Curso clínico de refluxo vesicoureteral primário em 735 crianças e adolescentes

Exportado OPUSMade available in DSpace on 2019-08-14T03:55:42Z (GMT). No. of bitstreams: 1 jos__maria_penido_silva.pdf: 1974499 bytes, checksum: 47fe76f8b3afb56b0ae939469ff7872d (MD5) Previous issue date: 10Objetivos: Descrever as características clínicas, laboratoriais e radiológicas de pacientes com refluxo vesicoureteral primário (RVU) e avaliar o curso clínico. Estudar as diferentes características do refluxo de acordo como sexo, estudar os fatores preditivos da involução espontânea do refluxo. Métodos: Dados foram btidosresrospectivamente dos prontuários dos pacientes portadores de RVU encaminhados entre 1969 a 2004. Foram registrados os seguintes dados: sexo, idade do diagnóstico da infecção urinária (ITU) e do RVU, pressão arterial, surtos de ITU, níveis de uréia e creatina, tempo de seguimento, e a evolução do refluxo. Os seguintes exames de imagem foram obtidos: ultra-sonografia (US), uretrocistografia meccional (UCM) e cintilografia renal. Para comparação de proporções foi utilizado o teste do qui-quadrado. Foram calculados odds ratio(OR) e intervalo de confiança a 95% (IC 95%) para comparação de risco. A involução do refluxo e o risco de insuficiência foram estudados através de análise de sobrevida e modelo multivariado de Cox. Resultados: Um total de 735 pacientes foi incluído na análise. Houve predomínio do sexo feminino (71%) e da cor branca (80%). A apresentação clínica inicial mais freqüente foi ITU (92,4%). O RVU foi bilateral em 385 (52%). Assim, um total de 1.124 unidades renais apresentava refluxo; 373 apresentavam cicatrizes renais na admissão. Do total de 739 pacientes, 677 (91,6%) foram abordados com tratamento conservador e 62 (8,4%) submetidos a procedimentos cirúrgicos. Os pacientes foram acompanhados por um tempo médio de 76 meses (DP = 55 meses). Durante o acompanhamento, 319(43%) pacientes não apresentaram surtos de ITU. Hipertensão arterial foi detectada em 21 (2,8%) e insuficiência renal em 24 (3,2%) pacientes. Fatores preditivos da resolução do refluxo leve: sexo masculino (RR = 1.7, IC95%, 1.1 2.6, p 0.012), ausência de dano renal (RR = 3.4, IC95%, 1.8 6.4, p < 0.001), e refluxo unilateral (RR = 1.6, IC95% 1.1 2.3, p = 0.004). Refluxo moderado/grave reflux: pacientes não brancos (RR = 1.7, IC95%, 1.1 2.6, p = 0,01), ausência de dano renal (RR = 3.0, IC95%, 2.0 4.4, p < 0.001), e ausência de disfunção miccional (RR = 2.8, IC95%, 1.4 5.5, p = 0.004). Conclusão: O RVU é uma entidade clínica heterogênea. Nossa casuística mostra que a conduta conservadora é eficaz, mas independentemente da abordagem inicial esses pacientes devem ser acompanhados até a idade adulta, especialmente aqueles com nefropatia do refluxo

A INFLUÊNCIA DO SISTEMA DE INFORMAÇÃO CONTÁBIL COMO INSTRUMENTO DE APOIO À GERAÇÃO DE INFORMAÇÕES FIDEDIGNAS PELA CONTROLADORIA: UM ESTUDO DE CASO

Com o surgimento dos Sistemas de Informações Contábeis (SIC), a contabilização em papéis perdeu espaço, e o contador deixou de ser apenas guardador de livros, transformando-se em peça fundamental na tomada de decisão. Com uma economia totalmente globalizada, as decisões precisam ser tomadas instantaneamente para garantir o bom desenvolvimento das atividades comerciais, otimizando o resultado econômico. Os SICs tornaram-se um meio de alcançar esse objetivo por meio do eficiente controle das informações gerenciais. O presente objetivou identificar a influência do SIC como instrumento de apoio à geração de informações fidedignas pela Controladoria. Trata-se de um estudo qualitativo cuja metodologia aplicada foi a pesquisa bibliográfica e documental, por meio também de um estudo de caso em uma empresa de construção civil, buscando captar a percepção dos colaboradores acerca da utilização do SIC como ferramenta de suporte e seu papel no processamento da informação contábil na organização. Concluiu-se que o SIC possui aspectos que o diferenciam dos demais sistemas de informação, por gerar informações em formatos compatíveis com as diretrizes contábeis, o que contribui para o aspecto da qualidade operacional da empresa, facilitando a tomada de decisão e o levantamento de informações pela Controladoria com maior agilidade, veracidade e segurança

T-piece versus self-inflating bag ventilation in preterm neonates at birth

Objective To verify whether the use of the T-piece resuscitator compared with the self-inflating bag in preterm infants ventilated at birth modifies survival to hospital discharge without major morbidities. Design Pragmatic prospective cohort study. Setting 20 Brazilian university hospitals of Brazilian Network on Neonatal Research. Patients were 1962 inborn infants in 2014-2015 ventilated at birth with 23-33' weeks gestation and birth weight 400-1499 g without malformations. Patients transferred until the 27th day after birth were excluded. Interventions Positive pressure ventilation at birth with T-piece resuscitator or self-inflating bag without positive end expiratory pressure valve. Intervention with ventilation followed the Brazilian Society of Pediatrics guidelines. The choice of the equipment was at the neonatologist's discretion in each delivery. The main outcome measures were survival to hospital discharge without bronchopulmonary dysplasia, severe peri-intraventricular haemorrhage and periventricular leucomalada. Logistic regression adjusted for confounding variables was applied for main outcome. Results 1456 (74%) were only ventilated with T-piece resuscitator and 506 (26%) with the self-inflating bag. The characteristics of those ventilated with T-Piece resuscitator versus self-inflating bag were birth weight 969 +/- 277 vs 941 +/- 279 g, gestational age 28.2 +/- 2.5 vs 27.8 +/- 2.7 weeks and survival to hospital discharge without major morbidities 47% vs 35%, Logistic regression adjusted for maternal characteristics, obstetric and neonatal morbidities showed that the T-piece resuscitator increased the chance of survival to hospital discharge without major morbidities (OR=1.38; 95% Cl 1.06 to 1.80; Hosmer-Lemeshow goodness of fit: 0.695). Conclusion This study is the first that highlights the effectiveness of T-piece resuscitator ventilation in improving relevant outcomes in preterm neonates.Univ Fed Sao Paulo, Div Neonatal Med, Sao Paulo, BrazilUniv Sao Paulo, Dept Pediat, Fac Med Ribeirao Preto, Ribeirao Preto, BrazilUniv Fed Maranhao, Dept Pediat, Sao Luis, BrazilUniv Estadual Campinas, Dept Pediat, Fac Ciencias Med, Campinas, SP, BrazilUniv Sao Paulo, Dept Pediat, Fac Med, Sao Paulo, BrazilUniv Estadual Paulista, Div Neonatol, Fac Med Botucatu, Botucatu, SP, BrazilFundacao Oswaldo Cruz, Div Neonatol, Rio De Janeiro, BrazilPontificia Univ Catolica Rio Grande do Sul, Dept Pediat, Hosp Sao Lucas, Fac Med, Porto Alegre, RS, BrazilUniv Fed Rio Grande do Sul, Div Neonatol, Hosp Clin Porto Alegre, Porto Alegre, RS, BrazilUniv Estado Rio de Janeiro, Dept Pediat, Hosp Univ Pedro Ernesto, Rio De Janeiro, BrazilUniv Fed Minas Gerais, Div Neonatol, Belo Horizonte, MG, BrazilUniv Fed Uberlandia, Pediat, Uberlandia, MG, BrazilMaternidade Hilda Brandao, Dept Pediat, Fac Ciencias Med Minas Gerais, Belo Horizonte, MG, BrazilUniv Sao Paulo, Sch Med, Dept Pediat, Sao Paulo, SP, BrazilHosp Estadual Sumare, Neonatal Div, Sumare, BrazilHosp Geral Pirajussara, Neonatal Unit, Taboao Da Serra, BrazilHosp Estadual Diadema, Neonatal Unit, Diadema, BrazilUniv Estadual Londrina, Dept Pediat, Hosp Univ, Curitiba, Parana, BrazilUniv Fed Parana, Dept Pediat, Hosp Clin, Curitiba, Parana, BrazilInst Med Integral Prof Fernando Figueira, Dept Pediat, Recife, PE, BrazilInst Fernandes Figueira FIOCRUZ, Dept Pediat, Rio De Janeiro, BrazilUniv Fed Sao Paulo, Div Neonatal Med, Sao Paulo, BrazilWeb of Scienc

Burden of disease scenarios for 204 countries and territories, 2022–2050: a forecasting analysis for the Global Burden of Disease Study 2021

BackgroundFuture trends in disease burden and drivers of health are of great interest to policy makers and the public at large. This information can be used for policy and long-term health investment, planning, and prioritisation. We have expanded and improved upon previous forecasts produced as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) and provide a reference forecast (the most likely future), and alternative scenarios assessing disease burden trajectories if selected sets of risk factors were eliminated from current levels by 2050.MethodsUsing forecasts of major drivers of health such as the Socio-demographic Index (SDI; a composite measure of lag-distributed income per capita, mean years of education, and total fertility under 25 years of age) and the full set of risk factor exposures captured by GBD, we provide cause-specific forecasts of mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) by age and sex from 2022 to 2050 for 204 countries and territories, 21 GBD regions, seven super-regions, and the world. All analyses were done at the cause-specific level so that only risk factors deemed causal by the GBD comparative risk assessment influenced future trajectories of mortality for each disease. Cause-specific mortality was modelled using mixed-effects models with SDI and time as the main covariates, and the combined impact of causal risk factors as an offset in the model. At the all-cause mortality level, we captured unexplained variation by modelling residuals with an autoregressive integrated moving average model with drift attenuation. These all-cause forecasts constrained the cause-specific forecasts at successively deeper levels of the GBD cause hierarchy using cascading mortality models, thus ensuring a robust estimate of cause-specific mortality. For non-fatal measures (eg, low back pain), incidence and prevalence were forecasted from mixed-effects models with SDI as the main covariate, and YLDs were computed from the resulting prevalence forecasts and average disability weights from GBD. Alternative future scenarios were constructed by replacing appropriate reference trajectories for risk factors with hypothetical trajectories of gradual elimination of risk factor exposure from current levels to 2050. The scenarios were constructed from various sets of risk factors: environmental risks (Safer Environment scenario), risks associated with communicable, maternal, neonatal, and nutritional diseases (CMNNs; Improved Childhood Nutrition and Vaccination scenario), risks associated with major non-communicable diseases (NCDs; Improved Behavioural and Metabolic Risks scenario), and the combined effects of these three scenarios. Using the Shared Socioeconomic Pathways climate scenarios SSP2-4.5 as reference and SSP1-1.9 as an optimistic alternative in the Safer Environment scenario, we accounted for climate change impact on health by using the most recent Intergovernmental Panel on Climate Change temperature forecasts and published trajectories of ambient air pollution for the same two scenarios. Life expectancy and healthy life expectancy were computed using standard methods. The forecasting framework includes computing the age-sex-specific future population for each location and separately for each scenario. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline.FindingsIn the reference scenario forecast, global and super-regional life expectancy increased from 2022 to 2050, but improvement was at a slower pace than in the three decades preceding the COVID-19 pandemic (beginning in 2020). Gains in future life expectancy were forecasted to be greatest in super-regions with comparatively low life expectancies (such as sub-Saharan Africa) compared with super-regions with higher life expectancies (such as the high-income super-region), leading to a trend towards convergence in life expectancy across locations between now and 2050. At the super-region level, forecasted healthy life expectancy patterns were similar to those of life expectancies. Forecasts for the reference scenario found that health will improve in the coming decades, with all-cause age-standardised DALY rates decreasing in every GBD super-region. The total DALY burden measured in counts, however, will increase in every super-region, largely a function of population ageing and growth. We also forecasted that both DALY counts and age-standardised DALY rates will continue to shift from CMNNs to NCDs, with the most pronounced shifts occurring in sub-Saharan Africa (60·1% [95% UI 56·8–63·1] of DALYs were from CMNNs in 2022 compared with 35·8% [31·0–45·0] in 2050) and south Asia (31·7% [29·2–34·1] to 15·5% [13·7–17·5]). This shift is reflected in the leading global causes of DALYs, with the top four causes in 2050 being ischaemic heart disease, stroke, diabetes, and chronic obstructive pulmonary disease, compared with 2022, with ischaemic heart disease, neonatal disorders, stroke, and lower respiratory infections at the top. The global proportion of DALYs due to YLDs likewise increased from 33·8% (27·4–40·3) to 41·1% (33·9–48·1) from 2022 to 2050, demonstrating an important shift in overall disease burden towards morbidity and away from premature death. The largest shift of this kind was forecasted for sub-Saharan Africa, from 20·1% (15·6–25·3) of DALYs due to YLDs in 2022 to 35·6% (26·5–43·0) in 2050. In the assessment of alternative future scenarios, the combined effects of the scenarios (Safer Environment, Improved Childhood Nutrition and Vaccination, and Improved Behavioural and Metabolic Risks scenarios) demonstrated an important decrease in the global burden of DALYs in 2050 of 15·4% (13·5–17·5) compared with the reference scenario, with decreases across super-regions ranging from 10·4% (9·7–11·3) in the high-income super-region to 23·9% (20·7–27·3) in north Africa and the Middle East. The Safer Environment scenario had its largest decrease in sub-Saharan Africa (5·2% [3·5–6·8]), the Improved Behavioural and Metabolic Risks scenario in north Africa and the Middle East (23·2% [20·2–26·5]), and the Improved Nutrition and Vaccination scenario in sub-Saharan Africa (2·0% [–0·6 to 3·6]).InterpretationGlobally, life expectancy and age-standardised disease burden were forecasted to improve between 2022 and 2050, with the majority of the burden continuing to shift from CMNNs to NCDs. That said, continued progress on reducing the CMNN disease burden will be dependent on maintaining investment in and policy emphasis on CMNN disease prevention and treatment. Mostly due to growth and ageing of populations, the number of deaths and DALYs due to all causes combined will generally increase. By constructing alternative future scenarios wherein certain risk exposures are eliminated by 2050, we have shown that opportunities exist to substantially improve health outcomes in the future through concerted efforts to prevent exposure to well established risk factors and to expand access to key health interventions.FundingBill & Melinda Gates Foundation.</p