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A presente dissertação tem por objetivo analisar os discursos de estudantes com deficiência física no ensino superior, utilizando-se dos aportes arqueogeneálogicos elaborados por Michel Foucault. Nesse sentido, esta pesquisa percorrera as diferentes perspectivas históricas acerca do sujeito anormal, a fim de evidenciar as transformações e rupturas ocorridas nos regimes de verdade, nas constituições dos saberes acerca da anormalidade ao longo do tempo. Realizouse entrevistas semiestruturadas com três estudantes com foco em suas vivencias no ambiente acadêmico, explorando os desafios encontrados, a relação com professores e colegas e suas trajetórias de vida. Em um primeiro momento da análise, denominado perspectiva histórica, teorizou-se sobre o surgimento na Idade Média da figura dos bufões e a utilização das anomalias para fins de teatralização, transformando-se no início do capitalismo em um modo de espetacularização denominado freak shows. Na segunda metade do século XX incidiu sobre o anormal um processo de medicalização e patologização de sua condição. Os modelos de deficiência surgidos posteriormente permitiram a estes sujeitos acessar direitos e a possibilidade de serem incluídos em espaços que outrora foram-lhes negados. O segundo momento da análise, chamado caracol enunciativo, visou analisar a emergência dos discursos inclusivos na atualidade, os jogos de verdades e a materialidade destes enunciados. Em um horizonte de governamentalidade neoliberal há um imperativo por inclusão. Vive-se em uma sociedade do desempenho, onde o tempo é acelerado. A mercantilização do viver que torna o homem cada vez mais empresário de si mesmo dá lugar ao creep, esta aberração contemporânea. Este se situa imerso nos discursos de otimização do ser, estando ao mesmo tempo incluído em determinados espaços e excluído de outros, gradientes de in/exclusão. No terceiro momento chamado intencionalidade, verificou-se como as relações de poder atuam sobre estes sujeitos dentro de uma arena agonística. Da mesma forma que as relações de poder objetivam normalizar o creep por meio do imperativo de inclusão, para melhor controlá-lo e governá-lo, existe a liberdade de insurgir-se perante aquilo que intenta os assujeitar. Assim, o último momento de análise, intitulado estatuto de presença, baseia suas reflexões nesta possibilidade de transgressão, de transformação e de criação de outros modos de existência. Portanto, a experiência creep no ensino superior pode auxiliar na problematização de como está acontecendo os processos inclusivos hoje em voga, a maneira de se conduzir diante da existência, potencializando o viés de criação frente à toda forma de instrumentalização e de mercantilização impostas pela governamentalidade neoliberal This paper aims at analyzing the discourses made by undergraduate students with physical disabilities. This analysis will be conducted with Michael Foucault´s archeogenealogy. In this regard, the research goes through the many different historical perspectives about the abnormal subject in order to showcase the transformations and ruptures which took place within both the regimen of truth and the constitution of knowledge regarding abnormality throughout time. Semi structured interviews were performed with three students, with special focus to their experiences in the academic environment, exploring the challenges they lived, their relationships with professors and peers as well as their life trajectories. In a first moment of the analysis called historical perspective, a theory was created regarding the origin of the court jester during the Medieval Age and how anomalies were used for theatrical ends, transforming them in the beginning of capitalism into a variation of theater called freak shows. In the second half of the 20th Century, a process of medicalization and pathologizing of their condition befell the abnormal. The handicap models which came about afterwards allowed for the subjects to have access to rights and the possibility of inclusion into spaces which were otherwise denied to them. The second moment of analysis, called enunciative spiral, aims at analyzing the emergence of inclusive discourses at the present time, as well as the games of truths and materiality of such enunciations. In a horizon of neoliberal governmentality there is an impetus for inclusion. We live in a performance-based society, in which time is sped up. The massproducing of life, which makes men more and more business owners of themselves, gives way to the contemporary aberration known as the creep. He is immersed in the discourse of optimization of the being, being included in some spaces and excluded from others. In the third moment, called intentionality, it is possible to realize how the relations of power act over these people within an agonistic arena. At the same token in which the power relations aim at normalizing the creep via the impetus of inclusion to better control and govern them, there is freedom to rise against that which wants to subjugate us. Therefore, in the last moment of analysis, entitled statute of presence, there are insights based on the possibility of transgressing, transforming and creating other ways of existing. Therefore, the creep experience in higher education can aid in implementing the current inclusive processes, how we posture ourselves before existence, potentializing our creation bias in face of the instrumentalization and massproduction imposed onto us by the neoliberal governanmentality.

New generations incorporate technologies into their normal operations; however, this may not always positively impacts the learning environment. Faced with this phenomenon, the present research tries to verify if the possession, knowledge and use of technology are associated with the views and positive attitudes towards their instrumental use in academic spaces, and if there is any relationship with the users thinking styles; and with the positive attitudes and pointsof view on ICT for solving problems. This was anexploratory research, not an experimental one. On a sample of 94 students, two instruments were applied: Thinking Styles Inventory and some issues related to ICT. The results showed that technological tools are important and necessary to improve learning. It was noted that there is a favorable opinion towards ICT as a mean to facilitate and enhance learning, due to the relationship between technological equipment, use of tools, knowledge and attitude towards them. In general, positive judgments about the technological tools are associated with an attitude that promotes academic use. The value judgment that students have about ICT correlates significantly with the attitude they have about their use in solving problems. Although the thinking styles, they do not have connection with the ownership, using and knowledge of technological tools; it seems that regardless on the student's way of thinking; on the contrary, they manipulates the technological tools depending on the answer they can give to their needs. Ifthis relates to the students thinking and their predisposition towards technology, it is an interesting combination that teachers can use to generate instructional strategies to strengthen and consolidate the educational processes. RESUMEN Las nuevas generaciones incorporan tecnologias en su quehacer habitual; sin embargo, no siempre esto impacta positivamente el entorno pedagogico. Ante este fenomeno, la investigacion que se presenta intenta verificar si, de alguna manera, la tenencia, el conocimiento y el uso de la tecnologia se asocian con las opiniones y las actitudes positivas hacia su uso instrumental en espacios academicos, y si hay alguna relacion con los estilos de pensamiento de los usuarios; asi como, con las actitudes positivas y las opiniones sobre las TIC para la resolucion de problemas. Se trato de una investigacion exploratoria, no experimental. A una muestra de 94 estudiantes, se les aplicaron dos instrumentos: cuestionario sobre Estilos de Pensamiento y sobre aspectos relacionados con las TIC. Los resultados expresaron que, las herramientas tecnologicas son importantes y necesarias para optimizar el aprendizaje. Se observo que existe una opinion favorable hacia las TIC, como medio para facilitar y mejorar el aprendizaje, marcada por la relacion entre la tenencia de equipos tecnologicos, el uso de herramientas, su conocimiento y la actitud hacia las mismas. En general, los juicios positivos hacia las herramientas tecnologicas se asocian con una actitud que favorece su utilizacion academica. El juicio de valor que emiten los estudiantes sobre las TIC correlaciona significativamente con la actitud que tiene ellos en su uso en la resolucion de problemas. Aunque los estilos de pensamiento, no guardan relacion alguna con la tenencia, uso y conocimiento de las herramientas tecnologicas; pareciera que independientemente de la manera de pensar del estudiante, este manipula las herramientas tecnologicas en funcion de la respuesta que puedan dar a su necesidad. Si esto se relaciona con la manera de pensar de los estudiantes y su predisposicion hacia la tecnologia, resulta una combinacion interesante que el docente puede aprovechar para generar estrategias instruccionales que permitan fortalecer y consolidar los procesos educativos.

Neonates with critical heart disease are at risk of significant deficiencies in systemic oxygen delivery. The incidence and clinical pattern of hyperlactatemia in neonates presenting with critical heart disease has not been described. We reviewed the lactate pattern of neonates transferred to our cardiac intensive care unit for surgical management of their heart disease over a 1-year period. Stabilization of these neonates began in the referring institutions. From 8/4/03 to 8/4/04, 75 neonates with critical heart disease were transferred to our unit for stabilization and subsequent surgery. Blood lactate was measured on admission and subsequently in any patient thought to be at risk of low systemic oxygen delivery. Lactate was measured in 59 patients on admission and in 63 patients within the first 48 h of admission. Median age on admission was 1 day (range 0–13). Median age at surgery was 8 days (range 1–30). Median length of stay was 20 days. Peak lactate was noted on admission in 51 patients, and at 12–24 h in 8 patients. Mild hyperlactatemia (2.3–5 mmol/l) was present in 30 patients on admission and moderate-to-severe hyperlactatemia (≧5 mmol/l) was present in 8 patients. Mean lactate level on admission was 3.1 ± 0.6 mmol/l, and this did not return to normal (

Patients undergoing congenital heart surgery may occasionally require additional surgical procedures in the form of tracheostomy and gastrostomy. These procedures are often performed in an attempt to diminish hospital morbidity and length of stay. We reviewed the Web-based medical records of all patients undergoing congenital heart surgery at Miami Children’s Hospital from February 2002 through August 2007. Patients who were deemed preterm and had undergone closure of a patent ductus arteriosis were eliminated. The records of all other patients were queried for the terms gastrostomy, g-tube, Nissan, fundal plication, tracheostomy, or tracheotomy. Patients’ medical records in which these terms appeared in any portion were completely reviewed. There were 1660 congenital heart operations performed in the study period. There were 592 operations performed on patients whose age ranged from 1 month to 1 year and 441 neonatal operations. Mortality was 2%. Median postoperative stay was 8 days (range, 1–191 days), 12 days for neonates (range, 3–142 days), and 19 days for neonates undergoing RACHS-1 category 6 operations (range, 4–142 days). Tracheostomies were performed in four patients (0.2%). Gastrostomies were performed on eight patients (0.4%), representing 0.8% of patients

Mortality for the arterial switch operation (ASO) has diminished significantly over the past few decades. Some patients do, however, continue to have protracted and complicated courses after surgery. We attempted to determine which preoperative factors were best associated with prolonged hospital stay after ASO. We retrospectively reviewed all patients that underwent an ASO over a 10-year period. Outcomes of patients with postoperative stays (POS) >14 days (long stay group-LS) were compared with those patients with POS

We conducted a study with the objective of comparing the performance of two different systems for patient-triggered ventilation in neonates (impedance versus flow/volume-triggered) by measuring response time, autotrigger and trigger failure rates, ventilation, and gas exchange. The two ventilator systems were applied in random order in 10 preterm neonates (median gestational age: 30.5 wk; range: 27 to 34 wk; body weight: 1,266 g; range: 840 to 2,240 g) using identical ventilator settings. The median (range) response time was 169 (98 to 305) ms for the impedance system and 115 (79 to 184) ms for the flow/volume system (p < 0.01). The longer and more variable response time of the impedance system was secondary to a phase lag of the impedance signal caused by chest wall distortion. Although 13.1 (0.2 to 29.4)% of mechanical breaths were autotriggered with the impedance system, there were no autotriggered breaths using the flow/volume system (p < 0.01). The rate of trigger failures was not significantly different with the two systems, at 1.2 (0 to 4.4)% (impedance) versus 3.1 (0 to 6.4)% (flow/volume). Minute ventilation was smaller with the impedance system (p < 0.001), because of the larger number of breaths triggered late in inspiration or during expiration. We conclude that the flow/volume-triggered system is less prone to autotriggering and has a shorter and more consistent response time than the impedance-triggered system. The impedance-triggered system is more susceptible to artifacts and chest wall distortion.

We studied the effect of leaks around the endotracheal tube (ETT) on the measurement of pulmonary mechanics during mechanical ventilation. We also evaluated the influence of different ventilator settings on the magnitude of leak. An adjustable leak was created at the end of the ETT in a lung model with constant compliance. Flow, tidal volume, and pressure changes were measured above and below the leak. Compliance (Ci) and resistance (Ri) during inspiration were determined by linear regression analysis (LRA) using the equation of motion and the Mead and Wittenberger method (MWM). The ventilatory change that influenced the degree of leak most was prolongation of inspiratory time (Ti). The presence of a leak around the ETT resulted in an overestimation of the Ci and Ri values, which was proportional to the size of the leak. This overestimation was also influenced by the method used to determine Ci and Ri. Because the contribution of the leak to the fidal volume progressively increases as inspiration continued, methods of analysis that depended mainly on measurement points at the end of inspiration showed a larger deviation from the true Ci and Ri values than methods mainly influenced by measurement points at the beginning of inspiration. Because of this, shortening of inspiration, or analysis of points at the beginning of inspiration reduces the error in the measurements of Ci and Ri when a leak is present. Breaths with a large leak should be excluded from any analysis of pulmonary mechanics.

The following is a case report of a 1-month-old patient who developed adverse hemodynamic sequelae during the use of nitric oxide (NO) in the postoperative period for pulmonary hypertension after correction of total anomalous pulmonary venous return. At the time of diagnosis, the patient had evidence of systemic right ventricular pressures estimated by continuous-wave Doppler. He was sedated and paralyzed for hyperventilation in preparation for surgery and underwent pulmonary vein confluence to left atrial anastomosis. Postoperative pulmonary hypertension was managed by hyperventilation, sedation, and paralysis until a sudden onset of systemic-level pulmonary pressure required NO therapy. Satisfactory results were obtained in minutes, but a rebound pulmonary hypertension occurred with concomitant systemic hypertension and no radiographic changes. We suspected left atrial hypertension secondary to a sudden increase in pulmonary blood flow to an noncompliant left ventricle. Discontinuation of NO resulted in stabilization of the hemodynamic profile of the patient and he continued to be managed with paralysis, hyperventilation, and sedation. Based on this experience we suggest that NO should be used with caution in patients with obstructive lesions at the atrial level prior to surgery (mitral valve stenosis and cor triatriatum) or in patients with a poorly compliant left ventricle (cardiomyopathy and left ventricular dysfunction). These entities are unable to tolerate a sudden increase in pulmonary blood return thus creating paradoxical pulmonary hypertension.

OBJECTIVE Temporary pacing wires have been associated with serious postoperative complications. Recommendations for their routine use after open heart surgery are decades old, and may not reflect current surgical techniques and outcomes. METHODS The electronic web-enabled medical records of all patients undergoing congenital cardiac surgery from February, 2002, through December, 2005, were reviewed, excluding patients undergoing implantation of pacemakers as a primary procedure, or those undergoing ligation of a patent arterial duct. RESULTS There were 1193 surgical procedures performed, 1041 with cardiopulmonary bypass. Median age of the patients was 5.8 months, with a range from 0 days to 54 years, weighing 6.2 kilograms, with a range from 1 to 114 kilograms. Mortality prior to discharge was 2.5%, and median postoperative stay was 6 days. No deaths were attributed to arrhythmias. Temporary pacing wires were placed 14 times (1.2%). Indications for placement included sinus nodal dysfunction in 8 patients, preoperative in 4 and intraoperative in 4, high degree atrioventricular block in 4 patients, and intraoperative atrial flutter in 2 patients. Of these patients, 4 (0.3%) eventually underwent permanent implantation of a pacemaker, 2 for persistent sinus nodal dysfunction, and 2 for persistent atrioventricular block. Postoperative junctional ectopic tachycardia requiring antiarrhythmic therapy occurred in 9 patients (0.8%). All recovered without incident, and none were treated with temporary pacing. CONCLUSIONS The diminished risk of unexpected postoperative arrhythmias in the current era alleviates the necessity for routine placement of temporary pacing wires. Those institutions with experienced surgical and cardiac critical care teams may be able to predict the need for temporary pacing wires preoperatively or intraoperatively.

A goal-directed therapy algorithm based on serial lactate values obtained from a point-of-care testing device was utilized in an attempt to reduce the mortality of patients after congenital heart surgery. Prospective study of patients undergoing surgery utilizing a goal-directed therapy algorithm in the postoperative period. The results of this group are compared with a historical cohort. Operative risk was determined using the RACHS-1 scoring system. A 12-bed cardiac intensive care unit (ICU) in a pediatric hospital. Patients undergoing surgery from July 2001 through September 2003 (group B, n=710) were compared to cohorts from June 1995 through June 2001 (group A, n=1,656). Group B patients were smaller and younger (median weight 6.2 vs 8 kg, p

We continuously measured proximal and carinal pressures at low and high flow rates and frequencies during conventional mechanical ventilation (CMV) and intratracheal pulmonary ventilation (ITPV), using an artificial lung. The proximal peak inspiratory pressure (PIP), carinal PIP, proximal positive end expiratory pressure (PEEP), and carinal PEEP, or negative end expiratory pressure (NEEP), were measured during simulated CMV and ITPV. Two levels of frequency (30 and 90 per min) and two gas flow rates (3 and 6 L/min) were examined, in both dry and humid states (four combinations of gas flow and frequency at each state). The gas flow and inspiratory time were held constant throughout the CMV and ITPV trials. Humidification of the ventilatory circuit during ITPV prevented the accurate measurement of carinal pressures. This problem was solved by introducing a continuous "bias flow" of 11 ml/min into the pressure monitoring line. A combination of low gas flow and low frequency with CMV showed no significant differences between the proximal and carinal PIP, as well as the proximal and carinal PEEP. The same combination with ITPV, however, resulted in a significantly lower carinal PIP and PEEP, compared to proximal PIP and PEEP. Carinal PIP and PEEP during ITPV were also significantly lower than those observed during CMV with a low flow and low frequency rates. During both CMV and ITPV, using a combination of a high flow rate with a high breathing frequency, carinal PIPs were significantly lower than proximal PIPs. ITPV, however, generated much larger differences between proximal and carinal PIPs than the CMV. A significant NEEP was generated at the carinal level during ITPV with high flow rates, both with high and low frequencies. The NEEP did not occur with a low gas flow, in combination with either a low frequency or a high frequency. The "bias flow" had no significant effect on carinal pressures. In conclusion, ITPV, compared with CMV, generates a significantly lower carinal PIP, but it may also generate carinal NEEP. For safety reasons, therefore, it is essential to monitor carinal pressures continuously in patients treated with ITPV.

To ascertain possible mechanisms implicated in the development of transient episodes of hypoxemia (oxygen saturation85%) frequently observed in preterm infants undergoing mechanical ventilation, even after the acute phase of respiratory failure has passed.Tidal flow, airway and esophageal pressure, and oxygen saturation were continuously recorded in 10 infants (mean +/- SD, birth weight 733 +/- 149 gm, gestational age 25.5 +/- 2.2 weeks, age 26.3 +/- 11.9 days) who had repeated episodes of hypoxemia without any evident cause. Measurements of minute ventilation (VE) inspiratory compliance (Ci), and inspiratory resistance (Ri) were compared before and during episodes of hypoxemia.All episodes of hypoxemia were preceded by an active exhalation that produced a mean decrease in end-expiratory lung volume of 6.4 +/- 2.8 ml/kg. The reduction in lung volume was immediately followed by a sudden decrease in tidal flow and volume, despite continuation of mechanical ventilation at the same rate and peak pressure. The resulting hypoventilation was associated with a drop in Ci to approximately one half and an increase in Ri to more than double the baseline values. Approximately 30 seconds after the beginning of hypoventilation, the arterial oxygen saturation reached a hypoxemic level (oxygen saturation85%)Most hypoxemic episodes were triggered by an expiratory effort that produced a large decrease in lung volume. This reduction in lung volume probably leads to closure of small airways and the development of intrapulmonary shunts, which would explain the rapid development of hypoxemia.

Introduction: Accurate measurement of airway pressures (Paw) are crucial during mechanical ventilation. Intratracheal pulmonary ventilation(ITPV) utilizes a reverse thruster device to deliver a continuous flow of gas at the level of the carina, thereby generating a different carinal Paw than conventional ventilation (CV). This study compares the proximal and carinal Paw during CV and ITPV, in both an artificial lung an in a rabbit model.

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV) is a rare, neonatally lethal developmental disorder of the lung with defining histologic abnormalities typically associated with multiple congenital anomalies (MCA). Using array CGH analysis, we have identified six overlapping microdeletions encompassing the FOX transcription factor gene cluster in chromosome 16q24.1q24.2 in patients with ACD/MPV and MCA. Subsequently, we have identified four different heterozygous mutations (frameshift, nonsense, and no-stop) in the candidate FOXF1 gene in unrelated patients with sporadic ACD/MPV and MCA. Custom-designed, high-resolution microarray analysis of additional ACD/MPV samples revealed one microdeletion harboring FOXF1 and two distinct microdeletions upstream of FOXF1, implicating a position effect. DNA sequence analysis revealed that in six of nine deletions, both breakpoints occurred in the portions of Alu elements showing eight to 43 base pairs of perfect microhomology, suggesting replication error Microhomology-Mediated Break-Induced Replication (MMBIR)/Fork Stalling and Template Switching (FoSTeS) as a mechanism of their formation. In contrast to the association of point mutations in FOXF1 with bowel malrotation, microdeletions of FOXF1 were associated with hypoplastic left heart syndrome and gastrointestinal atresias, probably due to haploinsufficiency for the neighboring FOXC2 and FOXL1 genes. These differences reveal the phenotypic consequences of gene alterations in cis.