Orientadores: Lucia Helena Simões da Costa Paiva, Luis Otavio Zanatta Sarian / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-11-09T15:59:32Z (GMT). No. of bitstreams: 1 Pinheiro_RosilenedeLima_M.pdf: 979982 bytes, checksum: d2884ebad26e9df7e5560eea68502e27 (MD5) Previous issue date: 2008 / Resumo: Objetivo: Avaliar a relação entre parâmetros corporais usados para definir obesidade central, circunferência da cintura (CC) e relação cintura quadril (RCQ), e a expressão de receptores esteróides em mulheres com carcinoma de mama na pré e pós-menopausa. Métodos: Realizado um estudo seccional com 473 mulheres com doença maligna da mama, estadiamento I a III, tratadas no Instituto Nacional de Câncer, Brasil, em 2004. Dados epidemiológicos e clínicos foram obtidos. Os parâmetros antropométricos usados para definir obesidade foram obtidos na visita de admissão, antes do procedimento cirúrgico, com técnicas recomendadas pela Organização Mundial de Saúde: peso (Kg), altura (cm), circunferência da cintura (cm), Índice de massa corporal (IMC, peso/(altura2)) e relação cintura quadril. A expressão de receptores para estrogênio (RE) e progesterona (RP) foi determinada por imunohistoquimica. O estudo foi aprovado pelo Comitê de Ética da Instituição. Comparações de freqüências foram analisadas através do teste exato de Fisher. Razão de prevalência (PrevR) foi calculada para avaliar as diferenças nas prevalências de RH com as categorias para IMC, CC e RCQ. Resultados: A maior parte das mulheres apresentava sobrepeso (68,9%) e obesidade central (CC > 88cm e RCQ > 0,85 em 64,3% e 73,4%, respectivamente). A maioria (54,1%) apresentou tumores com expressão para RE e RP, sendo 78,6% expressando, pelo menos, um dos RH. Existiu uma proporção significantemente maior de tumores RE+/RP+ em mulheres na pósmenopausa (p<0,001). BMI (p=0,12), WC (p=0,07) e RCQ (p=0,55) não foram relacionados à expressão de RH em mulheres na pré-menopausa. Em mulheres na pós-menopausa, BMI (p=0,30), WC (p=0,35) e RCQ (p=1,00) também não foram relacionados à expressão de RH. Conclusão: O presente estudo reforça o conceito de que a expressão dos receptores hormonais para tumores mamários é dependente do estado menopausal. CC e RCQ podem não ser bons preditores de expressão de RH em doenças malignas da mama para mulheres na pré e pósmenopausa. Palavras-chave: câncer de mama, obesidade, receptor hormonal, circunferência da cintura / Abstract: Objective: to evaluate the relation between body parameters used to define central obesity -waist circumference (WC) and waist to hip ratio (WRH)- and steroid receptor status in breast carcinomas of pre- and postmenopausal women. Subjects and methods: This is a cross-sectional study on 473 women with breast malignancies stage I-III, treated at the National Cancer Institute, Brazil, in 2004. Clinical and epidemiological data were obtained. The anthropometrics used to define obesity were obtained at the admission visit, before the surgical procedure, with the techniques recommended by the World Health Organization: weight (Kg), height (cm), the waist and hip circumferences (cm), body mass index (BMI, weight/(height^2)), and the waist to hip ratio. The expression of estrogen (ER) and progesterone (RP) receptors were determined with imunohistochemistry. The institutons¿ ethics review board has approved the study. Frequency comparisons were analyzed with Fisher¿s exact tests. Prevalence ratios (PrevR) were calculated to assess the differences in prevalence for HR within the categories for BMI, WC and WHR. Results: Most women were overweight or obese (68.9%), and had central obesity (WC>=88 and WHR>=0.85 in 64.3 and 73.4%, respectively). The majority (54.1%) of the women had tumors that expressed ER and PR, being that 78.6% of the sample expressed at least one of the HR. There was a significantly higher proportion of positive RE+/RP+ tumors in postmenopausal women (p < 0.001). BMI (p=0.12), WC (p=0.07) and WHP (p=0.55) were not related to the HR status in premenopausal women. In postmenopausal women, BMI (p=0.30), WC (p=0.35) and WHP (p=1.00) were also not related to the HR status. Conclusions: The present study reinforces the concept that the HR status of breast tumors is dependent upon the menopausal status. WC or WHR may not be good predictors of HR status in breast malignancies of pre- and postmenopausal women. Keywords: breast cancer, obesity, hormonal receptor, waist circumference / Mestrado / Ciencias Biomedicas / Mestre em Tocoginecologia

Made available in DSpace on 2014-06-11T19:29:33Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-08-31Bitstream added on 2014-06-13T20:19:26Z : No. of bitstreams: 1 caliani_kgms_me_botfm.pdf: 186347 bytes, checksum: c2dbdf526030ad8a050af11011a8beb6 (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / A obesidade é considerada um grave problema da Saúde Pública mundial, apresentando prevalência crescente nas últimas décadas em diversas populações. Entretanto, a concentração da gordura corporal na região abdominal tem se mostrado mais fortemente associada com riscos metabólicos e cardiovasculares e com uma variedade de doenças crônicas. Objetivo: Identificar os fatores socioeconômicos e comportamentais associados à adiposidade abdominal de adultos. Metodologia: foram aplicados: questionário para avaliar as condições socioeconômicas e demográficas, Recordatório de 24 horas para obtenção do consumo alimentar, questionário de atividade física cotidiana (IPAQ, versão 8, forma longa) e realizada avaliação da composição corporal através de peso, estatura, circunferência abdominal e impedância bioelétrica. Resultados: Foram avaliados 1455 indivíduos, sendo 74,0% do sexo feminino e 73,5% com idade inferior a 60 anos. A maioria referiu ser solteiro/viúvo/divorciado (62,2%), apresentar renda familiar de até seis salários-mínimos (62,0%) e ser analfabeto ou possuir Ensino Fundamental incompleto ou completo (62,2%). Apresentaram alta prevalência de excesso de peso e obesidade (77,7%), circunferência abdominal aumentada (60,5%), e alimentação inadequada (93,4%). A hiperadiposidade abdominal apresentou associação com excesso de peso, renda e estado civil, sendo a baixa renda fator preditor e estado civil solteiro/viúvo/divorciado fator protetor. Conclusão: Na população estudada foi encontrada alta prevalência de excesso de peso, circunferência abdominal aumentada e alimentação de baixa qualidade. Portanto, é essencial a adoção de ações que visem a mudança do estilo de vida com o objetivo de prevenir o aparecimento ou agravamento de doenças crônicas nessa população. / The obesity is considered a serious problem in the Public Health sector world widely, and it has been increasing in several populations over the last decades. However, the adipose tissue concentration around the abdominal area has been strongly associated with metabolic and cardiovascular risks and a great number of chronic diseases. Objective: To identify the socioeconomic and behavioral factors related to the abdominal adiposity in adults. Method: a questionnaire was used to evaluate the socioeconomic and demographic conditions, a 24-hour recall was done to obtain information about their dietary habits, a questionnaire about the routine physical activity was applied (IPAQ 8, long form), and an evaluation of the weight, height, abdominal size, bioelectrical impedance was done to check the body composition. Results: a study was conducted among 1455 people, 74,0% females and 73,5% under 60 years old. Most of whom said they were single/widow/divorced (62,2%), with a familiar income up to six basic salary (62,0%), and were illiterate or had or hadn’t graduated from elementary school (62,2%). 77,7% presented a great predominance of overweight and obesity, 60,5% had an increased abdominal circumference and 93,4% had an inadequate dietary. The abdominal hyper adiposity presented to be associated with overweight, income and marital status, since the low income was the predictor and the marital status (single/widow/divorced) was the protector factor. Conclusion: Among the studied population, a high predominance of overweight, increased abdominal circumference and low quality dietary was found. Therefore, it is essential to adopt actions which can change these people’s life style as a way to prevent chronic diseases.

Made available in DSpace on 2015-07-15T13:31:40Z (GMT). No. of bitstreams: 1 Rogerio Tosta.pdf: 1407696 bytes, checksum: 05707143133f12bb9926534f77e3561d (MD5) Previous issue date: 2008-02-27 / The corporal fat located one in the abdominal region seems to be bigger predictor of higher risks to human health comparing with the generalized fat, consisting in a great problem of public health, with high financial and social costs. The Abdominal Obesity (AO) in the Brazilian female population has increase in the last few decades. The objectives of this study had been to evaluate the performance of the cut-off point the anthropometrics indices of AO Conicity Index (CIN), Waist Circumference (WC), Waist-to-Hip Ratio (WHR) and Waist-to-height (WTH) - to discriminate Coronary High Risk (CHR) in workers of an University and esteem the prevalence of AO and its relation with socio-demographic, occupational and lifestyle factors. It s about a study of cross-sectional in Feira de Santana-BA-Brazil with 461 technician-administrative and general services workers women of an University with age enters 20-69 years. The analysis of the cut-off points the anthropometrics indices was made through curves ROC. Values of sensitivity and specificity had been verified to identify and to compare the best cut-off points to discriminate CHR, calculated on the basis of Score of Framingham (SF). The prevalence as measured of occurrence was adopted. The Hazard Ratio had been used to evaluate the associations between the variables. The cut-off points and the joined prevalence had been: WC (86 cm / 37.3%), WHR (0,87 / 28.9%), CIN (1,25 / 32.3%) and WTH (0,55 / 29.1%), being, respectively, the areas under curve ROC of 0,70 (IC95% = 0,63-0,77), 0,74 (IC95% = 0,67-0,81), 0,76 (IC95% = 0,70-0,83) and 0,74 (IC95% = 0,67-0,81). CIN was the pointer that presented optimum to be able discriminatory, followed for the WHR and the WHT and, finally for the WC. Association met positive and with significance statistics it enters all the indicators of AO and greater age, greater number of children, minor schooling, greater service time, tobaccoism (smoking and former-smokers) and greater sugar consumption. The consumption of bovine meat also was associated with the AO, not being significant statistical, only for CIN. The civil status (married/free union) was positively associated with the AO from all indicators, however presented association statistics only through the WHT. The abdominal one expects especially that these results can contribute for the briefing of the phenomenon of the obesity in the Brazilian female population, supplying information so that the health professionals act in the prevention of this multifactorial clinical condition preventing the appearance of the cardiovascular illnesses. / A gordura corporal localizada na regi?o abdominal tem sido apontada como preditora mais relevante de riscos elevados ? sa?de do que a gordura generalizada, constituindo-se grande problema de sa?de p?blica, com alto custo financeiro e social. A obesidade abdominal (OABD) na popula??o feminina brasileira tem aumentado nas ?ltimas d?cadas. Os objetivos deste estudo foram avaliar o desempenho de diferentes pontos de corte dos indicadores antropom?tricos de OABD ?ndice de Conicidade (?ndice C), Circunfer?ncia de Cintura (CC), Raz?o Cintura-Quadril (RCQ) e Raz?o Cintura/Estatura (RCEst) para discriminar Risco Coronariano Elevado (RCE) em funcion?rias de uma Institui??o de Ensino Superior (IES) e estimar a preval?ncia de OABD e sua rela??o com vari?veis sociodemogr?ficas, ocupacionais e comportamentais. Trata-se de um estudo de corte transversal realizado em Feira de Santana-BA-Brasil com 461 funcion?rias t?cnico- administrativas e de servi?os gerais de uma IES com idade entre 20-69 anos. A an?lise dos pontos de corte dos indicadores antropom?tricos foi feita atrav?s das curvas ROC. A sensibilidade e a especificidade foram estimadas para identificar e comparar os melhores pontos de corte para discriminar RCE, calculado com base no Escore de Risco de Framingham (ERF). Foi adotada a preval?ncia como medida de ocorr?ncia. A raz?o de preval?ncia foi utilizada para avaliar as associa??es entre as vari?veis. Os pontos de corte e as preval?ncias encontradas foram: CC (86 cm / 37,3%), RCQ (0,87 / 28,9%), ?ndice C (1,25 / 32,3%) e RCEst (0,55 / 29,1%), sendo, respectivamente, as ?reas sob a curva ROC de 0,70 (IC95% = 0,63-0,77), 0,74 (IC95% = 0,67-0,81), 0,76 (IC95% = 0,70-0,83) e 0,74 (IC95% = 0,67-0,81). O ?ndice C foi o indicador que apresentou o melhor poder discriminat?rio, seguido pela RCQ e pela RCEst e, por fim pela CC. Encontrou-se associa??o positiva e com signific?ncia estat?stica entre todos os indicadores de OABD e maior idade, maior n?mero de filhos, menor escolaridade, maior tempo de servi?o, tabagismo (fumantes e exfumantes) e maior consumo de a??car. O consumo de carne bovina tamb?m esteve associado com a OABD, n?o sendo significante estatisticamente, apenas pelo ?ndice C. A situa??o conjugal (casada/uni?o est?vel) foi positivamente associada ? OABD a partir de todos indicadores, entretanto apresentou associa??o estat?stica somente atrav?s da RCEst. Espera-se que estes resultados possam contribuir para a elucida??o do fen?meno da obesidade, especialmente a abdominal, na popula??o feminina brasileira, fornecendo informa??es para que os profissionais de sa?de atuem na preven??o dessa condi??o cl?nica multifatorial evitando o aparecimento das doen?as cardiovasculares.

Orientador: Roberto Carlos Burini / Banca: Luis Carlos Giarola / Banca: Nailza Maestá / Resumo: A obesidade é considerada um grave problema da Saúde Pública mundial, apresentando prevalência crescente nas últimas décadas em diversas populações. Entretanto, a concentração da gordura corporal na região abdominal tem se mostrado mais fortemente associada com riscos metabólicos e cardiovasculares e com uma variedade de doenças crônicas. Objetivo: Identificar os fatores socioeconômicos e comportamentais associados à adiposidade abdominal de adultos. Metodologia: foram aplicados: questionário para avaliar as condições socioeconômicas e demográficas, Recordatório de 24 horas para obtenção do consumo alimentar, questionário de atividade física cotidiana (IPAQ, versão 8, forma longa) e realizada avaliação da composição corporal através de peso, estatura, circunferência abdominal e impedância bioelétrica. Resultados: Foram avaliados 1455 indivíduos, sendo 74,0% do sexo feminino e 73,5% com idade inferior a 60 anos. A maioria referiu ser solteiro/viúvo/divorciado (62,2%), apresentar renda familiar de até seis salários-mínimos (62,0%) e ser analfabeto ou possuir Ensino Fundamental incompleto ou completo (62,2%). Apresentaram alta prevalência de excesso de peso e obesidade (77,7%), circunferência abdominal aumentada (60,5%), e alimentação inadequada (93,4%). A hiperadiposidade abdominal apresentou associação com excesso de peso, renda e estado civil, sendo a baixa renda fator preditor e estado civil solteiro/viúvo/divorciado fator protetor. Conclusão: Na população estudada foi encontrada alta prevalência de excesso de peso, circunferência abdominal aumentada e alimentação de baixa qualidade. Portanto, é essencial a adoção de ações que visem a mudança do estilo de vida com o objetivo de prevenir o aparecimento ou agravamento de doenças crônicas nessa população. / Abstract: The obesity is considered a serious problem in the Public Health sector world widely, and it has been increasing in several populations over the last decades. However, the adipose tissue concentration around the abdominal area has been strongly associated with metabolic and cardiovascular risks and a great number of chronic diseases. Objective: To identify the socioeconomic and behavioral factors related to the abdominal adiposity in adults. Method: a questionnaire was used to evaluate the socioeconomic and demographic conditions, a 24-hour recall was done to obtain information about their dietary habits, a questionnaire about the routine physical activity was applied (IPAQ 8, long form), and an evaluation of the weight, height, abdominal size, bioelectrical impedance was done to check the body composition. Results: a study was conducted among 1455 people, 74,0% females and 73,5% under 60 years old. Most of whom said they were single/widow/divorced (62,2%), with a familiar income up to six basic salary (62,0%), and were illiterate or had or hadn't graduated from elementary school (62,2%). 77,7% presented a great predominance of overweight and obesity, 60,5% had an increased abdominal circumference and 93,4% had an inadequate dietary. The abdominal hyper adiposity presented to be associated with overweight, income and marital status, since the low income was the predictor and the marital status (single/widow/divorced) was the protector factor. Conclusion: Among the studied population, a high predominance of overweight, increased abdominal circumference and low quality dietary was found. Therefore, it is essential to adopt actions which can change these people's life style as a way to prevent chronic diseases. / Mestre

Submitted by Fabio Sobreira Campos da Costa (fabio.sobreira@ufpe.br) on 2016-08-05T13:04:39Z No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) Tese_Final_versão_biblioteca (2).pdf: 8187833 bytes, checksum: e76d125aa3b04c57265a2a3a15aca042 (MD5) / Made available in DSpace on 2016-08-05T13:04:39Z (GMT). No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) Tese_Final_versão_biblioteca (2).pdf: 8187833 bytes, checksum: e76d125aa3b04c57265a2a3a15aca042 (MD5) Previous issue date: 2016-02-24 / Introdução: Os tecidos adiposos subcutâneo (TAS) e, sobretudo, o visceral (TAV), quando em excesso, predizem riscos cardiometabólicos. Os métodos de quantificação do TAV e do TAS têm uso limitado na prática clínica sendo necessário identificar um marcador de alta validade para estimar a adiposidade visceral, que seja simples e de baixo custo. A circunferência abdominal (CA) é uma medida comumente empregada como proxy do TAV. No entanto, existe uma grande variação de protocolos para sua obtenção, comprometendo seu uso e comparação de resultados. Objetivos: Estimar a concentração de TAV e TAS e os fatores associados; estimar o grau de variabilidade da CA em diferentes sítios anatômicos e comparar a performance dos locais de medição como preditores de TAV, TAS e anormalidades cardiometabólicas; desenvolver um modelo preditivo para estimar o volume de TAV, a partir de idade e parâmetros antropométricos factíveis de serem utilizados na prática clínica; avaliar o efeito da perda de peso no TAV e TAS, e os efeitos da redução do TAV no perfil cardiometabólico. Métodos: Foram desenvolvidos dois delineamentos: um corte transversal para avaliar os fatores associados à concentração de TAV e TAS e aspectos metodológicos na estimativa do TAV; e uma intervenção clínica para verificar o efeito da restrição calórica no TAV, após um período de 3 meses, envolvendo adultos com excesso de peso, atendidos em hospital no Nordeste brasileiro. O TAV e TAS foram quantificados por tomografia computadorizada. A CA foi avaliada em seis sítios de medição. Outros parâmetros antropométricos avaliados foram: Índice de Massa Corpórea (IMC), Razão Cintura Quadril, Razão Cintura-Estatura, Diâmetro Sagital, Índice Sagital, Índice de Conicidade, Circunferência do Pescoço, Razão Pescoço-Coxa, Razão Cintura-Coxa e Índice de Adiposidade Corporal. Resultados: O estudo transversal envolveu 109 pacientes (50,3±12,2anos). Os homens apresentaram maior concentração de TAV. Presença de hipertensão arterial (HA), maior IMC e menor consumo de alimentos protetores associaram-se à maior concentração de TAV em homens (R²ajustado=46,4%); maior idade, presença de HA, maior IMC e consumo de álcool foram associadas ao TAV em mulheres (R2ajustado=17,6%). Houve maior variabilidade nos valores de CA no sexo feminino. A cintura mínima apresentou maior correlação com o TAV (r=0,70) em homens. Entre as mulheres, as medidas da CA apresentaram maior correlação com o TAS. A equação preditiva para os homens apresentou maior poder preditivo (64,1%), que o modelo desenvolvido para as mulheres (40,4%). Dos 51 pacientes submetidos à intervenção dietética, houve uma redução ponderal de 5,8(±6,2)% nos homens, com redução de 11,2(±7,9)% de TAV; 6,8(±11,2)% de TAS e 54,9% nos triglicérides. Entre as mulheres, a redução de 4,1(±2,5)% do peso inicial, resultou em uma diminuição de 11,1(±8,8)% de TAV; 5,6(±7,4)% de TAS, 12,2% no colesterol e 31,4% nos triglicérides. Conclusão: Múltiplos fatores determinam o volume de TAV e TAS em homens e mulheres. Maior variabilidade entre os sítios de medição de CA foi observada no sexo feminino. Nos homens, a cintura mínima apresentou melhor poder preditivo do TAV. Uma perda ponderal de aproximadamente 5% promoveu uma mobilização substancial de TAV e TAS, com potenciais benefícios cardiometabólicos. / Introduction: When in excess, subcutaneous adipose tissue (SAT), and, remarkably, visceral adipose tissue (VAT) predict cardiometabolic risks. Quantification methods of SAT, and VAT have limited use in clinical practice, and the identification of a simple, low cost, high value marker, to estimate visceral fat, is nedeed. Abdominal cirumference (AC) is a common method used as VAT‟s proxy. However, there‟s a great protocol variation for its execution, wich jeorpadizes its use, and the results‟ comparison. Objectives: To estimate concentration of VAT and SAT , and associated factors; to estimate variability of AC in different anatomical regions, and compare measurament sites performance as predictors of SAT, VAT, and cardiometabolic anormalities; to develop a predective model to estimate volume of VAT from athropometric criteria easily applied in clinical practice; to evaluate weight loss effect on VAT, and SAT, and also VAT reduction effects on cardiometabolic profile. Method: Two designs were developed: a cross-sectional study to analyse associated factors to SAT and VAT concentration, and methodological aspects of VAT valuation; a clinical intervention to verify the result of calorie restriction on VAT after 3 months, involving overweight adults assisted in a northeastern Brazilian hospital. VAT and SAT were quantified by computerized tomography. AC was measured in six different sites. Other anthropometric parameters evaluated were: Body Mass Index (BMI), Waist-Hip Ratio, Waist-Height Ratio, Sagittal Diameter, Sagittal Index, Conicity Index, Neck Circumference, Neck-Thigh Ratio, Waist-Thigh Ratio, Body Adiposity Index. Results: The transversal study involved 109 patients (50,3±12,2years). Higher concentration of VAT was found in males. Arterial Hypertension (AH), higher BMI , and lower ingestion of protective food were associated with higher concentration of VAT in men (R²adjusted=46.4%); older age, AH, higher BMI e alcohol consumption were associated to VAT in women (R2adjusted=17.6%). Greater variability on AC values was found in females. Minimal waist size showed greater correlation with VAT (r=0,70) in males. Among women, AC measures demonstrated greater correlation with SAT. Predictive equation for men exposed higher predictive power (64.1%) than the model developed for women (40.4%). There was a weight loss of 5.8(±6.2)% in males from the 51 patientes submitted to intervention on diet, a reduction of VAT of 11.2(±7.9)%; 6.8(±11.2)% of SAT, and 54.9% of triglycerides. Among females, reduction of 4.1(±2.5)% from the initial weight resulted in a decrease of 11.1(±8.8)% of VAT; 5.6(±7.4)% of SAT, 12.2% of choleterol, and 31,4% of triglycerides. Conclusion: Multiple factors determine volume of VAT and SAT in men and women. Greater variability of measurement sites were observed in females. Among men, minimal waist determined better predictive power of VAT. A 5% loss of weight promoted a significant mobilization of SAT and VAT, with potential cardiometabolic benefits.

Objetivo: Comparar o desempenho de diferentes curvas de referência de crescimento fetal em gestações gemelares com insuficiência placentária grave. Método: Estudo retrospectivo envolvendo gestações gemelares (n=47), com fluxo diastólico zero ou reverso, no estudo dopplervelocimétrico da artéria umbilical de um dos fetos, e ambos os fetos vivos no momento do diagnóstico. Não foram incluídas gestações com anomalia fetal \"major\", síndrome de transfusão feto-fetal, ou de ordem maior. Em ambos os fetos (acometido, FA; e cogemelar, CG), as estimativas de peso fetal foram convertidas em escore zeta de acordo com os critérios de Hadlock, Liao e Araújo. As medidas de circunferência abdominal foram convertidas de acordo com as curvas de Hadlock, Liao, Araújo, Ong e STORK. A análise estatística foi realizada segundo modelos de equações de estimação generalizada. Resultados: A idade materna média foi 27,8 ± 7,4 anos, 24 (51%) pacientes eram primigestas, 12 (25,5%) apresentavam antecedentes clínicos significativos e 61,7% (n=29) eram monocoriônicas. A idade gestacional média no momento do diagnóstico da diástole zero ou reversa foi de 27,4 ± 4,7 semanas. A idade gestacional média do parto foi de 32,9 ± 2,9 semanas e o peso médio ao nascimento dos fetos acometidos foi de 1075 ± 469 g, e dos cogemelares, 1749 ± 544 g. No modelo investigado, foram preditores significativos do escore-zeta: sexo fetal (p < 0,001) e a interação sub-grupo (feto acometido/cogemelar) e critério (p < 0,001). As estimativas do escore zeta médio (erro padrão) para o peso fetal estimado segundo cada critério examinado foram Hadlock FA: -2.98 (0,18), CG: -1,16 (0,15), Liao FA: -2,89 (0,24), CG: -0,58 (0,19), Araújo FA: -3,05 (0,29), CG: - 0,75 (0,18). Para circunferência abdominal, Hadlock FA: -3,14 (0,26), CG: - 1,13 (0,19), Liao FA: -2,63 (0,27), CG: -0,42 (0,19), Araújo FA: -2,44 (0,22), CG: -0,71 (0,14), Ong FA: -3,36 (0,34), CG: -1,48 (0,23) e STORK FA: -2,36 (0,14), CG: -1,18 (0,10). Conclusão: Em gestações gemelares, com diástole zero ou reversa em um dos fetos, as curvas que melhor diferenciaram os fetos acometidos de seus cogemelares foram as curvas nacionais, publicadas por Liao et al. e Araújo et al / Objectives: To compare the performance of different fetal growth reference curves in twin pregnancies with severe placental insufficiency. Methods: Retrospective analysis of 47 twin pregnancies with absent or reverse end diastolic flow in the umbilical artery in one fetus, and both twins alive at diagnosis. Pregnancies with major fetal abnormality, twin-twin transfusion and higher order were not included. At each ultrasound evaluation, estimated fetal weight zeta-scores were calculated for both fetuses (abnormal Doppler, AD; co-twin, CT) according to the following criteria: Hadlock, Liao and Araújo. Abdominal circumference zeta-scores were calculated according to Hadlock, Liao, Araújo, Ong and STORK. Statistical analysis was performed with generalized estimating equation regression. Results: Mean maternal age was 27.8 ± 7.4 years, 24 (51%) women were primigravida, 12 (25.5%) had a previous clinical history and 29 (61.7%) were monochorionic. Gestational age at abnormal Doppler diagnosis was 27.4 ± 4.7 weeks. Gestational age at delivery was 32.9 ± 2.9 weeks and mean birthweight was 1075 ± 469 g for AD twin, and 1749 ± 544 g in CT group. Zeta-score values were significantly related to fetal sex (p < 0.001) and subgroup (abnormal Doppler/co-twin) versus criteria interaction (p < 0.001). Estimated fetal weight mean zeta-score (standard error) according to each criteria were: Hadlock AD: -2.98 (0.18), CT: -1.16 (0.15), Liao AD: -2.89 (0.24), CT: -0.58 (0.19), Araújo AD: -3.05 (0.29), CT: -0.75 (0.18). Values for abdominal circumference were: Hadlock AD: -3.14 (0.26), CT: -1.13 (0.19), Liao AD: -2.63 (0.27), CT: -0.42 (0.19), Araújo AD: -2.44 (0.22), CT: -0.71 (0.14), Ong AD: -3.36 (0.34), CT: -1.48 (0.23) and STORK AD: -2.36 (0.14), CT: -1.18 (0.10). Conclusion: In twin pregnancies with absent or reversed end diastolic flow in the umbilical artery of one fetus, affected fetuses and their co-twins are best differentiated by Liao et al. and Araújo et al. reference ranges

Gestationdiabetes (GDM) ist eine der häufigsten Schwangerschaftserkrankungen mit einer Inzidenz von 3-10% je nach untersuchter Population. GDM ist definiert als eine erstmals in der Schwangerschaft diagnostizierte Glukosetoleranzstörung. Die kindlichen Komplikationen resultieren aus der maternalen Hyperglykämie , die zu erhöhten fetalen Blutglukosespiegeln und reaktivem fetalen Hyperinsulinismus führt. Der fetale Hyperinsulinsmus gilt als Ursache für die typische Diabetes assoziierte fetale und neonatale Morbidität, wie Makrosomie, verzögerte Lungenreife, Totgeburten, neonataler Hypoglykämie und nicht zu vergessen, einem lebenslang erhöhten Risiko für Diabetes. Die Behandlung des GDM konzentriert sich auf eine strenge Stoffwechselkontrolle zur Vermeidung von maternaler Hyperglykämie. Dies erfordert Diät und intensive Blutzuckerselbstkontrolle bei allen und zusätzliche Insulintherapie bei 30% der Schwangeren. Trotz dieser Intervention ist die Rate an neonatalen Komplikationen weiterhin erhöht. Das primäre Ziel der in der vorgelegten Habilitationsschrift zusammengefassten Studien war, zu bestimmen, in welchem Ausmaß die maternalen Glukosewerte in Schwangerschaften , die nach dem Standardmanagement behandelt wurden, prädiktiv sind für kindliche Morbidität sowohl in der frühen als auch im späteren Verlauf der Schwangerschaft. In einem zweiten Schritt wollten wir untersuchten, ob die Einbeziehung des fetalen Wachstums das Outcome verbessert und als Mittel zu antenatalen Risikoabschätzung hilfreich ist. Wir fanden eine ausgezeichnete Korrelation zwischen dem Grad der maternalen Hyperglykämie und der Morbidität in der Frühschwangerschaft. Die Höhe der Nüchternglukosewerte zum Zeitpunkt der Diagnose war der stärkste Prädiktor für kongenitale Fehlbildungen in einer großen Kohorte von 3700 Frauen. Dahingegen waren weder die diagnostischen Kriterien für GDM noch die Werte der mütterlichen Blutzuckertagesprofile prädiktiv für Morbidität in späteren Verlauf der Schwangerschaft. Entgegen der Übereinkunft, dass die Diagnose GDM mindestens zwei pathologische Werte in einem oralen Glukosetoleranztest erfordert, fanden wir bereits bei einem pathologischen Wert eine erhöhte Rate an fetalem Hyperinsulinismus, Makrosomie und neonataler Hyperglykämie. Im Gegensatz dazu war das Vorliegen einer maternalen Adipositas eng mit der Entstehung einer fetalen Makrosomie assoziiert. Wir wählten den fetalen Abdominalumfang (AU) als Mass für Makrosomie, da sich dieser als hervorragender Prädiktor für die Entstehung einer Diabetes assoziierten Maskrosomie erwiess. Zudem sahen wir eine gute Korrelation der fetalen Insulinspiegel, indirekt bestimmt über das Insulin im Fruchtwasser , und dem fetalen AU. Nach unseren Daten, schließt ein AU < 75. Perzentile das Vorliegen eines gravierenden Hyperinsulinismus aus. Basierend auf dieser Erkenntnis führten wir drei Interventionsstudien durch, bei denen die Indikation für Insulintherapie bei Schwangeren mit GDM primär nach dem fetalen AU gestellt wurde. Wir konnten zeigen, dass dieser Therapieansatz, der Insulintherapie auf Frauen mit Risiko für neonatale Morbidität , definiert als AU > 75. Perzentile , konzentriert, in einer niedrigeren Makrosomie- und Sektiorate resultiert, wenn bei Schwangerschaften mit AU > 75. Perzentile trotz maternaler Normoglykämie Insulin gegeben wird. Anderseits konnte 40% der Frauen mit Hyperglykämie eine Insulintherapie erspart werden ohne Verschlechterung des Outcomes , da der Fet während der gesamten Schwangerschaft ein normales Wachstum zeigte. Im Gegenteil, bei diesen Frauen war die Rate an Wachstumsretardierung deutlich geringer als in der Standardgruppe, in der hyperglykämische Frauen mit Insulin behandelten wurden trotz normalem oder bereits grenzwertigem fetalen Wachstum. Zusammenfassend lässt sich feststellen , das bei Schwangerschaften mit GDM die maternalen Blutzuckerwerte ein guter Prädiktor sind für Morbidität in der Frühschwangerschaft , jedoch nur begrenzt hilfreich sind, einen fetalen Hyperinsulinismus und seine Folgen hervorzusagen. Die Einbeziehung der fetalen Makrosomie als klinisches Zeichen eines möglichen Hyperinsulinismus, ermöglicht, die intensive Intervention durch Insulintherapie auf Schwangere zu konzentrieren mit erhöhten Risiko für neonatale Morbidität. / Gestational diabetes (GDM) is one of the most frequent disorders in pregnancy. The incidence ranges between 3-10% dependent on the background diabetes risk of the investigated population. GDM is defined as any glucose intolerance diagnosed first in pregnancy. The implications for the offspring result from the maternal hyperglycemia which leads to increased fetal blood glucose concentration and reactive fetal hyperinsulinism. Fetal hyperinsulinism is the cause for the diabetes associated fetal and neonatal morbidity, like macrosomia, delayed maturity of lungs and liver, stillbirth , neonatal hypoglycemia and an increased risk for diabetes in later life. Treatment of GDM focuses on tight glucose control to avoid maternal hyperglycemia. This requires diet and intensive self glucose monitoring for all women and additionally insulin therapy in 30% of the patients. Despite good glucose control the rate of neonatal morbidity is still elevated compared to pregnancies without glucose intolerance. The primary goal of the presented work was to determine to what extend maternal glycemia in GDM pregnancies treated according to the standard management predicts morbidity as well in early as well as in late pregnancy. In a second step, we investigated whether inclusion of fetal growth pattern improves the neonatal outcome and provides an additional tool for antenatal risk assessment. We found an excellent correlation between the level of maternal hyperglycemia and morbidity in early pregnancies. The fasting glucose at diagnosis of GDM was the strongest predictor for congenital anomalies in a large cohort of 3700 women with GDM. In later pregnancy, we were faced with a different situation. The data of our studies indicated that neither the current diagnostic criteria nor the maternal glucose values during therapy reliably predict neonatal morbidity. The diagnosis of GDM requires two elevated values in an oral glucose tolerance test but we found elevated amniotic fluid insulin, neonatal macrosomia and hypoglycemia even in women with only one elevated value. The values of the daily glucose profiles had not been predictive for the development of fetal macrosomia defined as an abdominal circumference (AC) > 90the percentile. In contrast, maternal obesity was tightly related to excessive fetal growth. We choose the fetal AC to diagnose intrauterine macrosomia since the fetal AC revealed to be an excellent predictor for neonatal macrosomia. Additionally, the fetal AC showed a good correlation to the fetal insulin levels determined by measurements of amniotic fluid insulin. A fetal AC > 75th percentile reliable excluded severe hyperinsulinism in our population. Based on this knowledge we performed three intervention studies where the decision for insulin therapy in women with GDM was predominately based on the fetal AC measurement. We could show that insulin therapy concentrated on pregnancies at risk for morbidity, defined as AC > 75th percentile, is a safe approach which results in a lower rate of neonatal macrosomia when insulin is given in pregnancies with AC > 75th percentile despite of normal maternal glucose level. On the other side, insulin could be avoided in 40% of the women with hypergylcemia since the fetal AC stayed < 75th percentile. In these women, the outcome even could be improved since insulin therapy in pregnancies with normal growth resulted in a high rate of growth retardation in the study group treated according the standard management. In summary, in pregnancies with GDM maternal blood glucose predicts morbidity in early pregnancy but it is of limited value to predict fetal hyperinsulinsm and it’s sequelae. The inclusion of fetal growth pattern in the considerations of therapy offers the opportunity to concentrate intensive intervention on pregnancies at high risk for morbidity.

Objetivo: Comparar o desempenho de diferentes curvas de referência de crescimento fetal em gestações gemelares com insuficiência placentária grave. Método: Estudo retrospectivo envolvendo gestações gemelares (n=47), com fluxo diastólico zero ou reverso, no estudo dopplervelocimétrico da artéria umbilical de um dos fetos, e ambos os fetos vivos no momento do diagnóstico. Não foram incluídas gestações com anomalia fetal \"major\", síndrome de transfusão feto-fetal, ou de ordem maior. Em ambos os fetos (acometido, FA; e cogemelar, CG), as estimativas de peso fetal foram convertidas em escore zeta de acordo com os critérios de Hadlock, Liao e Araújo. As medidas de circunferência abdominal foram convertidas de acordo com as curvas de Hadlock, Liao, Araújo, Ong e STORK. A análise estatística foi realizada segundo modelos de equações de estimação generalizada. Resultados: A idade materna média foi 27,8 ± 7,4 anos, 24 (51%) pacientes eram primigestas, 12 (25,5%) apresentavam antecedentes clínicos significativos e 61,7% (n=29) eram monocoriônicas. A idade gestacional média no momento do diagnóstico da diástole zero ou reversa foi de 27,4 ± 4,7 semanas. A idade gestacional média do parto foi de 32,9 ± 2,9 semanas e o peso médio ao nascimento dos fetos acometidos foi de 1075 ± 469 g, e dos cogemelares, 1749 ± 544 g. No modelo investigado, foram preditores significativos do escore-zeta: sexo fetal (p < 0,001) e a interação sub-grupo (feto acometido/cogemelar) e critério (p < 0,001). As estimativas do escore zeta médio (erro padrão) para o peso fetal estimado segundo cada critério examinado foram Hadlock FA: -2.98 (0,18), CG: -1,16 (0,15), Liao FA: -2,89 (0,24), CG: -0,58 (0,19), Araújo FA: -3,05 (0,29), CG: - 0,75 (0,18). Para circunferência abdominal, Hadlock FA: -3,14 (0,26), CG: - 1,13 (0,19), Liao FA: -2,63 (0,27), CG: -0,42 (0,19), Araújo FA: -2,44 (0,22), CG: -0,71 (0,14), Ong FA: -3,36 (0,34), CG: -1,48 (0,23) e STORK FA: -2,36 (0,14), CG: -1,18 (0,10). Conclusão: Em gestações gemelares, com diástole zero ou reversa em um dos fetos, as curvas que melhor diferenciaram os fetos acometidos de seus cogemelares foram as curvas nacionais, publicadas por Liao et al. e Araújo et al / Objectives: To compare the performance of different fetal growth reference curves in twin pregnancies with severe placental insufficiency. Methods: Retrospective analysis of 47 twin pregnancies with absent or reverse end diastolic flow in the umbilical artery in one fetus, and both twins alive at diagnosis. Pregnancies with major fetal abnormality, twin-twin transfusion and higher order were not included. At each ultrasound evaluation, estimated fetal weight zeta-scores were calculated for both fetuses (abnormal Doppler, AD; co-twin, CT) according to the following criteria: Hadlock, Liao and Araújo. Abdominal circumference zeta-scores were calculated according to Hadlock, Liao, Araújo, Ong and STORK. Statistical analysis was performed with generalized estimating equation regression. Results: Mean maternal age was 27.8 ± 7.4 years, 24 (51%) women were primigravida, 12 (25.5%) had a previous clinical history and 29 (61.7%) were monochorionic. Gestational age at abnormal Doppler diagnosis was 27.4 ± 4.7 weeks. Gestational age at delivery was 32.9 ± 2.9 weeks and mean birthweight was 1075 ± 469 g for AD twin, and 1749 ± 544 g in CT group. Zeta-score values were significantly related to fetal sex (p < 0.001) and subgroup (abnormal Doppler/co-twin) versus criteria interaction (p < 0.001). Estimated fetal weight mean zeta-score (standard error) according to each criteria were: Hadlock AD: -2.98 (0.18), CT: -1.16 (0.15), Liao AD: -2.89 (0.24), CT: -0.58 (0.19), Araújo AD: -3.05 (0.29), CT: -0.75 (0.18). Values for abdominal circumference were: Hadlock AD: -3.14 (0.26), CT: -1.13 (0.19), Liao AD: -2.63 (0.27), CT: -0.42 (0.19), Araújo AD: -2.44 (0.22), CT: -0.71 (0.14), Ong AD: -3.36 (0.34), CT: -1.48 (0.23) and STORK AD: -2.36 (0.14), CT: -1.18 (0.10). Conclusion: In twin pregnancies with absent or reversed end diastolic flow in the umbilical artery of one fetus, affected fetuses and their co-twins are best differentiated by Liao et al. and Araújo et al. reference ranges

In my thesis I am studying and analyzing a long time monitoring of physical growth of children from 6 to 15 years. There were selected children of both genders from the whole database monitoring children and there is noticed physical growth into individual growth curves. The evaluation of individuals was about these physical parameters: body height, body weight, Body Mass Index, abdominal circumference, gluteal circumference and subscapular skinfold.

Conselho Nacional de Desenvolvimento CientÃfico e TecnolÃgico / CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Objetivos: testar a validade da relaÃÃo diÃmetro transverso do cerebelo (DTC) /circunferÃncia abdominal (CA) como mÃtodo diagnÃstico ultra-sonogrÃfico da restriÃÃo de crescimento fetal (RCF). Determinar, atravÃs de curva ROC (receiver operator characteristic), o melhor ponto de corte da relaÃÃo DTC/CA. Verificar se a relaÃÃo DTC/CA tem sua acurÃcia modificada na dependÃncia do tipo de RCF (simÃtrica ou assimÃtrica) ou do tempo entre a ultra-sonografia e o parto. Comparar DTC/CA, no ponto de corte obtido, com a relaÃÃo comprimento do fÃmur (CF) /circunferÃncia abdominal (CA). MÃtodo: estudo prospectivo, seccional, envolvendo 250 gestantes com gravidez Ãnica, idade gestacional precisa, feto vivo. Foram realizadas ultra-sonografias obstÃtricas atà a resoluÃÃo da gestaÃÃo, mas somente a Ãltima foi considerada para anÃlise. Os neonatos cujas relaÃÃes DTC/CA estiveram maiores do que o ponto de corte determinado pela curva ROC foram considerados acometidos por RCF. Idem para a relaÃÃo CF/CA. Considerou-se como padrÃo-ouro para o diagnÃstico de RCF os recÃm-nascidos cujos pesos situaram-se abaixo do percentil 10 para a idade gestacional nas curvas de Lubchenco et al. (1963), corrigidas para sexo. Definiu-se RCF simÃtrica neonatos com Ãndice ponderal de Rohrer situado entre 2,2 e 3.0. Aqueles com RCF cujos Ãndices fossem < 2,2 foram classificados como RCF assimÃtrica. Resultados: a prevalÃncia da RCF foi de 12,4%. O ponto de corte da relaÃÃo DTC/CA determinado pela curva ROC foi 16,15. A sensibilidade, especificidade, valores preditivos positivo e negativo, acurÃcia, razÃes de verossimilhanÃa positiva e negativa foram de 77,4%, 82,6%, 38,7%, 96,3%, 82%, 4,5 e 3,7, respectivamente. Na RCF simÃtrica a sensibilidade e especificidade foram de 80,8% e 81,7%, respectivamente. Na assimÃtrica a sensibilidade e especificidade foram 60% e 75%, respectivamente. Resultados menores do que na simÃtrica, porÃm, nÃo estatisticamente significantes (p > 0,05). No intervalo de zero a sete dias entre a Ãltima ultra-sonografia e o parto, a sensibilidade e especificidade foram de 81,5% e 82,1%, respectivamente. No intervalo de oito a 14 dias, a sensibilidade e especificidade foram de 50% e 84,3%, respectivamente, sem diferenÃa estatisticamente significante entre os dois intervalos (p > 0,05). O ponto de corte da relaÃÃo CF/CA foi de 22,65, com sensibilidade, especificidade, valores preditivos positivo e negativo, acurÃcia, razÃes de verossimilhanÃa positiva e negativa de 67,7%, 81,7%, 34,4%, 94,7%, 80%, 3,7 e 2,5, respectivamente. ConclusÃes: a relaÃÃo DTC/CA no ponto de corte 16,15 mostrou-se mÃtodo eficaz no diagnÃstico de RCF, tanto simÃtrica quanto assimÃtrica, nÃo sendo influenciada pelo tempo entre a Ãltima ultra-sonografia e o parto. Sendo mÃtodo independente da idade gestacional, à especialmente Ãtil nos casos em que este dado à ignorado. A relaÃÃo CF/CA mostrou-se menos eficaz do que a DTC/CA no diagnÃstico da RCF. / Objectives: to evaluate the validity of transverse cerebellar diameter (TCD)/abdominal circumference (AC) ratio as an ultrasonographic diagnosis method of fetal growth restriction (FGR). To calculate by receiver operator characteristic (ROC) curve the best cut-off value of TCD/AC ratio. To verify whether TCD/AC has its accuracy modified according to the dependence of type of FGR (symmetric and asymmetric) or according to the time between ultrasonography and deliverance. To compare TCD/AC ratio at its cut-off with the femur length (FL)/ abdominal circumference (AC) ratio. Method: a prospective cross-sectional study, carried out in 250 pregnant women with singleton pregnancies between 20 and 42 weeks of gestation, known accurate gestational age with ultrasound confirmation, living fetuses. Obstetrics sonographic examinations were accomplished until gestation resolution, but only the last one, within 14 days of the deliverance, was used for analysis. Neonates with TCD/AC ratio greater than the cut-off, established by ROC curve were diagnosed as FGR. The same was considered for FL/AC ratio. We classified as gold standard for FGR in new-born infants, who presented birth weight bellow 10th percentile of gestational age according to the growth curves of Lubchenco et al. (1963), corrected according to their sex. Neonates showing FGR and Rohrer ponderal index between 2,2 and 3,0 were labeled as symmetric FGR. Those showing FGR and ponderal index below 2,2 were labeled as asymmetric FGR. Results: prevalence of FGR among the study group was 12,4%. The best cut-off value calculated by ROC curve for TCD/AC ratio was 16,15. The sensitivity, specificity, accuracy, positive predictive values and negative predictive values, likelihood ratio for positive and negative tests were 77,4%, 82,6%, 38,7%, 96,3%, 82%, 4,5 and 3,7, respectively. In the symmetric FGR, sensitivity and specificity were 80,8% and 81,7%, respectively. In the asymmetric FGR, sensitivity and specificity were 60% and 75%, respectively. Results lower than in the symmetric FGR, but not statistically significant (p > 0,05). In the interval zero to seven days between sonographic examination and deliverance, sensitivity and specificity were 81,5% and 82,1%, respectively. In the interval of eight to 14 days, sensitivity and specificity were 50% and 84,3%, respectively, with no statistically significant difference (p > 0,05). The best cut-off value calculated by ROC curve for FL/AC ratio was 22,65, showing sensitivity, specificity, accuracy, positive predictive values and negative predictive values, likelihood ratio for positive and negative tests of 67,7%, 81,7%, 34,4%, 94,7%, 80%, 3,7 and 2,5, respectively. Conclusions: TCD/AC ratio at cut-off 16,15 proved to be an effective method in antenatal diagnosis of FGR, both symmetric as asymmetric, with no influence of interval between ultrasonography examination and deliverance. As a gestational age-independent method, it is useful enough in the occurrence of cases where these data are unknown. FL/AC ratio proved is not so effective as TCD/AC ratio in diagnosis of FGR.