Análise dos fatores prognósticos do uso da ventilação não-invasiva em pacientes com diagnóstico de tumores sólidos em insuficiência respiratória aguda

Tese (doutorado) — Universidade de Brasília, Faculdade de Ceilândia, Programa de Pós-Graduação Stricto Sensu em Ciências e Tecnologias e Saúde, 2021.Introdução: A ventilação não invasiva (VNI) é um tratamento bem estabelecido para a insuficiência respiratória aguda (IRpA) em pacientes com câncer hematológico. No entanto, o impacto da VNI na mortalidade de pacientes com tumores sólidos não é bem estabelecido. Objetivo: Definir os preditores associados à falha da VNI e descrever o risco de mortalidade de pacientes com tumores sólidos que necessitaram de VNI para tratamento de IRpA em unidade de cuidados intensivos (UTI). Métodos: Estudo de coorte retrospectivo de pacientes com diagnóstico de tumores sólidos internados na UTI de um hospital público, referência em oncologia, entre janeiro de 2016 e dezembro de 2017, para tratamento de câncer que evoluíram com o quadro de IRpA, e que utilizaram a VNI como primeira linha de tratamento. As informações dos pacientes e os exames laboratoriais de interesse para o estudo foram obtidos a partir de um banco de dados, construído por meio prontuários eletrônicos e exames complementares. Nosso desfecho primário foi a falha frente ao uso da VNI, e o desfecho secundário a mortalidade na UTI e hospitalar. Um modelo regressão de riscos proporcionais de Cox foi usado para identificar variáveis associadas à mortalidade e falha da VNI. As análises de Kaplan-Meier foram realizadas para demonstrar a sobrevivência cumulativa. Resultados: Foram incluídos 226 pacientes com tumores sólidos. A mortalidade em UTI e hospitalar foi de 57,5% e 69,5%, respectivamente. A VNI falhou em 52,2% dos pacientes incluídos. O uso de vasopressores (HR 2,58 [IC 95%: 1,41-4,73] p = 0,02) e lactato basal (HR 1,13 [IC 95% 1,06-1,20] p = 0,001) foram associados à falha de VNI, com a duração da VNI (HR 0,93 [IC 95%: 0,89-0,97] p = 0,003) associada ao sucesso desta intervenção, enquanto o uso de vasopressores (HR 2,48 [IC 95%: 1,43-4,30] p = 0,001), lactato arterial basal (HR 1,20 [IC 95%: 1,07-1,35] p = 0,003), relação PaO2/FiO2 basal (HR 1,33 [1,11] -1,55] p = 0,002) e sucesso de VNI (HR 0,17 [IC 95%: 0,10-0,27] p = 0,005) foram independentemente associados à mortalidade hospitalar. Conclusões: O sucesso da VNI foi independentemente associado a uma redução nas taxas de mortalidade tanto na UTI como no hospital. Em pacientes com indicação de terapia para VNI, o aumento na duração dessa intervenção foi associado a maior probabilidade de sucesso da VNI.Background: Noninvasive Ventilation (NIV) is a well-established treatment for Acute Respiratory Failure (ARF) in hematological cancer. However, the NIV impact on mortality in patients with solid tumors is unclear. Objective: To define the predictors associated with NIV failure and mortality and to describe the mortality risk of patients with solid tumors requiring NIV for ARF treatment in the intensive care unit (ICU). Methods: Retrospective cohort study of patients diagnosed with solid tumors admitted to the ICU of a public hospital, a reference in oncology, between January 2016 and December 2017, for cancer treatment that evolved with ARF, and who used NIV as first line of treatment. Patient information and laboratory tests of interest for the study were obtained from a database, built using electronic medical records and complementary tests. Our primary outcome was failure due to the use of NIV, and the secondary outcome was mortality in the ICU and hospital. A Cox proportional hazards regression model was used to identify variables associated with NIV mortality and failure. Kaplan-Meier analyzes were performed to demonstrate cumulative survival. Results: A total of 226 patients with solid tumors were included. The ICU and hospital mortality were 57.5% and 69.5%, respectively. NIV failed in 52.2% of the patients. The use of vasopressors (HR 2.58 [95%CI:1.41-4.73] p=0.02) and baseline lactate (HR 1.13[95%CI:1.06-1.20] p=0.001) were associated with NIV failure, and NIV duration (HR 0.93[95%CI:0.89-0.97] p=0.003) were associated with NIV success. The use vasopressors (HR 2.48[95%CI:1.43-4.30] p=0.001), baseline lactate (HR 1.20[95%CI:1.07-1.35] p=0.003), baseline PaO2/FiO2 ratio (HR1.33[1.11-1.55] p=0.002) and NIV success (HR0.17[95%CI:0.10-0.27] p=0.005) were independently associated with hospital mortality. Conclusions: NIV success was independently associated with a decrease in both ICU and hospital mortality rates. In patients with NIV therapy indication, the duration of this intervention was associated with NIV success

Comportamento cardiovascular durante a reabilitação após cirurgia de revascularização do miocárdio

OBJECTIVE: The aim of the present study was to assess the behavior of cardiovascular variables during an in-hospital cardiovascular rehabilitation program in patients following myocardial revascularization surgery. METHODS: A total of 14 patients (mean age: 55.4 ± 6.4 years, 78.6% male) participated in the study, all of whom had a previous diagnosis of coronary insufficiency and indication for elective surgery. The protocol consisted of a group of low-impact (2-3 METs) upper/lower extremity and walking exercises performed both pre and post-operatively (3rd and 4th days). The following variables were evaluated at rest and following the exercise program: heart rate (HR, bpm); systolic arterial pressure (SAP, mmHg); diastolic arterial pressure (DAP, mmHg); mean arterial pressure (MAP, mmHg); double product (DPr, bpm/mmHg); and the Rating of Perceived Exertion (RPE) scale. RESULTS: There was a significant increase in HR and DPr in the individual analysis (P<0.001) as well as in between days (P<0.001 for HR and P<0.05 for DPr), but only attaining maximal values that were < 30% of predicted. Moreover, a negative correlation was found between the RPE scale and both SAP and MAP. CONCLUSION: The exercises proposed proved to be safe with the change in key physiologic variables throughout the experiment below recommended values for the hospitalization phase. Furthermore, the RPE scale appears to have a correlation with some hemodynamic variables and thus may be a useful tool for this group of patients. _______________________________________________________________________________ RESUMOObjetivo: O objetivo do presente estudo foi avaliar o comportamento das variáveis cardiovasculares durante um programa de reabilitação cardiovascular hospitalar em pacientes submetidos à cirurgia de revascularização do miocárdio.Métodos: Um total de 14 pacientes (idade média: 55,4 ±6,4 anos, 78,6% do sexo masculino) participaram do estudo,todos apresentavam diagnóstico prévio de insuficiência coronariana e indicação de cirurgia eletiva. O protocolo consistiu de um grupo de exercícios de baixo impacto (2-3METs) para extremidade superior e inferior e exercícios de caminhada realizados no pré e pós-operatório (3 e 4 dias).As seguintes variáveis foram avaliadas em repouso e após o programa de exercício: frequência cardíaca (FC, bpm),pressão arterial sistólica (PAS, mmHg), pressão arterial diastólica (PAD, mmHg), pressão arterial média (MAP,mmHg), duplo produto (DPr, bpm/mmHg) e escala de Índice de Percepção de Esforço (IPE).Resultados: Houve aumento significativo da FC e DPr na análise individual (P <0,001), bem como na análise entre os dias de avaliação (P <0,001 para FC e P <0,05 para DPr), mas apenas atingindo valores máximos que foram < 30% do previsto. Além disso, ocorreu correlação negativa entre a escala IPE e SAP e MAP.Conclusão: Os exercícios propostos mostraram-se seguros com a mudança de variáveis fisiológicas fundamentais em todo o experimento abaixo do valor recomendado para a fase de hospitalização. Além disso, a escala percepção de esforço parece ter correlação com algumas variáveis hemodinâmicas e, portanto, pode ser uma ferramenta útil para este grupo de pacientes

Familial hypercholesterolaemia in children and adolescents from 48 countries: a cross-sectional study

Background: Approximately 450 000 children are born with familial hypercholesterolaemia worldwide every year, yet only 2·1% of adults with familial hypercholesterolaemia were diagnosed before age 18 years via current diagnostic approaches, which are derived from observations in adults. We aimed to characterise children and adolescents with heterozygous familial hypercholesterolaemia (HeFH) and understand current approaches to the identification and management of familial hypercholesterolaemia to inform future public health strategies. Methods: For this cross-sectional study, we assessed children and adolescents younger than 18 years with a clinical or genetic diagnosis of HeFH at the time of entry into the Familial Hypercholesterolaemia Studies Collaboration (FHSC) registry between Oct 1, 2015, and Jan 31, 2021. Data in the registry were collected from 55 regional or national registries in 48 countries. Diagnoses relying on self-reported history of familial hypercholesterolaemia and suspected secondary hypercholesterolaemia were excluded from the registry; people with untreated LDL cholesterol (LDL-C) of at least 13·0 mmol/L were excluded from this study. Data were assessed overall and by WHO region, World Bank country income status, age, diagnostic criteria, and index-case status. The main outcome of this study was to assess current identification and management of children and adolescents with familial hypercholesterolaemia. Findings: Of 63 093 individuals in the FHSC registry, 11 848 (18·8%) were children or adolescents younger than 18 years with HeFH and were included in this study; 5756 (50·2%) of 11 476 included individuals were female and 5720 (49·8%) were male. Sex data were missing for 372 (3·1%) of 11 848 individuals. Median age at registry entry was 9·6 years (IQR 5·8-13·2). 10 099 (89·9%) of 11 235 included individuals had a final genetically confirmed diagnosis of familial hypercholesterolaemia and 1136 (10·1%) had a clinical diagnosis. Genetically confirmed diagnosis data or clinical diagnosis data were missing for 613 (5·2%) of 11 848 individuals. Genetic diagnosis was more common in children and adolescents from high-income countries (9427 [92·4%] of 10 202) than in children and adolescents from non-high-income countries (199 [48·0%] of 415). 3414 (31·6%) of 10 804 children or adolescents were index cases. Familial-hypercholesterolaemia-related physical signs, cardiovascular risk factors, and cardiovascular disease were uncommon, but were more common in non-high-income countries. 7557 (72·4%) of 10 428 included children or adolescents were not taking lipid-lowering medication (LLM) and had a median LDL-C of 5·00 mmol/L (IQR 4·05-6·08). Compared with genetic diagnosis, the use of unadapted clinical criteria intended for use in adults and reliant on more extreme phenotypes could result in 50-75% of children and adolescents with familial hypercholesterolaemia not being identified. Interpretation: Clinical characteristics observed in adults with familial hypercholesterolaemia are uncommon in children and adolescents with familial hypercholesterolaemia, hence detection in this age group relies on measurement of LDL-C and genetic confirmation. Where genetic testing is unavailable, increased availability and use of LDL-C measurements in the first few years of life could help reduce the current gap between prevalence and detection, enabling increased use of combination LLM to reach recommended LDL-C targets early in life

Optimasi Portofolio Resiko Menggunakan Model Markowitz MVO Dikaitkan dengan Keterbatasan Manusia dalam Memprediksi Masa Depan dalam Perspektif Al-Qur`an

Risk portfolio on modern finance has become increasingly technical, requiring the use of sophisticated mathematical tools in both research and practice. Since companies cannot insure themselves completely against risk, as human incompetence in predicting the future precisely that written in Al-Quran surah Luqman verse 34, they have to manage it to yield an optimal portfolio. The objective here is to minimize the variance among all portfolios, or alternatively, to maximize expected return among all portfolios that has at least a certain expected return. Furthermore, this study focuses on optimizing risk portfolio so called Markowitz MVO (Mean-Variance Optimization). Some theoretical frameworks for analysis are arithmetic mean, geometric mean, variance, covariance, linear programming, and quadratic programming. Moreover, finding a minimum variance portfolio produces a convex quadratic programming, that is minimizing the objective function ðð¥with constraintsð ð 𥠥 ðandð´ð¥ = ð. The outcome of this research is the solution of optimal risk portofolio in some investments that could be finished smoothly using MATLAB R2007b software together with its graphic analysis

Search for heavy resonances decaying to two Higgs bosons in final states containing four b quarks

A search is presented for narrow heavy resonances X decaying into pairs of Higgs bosons (H) in proton-proton collisions collected by the CMS experiment at the LHC at root s = 8 TeV. The data correspond to an integrated luminosity of 19.7 fb(-1). The search considers HH resonances with masses between 1 and 3 TeV, having final states of two b quark pairs. Each Higgs boson is produced with large momentum, and the hadronization products of the pair of b quarks can usually be reconstructed as single large jets. The background from multijet and t (t) over bar events is significantly reduced by applying requirements related to the flavor of the jet, its mass, and its substructure. The signal would be identified as a peak on top of the dijet invariant mass spectrum of the remaining background events. No evidence is observed for such a signal. Upper limits obtained at 95 confidence level for the product of the production cross section and branching fraction sigma(gg -> X) B(X -> HH -> b (b) over barb (b) over bar) range from 10 to 1.5 fb for the mass of X from 1.15 to 2.0 TeV, significantly extending previous searches. For a warped extra dimension theory with amass scale Lambda(R) = 1 TeV, the data exclude radion scalar masses between 1.15 and 1.55 TeV

Search for supersymmetry in events with one lepton and multiple jets in proton-proton collisions at root s=13 TeV

Peer reviewe

Measurement of the top quark mass using charged particles in pp collisions at root s=8 TeV

Peer reviewe

Measurement of the Splitting Function in &ITpp &ITand Pb-Pb Collisions at root&ITsNN&IT=5.02 TeV

Data from heavy ion collisions suggest that the evolution of a parton shower is modified by interactions with the color charges in the dense partonic medium created in these collisions, but it is not known where in the shower evolution the modifications occur. The momentum ratio of the two leading partons, resolved as subjets, provides information about the parton shower evolution. This substructure observable, known as the splitting function, reflects the process of a parton splitting into two other partons and has been measured for jets with transverse momentum between 140 and 500 GeV, in pp and PbPb collisions at a center-of-mass energy of 5.02 TeV per nucleon pair. In central PbPb collisions, the splitting function indicates a more unbalanced momentum ratio, compared to peripheral PbPb and pp collisions.. The measurements are compared to various predictions from event generators and analytical calculations.Peer reviewe

Measurement of nuclear modification factors of gamma(1S)), gamma(2S), and gamma(3S) mesons in PbPb collisions at root s(NN)=5.02 TeV

The cross sections for ϒ(1S), ϒ(2S), and ϒ(3S) production in lead-lead (PbPb) and proton-proton (pp) collisions at √sNN = 5.02 TeV have been measured using the CMS detector at the LHC. The nuclear modification factors, RAA, derived from the PbPb-to-pp ratio of yields for each state, are studied as functions of meson rapidity and transverse momentum, as well as PbPb collision centrality. The yields of all three states are found to be significantly suppressed, and compatible with a sequential ordering of the suppression, RAA(ϒ(1S)) > RAA(ϒ(2S)) > RAA(ϒ(3S)). The suppression of ϒ(1S) is larger than that seen at √sNN = 2.76 TeV, although the two are compatible within uncertainties. The upper limit on the RAA of ϒ(3S) integrated over pT, rapidity and centrality is 0.096 at 95% confidence level, which is the strongest suppression observed for a quarkonium state in heavy ion collisions to date. © 2019 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). Funded by SCOAP3.Peer reviewe