorrÃncia de CHC apÃs o TH. As variÃveis analisadas foram: sexo, idade, tipo sanguÃneo, etiologia da cirrose, nÃvel de alfa-fetoproteÃna, mÃtodos diagnÃsticos de imagem, critÃrios de MilÃo, tempo entre o diagnÃstico do CHC e a realizaÃÃo do TH, tempo em lista de espera para o TH e caracterÃsticas anatomopatolÃgicas do tumor no explante. O CHC foi mais frequente em homens com idade mÃdia de 56 anos, infectados pelo vÃrus da hepatite C. A taxa de recorrÃncia do carcinoma hepatocelular apÃs o transplante de fÃgado foi de 8,57% e ocorreu mais frequentemente nos dois primeiros anos apÃs o transplante, tendo como local mais comum o enxerto hepÃtico. Concluiu-se que o tempo de permanÃncia em lista de transplante acima de 7,8 meses, a presenÃa de mais de 3,5 nÃdulos no explante, o tumor excedendo os critÃrios de MilÃo, o nÃvel de Alfa-fetoproteÃna acima de 1000 ng/ml e a presenÃa de invasÃo microvascular sÃo fatores de risco independentes para recorrÃncia de carcinoma hepatocelular apÃs a realizaÃÃo do transplante hepÃtico.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado.
OBJECTIVE: An estimated 20-30% of patients with primary Clostridium difficile infection (CDI) develop recurrent CDI (rCDI) within 2 weeks of completion of therapy. While the actual mechanism of recurrence remains unknown, a variety of risk factors have been suggested and studied. The aim of this systematic review and meta-analysis was to evaluate current evidence on the risk factors for rCDI. DESIGN: We searched MEDLINE and 5 other databases for subject headings and text related to rCDI. All studies investigating risk factors of rCDI in a multivariate model were eligible. Information on study design, patient population, and assessed risk factors were collected. Data were combined using a random-effects model and pooled relative risk ratios (RRs) were calculated. RESULTS: A total of 33 studies (n=18,530) met the inclusion criteria. The most frequent independent risk factors associated with rCDI were age≥65 years (risk ratio [RR], 1.63; 95% confidence interval [CI], 1.24-2.14; P=.0005), additional antibiotics during follow-up (RR, 1.76; 95% CI, 1.52-2.05; P<.00001), use of proton-pump inhibitors (PPIs) (RR, 1.58; 95% CI, 1.13-2.21; P=.008), and renal insufficiency (RR, 1.59; 95% CI, 1.14-2.23; P=.007). The risk was also greater in patients previously on fluoroquinolones (RR, 1.42; 95% CI, 1.28-1.57; P<.00001). CONCLUSIONS: Multiple risk factors are associated with the development of rCDI. Identification of modifiable risk factors and judicious use of antibiotics and PPI can play an important role in the prevention of rCDI.

The public use version of the National Comorbidity Survey - Replication (NCS-R) dataset was used (N = 995) to investigate risk factors for recurrent major depressive disorder (MDD) that are evident before recovery from the first major depressive episode (MDE) by comparing persons diagnosed with MDD who experienced a single MDE to persons with recurrent MDD. Multiple logistic regression analyses assessed the independent risk of recurrent MDD for each of the following risk factors: an early age of onset (old), absence of a life stress trigger, chronic first episode, childhood parental loss, parental maltreatment, parental depression, comorbid anxiety disorder, and comorbid substance disorder. The relative excess risk due to interaction (RERI) assessed the risk of recurrent MDD associated with the interaction of an early onset with three childhood-based vulnerabilities: a) parental depression, b) parental loss, and c) parental maltreatment. There was a statistically significant risk of recurrent MDD found for the following risk factors: early onset, stress trigger absent, childhood parental loss, parental maltreatment, parental depression, and anxiety disorder; marginally significant results suggested an increased risk of recurrent MDD for substance disorder. There was a significant increased risk found for the interaction of an early onset with parental depression and similar non-significant trends were found for the interactions of early onset with parental loss and early onset with parental maltreatment. An early onset, the absence of a life stress trigger, and the presence of parental loss, parental maltreatment, parental depression, a comorbid anxiety disorder, and a comorbid substance disorder each confer greater risk of recurrent MDD among persons that have not yet recovered from their first lifetime MDE. The presence of an early onset combined with a childhood-based vulnerability such as parental depression, parental loss, or parental maltreatment, indicate an especially high risk of recurrent MDD. These findings may inform the development of a screening tool to assess risk for recurrent MDD and early intervention to prevent recurrent MDD. Future research should employ a longitudinal research design to replicate and expand upon these findings.

Background Many risk factors for stroke are well characterized and might, at least to some extent, be similar for first-ever stroke and for recurrent stroke events. However, previous studies have shown heterogeneous results on predictors and rates of stroke recurrence. Patients who survive spontaneous intracerebral hemorrhage (ICH) often have compelling indications for antithrombotic (AT) treatment (antiplatelet (AP) and/or anticoagulant (AC) treatment), but due to controversy of the decision to treat, a large proportion of these patients are untreated. In the absence of evidence from randomized controlled trials (RCTs), there is need for more high- quality observational data on the clinical impact of, and optimal timing of AT in ICH survivors. The aims of this thesis were to assess time trends in stroke recurrence, to determine the factors associated with an increased risk of stroke recurrence – including socioeconomic factors – and to determine to what extent ICH survivors with and without atrial fibrillation (AF) receive AT treatment and to determine the optimal timing (if any) of such treatment.  Methods The population-based Monitoring Trends and Determinants of Cardiovascular Disease (MONICA) stroke incidence register was used to assess the epidemiology and predictors of stroke recurrence after ischemic stroke (IS) and ICH from 1995 to 2008 in northern Sweden. Riksstroke, the Swedish stroke register, linked with the National Patient Register and the Swedish Dispensed Drug Register, made it possible to identify survivors of first-ever ICH from 2005 to 2012 with and without concomitant AF to investigate to what extent these patients were prescribed AP and AC therapy. The optimal timing of initiating treatment following ICH in patients with AF 2005–2012 was described through separate cumulative incidence functions for severe thrombotic and hemorrhagic events and for the combined endpoint “vascular death or non-fatal stroke”. Riksstroke data on first-ever stroke patients from 2001 to 2012 was linked to the Longitudinal Integration Database for Health Insurance and Labour market studies to add information on education and income to investigate the relationship between socioeconomic status and risk of recurrence. Results Comparison between the cohorts of 1995–1998 and 2004–2008 showed declining risk of stroke recurrence (hazard ratio: 0.64, 95% confidence interval (CI): 0.52-0.78) in northern Sweden. Significant factors associated with an increased risk of stroke recurrence were age and diabetes. Following ICH, a majority (62%) of recurrent stroke events were ischemic.  The nationwide Riksstroke study confirmed the declining incidence, and it further concluded that low income, primary school as highest attained level of education, and living alone were associated with a higher risk of recurrence beyond the acute phase. The inverse effects of socioeconomic status on risk of recurrence did not differ between men and women and persisted over the study period. Of Swedish ICH-survivors with AF, 8.5% were prescribed AC and 36.6% AP treatment, within 6 months of ICH. In patients with AF, predictors of AC treatment were less severe ICH, younger age, previous anticoagulation, valvular disease and previous IS. High CHA2DS2-VASc scores did not seem to correlate with AC treatment. We observed both an increasing proportion of AC treatment at time of the initial ICH (8.1% in 2006 compared with 14.6% in 2012) and a secular trend of increasing AC use one year after discharge (8.3% in 2006 versus 17.2% in 2011) (p<0.001 assuming linear trends). In patients with high cardiovascular event risk, AC treatment was associated with a reduced risk of vascular death and non-fatal stroke with no significantly increased risk of severe hemorrhage. The benefit appeared to be greatest when treatment was started 7–8 weeks after ICH. For high-risk women, the total risk of vascular death or stroke recurrence within three years was 17.0% when AC treatment was initiated eight weeks after ICH and 28.6% without any antithrombotic treatment (95% CI for difference: 1.4% to 21.8%). For high-risk men, the corresponding risks were 14.3% vs. 23.6% (95% CI for difference: 0.4% to 18.2%). Conclusion Stroke recurrence is declining in Sweden, but it is still common among stroke survivors and has a severe impact on patient morbidity and mortality. Age, diabetes and low socioeconomic status are predictors of stroke recurrence. Regarding ICH survivors with concomitant AF, physicians face the clinical dilemma of balancing the risks of thrombosis and bleeding. In awaiting evidence from RCTs, our results show that AC treatment in ICH survivors with AF was initiated more frequently over the study period, which seems beneficial, particularly in high-risk patients. The optimal timing of anticoagulation following ICH in AF patients seems to be around 7–8 weeks following the hemorrhage.

Background - Current guidelines suggest that all cancer patients with venous thrombosis be treated with long-term low molecular weight heparin. Whether treatment strategies should vary according to clinical characteristics remains unknown. // Systematic review - A systematic review was performed to determine current understanding of the association between malignancy characteristics in patients with cancer-associated VTE and the risk of VTE recurrence. Four retrospective and 6 prospective studies were included. They suggest that lung cancer, metastases, and adenocarcinomas confer an increased the risk of recurrence and breast cancer a low risk. // Survey - I performed survey to evaluate thrombosis experts’ opinion about the low risk of VTE recurrence they would consider acceptable for patients with cancer- associated thrombosis 103 specialists participated. 80% of respondents agreed that a risk of recurrent VTE during anticoagulation below 7% is low enough. 92% agreed that a CPR that categorizes risk of recurrence is relevant. // Retrospective Study - I performed a single retrospective cohort study to assess the feasibility of derivation of a CPR that stratifies VTE recurrence risk in patients with cancer–associated thrombosis. The study included 543 patients. A multivariate analysis selected female, lung cancer and prior history of VTE as high risk predictors and breast cancer and stage I disease as low risk. // Conclusion - Patients with cancer-associated thrombosis do have varying risks of recurrent VTE depending on clinical characteristics.

Abstract Intracerebral hemorrhage (ICH) is the most pernicious form of stroke, with high mortality. Warfarin-associated ICH (WA-ICH) carries an even higher mortality rate. The major reason for the high mortality is explained by early hematoma growth. Warfarin use has rapidly increased with the aging of the population. We investigated temporal trends in the incidence and outcome of WA-ICHs. We found that although the proportion of warfarin users almost quadrupled in our population, the annual incidence and case fatality of WA-ICHs decreased. Management of ICH is mostly supportive. Prevention of associated complications is the issue in improving outcome. Hypertension is the most important modifiable risk factor for primary ICH, but little is known of the effect of preceding hypertension on outcome. Aggressive lowering of blood pressure is suggested to be a feasible treatment option. Reversal of warfarin anticoagulation with prothrombin complex concentrate (PCC) has been implemented as an acute treatment option for patients with WA-ICH. We found that the survival of WA-ICH subjects among our population improved after implementation of reversal of warfarin anticoagulation with PCC, likely because of the introduction of PCC. Because high mean arterial blood pressure (BP) at admission is an independent predictor of early death in patients with ICH, we explored its role in survival and poor outcome separately in normotensive subjects and subjects with treated and untreated hypertension. We found that despite their higher BP values at admission, subjects with untreated hypertension showed better survival and more often a favorable outcome after BP-lowering therapy than other patients. Studies on recurrent ICH are scarce. Underlying comorbidities, prior strokes, and drug-induced impaired platelet function may increase the risk for primary ICH (PICH). A lobar location of primary ICH may predict recurrent ICH. We investigated whether these factors predicted recurrence of PICH. In our study the annual incidence of recurrent ICH was 1.67%. Cumulative 5- and 10-year incidences were 9.6% and 14.2%. In multivariable analyses, prior ischemic stroke and diabetes proved to be independent predictors for recurrence. Moreover, diabetes was an independent risk factor for fatal recurrent PICH. Use of aspirin and serotonergic drugs did not significantly contribute to the risk
Tiivistelmä Aivoverenvuoto (ICH) on aivoverenkiertohäiriöistä vakavin. Sille on tyypillistä korkea kuolleisuus erityisesti varfariinihoitoon liittyen, ja eloonjääneetkin vammautuvat usein vakavasti. Verenvuodon koon kasvu alkuvaiheessa selittänee korkean kuolleisuuden. Väestön ikääntymisen myötä varfariinin käyttö on lisääntynyt nopeasti. Aivoverenvuodon hoito perustuu pitkälti ennusteen parantamiseen komplikaatioita estämällä. Verenpaine on tärkein hoidettavissa oleva riskitekijä, mutta tutkimustieto akuutin vaiheen verenpainetason merkityksestä ennusteeseen on vähäistä. Tehokasta verenpaineen alentamista alkuvaiheessa pidetään lupaavana hoitomenetelmänä. Vuodon koon kasvua pyritään rajoittamaan kumoamalla varfariinin antikoaguloiva vaikutus protrombiinikompleksi-konsentraatilla (PCC). Väitöstyössäni selvitän varfariinin käyttöön liittyvien aivoverenvuotojen (WA-ICH) esiintymistiheyttä ja ennustetta ajan myötä. Tutkin myös vuodon koon kasvun rajoittamista ja alkuvaiheen korkean verenpaineen alentamista hoitomenetelminä sekä selvitän, mitkä tekijät johtavat ICH:n uusiutumiseen. Totesimme WA-ICH:n ilmaantuvuuden ja tapauskuolleisuuden pienentyneen, vaikka varfariinin käyttö miltei nelinkertaistui väestössämme. Toisaalta WA-ICH -potilaiden kuolleisuus pieneni PCC-hoidon aloittamisen jälkeen, mahdollisesti sen ansiosta. Tutkiessamme riippumattomasti varhaista kuolemaa ennustavan korkean tulovaiheen verenpaineen roolia normaaliverenpaineisilla, hoidettua ja hoitamatonta verenpainetautia sairastavilla totesimme hoitamattomien hypertonia-potilaiden selvinneen akuutin vaiheen lääkehoidon myötä muita useammin hengissä ja hyväkuntoisina korkeista tulovaiheen verenpainearvoista huolimatta. Aivoverenvuodon uusiutumiseen vaikuttavista tekijöistä on vähän tutkimustietoa. Muu sairastavuus, aiemmat aivoverenkiertohäiriöt ja trombosyyttien toimintaan vaikuttavat lääkkeet saattavat lisätä ICH:n uusiutumisriskiä. Totesimme vuosittaisen uuden ICH:n esiintymistiheyden olevan 1,67 %. Aikaisempi aivoinfarkti ja diabetes osoittautuivat riippumattomiksi uusiutumista ennustaviksi riskitekijöiksi, minkä lisäksi diabetes ennusti kuolemaan johtavaa uutta ICH:a. Asetyylisalisyylihapon ja selektiivisten serotoniinin takaisinoton estäjien käyttäminen ei vaikuttanut merkittävästi uusiutumisriskiin

Résumé : Depuis 2002, une augmentation des taux d’issues défavorables de l’infection à Clostridium difficile (ICD) a été attribuable à l’émergence de la souche NAP1/BI/R027. Il est indispensable d’identifier les facteurs de risque de développer des complications (ICDc) et des récidives (ICDr), et de pouvoir les prédire lors du diagnostic afin d’optimiser le traitement. Le projet de recherche a comme objectifs: i) l’identification des facteurs de risque pour le développement d’ICDc et ICDr et ii) le développement et la validation d’un outil de prédiction à partir de variables mesurées dans les 48h du diagnostic d’une ICD. Méthode: Une cohorte multicentrique prospective de patients adultes hospitalisés pour une ICD. Les données suivantes ont été recueillies: i) démographiques; ii) comorbidités; iii) traitements et procédures reçus dans les 2 mois avant le diagnostic; iv) paramètres cliniques, vi) biochimiques, hématologiques et vii) microbiologiques (ribotypage). Un suivi à 30 et 90 jours a été effectué. Les facteurs de risque ont été identifiés par des modèles multivariés de régression logistique et d'analyse de survie. La méthode de validation croisée a été utilisée pour la dérivation et la validation interne. Différents modèles ont été comparés selon l’aire sous la courbe ROC (ASC), l’erreur de prédiction (EP) et les paramètres de performance. Un score prédictif a été dérivé à partir du modèle optimal. Résultats: Au total, 1380 patients ont été inclus dont 96% suivis 90 jours. Une ICDc a été observée chez 8% et une ICDr chez 26%. La souche R027 représentait 52% des souches caractérisées. Les ICDc sont associées à un âge ≥80 ans, un rythme cardiaque >90/min, un rythme respiratoire >20/min, globules blancs (GB) <4 et ≥20×10[indice supérieur 9]/L, albumine sérique <25 g/L, urée sérique >7 mmol/L, et CRP ≥150 mg/L. Les ICDr sont associés à l'âge ≥ 65 ans, à l’exposition à des macrolides et/ou clindamycine, CRP ≥150 mg/L, R027, et une hospitalisation ≥14 jours suivant l'ICD. Un sous-groupe de 1038 cas complets a été utilisé pour la modélisation prédictive. Le modèle optimal contenait l’âge ≥80 ans, GB ≥12×10[indice supérieur 9]/L, albumine sérique <26 g/L et urée sérique >7 mmol/L, avec une ASC de 0,84 et une EP de 6%. Un score variant entre 0 et 17 points a été construit. En validation, un score >10 points présentait une sensibilité de 50% (IC[indice inférieur 95]% = 28-72), une spécificité de 85% (81-89), une valeur prédictive positive de 17% (7-27) et une valeur prédictive négative de 96% (94-99). Conclusions: En utilisant une large cohorte prospective multicentrique et plusieurs étapes de modélisation prédictive et de validation interne, nous avons identifié les facteurs associés aux ICDc et ICDr et dérivé un score prédictif des ICDc ayant une performance acceptable. Au moment du diagnostic de l’ICD, ces facteurs sont à considérer pour envisager le traitement le plus optimal afin de prévenir ces issues.
Abstract : A significant increase in Clostridium difficile infection (CDI) unfavourable outcomes was observed since 2002 and was associated with the emergence of the strain NAP1/BI/R027. Identifying patients at high risk of developing complications (cCDI) and recurrences (rCDI), and predicting these outcomes early in the course of illness could improve clinical decision-making. The main objectives of this research were to: i) identify risk factors for cCDI and rCDI, and ii) develop and validate a clinical prediction rule for cCDI using predictors measured within 48h of CDI diagnosis. Methods: Adult in patients with confirmed CDI diagnosis in 10 acute care hospitals, were enrolled in a prospective cohort. Data at enrolment were collected : demographics, underlying illnesses, past medical and drug history (two months prior to CDI), clinical signs, blood tests, and C. difficile strain type. A follow-up was completed on day 30 and 90 after enrolment. Risk factors were identified by multivariate logistic regression and survival analyses. Split-sample technique was used for training and validation sets. Several predictive models were derived and assessed in both sets by AUC/ROC, prediction error (PE), and performance parameters. A predictive score was built using the optimal predictive model. Results: A total of 1380 patients were enrolled and 96% had 90 days follow -up. cCDI was observed in 8% and rCDI in 26%. R027 was identified in 52% of patients. Age ≥80 years, heart rate >90/min, respiratory rate >20/ min, white cell count <4 or ≥20 × 109/L, albumin <25 g/L, blood urea nitrogen >7 mmol/L, and C-reactive protein (CRP) ≥150 mg/L were independently associated with cCDI. Age ≥65 years, increased CRP, expos ure to macrolides/clindamycin, R 027, and prolonged hospital stay were associated with rCDI. A sub-group of 1038 complete cases was used for predictive modelling. In the training set, the optimal model with 6% PE and AUC 0.84 included age≥80, WBC≥12x10 [superscript 9]/L, BUN>7 mmol/L, and serum albumin <26 g/L. A predictive score was built with minimum 0 and maximum 17 points. A score >10 points showed 50% sensitivity (95%CI, 28-72), 85% specificity (81-89), 17% (7-27) positive predictive value, and 96% (94-99) negative predictive value. Conclusion: Through a large multicenter prospective cohort and multiple modelling approached, independent risk factors of complications and recurrence of CDI were identified. We derived a predictive score that included easily available meas ures at the bedside and showed acceptable performance. At time of CDI diagnosis, these predictors could be used by clinicians to identify patients at higher risk and adjust for the most optimal treatment that could prevent unfavourable outcomes.

Dissertação de Mestrado Integrado em Medicina Veterinária
Hérnia perineal é uma entidade clínica reconhecida em várias espécies, especialmente no cão macho não castrado de idade adulta a avançada, surgindo por enfraquecimento e separação dos componentes do diafragma pélvico, o que permite a passagem de estruturas entre eles. Pensa-se que se trate de uma entidade de etiologia multifatorial, tendo sido implicados diversos fatores: atrofia dos músculos do diafragma pélvico, alterações retais, desequilíbrios hormonais, excesso de pressão no diafragma pélvico e efeito da relaxina prostática sobre as fibras musculares. O diagnóstico é essencialmente clínico e, embora uma abordagem médica possa ser tentada, a resolução cirúrgica é o tratamento de eleição, havendo diversas técnicas de herniorrafia descritas para o efeito. A realização concomitante de orquiectomia, embora não consensual, está indicada. Técnicas adjuvantes, como colopexia, cistopexia e vasopexia, podem também ser necessárias. As complicações póscirúrgicas mais frequentes incluem: tenesmo fecal, incontinência fecal e urinária, prolapso retal, alterações da região intervencionada, claudicação e recidiva. A avaliação de eventuais fatores de risco para a evolução clínica e o prognóstico desta afeção foi o objetivo primordial do presente trabalho, realizado retrospetivamente numa amostra de 75 canídeos machos (N=75) diagnosticados com hérnia perineal. Os resultados obtidos mostraram que a presença de tenesmo fecal pré-cirúrgico, quistos prostáticos e retroflexão da bexiga estão associados a uma maior prevalência de hérnias bilaterais. Quanto ao prognóstico a curto (complicações pós-cirúrgicas) e a longo (recidiva) prazo, verificou-se que a realização de tratamento médico previamente ao tratamento cirúrgico é contraditória, pois associa-se a uma diminuição das complicações e concomitantemente a um aumento da probabilidade de recidiva. A abordagem cirúrgica parece influenciar o resultado final do curso clínico da patologia, embora sem significância estatística, devendo optar-se pela realização de técnicas adjuvantes em conjunto com a herniorrafia, e no caso particular das hérnias bilaterais, por uma herniorrafia bilateral faseada.
ABSTRACT - EVALUATION OF RISK FACTORS FOR THE CLINICAL EVOLUTION, SHORT AND LONG TERM PROGNOSIS OF PERINEAL HERNIAS – RETROSPECTIVE STUDY IN 75 ANIMALS OF THE CANIS FAMILIARIS SPECIES - Perineal hernia is a clinical entity recognized in several species, especially in older intact male dogs, appearing in consequence of fragility and separation of the components of the pelvic diaphragm, thus allowing passage of structures between them. It is thought to be an entity of multifactorial origin, and several factors have been implied: muscle atrophy of the pelvic diaphragm, rectal abnormalities, hormonal imbalance, excessive pressure on the pelvic diaphragm and prostatic relaxin’s effects on muscle fiber weakening. Diagnosis is mainly clinical and, although a medical approach can be attempted, surgical closure is the treatment of choice, with multiple herniorrhaphy techniques available. Orchiectomy simultaneous to the herniorrhaphy, although not consensual, is indicated. Adjuvant techniques, such as colopexy, cystopexy and vasopexy, may also be necessary. The most common surgical complications include: fecal tenesmus, fecal and urinary incontinence, rectal prolapse, incisional alterations, lameness, and recurrence. Evaluation of risk factors for the clinical evolution and prognosis of this disease was the primary goal of the present study, retrospectively made with a sample of 75 male dogs (N=75) diagnosed with perineal hernia. The results showed that the presence of pre-surgical tenesmus, prostatic cysts and bladder retroflexion are associated with a higher prevalence of bilateral hernias. Regarding to short (post-surgical complications) and long-term (recurrence) prognosis, performing medical treatment before surgical repair was contradictory, with reduction of complications but an increasing probability of recurrence. Surgical approach seems to have an influence on the outcome, although without statistical relevance, being preferable to perform adjuvant techniques with the herniorrhaphy and, in the particular case of bilateral hernias, to privilege a staged approach.
N/A

Contexte : La tentative de suicide (TS) concerne 8 à 10 % des adolescents et la récidive précoce 14 à 20% des adolescents. La TS peut avoir des répercussions à long terme chez les adolescents, tant au niveau scolaire/professionnel, qu’au niveau affectif et psychique. Objectifs : 1) Décrire le devenir psychosocial des suicidants et le poids de la récidive sur ce devenir, 2) étudier l’impact du fait de ne plus être joignable par l’équipe de soins 1 an après la TS et 3) étudier les modalités de communication, le soutien social et la santé perçue des jeunes suicidants. Méthode : 1) 309 sujets ont été inclus avec une évaluation au moment du geste et à 10 ans, 2) étude de l’association du fait de ne plus être joignable par l’équipe de soins avec la récidive suicidaire chez 249 patients, 3) modalité d’utilisation des moyens de communication, perception du soutien social et santé perçue de 58 adolescents suicidants. Résultats : Devenus adultes, les jeunes suicidants ont un devenir psychosocial altéré, d’autant plus lorsqu’ils avaient récidivé durant l’année suivant le geste d’inclusion. Le fait de ne plus être joignable par les soignants un an après la TS d’inclusion majore le risque de récidive suicidaire dans les 10 ans. Chez les suicidants, l’utilisation des SMS est privilégiée pour « rester en lien » avec les proches ; soutien social et santé perçue sont évalués de manière moins positive que chez leurs pairs. Perspectives : Dans un but de prévention de la récidive, nous avons développé un dispositif de veille s’appuyant sur l’envoi de SMS qui sera évalué dans un essai randomisé contrôlé
Background: Suicide attempt (SA) concerns 8% to 10% of adolescents and SA recurrence within the year 14% to 20% of adolescents. SA of young patients may have implications over the long term on an academic/professional level, as well as on an affective and psychic level. Objectives: 1) To describe psychosocial outcomes of SAers and the weight of recurrence on these outcomes, 2) to study the impact of losing contact with caregivers during the year following SA, and 3) to study how young SAers use means of communication, and perceive social support they receive and their health-related quality of life. Methods: Three researches were carried out on adolescent SAers. 1) 309 SAers were evaluated at time of SA and 10 years after SA, 2) study of the correlation between a loss of contact with caregivers and SA recurrence occurring between 1 to 10 years after the initial SA of 249 young patients, 3) how 58 SAers use means of communication, and perceive social support they receive and their health-related quality of life. Results: As an adult, the psychosocial situation of young SAers is impaired, especially for those who have a recurrence of SA during the year after index SA. The risk of recurrence increases in the ten years following index SA for early SAers, and in the year following index SA when contact has been lost with caregivers. SAers preferentially use SMS to “keep in touch” with relatives and they assess on a less positive note than peers their social support and health-related quality of life. Perspectives: We developed a monitoring device based on SMS sending in order to prevent SA recurrence which will be assessed through a randomized controlled clinical trial

O câncer gástrico precoce é definido como adenocarcinoma que não ultrapassa a camada submucosa, independentemente o acometimento linfonodal. O diagnóstico é feito através do exame de endoscopia digestiva alta e da avaliação histopatológica. Pode ser tratado através de mucosectomia endoscópica, sendo reconhecidos vários fatores que influenciam a chance de cura após a ressecção. Quando o adenocarcinoma gástrico precoce bem diferenciado está à restrito a mucosa, com margens de ressecção livres de neoplasia, sem ulceração histológica, invasão linfática ou venosa é alta a chance de cura após a ressecção endoscópica. A freqüência de recidiva local nestes casos varia de 2,8% a 5,7%. Por outro lado, a expressão de antígenos por células tumorais detectadas através da imunohistoquímica pode indicar o comportamento biológico dos tumores. O carcinoma gástrico precoce tipo diferenciado pode apresentar propriedades fenotípicas diferentes que se correlacionam com a expressão de mucinas. Através da expressão de mucinas é possível estratificar o adenocarcinoma diferenciado em tipo intestinal, gástrico, misto ou indeterminado. O objetivo deste estudo foi avaliar os fatores preditivos para a ressecção incompleta e recidiva local do câncer gástrico precoce tratado através de mucosectomia endoscópica e com acompanhamento superior a um ano. De junho de 1994 a dezembro de 2005, avaliaram-se 46 pacientes com câncer gástrico precoce submetidos a 47 mucosectomias endoscópicas. Através da análise de dados de prontuário, identificaram-se possíveis fatores preditivos para a ressecção endoscópica incompleta e para a recidiva local. Vinte e dois pacientes com critérios para alta probabilidade de cura foram avaliados prospectivamente em relação aos fatores para recidiva e submetidos a perfil imunohistoquímico das lesões ressecadas. Houve recuperação de peças ressecadas em 18 (81,8%) casos. Neste grupo, houve recidiva local em cinco (27,7%) casos. Assim, os pacientes foram avaliados pelos dados demográficos, endoscópicos e histopatológicos. As mucosectomias endoscópicas foram consideradas como ressecção completa ou incompleta. No grupo ressecção completa, os pacientes foram divididos nos subgrupos com ou sem recidiva. Os pacientes com critérios de alta probabilidade para cura foram divididos nos grupos com ou sem recidiva e comparados pelos dados demográficos, endoscópicos, e histopatológicos e imunohistoquímico. As peças ressecadas foram avaliadas quanto à expressão dos marcadores Muc-2, Muc-5a, CD-10, p-53 e Ki-67. O tempo médio de seguimento foi de 69,4 meses ± 36,5 meses. Sobrevida em cinco anos foi de 84,78%. Observaram-se sete (15,21%) óbitos. Houve ressecção completa em 36 casos (76,6%). Foram fatores preditivos de ressecção incompleta, as localizações em parede posterior de terço superior e inferior do estômago (p= 0,035), o tipo histológico indiferenciado (p=0,021), o tamanho da lesão maior que dois centímetros (p= 0,022) e o número de fragmentos maiores ou iguais a dois fragmentos (p= 0,013). Em análise estatística multivariada, o tipo histológico indiferenciado (OR= 0,8; IC (95%)= 0,036-0.897) e números de fragmentos (OR=7,34; IC (95%) = 1.266- 42.629) foram fatores preditivos independentes para ressecção incompleta. No grupo ressecção completa, observou-se que quanto maior o tamanho da lesão, maior o número de fragmentos ressecados (p=0,018). Houve recidiva local em 9 casos (25%). Como fator preditivo para recidiva local, destaca-se a técnica tipo cap com 5/7 casos (71,4%) (p=0,006). Na análise dos pacientes com critérios de alta probabilidade de cura, os dados demográficos (sexo, idade e raça), endoscópicos (tipo macroscópico, localização, número de fragmentos ressecados, técnica de ressecção empregada) e histopatológico (tamanho da lesão e nível de invasão) não mostraram diferença estatística significativa entre os grupos sem ou com recidiva. A análise imunohistoquímica revelou que o marcador Muc-5a esteve presente em 4/5 (80%) dos casos do grupo com recidiva (p=0,026) e quando se estratificaram os casos pela expressão de mucinas, observou-se que o tipo misto se apresentou em 4/5 (80%) casos no grupo com recidiva e o tipo intestinal em 10/13(76,9%) casos no grupo sem recidiva (p=0,004). O adenocarcinoma indiferenciado e números de fragmentos são fatores preditores para ressecção incompleta. O tamanho e a localização da lesão também foram fatores preditores de ressecção incompleta, porém, não de forma independente. A recidiva local teve como fator preditivo o tipo de técnica. O estudo imunohistoquímico se mostrou importante na presunção de recidiva local, nos casos em que os critérios para alta probabilidade de cura foram respeitados. O adenocarcinoma gástrico com expressão das mucinas para o fenótipo do tipo misto se mostrou como fator preditivo para recidiva local do câncer gástrico precoce.
Endoscopic mucosal resection (EMR) has recently become an accepted treatment for early gastric cancer. The histopathologic criteria that are used to define curative endoscopic resection include: intramucosal well-differentiated adenocarcinoma, lateral and deep margins free of tumor, no histologic ulceration, and lastly, no venous or lymphatic emboli. These criteria were defined by a large series of EMR from Japanese centers. Local neoplastic recurrence has been described in up to 6% of cases even when all of the above mentioned criteria are met. On the other hand, the antigen expression of neoplastic cells is related to the biologic behavior of several tumors. The aim of this study was evaluate the factors that predict incomplete resection and local recurrence of early gastric cancer treated by EMR followed up for at least one year in a Western tertiary referral center. It was also evaluated the role of different type of mucins, p53 and ki-67 expression as predictive factors of recurrence even when the standard histopathologic criteria for cure were met. The patients were evaluated retrospectively from June 1994 to December 2005. Forty six patients (23 female and 23 male; mean age 69 ± 14.1y) with early gastric cancer were submitted to EMR. Twenty-two patients with a diagnosis of early gastric cancer were considered cured by EMR were evaluated prospectively for local reccurrence. Local recurrences occurred in five (22.7%) of them. It was possible to perform immunohistochemistry panel in 18 (81.8%) resected specimens. Demographic data (gender, age and race), endoscopic (macroscopic classification, localization, number of resected fragments and technique employed) were retrospectively collected. Histopathologic data (size of tumor, depth of invasion and adenocarcinoma classification) were prospectively assessed by one senior pathologist blinded to the previous diagnosis. Resection was considered incomplete when the lateral or deep margins of the specimen proved positive for tumor. In the complete resection group, patients were followed up, and at the end of this study were divided into two groups: patients recurrence with and without local recurrence. The patients with histopathologic criteria for cure were divided into two groups: with local recurrence and without local recurrence. These were then compared by demographic, endoscopic, histologic and immunohistochemistry profiles. Expression of Muc-2, Muc-5a, CD-10, p-53 and ki-67 were analyzed. Mucin expression allowed a reclassification of the well- differentiated gastric cancer in intestinal, gastric, mixed or null phenotypes. The mean follow up was 69.4 months ± 36.5 months. Five-year survival was 84.78%. Seven (15.21%) patients died from other diseases not related to the gastric lesion. Complete resection was possible in 36 cases (76,6%). Predictive factors for incomplete resection were localization (p= 0,035), histologic type (p=0,021), size of the lesion (p= 0,022) and number of fragments resected (p= 0,013). In the multivariate statistical analysis, the undifferentiated histologic type (OR= 0,8; IC (95%)= 0,036-0.897) and piece-meal resection (OR=7,34; IC (95%) = 1.266-42.629) were independent risk factors for incomplete resection. On the other hand, in the complete resection group, it was noted that lesions >2cm were more frequently resected in piece-meal fashion (p=0,018). Local recurrence occured in 9 cases (group I) (25%). The cap technique was the only predictive factor for local recurrence (5/7 cases - 71,4%, p=0,006). In the group of patients with histopathologic criteria for cure, the demographic (gender, age and race), endoscopic (macroscopic classification, localization, total number of resected fragments, EMR technique) and histopathologic findings (size of the tumor and depth of invasionm1, m2,m3), p-53 and ki-67 expressions did not correlate with neoplastic recurrence. Muc-5a marker was expressed in 80%(4/5) of the cases in group I and in 15.4% (12/13) of the cases in group II (p=0,026). The mixed phenotype (Muc-2 and Muc- 5a positive) was found in 80%(4/5) of the cases of group I and the intestinal type (Muc-2 positive and Muc-5a negative) in 76.9% (10/13) of group II (p=0,004). In conclusion, the undifferentiated adenocarcinoma and piece-meal resection were independent risk factors for incomplete resection. The cap technique for EMR was related to local recurrence after complete resection. Larger lesions are usually resected in more than one fragment. The expression of Muc-5a and the mixed phenotype of well-differentiated adenocarcinoma were related to a higher probability of local recurrence after EMR of early gastric lesions considered cured by the endoscopic intervention.

INTRODUÇÃO: Meduloblastoma é o tumor cerebral embrionário maligno mais comum da infância. O esquema de tratamento atual inclui ressecção cirúrgica, radioterapia e quimioterapia. Embora a taxa de sobrevida global tenha aumentado nos últimos anos, em decorrência do tratamento os sobreviventes frequentemente sofrem com sequelas de ordem neurológica, endocrinológica e social. O esquema de classificação de risco atual não considera a heterogeneidade existente entre os pacientes e entre os tumores. No entanto, estudos recentes reconheceram quatro subgrupos moleculares distintos de meduloblastomas (WNT, SHH, Grupo 3 e Grupo 4), que confirmam essa heterogeneidade e formam, em conjunto, o melhor fator definidor de prognóstico para essa neoplasia. Esses subgrupos poderiam ser identificados através de marcadores imuno-histoquímicos representativos para cada um deles. O presente estudo teve como objetivo definir a frequência dos subgrupos de meduloblastomas na população brasileira através da positividade imuno-histoquímica para esses marcadores e analisar a frequência de positividade de outros marcadores também descritos como tendo importância prognóstica. MÉTODOS: 61 casos de meduloblastoma foram submetidos a estudo imuno-histoquímico para 5 marcadores descritos como tendo importância prognóstica (p53, ciclinaD1, p16, bcl2 e HER2) e para 5 marcadores descritos como representativos dos subgrupos moleculares de meduloblastoma (DKK1 e ?-catenina (subgrupo WNT), SFRP1 (subgrupo SHH), NPR3 (Grupo 3) e KCNA1 (Grupo 4). Os resultados foram correlacionados com os dados demográficos, histológicos e clínicos. RESULTADOS: Nenhum dos 10 marcadores imuno-histoquímicos revelou-se fator prognóstico em meduloblastoma. Os 5 marcadores representativos dos subgrupos moleculares apresentaram positividade para mais de 1 marcador ou negatividade para todos os marcadores na maioria dos casos. Apesar disso, foi possível classificar 22 casos nos quatro subgrupos de meduloblastomas por meio da positividade exclusiva para esses marcadores. Os resultados das análises entre os subgrupos e as respectivas frequências quanto às variáveis demográficas, histológicas, clínicas e prognósticas foram semelhantes aos descritos na literatura. CONCLUSÕES: Os marcadores imuno-histoquímicos analisados não apresentaram valor prognóstico nesta casuística, e os marcadores descritos como representativos dos quatro subgrupos moleculares mostraram-se pouco sensíveis e específicos para classificar os meduloblastomas
INTRODUCTION: Medulloblastoma, a malignant embryonal brain tumor, is the most frequently occurring brain tumor in children. Treatment strategy involves surgery, radiotherapy and chemotherapy. Overall survival rate has increased in recent years, but survivors often present neurological sequelae, as well as endocrine and social disorders, as a result of the treatment. Medulloblastoma is no longer consider a single disease: standard risk stratification disregards heterogeneity related to both patients and tumors, and recent work has generated a molecular stratification of the medulloblastomas into 4 distinct subgroups (WNT, SHH, Group 3 and Group 4), currently considered the best prognostic factor. Representative immunohistochemical markers could help identify each one of those subgroups. Our study aimed to establish the frequency of subgroups of medulloblastomas, in brazilian population, by immunohistochemical positivity for its specific markers, and also analyze the frequency of positivity for other markers that are equally implicated in prognosis. METHODS: We evaluated immunohistochemistry expression of 5 markers - DKK1 and ?-catenin (subgroup WNT), SFRP1 (subgroup SHH), NPR3 (Group 3) and KCNA1 (Group 4) - to determine molecular subgroup affiliation of 61 cases of medulloblastomas, along with 5 other markers widely used in daily practice that may have prognostic value in medulloblastomas (p53, cyclinD1, p16, bcl2 and HER2). Results were correlated to demographic, histological and clinical data. RESULTS: None of the 10 immunohistochemical markers investigated proved to be significant prognostic factor in our series. Five representative immunohistochemical markers of the molecular subgroups exhibited positivity for more than one marker or negativity for all markers in most cases. Nevertheless, we manage to determine molecular affiliation in one of the 4 subgroups in 22 cases, due to their exclusive positivity related to the representative markers. Regarding frequencies of occurrence, demographics, histological characteristics, clinical aspects and prognosis, our results related to the 22 cases were similar to those reported in the literature. CONCLUSIONS: Immunohistochemical markers considered representative for each of the 4 molecular subgroups were poorly sensitive and specific, and others markers evaluated did not reveal prognostic value in our series

Fixed retainer after orthodontic treatment is an increasing retention appliance. For the mandibular incisors there are two different fixed retainers that are commonly used, either a canine-to-canine retainer bonded only to the canines or a twistflex retainer bonded to each of the mandibular incisors and canines. Increased mandibular incisor irregularity seems to be a continuous process throughout life even in untreated patients. The natural physiological changes during aging causes changes like those that occur after orthodontic treatment and the removal of retainers. There are few long-term studies that have compared patients who have had a mandibular fixed retainer with patients without retention appliance after treatment, and then compared the treated patients with untreated subjects.The overall aim of this thesis was to compare and evaluate two different mandibular fixed retainers and also to compare orthodontically treated cases with untreated long-term. This thesis is based on two studies and a PAR Index evaluation was presented in the frame story:Paper I is a retrospective longitudinal study done on dental casts and lateral head radiographs from patients who had received either a canine-to-canine retainer or a twistflex retainer after treatment. Different variables were measured, were Little’s Irregularity Index was the main outcome measure. The measurements were done at four different occasions, were the last registration was 12 years after treatment, i.e. 9 years after removal of retainer. Paper II is also a retrospective longitudinal study with three different groups, one group received a fixed mandibular retainer, one group did not receive any retention appliance after treatment and the third group was untreated subjects. Measurements were done on dental casts and lateral head radiographs at four different occasions to analyze dental and skeletal changes 12 years after treatment. Also here Little’s Irregularity Index was the main outcome measure. PAR Index evaluation is done to evaluate the stability of orthodontic treatment outcome after treatment and long-term for two different retainer groups and one non-retention group. The following conclusions were drawn: Paper I•Both the canine-to-canine retainer and the twistflex retainer can be recommended since both are equally effective during retention period.•None of the retention types prevent long-term changes of mandibular incisor irregularity or available space for the mandibular incisors after removal of the retainers.•No differences in bonding failures between the two retainers were found. Paper II•There were no differences found 12 years after treatment in Little’s Irregularity Index for the mandibular incisors between the group that had a retainer and the group that had no retainer after treatment•In the untreated group, Little’s Irregularity Index was increased over time but not to the same extent as in the treated groups. •The crowding before treatment did not explain the crowding at the last registration.•The use of mandibular retainers for two to three years does not appear to prevent long-term relapse. •If the patient wants to constrain the changes that come with natural development, then lifelong retention is needed.•The overjet and overbite were stable long-term.PAR Index evaluation•Twelve years after treatment the mean reduction in PAR score was over 70 per cent only for the groups who had a mandibular retainer after treatment. However, the non-retention group had a PAR score of 66 per cent.•There were more cases in the retention groups that were ”greatly improved and/or improved” 12 years after treatment compared to the non-retention group. After treatment between 16 and 23.3 per cent of all the cases were ”worse or not improved”. Twelve years after treatment between 36 and 43.6 per cent of the total cases were ”worse or not improved”.

O objetivo desta pesquisa foi estudar um grupo de 106 gestantes adolescentes multigestas, comparando-as com 510 adolescentes primigestas quanto a variáveis demográficas, obstétricas e psicossociais. As pacientes foram recrutadas no ambulatório de obstetrícia no setor de gravidez na adolescência da clínica obstétrica do HC-FMUSP entre janeiro de 2000 a janeiro de 2006. As pacientes tinham até 18 anos e tiveram acompanhamento multiprofissinal. Os dados foram coletados de prontuário eletrônico (Acess-microsoft 98), apresentados de forma descritiva e analisados por teste do χ2, exato de Fisher, t de Student, Mann-Whytney e índice de Kappa, de acordo com a indicação do uso de cada um. Concluiu-se que não ocorrreram diferenças estatisticamente significativas entre multigestas e primigestas quanto a cor, naturalidade, renda familiar, exercício de alguma atividade remunerada, a idade das mães das adolescentes grávidas, a idade gestacional ao iniciar as consultas de Pré-Natal, número de consultas, estatura, peso no início e término do Pré-Natal, índice de massa corpórea, ganho ponderal durante a gravidez, classificação do ganho de peso pelo gráfico de Rosso, presença de doença hipertensiva específica da gravidez, presença de oligoâmnio, complicação por infecção urinária e amniorrexe prematura. O mesmo foi observado em relação à instituição onde o parto ocorreu, condição dos recém-nascidos, peso dos recémnascidos, adequação peso para idade gestacional dos recém-nascidos, índice de Apgar de primeiro e de quinto minutos não foram diferentes. Também não houve diferença significativa quanto ao desejo e aceitação da atual gravidez, intenção e tentativas de interrompê-la, tempo de uso de métodos anticoncepcionais, serem filhas de mulheres que foram mães adolescentes, tipo de relacionamento com as mães, com os pais e com os companheiros, reação do companheiro à notícia da gravidez, manutenção de grupo de amigos e de atividade esportiva. Diferenças com significância estatística foram observadas entre as multigestas e primigestas no que se refere à idade que foi maior no primeiro grupo. Em relação à escolaridade algumas multigestas atingem níveis mais altos, porém com menos probabilidade de continuarem os estudos durante a gestação sendo que mais da metade não concluí o ensino fundamental. As multigestas vivem em união estável mais freqüentemente e dependem financeiramente mais de seus companheiros e formam núcleo familiar independente da família de origem. Também seus companheiros são mais velhos que os das primigestas. Em relação às variáveis obstétricas a média da idade gestacional na última consulta foi menor e o trabalho de parto prematuro mais freqüente. Também a idade gestacional ao parto foi menor assim como a freqüência de recémnascidos de pré-termo. No parto a aplicação de fórcipes foi menos freqüente nas multigestas. Das variáveis psicossociais detectou-se que as multigestas planejaram mais suas gestações, iniciaram mais precocemente suas atividades sexuais, no entanto conheciam e se utilizavam com maior freqüência de métodos contraceptivos. Os pais e mães das adolescentes multigestas apresentaram melhor reação frente a noticia da gestação que os das primigestas.
This research studied a group of 106 adolescents patients with more than pregnancies and compared them to 510 with first pregnancy considering the demographics, obstetrics and psychosocial variables. The patients were recruited in the ambulatory service of obstetrics in the clinic of adolescent pregnancy of the HCFMUSP from January 2000 to January 2006. The oldest patients were 18 and assisted in comprehensive prenatal care. The data were collected from their electronic records (Access-Microsoft 98) presented in a descriptive form and analyzed through the χ2 test, exact of Fisher, t of Student, Mann-Whytney and Kappa index, according to the indication of each one. It was concluded that no statistical differences occurred between both groups regarding color, place of birth, family income, practice of any paid activity, maternal age of the teenagers, gestational age at the beginning of the pre-natal care, number of consultations, stature, initial and final weight in the pre-natal care, index of corporal mass, weight gain during pregnancy, classification of weight gain through the Rosso graphic, presence of pregnancy specific hypertension, presence of oligohydramnios, urinary infection complication, and preterm ruptured membranes. It was also the same in relation to the institution, condition and weight of the babies, balance of weight and gestational age, Apgar index at the first and fifth minutes were not different. Also, it was included the wish and acceptance of the present pregnancy, intention and tentative of abortion, length of use of contraceptive methods, daughter of adolescent mothers, type of relationship with mothers, with parents and with partner, reaction of the partner when the pregnancy was notified, maintenance of friends and athletic activities were not different. Significant statistical differences were observed between the patients with more pregnancies that are older than the primigravidas. Yet, considering their education, the patients with more pregnancies presented lower possibilities of continuing their studies during pregnancy. These patients presented a more stable union and financial dependence on their partners and formed a familiar nucleus independent of the original family. Their partners were also older than the ones of the patients with first pregnancy. The obstetric variables showed a lower gestational visit age in the last doctor visit with a more frequent premature labor. It was noticed that the smaller gestational age in labor had a higher frequency of preterm births. During labor the use of forceps was lesser in adolescents patients with more pregnancies. The psychosocial variables stated that this patients planned better their gestations, began their sexual activities earlier, knew and used contraceptive methods. The parents of the adolescents with more pregnancies had better reaction when compared with the parents of the adolescents in their first pregnancy.

A partir des données de deux études de cohortes hospitalières françaises (MEVE etFARIVE), nous nous sommes intéressés aux facteurs de risque de récidive de maladieveineuse thromboembolique (MVTE).Nous avons confirmé un excès de risque de récidive de MVTE chez les hommescomparés aux femmes et montré que cette relation dépendait en partie de l'âge, de lamutation du FV Leiden et de la prise d'hormones au premier événement. Une analyse enfonction du sexe a mis en évidence que l'âge, l'obésité et des niveaux élevés de D-dimèresaugmentaient significativement le risque de récidive de MVTE chez les femmes. Par ailleurs,contrairement aux estrogènes oraux, les estrogènes transdermiques seuls ou combinés à laprogestérone micronisée n'exposaient pas les femmes ménopausées à un risque accru derécidive de MVTE. Chez les hommes, la mutation du facteur V Leiden, un antécédent familialde maladie artérielle et un premier événement idiopathique étaient des facteurs de risqueindépendants de récidive.L'identification de profils de risque différents en fonction du sexe pourrait permettreune meilleure stratification du risque de récidive de MVTE. Ces résultats devraientcontribuer à améliorer la prise en charge de la maladie par une évaluation individuelle de ladurée optimale du traitement anticoagulant. De plus, une bonne sécurité d'emploi desestrogènes transdermiques seuls ou combinés à la progestérone micronisée ouvre desperspectives cliniques intéressantes dans le traitement des troubles sévères de laménopause chez des patientes avec un antécédent personnel de MVTE.Mots

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Fundação Oswaldo Cruz. Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira. Rio de Janeiro, RJ, Brasil.
Introdução: A cardiopatia reumática persiste como a principal doença cardiovascular adquirida em crianças e adultos jovens em todo o mundo, sendo responsável por altas taxas de morbimortalidade e evoluindo com frequência para a necessidade de cirurgia cardíaca valvar em pacientes na fase aguda ou crônica da doença. Objetivo: Estimar os fatores associados e o tempo desde o diagnóstico até a cirurgia cardíaca valvar em crianças e adolescentes portadores de cardiopatia reumática, em um centro cardiológico de referência terciária no Rio de Janeiro. Material e Métodos: estudo observacional longitudinal de base hospitalar, utilizando metodologia de análise de sobrevivência, para estimativa do tempo até a cirurgia, e modelo de regressão de Cox, para avaliar as razões de risco associadas segundo as covariáveis. A coorte foi composta por pacientes com 3 a 20 anos, cadastrados no Instituto Nacional de Cardiologia no Rio de Janeiro entre julho de 1986 e junho de 2006 e acompanhados até setembro de 2011. O diagnóstico da lesão valvar foi confirmado pelo exame Doppler-ecocardiográfico. As covariáveis, avaliadas no início do acompanhamento, foram reunidas em três dimensões: sociodemográfica (sexo, grupo etário, cor da pele, região de moradia e década do diagnóstico); clínica (apresentação clínica, classe funcional, número de surtos anteriores, profilaxia secundária, endocardite infecciosa e fibrilação atrial); e ecocardiográfica (lesão valvar por tipo e gravidade; diâmetro do átrio esquerdo, diâmetro sistólico do ventrículo esquerdo, função ventricular esquerda, hipertensão arterial pulmonar, e ruptura de cordoalha mitral). O banco de dados foi elaborado com o programa ACCESS 2000 e a análise estatística foi realizada pelo programa R versão 2.13.1. Foi considerado significativo o valor de - 0,05. Resultados: a coorte foi composta por 348 pacientes, 58% do sexo feminino, com idade mediana ao cadastro de 12,5 anos, e de 21,5 anos ao final do acompanhamento. O tempo médio de seguimento foi de 9,0 anos (2-21 anos). O evento cirurgia cardíaca ocorreu em 39% da amostra, com tempo mediano até a cirurgia de 22,3 anos. Na análise univariada todas as covariáveis das três dimensões (socioedemográfica, clínica e ecocardiográfica) apresentaram significância estatística e risco para realização de cirurgia cardíaca (hazard ratio>1), com exceção apenas da covariável região de moradia (p>0,5). Na análise multivariada, o modelo final incluiu as variáveis: década do diagnóstico, classe funcional, número de surtos anteriores, endocardite infecciosa, lesão valvar por tipo e gravidade, diâmetro do átrio esquerdo, diâmetro sistólico do ventrículo esquerdo e ruptura de cordoalha mitral. Conclusões: A realização da cirurgia cardíaca em pacientes com cardiopatia reumática está associada a fatores sociodemográficos, clínicos e ecocardiográficos.
Introduction: Rheumatic heart disease remains as the most common acquired heart disease in children and young adults all over the world, being responsible for high mortality and morbidity rates and often demanding valve surgery in the acute or chronic phase of the disease. Objective: To estimate the time from diagnosis until valve operation and the associated factors in children and young adults with rheumatic heart disease followed up in a tertiary center for cardiovascular care in Rio de Janeiro. Methods – It is a longitudinal observational study of a hospital based population, using survival analysis methodology for time estimation and Cox regression model for hazard risk evaluation of associated variables. Cohort was composed by 3 to 20 years old patients, registered in the National Institute of Cardiology (Instituto Nacional de Cardiologia), in Rio de Janeiro, between July 1986 and June 2006, and followed up until September 2011. Valve disease diagnosis was confirmed through Doppler echocardiography examination. Variables were evaluated at the patient´s first visit and separated in three dimensions: socio demographic (gender, age group, skin color, residence region, decade of diagnosis); clinic (disease status at presentation, functional class, number of previous rheumatic episodes, secondary prophylaxis, infectious endocarditis, atrial fibrillation); echocardiographic (valve lesion and severity, left atrium diameter, systolic left ventricle diameter, left ventricle function, pulmonary hypertension, rupture of mitral chordae). The database wasbased on the program ACCESS 2000 and statistical analysis was performed using the R Program version 2.13.1. For statistical analysis was considered as significant values for  value 0.05. Results – 348 patients were included in the cohort, 58% female. Median age at the register was 12.5 years, and 21.5 years at the end of follow up. Median follow-up time was 9.0 years (2 to 21 years). 39% underwent valve operation and the median time until surgery was 22.3 years. In the univariate analysis all the variables from the three dimensions (socio demographic, clinic and echocardiographic) presented statistical significance as hazard risk in predicting valve operation (hazard ratio>1), with only one exception, that was residence region (p>0.5). In the multivariate analysis the final model included the following variables: decade of diagnosis, functional class, number of anterior rheumatic episodes, infectious endocarditis, valve lesion and severity, left atrium diameter, systolic left ventricle diameter and rupture of mitral chordate. Conclusions: Valve surgery in patients with rheumatic heart disease is associated with socio demographic, clinic and echocardiographic factors.

Introduzione Il carcinoma epatocellulare ( HCC ) è il tumore epatico primitivo più frequente e la sua incidenza è in aumento nei paesi occidentali. I recenti progressi nelle tecniche chirurgiche di resezione epatica e l’accurata gestione perioperatoria, rendono attuabili interventi resettivi epatici per HCC con mortalità e morbilità prossime allo 0%. Ciononostante, la sopravvivenza a lungo termine dopo epatectomia è deludente a causa dell’ elevata incidenza di recidiva, che raggiunge il 70-100 % a 5 anni. Più del 60-80 % delle recidive intraepatiche di HCC sono suscettibili di nuovi trattamenti con sopravvivenze superiori al 50 % a 3 anni, in pazienti sottoposti a nuovi trattamenti con intento radicale. Gli obiettivi di questo studio sono stati: identificare i fattori di rischio per la recidiva precoce di HCC post resezione chirurgica, identificare il significato prognostico del tempo della recidiva e valutare i risultati del trattamento multimodale aggressivo della recidiva post resezione. Pazienti e Metodi: Abbiamo arruolato nel nostro studio 269 pazienti sottoposti a resezione epatica curativa per HCC dal gennaio 1990 al dicembre 2012. I pazienti che nel corso del follow-up hanno sviluppato recidive sono stati valutati per un nuovo trattamento: trapianto, ri – resezione, terapie ablative, chemioembolizzazione, chemioterapia, terapie di supporto; in funzione dello stadio della malattia , del grado di compromissione della funzionalità epatica e delle condizioni generali del paziente. Di ciascun paziente abbiamo raccolto i seguenti dati: sesso, età, eziologia e severità della cirrosi, presenza di complicanze (trombosi portale, ascite, varici esofagee e/o gastriche), evidenza di patologie concomitanti, emocromo, valori sierici di: albumina, bilirubina, transaminasi, αFP; classe Child- Pugh; caratteristiche dell’HCC: numero di noduli, dimensioni ,differenziazione istologica, presenza di capsula, infiltrazione vascolare, caratteristiche delle lesioni recidive: numero di noduli, dimensioni, tempo di insorgenza, numero di recidive e trattamento delle recidive. Analisi statistiche: Le differenze tra le variabili sono state analizzate con il test chi-quadro e il test esatto di Fisher. Le curve di sopravvivenza sono state calcolate utilizzando il metodo di Kaplan-Meier ed il test Log Rank è stato utilizzato per verificare la significatività delle differenze. Il test di regressione di Cox è stato utilizzato per l'analisi multivariata. Il valore P inferiore a 0,05 è stato considerato statisticamente significativo. Risultati: La sopravvivenza mediana per i pazienti inclusi nello studio è stata di 57,6 mesi (95 % CI 49,5 - 65,6 ) ; con sopravvivenza a 1, 3, 5 e 10 anni rispettivamente del 87,5 % , 67,9 % , 48,1 % , 17,1 % . Il 59% dei pazienti ha sviluppato recidiva dopo resezione chirurgica. Il 35% precoce (entro 1 anno) e il 65 % tardiva (dopo 1 anno) . La sopravvivenza libera da malattia a 1 , 3 e 5 anni è stata rispettivamente del 76,2 % , 41,8 % e 22,0 % . La sopravvivenza globale è stata significativamente peggiore nei pazienti con recidiva precoce ( 18,7mesi (95 % CI 7,0-20,4 )) rispetto ai pazienti con recidiva tardiva (63,8 mesi (95 % CI 48,7 -66,7 )) ( p < 0.001 ). Le dimensioni del tumore, le lesioni satelliti, l’invasione vascolare ed i livelli sierici di αFP sono risultati essere fattori di rischio per recidiva precoce. 77 % dei pazienti con recidiva sono stati sottoposti ad un nuovo trattamento: il 27 % a chemioembolizzazione (TACE) , il 39% a terapie ablative locali ( PEI e / o RFA ), l' 1 % a trapianto, l'8 % a ri - resezione e il 2 % a chemioterapie. Il 16% dei pazienti è stato sottoposto a terapie di supporto a causa dello stadio avanzato di HCC o della grave compromissione della funzionalità epatica. Il 36 % dei pazienti con recidiva precoce e il 61% dei pazienti con recidiva tardiva sono stati sottoposti a trattamenti con intento curativo. I pazienti non sottoposti ad alcun trattamento della recidiva hanno avuto una sopravvivenza significativamente minore rispetto a quelli sottoposti a trattamento con intento radicale, con una sopravvivenza mediana di 42,5 mesi e 65,6 mesi , rispettivamente ( p < 0.001 ) . la sopravvivenza dei pazienti con singola recidiva è stata significativamente minore rispetto a quella dei pazienti con 2-3 o più di 3 recidive con una sopravvivenza mediana di 49,5 ; 105,4 ; 74,2 mesi , rispettivamente. ( p < 0.001 ). Conclusioni : La recidiva di HCC dopo resezione chirurgica curativa è molto frequente. Il trattamento aggressivo delle recidive consente di prolungare la sopravvivenza di questi pazienti ed il numero delle recidive non influenza negativamente la sopravvivenza. I pazienti con recidiva precoce e quelli che sviluppano una sola recidiva hanno una prognosi peggiore rispetto a quelli con recidiva tardiva e a quelli con recidive multiple; pertanto questi gruppi di pazienti dovrebbero probabilmente essere indirizzati ad altri trattamenti o valutati per terapie adiuvanti aggressive .I fattori correlati con la recidiva precoce sono: dimensioni del tumore , lesioni satelliti , invasione vascolare e i livelli sierici di αFP . L'identificazione dei fattori di rischio per recidiva precoce e singola recidiva potrebbero contribuire a chiarire la selezione del trattamento ottimale per il paziente.
Introduction Hepatocellular carcinoma (HCC) is the most frequent primary tumor of the liver and its incidence is increasing in Western countries. With advances in surgical techniques and perioperative care, results of hepatic resection for HCC have greatly improved. Nonetheless, the long-term survival after hepatectomy is disappointing because of the high incidence of recurrence, that reaches 70-100% after 5 years. More than 60-80% of intrahepatic recurrences of HCC are susceptible to new treatments and survival rates are more than 50% in patients undergoing new treatments with radical intent. Prevention and effective management of recurrence with aggressive multimodality treatments are the most important strategies to improve the long term survival results. The aims of this study were: to identify risk factors for the early recurrence of HCC, identify the prognostic significance of the time of recurrence and to evaluate results of aggressive multimodal treatment of recurrent disease. Patients and Methods: We collected a series of 269 patients who underwent curative liver resection for HCC from January 1990 to December 2012. All patients after surgery underwent 6 months follow-up. Post-treatment monitoring was performed with clinical physical examination, contrast-enhanced imaging using computed tomography (CT) or Magnetic resonance (MRI) and the monitoring of serum level of alphafetoprotein (αFP). Patients with intrahepatic recurrences were evaluated for new treatment: transplant, re-resection, ablative therapy, chemoembolization, chemotherapy, supportive care; according to tumor stage, liver function impairment and general condition. The principle of selection for treatment was that repeated hepatic resection was the first choice whenever the tumor was considered resectable. The functional liver reserve was evaluated by blood chemical tests, Child's classification of liver function and retention rate of Indocyanine green at 15 minutes. Data were collected and analyzed with SPSS statistical software (SPSS version 19.0 Inc. Chicago Ill.) Variables included in the univariate and multivariate analyses to identify factors related to survival and recurrence were the following: sex, age, underlying liver disease (histologic status of the liver), tumor size, tumor numbers, Child-Pugh class, bilirubin level, albumin level, AFP level, tumor factors (histologic differentiation, encapsulation, vascular infiltration and type of resection). The differences between categorical and continue variables were analyzed with a chi-square test and Fisher’s exact tests. Survival curves were calculated using the Kaplan-Meier method. Clinical and pathological variables were evaluated by univariate survival analysis using a log rank test to determine any prognostic factors. Competing-risks Cox regression analysis was used for the multivariate analysis. Results: Median survival time for patients included into the study was 57,6 months (95 % CI 49,5 – 65,6); the actuarial 1- 3- 5- 10 years survival rate were 87,5%, 67,9%, 48,1%, 17,1%. In 159 (59%) patients cancer recurred after surgical resection in the remaining liver at median time of 24,5 months (SD ± 22,7 months). In 56 patients (35%) cancer recurred within 1 year and in 103 (65%) after 1 year. Median disease free survival was 30,3 months (range 24,1-36,4), with a 1, 3 and 5-years disease free survival of 76,2 %, 41,8 % and 22,0 % respectively. Survival was significant shorter in patients with early recurrence in comparison to patients with late recurrence, with a median survival time of 18,7 (95% CI 7,0-20,4) and 63,8 months (95% CI 48,7-66,7), respectively (p<0.001). Factors related with early recurrence were: size of the tumor, satellite lesions, vascular invasion, serum levels of αFP. 123 (77% ) patients with recurrence had new treatment : 28% were submitted to chemoembolization (TACE), 42% to local ablative therapy (PEI or/and RFA) 1% to transplant and 9% to re-resection, instead 3% were submitted to chemotheraphy. 17% of patients were not submit to additional treatment due to advanced stage of HCC or severe liver impairment and were submitted to supportive care. A curative treatment of the recurrent disease was feasible in 36% of patients with early recurrence and in 61% of patient with late recurrence. Patients without any treatment of the recurrent disease showed shorter overall survival compared to those submitted to treatment with radical intent of the recurrent disease, with a median survival time of 42,5 months and 65,6 months,respectively (p<0.001). Patients who developed a single recurrence had a significantly lower survival compared with patients with 2-3 or more than 3 recurrences with a median survival time of 49,5; 105,4; 74,2 months respectively. Conclusions: Recurrence after surgical resection of HCC is very frequent and aggressive treatment for HCC recurrences after curative resection improves survival. Patients with early recurrence and those with single recurrence have worse prognosis compared to those with late recurrence and those with multiple recurrences. So patients at risk for early recurrence and for single recurrence are poor candidate to surgical resection and probably these groups of patients should be addressed to other treatments or evaluated for aggressive adjuvant therapy. Furthermore aggressive treatment of relapses increases the survival and the number of relapses does not adversely influence the survival.

Trabalho Final do Mestrado Integrado em Medicina apresentado à Faculdade de Medicina
Introdução: O abcesso periamigdalino é a infeção cervical profunda mais comum, resultante da acumulação de pus no espaço periamigdalino. Permanece controversa a orientação terapêutica ideal para esta infeção potencialmente fatal, após o episódio agudo. Enquanto alguns autores recomendam a realização de amigdalectomia após o primeiro episódio, outros excluem, absolutamente, essa hipótese. Objetivo: Este estudo tem como objetivo caraterizar a epidemiologia, a clínica, o tratamento e o follow-up dos pacientes com abcesso periamigdalino e identificar eventuais fatores preditivos de recorrência de abcesso periamigdalino. Métodos: Foram analisados, retrospetivamente, os doentes diagnosticados com abcesso periamigdalino no período compreendido entre 2011 e 2015, num serviço terciário de Otorrinolaringologia. Resultados: Este estudo incluiu 283 doentes com 37.2 ± 14.8 anos [18-89 anos]. Antecedentes de amigdalite de repetição foram significativamente mais prevalentes em mulheres (p=0.03). A taxa de recorrência de abcesso periamigdalino foi de 14.1%. O grupo de doentes com recorrência de abcesso periamigdalino foi mais jovem e apresentou mais frequentemente história de amigdalite recorrente. Não foram encontradas diferenças estatisticamente significativas em outras características clínicas ou demográficas entre pacientes com ou sem recorrências de AP. Setenta e cinco porcento dos doentes recidivaram no período de 1 ano. No total, 40.8% dos doentes foram propostos para amigdalectomia. Conclusão: Neste estudo, menos de metade dos doentes foram propostos para amigdalectomia após o primeiro episódio de AP. Quando se optou por uma estratégia conservadora de tratamento, obteve-se uma taxa de recorrência não negligenciável, principalmente, durante o primeiro ano de follow-up. Doentes com história de amigdalite recorrente e doentes mais jovens desenvolveram mais recorrências de AP.
Introduction: Peritonsillar abscess (PTA) is the most common deep neck space infection, resulting from the accumulation of pus in the peritonsillar space. Controversy exists regarding the best management for this potentially fatal infection after the acute episode. Some authors recommend performing a tonsillectomy after the first episode, while others do not recommend a tonsillectomy at all.Objective: This study aims to characterize epidemiology, clinical features, management and follow-up of patients with PTA, to identify possible predictors of peritonsillar abscess recurrence. Methods: We retrospectively analyzed patients diagnosed with PTA, hospitalized between 2011 and 2015, at a tertiary otorhinolaryngology department.Results: This study included 283 patients, aged 37.2 ± 14.8 years [18-89 years]. An history of recurrent tonsillitis was significantly more common in females (p=0.03). In total, 14.1% of patients had PTA recurrence. PTA recurrence`s population was younger and had more frequently a previous history of recurrent tonsillitis. There were no significant differences in other clinical or demographic characteristics between patients with or without PTA recurrence. Seventy five percent of patients had a recurrent episode in the period of 1 year. In total, 40.8% of patients were proposed to tonsillectomy. Conclusion: In this cohort of PTA, less than half of patients are proposed to tonsillectomy after the first episode. When the option if for a conservative strategy, there is a non-negligible recurrence rate, mainly during the first year. Previous recurrent tonsillitis and younger age patients showed more frequent recurrent PTA episodes.

TB recurrence is defined as a new episode of bacteriologically positive TB in a patient previously declared successfully completed treatment. Our study objective was to identify risk factors of recurrence among HIV-infected and HIV-uninfected TB patients. Based on a population-based TB/HIV surveillance database of Chiang Rai Province, Thailand, a retrospective cohort of TB patients with successful completions of treatment between 1997 and 2008 was constructed. Poisson regression was used to model independent effects of risk factors. TB recurrence rates were 5.4/1,000 PYs and 9.7/1,000 PYs for HIV-uninfected and infected TB patients, respectively. We identified that among HIV-uninfected patients, older age, being hilltribe, being prisoners, were at higher risk of recurrence. While among HIV-infected patients, younger age, being male, and having been cured from initial episode were associated with higher recurrence rates. Targeted, practical preventive and treatment strategies for those patients need to be implemented to lower the TB recurrence rates.
Epidemiology

Introdução As hérnias do hiato ocorrem principalmente devido a fragilidade da membrana frenoesofágica e de outras estruturas próximas, como os pilares do diafragma. Isto resulta na migração intratorácica através do hiato esofágico de uma porção do tubo digestivo, o que acarreta um risco aumentado de complicações como refluxo, esofagite ou mesmo estrangulamento. A reparação cirúrgica é efetuada tradicionalmente por cirurgia aberta ou, mais recentemente, de forma minimamente invasiva. Os fatores que determinam a recorrência das hérnias do hiato após cirurgia aberta não estão ainda completamente esclarecidos. Métodos Seguindo as guidelines PRISMA, realizou-se uma revisão sistemática da literatura incidindo nos fatores de recorrência da hérnia do hiato após cirurgia aberta. Recorreu-se a duas bases de dados de referências, a Medline e a Scopus. Resultados Identificaram-se um total de 1070 referências. Após exclusão de duplicados, artigos não disponíveis ou irrelevantes, analisaram-se qualitativamente 18 artigos. Discussão Vários estudos consideram o impacto do tipo de apresentação (urgente, não urgente), um maior IMC, idade ou o tipo de cirurgia (com ou sem procedimento antirefluxo associado). Contudo, ainda não foi encontrada uma associação entre estes fatores e o aumento do risco de recorrência. Um estudo descreve uma associação entre complicações graves de refluxo e o maior risco de recorrência. Não existe uniformidade na definição de recorrência nem como a diagnosticar. Conclusão Os determinantes da recorrência após reparação aberta da hérnia do hiato permanecem controversos. Demonstra-se a necessidade de estudos prospetivos que permitam uma compreensão mais aprofundada com melhor evidência sobre as causas de recorrência da hérnia do hiato e como esta pode ser prevenida.
Introduction Due to fragility of phrenoesophageal membrane and nearby structures such as diaphragmatic crura (among other causes), hiatal hernias can develop. This results in intrathoracic migration of a portion of the digestive tube through the esophageal hiatus, with added risk of complications such as reflux, esophagitis, or even strangulation. This surgical repair can be performed traditionally with open surgery or, more recently, by minimal invasive surgery. The factors that determine hiatal hernia recurrence after open repair are not yet well understood. Methods Following the PRISMA guidelines, we performed a systematic review of literature regarding risk factors for recurrence after open surgery for hiatal hernia repair. We used both Medline and Scopus libraries. Results We identified a total of 1070 records. After exclusion of duplicates, unavailable and non-relevant articles, we included 18 studies in our qualitative analysis. Discussion Several studies consider the role of acute presentation, higher patient BMI, older age, or the type of surgery with or without a reflux procedure. However, a lack of significant association between these factors and a higher recurrence risk remains. A significant association was found between serious reflux complications the risk of recurrence, in one study. There is also a lack of consensus regarding what constitutes a recurrence, and how to diagnose it. Conclusion The factors related to the recurrence of hiatal hernia after open repair remain controversial. There is a need for prospective studies that allow for a more comprehensive understanding specially with better evidence on why hernias recur and how can this be prevented.

Introdução As hérnias do hiato ocorrem principalmente devido a fragilidade da membrana frenoesofágica e de outras estruturas próximas, como os pilares do diafragma. Isto resulta na migração intratorácica através do hiato esofágico de uma porção do tubo digestivo, o que acarreta um risco aumentado de complicações como refluxo, esofagite ou mesmo estrangulamento. A reparação cirúrgica é efetuada tradicionalmente por cirurgia aberta ou, mais recentemente, de forma minimamente invasiva. Os fatores que determinam a recorrência das hérnias do hiato após cirurgia aberta não estão ainda completamente esclarecidos. Métodos Seguindo as guidelines PRISMA, realizou-se uma revisão sistemática da literatura incidindo nos fatores de recorrência da hérnia do hiato após cirurgia aberta. Recorreu-se a duas bases de dados de referências, a Medline e a Scopus. Resultados Identificaram-se um total de 1070 referências. Após exclusão de duplicados, artigos não disponíveis ou irrelevantes, analisaram-se qualitativamente 18 artigos. Discussão Vários estudos consideram o impacto do tipo de apresentação (urgente, não urgente), um maior IMC, idade ou o tipo de cirurgia (com ou sem procedimento antirefluxo associado). Contudo, ainda não foi encontrada uma associação entre estes fatores e o aumento do risco de recorrência. Um estudo descreve uma associação entre complicações graves de refluxo e o maior risco de recorrência. Não existe uniformidade na definição de recorrência nem como a diagnosticar. Conclusão Os determinantes da recorrência após reparação aberta da hérnia do hiato permanecem controversos. Demonstra-se a necessidade de estudos prospetivos que permitam uma compreensão mais aprofundada com melhor evidência sobre as causas de recorrência da hérnia do hiato e como esta pode ser prevenida.
Introduction Due to fragility of phrenoesophageal membrane and nearby structures such as diaphragmatic crura (among other causes), hiatal hernias can develop. This results in intrathoracic migration of a portion of the digestive tube through the esophageal hiatus, with added risk of complications such as reflux, esophagitis, or even strangulation. This surgical repair can be performed traditionally with open surgery or, more recently, by minimal invasive surgery. The factors that determine hiatal hernia recurrence after open repair are not yet well understood. Methods Following the PRISMA guidelines, we performed a systematic review of literature regarding risk factors for recurrence after open surgery for hiatal hernia repair. We used both Medline and Scopus libraries. Results We identified a total of 1070 records. After exclusion of duplicates, unavailable and non-relevant articles, we included 18 studies in our qualitative analysis. Discussion Several studies consider the role of acute presentation, higher patient BMI, older age, or the type of surgery with or without a reflux procedure. However, a lack of significant association between these factors and a higher recurrence risk remains. A significant association was found between serious reflux complications the risk of recurrence, in one study. There is also a lack of consensus regarding what constitutes a recurrence, and how to diagnose it. Conclusion The factors related to the recurrence of hiatal hernia after open repair remain controversial. There is a need for prospective studies that allow for a more comprehensive understanding specially with better evidence on why hernias recur and how can this be prevented.

碩士
中山醫學大學
醫學研究所
103
Objective: Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide, especially in the Asia pacific area. Liver transplantation is theoretically the best option because it cures HCC and the underlying liver disease. The overall survival rate at 5 years after liver transplantation was around 70-75%. In contrast, 5-year survival rates after liver resection were only 40% to 65%, and the 10-year survival rate was 29%. The high incidence of HCC recurrence following liver resection is a serious issue. The recurrent rate is as high as 50-60% at 3 years and 70-100% at 5 years. This high recurrent rate precludes long-term tumor-free survival of the patients with liver resection for HCC. Our study reviewed the treatment of liver cancer patients receiving liver resection and their recurrence experience to analyze the impact of the risk factors for recurrence. Methods and Materials: This study enrolled the patients with early primary HCC who received liver resection in Medical University Hospital from June 2010 to February 2015. Retrospective study designs are applied. The data were evaluated with a logical formula regression analysis, and assess the risk factors that associated with recurrence followed by discussion. Results: We recorded a total of 89 patients with a mean age of 61.6 years. Total of 28 cases relapse after surgery. There are hepatitis B patients with and without the use of anatomical liver resection in patients must be more closely tracked. The probability of cancer recurrence that with hepatitis B is 10.476 times compared with no hepatitis B (recurrence hazard ratio: 10.476 ; 95% confidence interval, 0.928 - 118.245); the probability of cancer recurrence that not using anatomical resection, is 3.072 times (recurrence hazard ratio: 3.072; 95% confidence interval, 1.018 - 9.268) compared with have anatomical resection. Conclusion and Suggestion: According to our study, hepatitis B patients and patients without using anatomical liver resection must be more closely tracked; because of these two groups of patients have the higher probability of cancer relapse.

碩士
淡江大學
數學學系碩士班
93
The suicide rate in Taiwan has remained highly in the last decade. Gradually, the suicide related problems have been taken seriously. Researchers from many different fields have been devoting themselves to explore this topic, e.g. epidemiology, psychiatry, psychology, sociology, economics...etc. 　The aim of this study is to explore the possible risk factors for suicide and its recurrence. Accumulating four data sets from four medical centers in Taiwan, we applied logistic regression to explore the possible relationships between the odds of recurrent event of suicide and some potential prognostic factors. The comparisons of cumulative occurrence rates of suicide were done by the Kaplan-Meier method. Cox''s Proportion Hazards Models were used to compare the duration from date of birth to the time of first suicide or time to hospitalization due to suicide after adjusting the effects of some potential confounding variables. 　We found that the risk of recurrent rate was higher for younger person. Other significant risk factors were gender (Female was higher than male) and marriage status (single was higher than married). After adjusting the effect of age, the hazard rates of first time suicide and/or first time hospitalization due to suicide were statistically significant among different education levels and/or marital statuses. Especially, person with education level lower than or equal to junior high has lower occurrence rate compare to other education level person.

碩士
淡江大學
數學學系碩士班
93
The suicide rate in Taiwan has remained highly in the last decade. Gradually, the suicide related problems have been taken seriously. Researchers from many different fields have been devoting themselves to explore this topic, e.g. epidemiology, psychiatry, psychology, sociology, economics...etc. 　The aim of this study is to explore the possible risk factors for suicide and its recurrence. Accumulating four data sets from four medical centers in Taiwan, we applied logistic regression to explore the possible relationships between the odds of recurrent event of suicide and some potential prognostic factors. The comparisons of cumulative occurrence rates of suicide were done by the Kaplan-Meier method. Cox''s Proportion Hazards Models were used to compare the duration from date of birth to the time of first suicide or time to hospitalization due to suicide after adjusting the effects of some potential confounding variables. 　We found that the risk of recurrent rate was higher for younger person. Other significant risk factors were gender (Female was higher than male) and marriage status (single was higher than married). After adjusting the effect of age, the hazard rates of first time suicide and/or first time hospitalization due to suicide were statistically significant among different education levels and/or marital statuses. Especially, person with education level lower than or equal to junior high has lower occurrence rate compare to other education level person.

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2016
Introduction: In spite of the current different therapeutic approaches for the treatment of chronic subdural hematoma (CSDH), post-operative recurrence remains a frequent complication. The aim of this study is to identify risk factors for recurrence of CSDH. Methods: We conducted a retrospective case-control study with a series of consecutive surgically treated cases of CSDH. The following variables were analyzed as potential risk factors for recurrence of CSDH: gender, age, location of CSDH, treatment with antiaggregants or anticoagulants, thrombocytopenia and use of postoperative drain. Results: From a total of 257 patients analyzed, 40 (15.6%) presented with recurrent CSDH. We observed a higher recurrence rate in younger patients (p <0.05) and a tendency towards recurrence in patients treated with anticoagulants and in those who did not receive a subdural post-operative drain (p <0.2). The other variables were not associated with higher risk of recurrence. Patients with recurrence presented higher morbidity (p <0.05). Conclusions: In this series, recurrence of CSDH was associated with increased post-operative morbidity, and younger age was a risk factor for recurrence. Usual medication with anticoagulants and the absence of subdural post-operative drain may represent other risk factors.
Introdução: Apesar das diferentes abordagens terapêuticas atualmente existentes para o tratamento do hematoma subdural crónico (HSDC), a recidiva pós-cirúrgica mantém-se uma complicação frequente. O objetivo deste estudo é identificar fatores de risco para recidiva de HSDC. Métodos: Realizámos um estudo caso-controlo retrospetivo com uma série de casos consecutivos de HSDC tratados cirurgicamente. Relacionámos as seguintes variáveis com o risco de recidiva de HSDC: género, idade, localização do HSDC, terapêutica com antiagregantes ou anticoagulantes, trombocitopénia e utilização de dreno pós-operatório. Resultados: Dos 257 doentes analisados, 40 (15.6%) apresentaram recidiva do HSDC. Verificou-se maior taxa de recidiva nos doentes mais jovens (p <0.05) e tendência a recidiva nos doentes medicados com anticoagulantes e naqueles em que não foi utilizado dreno subdural pós-operatório (p <0.2). As outras variáveis não se associaram a maior risco de recidiva. Os doentes com recidiva apresentaram maior morbilidade (p <0.05). Conclusões: Na série analisada, a recidiva de HSDC esteve associada a maior morbilidade pós-cirúrgica, e a idade mais jovem constituiu um fator de risco para recidiva. A medicação habitual com anticoagulantes e a ausência de dreno subdural pós-operatório poderão constituir outros fatores de risco.

A research report submitted in fulfilment of the requirement for the degree Masters in Medicine in Surgery to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2019
Background: Phyllodes tumours are rare fibroepithelial neoplasms of the breast. The dilemma with phyllodes tumours is their tendency to local recurrence. This retrospective review of phyllodes tumours in a South African population aims to describe the most common histological and clinical features, and describe the clinical and histological risk factors for local recurrence. Methods: All histological reports of patients diagnosed with a phyllodes tumour after surgery at the University of the Witwatersrand Anatomical Pathology Laboratories in Johannesburg were assessed from 1 January 2005 to 30 June 2016. Clinical and histological parameters were analysed. Results: Over the study period, 185 patients were identified. The median age of the patients was 42 years. There were 89 (48.1%) patients with a benign tumour, 34 (18.4%) with a borderline tumour and 62 (33.5%) with a malignant tumour. The size of the tumours ranged from 11 to 460mm, with a median of 85.0mm  79.6 SD. Breast conserving surgery (BCS) was performed on 64.3% of patients and 35.7% of patients had a mastectomy. There was an overall local recurrence rate of 3.78% (2.2% for benign and 8.1% for malignant tumours). No clinical or histological factors, including margin status, were found to significantly predict local recurrence. Most recurrences (71.4%, n=5) occurred within the first two years. Conclusion: Our study did not find any predictors of local recurrence, but we provide further support to the recent suggestion of revising the common practice of wide local excision with a 1cm margin, to an excision with negative margins combined with close follow-up for two years.
TL (2020)

碩士
亞洲大學
健康管理研究所
95
Objective: Since the implementation of National Health Insurance, the method for payment is fee-for-service. The highest payment unit in medical equipment usage is per outpatient treatment in ESWL. This study is to understand the stone-free rate after ESWL and analysis the factors that affect the recurrence rate.Materials and Methods: Between Jul. 2000 to Jun 2001, total 706 patients underwent ESWL in Cheng-Ching general hospital. We retrospectively reviewed the stone-free rate and recurrence rate after ESWL. Furthermore,we investigated the factors that contributed the stone-free rate and recurrence rate with Logistic regression analysis. Results: There are 506 males and 200 females in this study. Mean age was 47.23 y/o (range from 16 to 86 y/o). Totally 763 renal units were enrolled. In these 763 renal units, 439 were stone-free after ESWL and the other 324 were not. The stone-free rate is 57.53%. Stone recurred in 123 of 439 renal units (28%). The stone size, number and location are significant factors that affect the stone-free rate. The stone free rate of upper ureteral and upper renal calyceal stones are higher than lower calyceal stone. Patients with an early onset of stone formation had the higher recurrence rate. In addition, lower calyceal stone is easier recurred than upper ureteral stone. Conclusion: ESWL is a less invasive and effective method for urolithiasis.However, lower stone-free rate and higher recurrence rate resulted in higher utilization of ESWL. Complete image study and a proper management will increase the stone free rate. In additional to age and stone location, education on changing in diet habit and life style is important.

碩士
長榮大學
護理學系碩士班
107
Head and neck cancers occur mostly in middle-aged men. If treatments are interrupted, the mortality rate will be increased. Furthermore, the burden and impact of families, communities, and countries will be induced. This is a retrospective secondary data analysis study. The subjects of this study were patients with head and neck cancer registered in the cancer registration database of a medical center in southern Taiwan during January 2013 to December 2016. We collected and analyzed information from two delinking databases. The study included a total of 544 patients with head and neck cancer. The major of subjects were men (89.5%) with age younger than 65 years old (82.9%). 57.4% patients’ stage of cancer was the fourth stage. Patients with squamous cell carcinoma (96.3%) received radiation therapy (90.8%) and chemotherapy (57.4%). Tumor location was dominated by oral cancer (52.6%) and nasopharyngeal carcinoma (19.9%). Over 70% patient had smoking (73.7%), over 60% patient had alcohol (58.6%) and betel nut (57.2%). The rate of treatment interruption was 12.5%. The recurrence and survival rates of treatment interruption were 20.6% and 29.4%, respectively. The recurrence and survival rates of without interruption treatment were 14.1% and 64.7%, respectively. The risk factors of interrupted treatment were stage 4 (OR: 1.936, p = 0.029), age greater than 65 years (OR: 2.887, p = 0.001), and no radiation therapy (OR:8.888, p < 0.001). The major reasons of interrupted treatment were side effects (39.7%), and comorbidities (23.5%). As a whole, the recurrence rate was higher and survival rate was lower on patients with treatment interruption than those did not. In future, for the high-risk group of patients with interrupted treatment, medical staff should treat side effects or complications actively. Furthermore, they could implement a comprehensive geriatric assessment and integration of oncology and palliative care to reduce interrupted treatment, cancer recurrence, and increase the survival of patients with head and neck cancer.

碩士
國立臺灣大學
預防醫學研究所
90
This study analyzed incidence rates of invasive cervical cancer and carcinoma in sit in Taiwan from 1979-1998. It retrieved data from Cancer Registry of Department of Health and analyzed changing trends in incidence of invasive cervical cancer and incidence of carcioma in situ along with changing patterns of age and histologic type. In addition, this study used data according to death certificate to analyze the trend in incidence of mortality and factors associated with mortality. In order the stratified the cases into different stages in order for survival analysis, we acquired data from National Taiwan University Hospital to analyze survival of patients with cervical cancer. Since most patients are at early stage of cervical according at time of diagnosis, we further retrieved individual medical charts of patients operated at National Taiwan University Hospital for further analysis on prognostic factors. Study shows that the incidence rate of invasive cervical cancer remained relatively steady. However, incidence of carcinoma in situ increased particular for women at younger age groups and after time of national funded Pap screening initiated in 1995. Mortality decreased in a secular fashion but it still increased for those aged 70 years and over. Further analysis showed that factors associated with survival included staging, histology and age. Analysis of patients operated at National Taiwan University Hospital shows that factors associate with recurrence include lymph node status, depth of stromal invasion, lymphovascular space invasion and etc. Clinicians should be prudent in selecting patients for the most appropriate treatment and pretreatment SCC-antigen level could provide clues to identification of patient that may require adjuvant radiotherapy.

碩士
國立中興大學
環境工程學系所
107
The objectives of this research were to investigate the associations of the risk factors of breast cancer, including body mass index (BMI, Kg/m2), age and the background levels of abasic sites (Abasic site or Apurinic/apyrimidinic site , AP sites) in Taiwanese women with healthy controls, breast cancer patients and breast cancer five-year postoperative treatment without recurrence (5-year survivors). Results indicated that the mean levels of AP sites in 5-year survivors (n=28) was estimated to be 35.2 ± 2.7 per 106 total nucleotides. The median is 34.7 per 106 total nucleotides with range 31.4 ~ 39.9 per 106 total nucleotides. Further investigation using putrescine cleavage assay indicated that the number of AP sites in 5-year survivors were about 50% induced by reactive oxygen species, similar to that of calf-thymus DNA (55%). Further investigation indicated that the number of AP sites detected in 5-year survivors was not statistically significant different from those of healthy controls (n = 140) nor breast cancer patients (n = 148) presumably due to limited sample size. Further investigation are warranty by recruiting more subjects in this study to verify the differences in the background levels of AP sites in breast cancer patients before and after treatment.