Introdução: A úlcera de estresse é uma complicação importante que pode ocorrer nos pacientes criticamente doentes, necessitando de cuidados intensivos. Apesar de ser pouco frequente, está associada com o aumento da morbidade e mortalidade em Unidades de Terapia Intensiva. É necessária uma avaliação precisa dos pacientes que estão em risco de desenvolverem úlcera de estresse para a indicação adequada de medicamento profilático. Objetivo: Avaliar a utilização de medicamentos profiláticos para úlcera de estresse nos pacientes internados de cinco Unidades de Terapia Intensivas Pediátricas (UTIP) de Porto Alegre. Métodos: Foi realizado um estudo multicêntrico, prospectivo, transversal, observacional, em cinco UTIPs de Porto Alegre. Foram avaliados os prontuários de todos os pacientes internados nestas unidades, em dia definido aleatoriamente para a visitação, no período de abril de 2006 a fevereiro de 2007. Foram excluídos os pacientes já avaliados em visitas anteriores e aqueles com hemorragia digestiva alta na admissão. Foram avaliados idade, sexo, diagnóstico na admissão, gravidade da doença, uso de medicamentos profiláticos para sangramento digestivo, justificativa do uso de profilaxia, medicamento profilático utilizado como primeira escolha. Resultados: Foram avaliados 398 pacientes, 57% do sexo masculino, com mediana de idade de 16 meses (Intervalo inter-quartil [IQ]: 4 - 65) e mediana de permanência em UTIP de 4 dias (IQ: 1 - 9). O principal motivo de internação foi doença respiratória (32,7%). Usaram profilaxia 77,5% dos pacientes avaliados, variando de 66 a 91%. A ranitidina foi o medicamento mais empregado (84,5%), sendo a ventilação mecânica (22,3%) a justificativa mais prevalente, seguida de rotina informal do serviço (21,4%). Apenas uma das UTIPs tinha protocolo assistencial para uso de profilaxia para úlcera de estresse. Em 3% dos pacientes houve indícios de sangramento digestivo, mas nenhum clinicamente importante. Conclusões: O uso de medicamentos profiláticos para úlcera de estresse é prática frequente nas UTIPs avaliadas, sendo a ranitidina a droga de escolha na maioria das vezes. Entre as indicações para profilaxia estabelecidas na literatura, a ventilação mecânica foi a indicação mais prevalente. Ressalta-se que o uso baseado em rotinas institucionais assumiu, na amostra estudada, igual prevalência, sugerindo que o uso de profilaxia para úlcera de estresse possa estar inadequado. / Introduction: Stress ulcer is an important complication that can affect critically ill patients, thus demanding intensive care. Although it is not very common, it is associated with the increase of morbidity and mortality in Intensive Care Units. A precise evaluation of patients at risk of developing stress ulcer is needed in order to correctly indicate the stress ulcer prophylaxis. Objective: To evaluate the use of stress ulcer prophylaxis in patients of five Pediatric Intensive Care Units (PICU) in Porto Alegre. Methods: A multicentric, prospective, cross-sectional, observational study was conducted in five PICUs in Porto Alegre. From April 2006 to February 2007, medical records of all patients at these units were evaluated; visiting days were randomly chosen. Patients that had already been evaluated in previous visits, as well as those that presented upper gastrointestinal bleeding when admitted, were excluded. Age, gender, admission diagnosis, severity of illness, use of stress ulcer prophylaxis, justification of prophylactic use and prophylactic drug used as first choice were evaluated. Results: 398 patients were evaluated, 57% males, the median age was 16 months (IQR: 4-65), the median length of PICU stay was 4 days (IQR:1-9). Respiratory illness was the main reason for admission, 32.7%. From the total sample of patients, 77.5% used prophylaxis, ranging from 66% to 91% for each individual PICU. Mechanical ventilation (22.3%) was the main justification, followed by informal routine service (21.4%). Only one of the PICUs had a specific protocol of assistance for the use of stress ulcer prophylaxis. Ranitidine was the most used drug (84.5%). There were traces of gastrointestinal bleeding in 3% of the patients, but none were clinically significant. Conclusions: The use of stress ulcer prophylaxis is a common practice in the appraised PICUs and ranitidine was the most used drug. Mechanical ventilation was the most common justification amongst those suggested in the literature. However, the use based on informal routines, in this study, showed equal prevalence, which suggests that the use of prophylactics might be inadequate.

Introdução: A úlcera de estresse é uma complicação importante que pode ocorrer nos pacientes criticamente doentes, necessitando de cuidados intensivos. Apesar de ser pouco frequente, está associada com o aumento da morbidade e mortalidade em Unidades de Terapia Intensiva. É necessária uma avaliação precisa dos pacientes que estão em risco de desenvolverem úlcera de estresse para a indicação adequada de medicamento profilático. Objetivo: Avaliar a utilização de medicamentos profiláticos para úlcera de estresse nos pacientes internados de cinco Unidades de Terapia Intensivas Pediátricas (UTIP) de Porto Alegre. Métodos: Foi realizado um estudo multicêntrico, prospectivo, transversal, observacional, em cinco UTIPs de Porto Alegre. Foram avaliados os prontuários de todos os pacientes internados nestas unidades, em dia definido aleatoriamente para a visitação, no período de abril de 2006 a fevereiro de 2007. Foram excluídos os pacientes já avaliados em visitas anteriores e aqueles com hemorragia digestiva alta na admissão. Foram avaliados idade, sexo, diagnóstico na admissão, gravidade da doença, uso de medicamentos profiláticos para sangramento digestivo, justificativa do uso de profilaxia, medicamento profilático utilizado como primeira escolha. Resultados: Foram avaliados 398 pacientes, 57% do sexo masculino, com mediana de idade de 16 meses (Intervalo inter-quartil [IQ]: 4 - 65) e mediana de permanência em UTIP de 4 dias (IQ: 1 - 9). O principal motivo de internação foi doença respiratória (32,7%). Usaram profilaxia 77,5% dos pacientes avaliados, variando de 66 a 91%. A ranitidina foi o medicamento mais empregado (84,5%), sendo a ventilação mecânica (22,3%) a justificativa mais prevalente, seguida de rotina informal do serviço (21,4%). Apenas uma das UTIPs tinha protocolo assistencial para uso de profilaxia para úlcera de estresse. Em 3% dos pacientes houve indícios de sangramento digestivo, mas nenhum clinicamente importante. Conclusões: O uso de medicamentos profiláticos para úlcera de estresse é prática frequente nas UTIPs avaliadas, sendo a ranitidina a droga de escolha na maioria das vezes. Entre as indicações para profilaxia estabelecidas na literatura, a ventilação mecânica foi a indicação mais prevalente. Ressalta-se que o uso baseado em rotinas institucionais assumiu, na amostra estudada, igual prevalência, sugerindo que o uso de profilaxia para úlcera de estresse possa estar inadequado. / Introduction: Stress ulcer is an important complication that can affect critically ill patients, thus demanding intensive care. Although it is not very common, it is associated with the increase of morbidity and mortality in Intensive Care Units. A precise evaluation of patients at risk of developing stress ulcer is needed in order to correctly indicate the stress ulcer prophylaxis. Objective: To evaluate the use of stress ulcer prophylaxis in patients of five Pediatric Intensive Care Units (PICU) in Porto Alegre. Methods: A multicentric, prospective, cross-sectional, observational study was conducted in five PICUs in Porto Alegre. From April 2006 to February 2007, medical records of all patients at these units were evaluated; visiting days were randomly chosen. Patients that had already been evaluated in previous visits, as well as those that presented upper gastrointestinal bleeding when admitted, were excluded. Age, gender, admission diagnosis, severity of illness, use of stress ulcer prophylaxis, justification of prophylactic use and prophylactic drug used as first choice were evaluated. Results: 398 patients were evaluated, 57% males, the median age was 16 months (IQR: 4-65), the median length of PICU stay was 4 days (IQR:1-9). Respiratory illness was the main reason for admission, 32.7%. From the total sample of patients, 77.5% used prophylaxis, ranging from 66% to 91% for each individual PICU. Mechanical ventilation (22.3%) was the main justification, followed by informal routine service (21.4%). Only one of the PICUs had a specific protocol of assistance for the use of stress ulcer prophylaxis. Ranitidine was the most used drug (84.5%). There were traces of gastrointestinal bleeding in 3% of the patients, but none were clinically significant. Conclusions: The use of stress ulcer prophylaxis is a common practice in the appraised PICUs and ranitidine was the most used drug. Mechanical ventilation was the most common justification amongst those suggested in the literature. However, the use based on informal routines, in this study, showed equal prevalence, which suggests that the use of prophylactics might be inadequate.

JUSTIFICATIVA E OBJETIVOS: Apesar da reconhecida eficácia da escleroterapia e da ligadura elástica no controle de hemorragia por varizes, os resultados do tratamento endoscópico em pacientes Child-Pugh classe C continuam pobres. O objetivo deste estudo retrospectivo foi descrever os resultados da injeção do adesivo tecidual N-butil-2-cianoacrilato no controle de episódios agudos de ruptura de varizes esofágicas em pacientes classe C Child-Pugh. PACIENTES E MÉTODOS: Estudo retrospectivo realizado em um único centro. De setembro de 2004 a janeiro de 2010, 63 pacientes cirróticos classe C de Child-Pugh foram admitidos na sala de emergência com episódio de hemorragia por varizes de esôfago. Todos foram tratados por injeção de cianoacrilato. Os pacientes foram divididos em dois grupos: Child-Pugh classe C com pontuações de 10 a 13 (Grupo I) e pacientes com escores de 14 ou 15 (Grupo II). As variáveis estudadas foram falha em controlar o sangramento (até cinco dias) e incapacidade de evitar ressangramento e mortalidade. Os dados foram analisados pelo teste do qui-quadrado. RESULTADOS: Sessenta e três pacientes foram incluídos no estudo, 50 do sexo masculino e 13 do sexo feminino, com idade média de 49 anos, faixa de 22-74. Os pacientes dos dois grupos (Grupo I = 50 pacientes e Grupo II = 13 pacientes) tinham características semelhantes. Quase 75% dos pacientes tiveram sucesso em controlar o sangramento nos primeiros cinco dias. Não houve diferença entre os grupos. Tampouco se evidenciou diferença estatística entre os grupos em relação às taxas de mortalidade até cinco dias (Grupo I = 20%; Grupo II = 38,5%). Trinta e quatro (54%) dos 63 pacientes apresentaram-se livres de sangramento até seis semanas, com diferenças estatisticamente significativas entre os dois grupos (Grupo I = 32 de 50, 64%; Grupo II = dois de 13, 15,4%; p < 0,001). A taxa de mortalidade global foi de 44,4 %, com diferença importante entre os dois grupos (Grupo I = 17 de 50, 34%; Grupo II = 11 de 13, 84,6%, p < 0,001). CONCLUSÃO: Estes resultados suportam a visão de que a injeção de cianoacrilato é uma boa opção no controle do sangramento por varizes esofágicas em pacientes Child-Pugh classe C. Além disso, os resultados sugerem que, para pacientes Child-Pugh classe C com pontuação baixa (10-13), a injeção de cianoacrilato pode ser considerada tratamento de primeira linha / BACKGROUND AND STUDY AIMS: Despite the recognized efficacy of sclerotherapy and elastic band ligation in controlling variceal hemorrhage, the results of endoscopic treatment in Child-Pugh class C patients remain poor. The aim of this retrospective study was to describe the results of the injection of tissue adhesive N-butyl-2-cyanoacrylate in controlling acute episodes of rupturing of esophageal varices in Child-Pugh class C patients. PATIENTS AND METHODS: Retrospective study carried out in a single center. From September 2004 to January 2010, 63 Child-Pugh class C cirrhotic patients were admitted to the emergency room with an acute episode of esophageal variceal bleeding. They were all treated by injection of cyanoacrylate. The patients were divided in two groups: Child-Pugh class C scores from 10 to 13 (Group I) and patients scoring 14 or 15 (Group II). Studied variables were initial failure in control bleeding (five days), failure to prevent re-bleeding and mortality. Data was analyzed by chi-square test. RESULTS: Sixty three patients were included in the study, 50 male and 13 female, mean age 49 years, range 22-74. The patients in the two groups (Group I = 50 patients and Group B = 13 patients) had similar characteristics. Almost 75% of the patients had success in controlling the bleeding in the first five days, with no difference between the groups. Neither there were no statistically differences between the groups related to the mortality rates until five days either (Group I = 20 %; Group II = 38,5 %). Thirty four (54%) of the 63 patients were found free of bleeding until six weeks, with statistically differences between the two groups (Group I = 32 of 50, 64%; Group II = two of 13, 15,4%; p < 0,001). The overall mortality rate was 44,4%, with important difference between the two groups (Group I=seventeen of 50, 34 %; Group II = 11 of 13, 84,6%; p<0,001). CONCLUSION: These findings support the view that cyanoacrylate injection is a good option to control esophageal variceal bleeding in Child-Pugh class C patients. Furthermore, the results suggest that for patients Child-Pugh class C with low score (10-13), cyanoacrylate injection may be considered first line treatment

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / FundaÃÃo Cearense de Apoio ao Desenvolvimento Cientifico e TecnolÃgico / Este trabalho teve como objetivos caracterizar fÃsico-quÃmica e estruturalmente polissacarÃdeos obtidos de folhas de Aloe barbadensis e avaliar suas atividades antiviral, anti-hemorrÃgica e prÃ-coagulante e possÃveis sinais de toxicidade. Foi realizada extraÃÃo aquosa de polissacarÃdeos totais (PT) de A. barbadensis, seguido de precipitaÃÃo por etanol e remoÃÃo dos contaminantes proteicos com TCA. A cromatografia em DEAE-celulose foi eficiente no fracionamento dos PT, onde foram obtidas as fraÃÃes PI e PII. A caracterizaÃÃo fÃsico-quÃmica mostrou que a fraÃÃo PI à composta por manose (78,4%), glucose (7,3%), galactose (2,1%), fucose (2,8%) e Ãcidos urÃnicos (10,0%), e isenta de grupos Ãster sulfato. Enquanto, a fraÃÃo PII à constituÃda por manose (39,2%), glucose (22,2%), galactose (26,3%), arabinose (3,8%), xilose (1,1%), Ãcidos urÃnicos (8,0%) e grupos Ãster sulfato (12,0%). Na revelaÃÃo das bandas polissacarÃdicas da fraÃÃo PII, obtidas por PAGE e gel de agarose corados com stainsall foi constatado a presenÃa de duas bandas que apresentaram diferentes coloraÃÃes, roxa e ciana, correspondentes a presenÃa de grupos sulfato e carboxilados, respectivamente. Na anÃlise estrutural das fraÃÃes PI e PII, por espectroscopia no IR, foi demonstrado que a fraÃÃo PI apresenta unidades monossacarÃdicas de Ã-manose O-acetiladas (812,2 e 960 onda.cm-1) e Ãcidos urÃnicos neutros (1738 onda.cm-1) em sua estrutura. Diferentemente, a fraÃÃo PII, mostrou-se ser constituÃda por unidades monossacarÃdicas de manose (1014,7 onda.cm-1), galactose (1078,2 onda.cm-1), Ãcidos urÃnicos carregados negativamente (1635 onda.cm-1) e Ãster sulfato (1329,5 e 1260,9 onda.cm-1). Na avaliaÃÃo estrutural da fraÃÃo PII por RMN foi comprovado à presenÃa do grupo Ãster sulfato. Em relaÃÃo Ãs atividades biolÃgicas, o teste de citotoxicidade mostrou que os PT e as fraÃÃes PI e PII nÃo apresentaram toxicidade para a maioria das cÃlulas testadas e nÃo foram eficientes na inibiÃÃo de vÃrus nÃo envelopados Ad-19 e Ad-41. No entanto, os PT e a fraÃÃo PI foram capazes de inibir a infecÃÃo causada por HSV-1 e HSV-2. Em ensaios com metapneumovÃrus (HMPV), a fraÃÃo PII apresentou atividade antiviral superior à ribavirina. Embora os PT e as fraÃÃes PI e PII nÃo terem apresentado atividade contra dengue vÃrus sorotipo 1 (DENV-1), os PT puderam inibir a hemorragia em ratos, diminuindo o tempo de sangramento e o tempo de protrombina. Os PT nÃo apresentaram toxicidade em camundongos, mas aumentaram o tamanho do baÃo e o nÃmero de plaquetas sanguÃneas. Pode ser concluÃdo que extratos foliares de A. barbadensis podem apresentar polissacarÃdeos neutros ou carregados negativamente por grupos carboxilados/sulfatados. Em adiÃÃo, alÃm de apresentar atividade inibitÃria contra os vÃrus HSV-1, HSV-2 e HMPV, podem tambÃm apresentar efeito anti-hemorrÃgico e prÃcoagulante, propriedades essas, importantes, visto que a complicaÃÃo de muitas viroses leva a quadros hemorrÃgicos. AlÃm disso, os PT de A. barbadensis nÃo apresentaram toxicidade expressiva, podendo ser utilizada como agente terapÃutico seguro e eficaz. / The aim of this study was to investigate the physicochemical and structural parameters of polysaccharides obtained from Aloe barbadensis leaves and to evaluate the antiviral and cytotoxic activities and procoagulant, anti-bleeding effects. In addition, toxicological analysis was carried out. The pulp was submitted to aqueous extraction (70 ÂC) and the total polysaccharides (PT) obtained by ethanol precipitation, TCA was used to remove the protein contamination. The fractionation of PT with DEAE-celulose resulted in two fractions (PI and PII). The physicochemical characterization showed that PI fraction presents mannose (78,4%), glucose (7,3%), galactose (2,1%), fucose (2,8%) and uronic acid (10,0%). Sulfate esters were not detected in PI fraction. On the other hand, PII fraction presents the monosaccharides mannose (39,2%), glucose (22,2%), galactose (26,3%), arabinose (3,8%), xylose (1,1%), uronic acids (8,0%) and sulfate esters groups (12,0%). The polysaccharidics of PII obtained by PAGE and agarose gel electrophoresis were revealed with toluidine blue and stainsall dye showing the presence of two different bands, one purple (indicative of sulfate) and another cyan (indicative of carboxilated groups). Structural analysis of PI and PII fractions by IR spectroscopy demonstrated that PI fraction is composed of residues of Ã-mannose O-acetylated (812.2 and 960 cm-1) and uronic acids (1738 cm-1). In contrast, the PII fraction is composed of mannose (1014.7 cm-1), galactose (1078.2 cm-1), negatively charged uronic acids (1635 cm-1) and sulfate ester (1329.5 and 1260.9 cm-1). These results corroborate with NMR analyses that suggest the presence of sulfate groups in PII structure. The cytotoxicity evaluation showed that PT and the fractions PI and PII did not show toxicity against most of tested cells and the same fractions were not effective against non-enveloped virus (Ad 19 and Ad 41) inhibition. However, the PT and PI fraction were able to inhibit the infection caused by HSV-1 and HSV-2. In addition, PII fraction presents antiviral activity against metapneumovirus. Although the PT and the fractions PI and PII did not show activity against dengue virus serotype 1 (DENV-1), PT could inhibit the bleeding effects in rats, reducing the bleeding and prothrombin time. The PT showed no toxicity in mice, but increased spleen size and number of blood platelets. In conclusion, A. barbadensis leaves contain neutral or negatively charged carboxylated/sulfated polysaccharides. In addition, besides having inhibitory activity against HSV-1, HSV-2 and HMPV, they can also anti-bleeding and procoagulant effect. Moreover, the PT of A. barbadensis showed no significant toxicity and can be used as a safe and effective therapeutic agent.

Objetivos: Estudar os diferenciais entre os indicadores de cárie dentária e alterações gengivais em escolares de áreas urbanas e rurais do Estado de São Paulo. Material e Métodos. Estudo de corte transversal analítico e ecológico foram os dois delineamentos utilizados. A população de estudo foram estudantes de escolas urbanas e rurais do Estado de São Paulo de 5 a 7 e de 10 a 12 anos; a fonte de informação foi o "Levantamento das Condições de Saúde Bucal - Estado de São Paulo, 1998". Foi estimada a prevalência de cárie dentária (índice ceo-d e CPO-D), do sangramento gengival durante a sondagem e de cálculo dental (índice CPI), para o estudo de associação com características sócio-demográficas dos escolares e indicador de desenvolvimento social (IDH-M) das cidades participantes do levantamento. Foram estimadas as odds ratios ajustadas e não ajustadas, por meio de análise de regressão logística de delineamento de modelos multivariados e multiníveis. O estudo de diferenciais de prevalência entre diferentes regiões do Estado empregou uma classificação de àreas rurais homogêneas pré-existentes. Resultados: Os indicadores de saúde bucal tiveram distibuição desigual entre os estratos, indicando pior condição para a população rural. Estudar em áreas rurais, em escolas públicas, ser negro ou pardo e ser do sexo masculino associaram com a manifestação de cárie não tratada e alterações gengivais, ao nível dos indivíduos. No modelo multinível, a presença de flúor na água de abastecimento público, o Índice de Desenvolvimento Humano (IDH-M) e o Índice de Cuidado associaram com as condições de saúde bucal estudadas ao nível das cidades participantes do levantamento. Áreas rurais cujo sistema produtivo apresentava maior implementação da economia agro-industrial tiveram os melhores indicadores de saúde bucal. Conclusões: Os escolares de área rural mostraram-se mais vulneráveis para todas as condições de saúde bucal avaliadas / Objectives: To assess differentials of prevalence of dental caries and gingival status in schoolchildren from rural and urban areas of the State of São Paulo. Material and Methods: The study population comprised schoolchildren aged 5 to 7 and 10 to 12 years old; the source of information was the “Survey of Oral Health Status – State of São Paulo, 1998”. The prevalence of dental caries (dmft and DMFT indices), gingival bleeding on probing and dental calculus (CPI index) were assessed for the appraisal of association with socio-demographic characteristics of schoolchildren and indices of social development of participating towns. The estimation of adjusted and non-adjusted odds ratios used logistic regression analysis, and the fitting of multivariate multilevel models. The study of prevalence differentials among regions of the State used a previous classification of homogeneous rural areas. Results: Indices of oral health had an unequal distribution among strata, indicating a poorer profile for rural population. Studying in rural areas, in public schools, being black and being a boy associated with the odds of presenting untreated dental caries and gingival status at the individual level. Fluoride addition to tap water and the human development index associated with these outcomes at the town level. Rural areas whose productive system presented enhancements associated with the agro-industry had an improved profile of oral health. Conclusion: Schoolchildren in rural areas had a poorer profile for all outcomes of oral health. These findings should instruct health services for programming specific interventions aimed at this stratum.

Introdução: A úlcera de estresse é uma complicação importante que pode ocorrer nos pacientes criticamente doentes, necessitando de cuidados intensivos. Apesar de ser pouco frequente, está associada com o aumento da morbidade e mortalidade em Unidades de Terapia Intensiva. É necessária uma avaliação precisa dos pacientes que estão em risco de desenvolverem úlcera de estresse para a indicação adequada de medicamento profilático. Objetivo: Avaliar a utilização de medicamentos profiláticos para úlcera de estresse nos pacientes internados de cinco Unidades de Terapia Intensivas Pediátricas (UTIP) de Porto Alegre. Métodos: Foi realizado um estudo multicêntrico, prospectivo, transversal, observacional, em cinco UTIPs de Porto Alegre. Foram avaliados os prontuários de todos os pacientes internados nestas unidades, em dia definido aleatoriamente para a visitação, no período de abril de 2006 a fevereiro de 2007. Foram excluídos os pacientes já avaliados em visitas anteriores e aqueles com hemorragia digestiva alta na admissão. Foram avaliados idade, sexo, diagnóstico na admissão, gravidade da doença, uso de medicamentos profiláticos para sangramento digestivo, justificativa do uso de profilaxia, medicamento profilático utilizado como primeira escolha. Resultados: Foram avaliados 398 pacientes, 57% do sexo masculino, com mediana de idade de 16 meses (Intervalo inter-quartil [IQ]: 4 - 65) e mediana de permanência em UTIP de 4 dias (IQ: 1 - 9). O principal motivo de internação foi doença respiratória (32,7%). Usaram profilaxia 77,5% dos pacientes avaliados, variando de 66 a 91%. A ranitidina foi o medicamento mais empregado (84,5%), sendo a ventilação mecânica (22,3%) a justificativa mais prevalente, seguida de rotina informal do serviço (21,4%). Apenas uma das UTIPs tinha protocolo assistencial para uso de profilaxia para úlcera de estresse. Em 3% dos pacientes houve indícios de sangramento digestivo, mas nenhum clinicamente importante. Conclusões: O uso de medicamentos profiláticos para úlcera de estresse é prática frequente nas UTIPs avaliadas, sendo a ranitidina a droga de escolha na maioria das vezes. Entre as indicações para profilaxia estabelecidas na literatura, a ventilação mecânica foi a indicação mais prevalente. Ressalta-se que o uso baseado em rotinas institucionais assumiu, na amostra estudada, igual prevalência, sugerindo que o uso de profilaxia para úlcera de estresse possa estar inadequado. / Introduction: Stress ulcer is an important complication that can affect critically ill patients, thus demanding intensive care. Although it is not very common, it is associated with the increase of morbidity and mortality in Intensive Care Units. A precise evaluation of patients at risk of developing stress ulcer is needed in order to correctly indicate the stress ulcer prophylaxis. Objective: To evaluate the use of stress ulcer prophylaxis in patients of five Pediatric Intensive Care Units (PICU) in Porto Alegre. Methods: A multicentric, prospective, cross-sectional, observational study was conducted in five PICUs in Porto Alegre. From April 2006 to February 2007, medical records of all patients at these units were evaluated; visiting days were randomly chosen. Patients that had already been evaluated in previous visits, as well as those that presented upper gastrointestinal bleeding when admitted, were excluded. Age, gender, admission diagnosis, severity of illness, use of stress ulcer prophylaxis, justification of prophylactic use and prophylactic drug used as first choice were evaluated. Results: 398 patients were evaluated, 57% males, the median age was 16 months (IQR: 4-65), the median length of PICU stay was 4 days (IQR:1-9). Respiratory illness was the main reason for admission, 32.7%. From the total sample of patients, 77.5% used prophylaxis, ranging from 66% to 91% for each individual PICU. Mechanical ventilation (22.3%) was the main justification, followed by informal routine service (21.4%). Only one of the PICUs had a specific protocol of assistance for the use of stress ulcer prophylaxis. Ranitidine was the most used drug (84.5%). There were traces of gastrointestinal bleeding in 3% of the patients, but none were clinically significant. Conclusions: The use of stress ulcer prophylaxis is a common practice in the appraised PICUs and ranitidine was the most used drug. Mechanical ventilation was the most common justification amongst those suggested in the literature. However, the use based on informal routines, in this study, showed equal prevalence, which suggests that the use of prophylactics might be inadequate.

Abstract The principal aim of this study was to explore associations between systemic inflammatory status and periodontal inflammation and tissue destruction. The study population consisted of 61 patients with chronic periodontitis, 30 periodontally healthy control subjects, and 80 subjects with type 1 diabetes mellitus (T1DM). The T1DM subjects were periodontally treated and re-examined eight weeks after completion of the treatment. The periodontal measures included plaque, probing depth (PD), bleeding on probing (BOP) and attachment level (AL). The serum levels of interleukin (IL)-6, tumor necrosis factor (TNF)-&#945;, and interleukin (IL)-10, as well as the gingival crevicular fluid (GCF) level of matrix metalloproteinase (MMP)-8 were analyzed using commercially available ELISA assays, and serum high density lipoprotein (HDL) level using direct enzymatic methods. Serum IL-6 level associated significantly with the extent of inflamed periodontal pockets in T1DM subjects. Moreover, serum IL-6 modulated local periodontal inflammation in T1DM patients; periodontal healing turned out to be poorer in subjects with a high level of serum IL-6 than in those with a low level. Serum TNF-&#945;/IL-10 ratio was three times higher in chronic periodontitis patients than in periodontally healthy control subjects. In T1DM subjects a significant inverse association between serum HDL level and the extent of inflamed periodontal pockets was found; subjects with a low serum HDL level presented 50% more inflamed periodontal sites than subjects with a high serum HDL level. A significant association between GCF MMP-8 level in shallow crevices and the extent of periodontal attachment loss in chronic periodontitis patients was observed. In conclusion, we focused on analyzing associations between systemic inflammatory status and periodontal conditions. According to our results, periodontal inflammation/infection is associated with systemic inflammatory status using serum IL-6, TNF-&#945;/IL-10 ratio and HDL as indicators. Also, a high level of MMP-8 in GCF in shallow crevices could be indicative of higher susceptibility to periodontal infection and tissue destruction. / Tiivistelmä Tutkimuksen tavoitteena oli tarkastella hampaiden kiinnityskudosten tulehduksen (pardodontiitti) ja siihen liittyvän inflammaation yhteyttä systeemiseen tulehdustilaan. Tutkimusaineistoon kuului 61 yleistervettä potilasta, joilla oli kohtalaisesti tai pitkälle edennyt parodontiitti, 30 yleistervettä yksilöä, joiden hampaiden kiinnityskudokset olivat terveet/lähes terveet (kontrolliryhmä), sekä 80 tyypin 1 diabetes mellitus (T1DM) potilasta, joilla esiintyi vaihtelevasti parodontiittia. T1DM potilaiden parodontiitti hoidettiin, ja heidät tutkittiin uudelleen kahdeksan viikon kuluttua hoidon päättymisestä. Tutkittavilta tarkastettiin plakin määrä, ientaskujen syvyys, ienverenvuoto ja hampaiden kiinnityskudoksen menetys. Systeemistä tulehdustilaa mitattiin käyttäen seerumin interleukiini (IL)-6, tuumorinekroosifaktori (TNF)-&#945; ja interleukiini (IL)-10 tasoja. Lisäksi määritettiin ientaskunesteen matriksimetalloproteinaasi (MMP)-8 taso. Kaikki edellä mainitut tulehduksen välittäjäainetasot määritettiin käyttäen ELISA-menetelmää. T1DM potilaiden seerumin IL-6 pitoisuuden ja tulehtuneiden ientaskujen määrän välillä vallitsi positiivinen yhteys. Lisäksi havaittiin, että seerumin korkea IL-6 taso heikensi parodontiitin paranemista. T1DM potilailla havaittiin käänteinen yhteys seerumin HDL-pitoisuuden ja tulehtuneiden ientaskujen määrän välillä. Tutkittavilla, joilla seerumin HDL-taso oli matala (&#60;1.35 mmol/l), oli 50&#160;% enemmän tulehtuneita ientaskuja kuin niillä, joilla HDL-taso oli korkea (&#8805;1.35). Parodontiitti-ryhmässä seerumin TNF-&#945;/IL-10 suhde oli kolminkertainen verrattuna kontrolliryhmän vastaavaan ilmentäen voimakkaampaa matala-asteista tulehdusta parodontiitti-potilailla. Matalista (&#60;4&#160;mm) ientaskuista kerätyn ientasunesteen MMP-8 pitoisuuden ja parodontiitin vaikeusasteen välillä vallitsi merkittävä postiivinen yhteys parodontiitti-potilailla. Yhteenvetona, systeemisen tulehdustilan ja hampaiden kiinnityskudosten välillä vallitsee kaksisuuntainen yhteys; toisaalta parodontiitti lisää matala-asteista systeemistä tulehdustilaa ja toisaalta kohonnut systeeminen tulehdustila lisää alttiutta parodontiittiin ja siihen liittyvään inflammaatioon. Lisäksi ientaskunesteen korkea MMP-8 pitoisuus matalissa ientaskuissa voi merkitä lisääntynyttä alttiutta parodontiumin alueen tulehdukselle ja kudostuholle.

Abstract The aim of the present study was to examine associations between serum 25-hydroxyvitamin D [25(OH)D] and 1,25-dihydroxyvitamin D[(1,25(OH)2D]—the circulating and active forms of vitamin D—and periodontal infection. The data were gathered from a case-control study (63 periodontitis patients and 30 periodontally healthy controls) and an intervention study among individuals with type 1 diabetes mellitus (T1DM, 80 patients at the baseline and 65 after periodontal treatment). The periodontal data and the levels of serum 25(OH)D, 1,25(OH)2D and parathyroid hormone (PTH) were available. A third data set included periodontal data and the serum level of 25(OH)D of 1262 non-smoking and non-diabetic 30–49-year-old individuals (Health 2000 Survey). Serum 25(OH)D analyses were done using enzyme-linked immunoassay and radioimmunoassay, 1,25(O)2D analyses using enzyme-immunoassay after purification of 1,25(OH)2D by immunoextraction and PTH analyses using electrochemiluminescence immunoassay. In the case-control study individuals with a low serum 1,25(O)2D level were more likely to belong to the periodontitis group than to the periodontally healthy group and an inverse association was observed between serum 1,25(OH)2D and severity of periodontitis at the baseline of the intervention study. Serum 1,25(OH)2D increased significantly after periodontal treatment in the T1DM patients; a finding that was considered suggestive of a causal relationship between serum 1,25(OH)2D and periodontal infection. Also, serum PTH increased after periodontal treatment; this increase, which was statistically significant (p = 0.016) in patients with moderate or severe periodontitis, may partly account for the earlier observed post-treatment increase in serum 1,25(OH)2D level. Possible explanations for low serum 1,25(OH)2D in periodontal infection may be increased degradation of 1,25(OH)2D, increased use of 1,25(OH)2D, or decreased hydroxylation of 25(OH)D The association between serum 25(OH)D level and periodontal infection was weak, if existent. An inverse association between serum 25(OH)D and the severity of periodontal infection was observed only in the T1DM patients. Among individuals with low plaque level, those in higher 25(OH)D quintiles tended to have fewer teeth with deepened periodontal pockets than those in lower quintiles; a finding which was interpreted to mean a slight protective role of 25(OH)D against periodontal infection. / Tiivistelmä Tutkimuksen tarkoituksena oli selvittää seerumin 25-hydroksivitamiini D:n [25(OH)D, D-vitamiinin varastomuoto] ja 1,25-dihydroksivitamiini D:n [1,25(OH)2D, D-vitamiinin aktiivinen muoto] tasojen yhteyttä parodontiumin alueen infektiosairauksiin. Tulokset perustuvat kolmeen tutkimusasetelmaan: tapaus-verrokki-tutkimus (63 parodontiitti-potilasta, 30 verrokkia), interventio-tutkimus [80 tyypin 1 diabetes mellitus (T1DM) potilasta, joista 65 osallistui seurantaan parodontologisen hoidon jälkeen] ja poikittaistutkimus Terveys 2000 tutkimuksen osa-aineistossa (1262 30-49 vuotiasta tupakoimatonta ei-diabeetikkoa). Tapaus-verrokki- ja interventiotutkimuksissa tutkittiin myös seerumin parathormoonin (PTH) yhteyttä parodontaali-infektioon sekä PTH:n vaikutusta seerumin 1,25(OH)2D tasoon infektion hoidon jälkeen. D-vitamiinin ja PTH:n tasot määritettiin immunologisin menetelmin. Yhteyksiä tutkittiin käyttäen vakioituja monimuuttujamalleja. Tapaus-verrokki-tutkimuksessa yksilöt, joilla seerumin 1,25(OH)2D taso oli alhainen, kuuluivat todennäköisemmin parodontiitti- kuin verrokkiryhmään. Interventiotutkimuksen alkutilanteessa seerumin 1,25(OH)2D:n ja parodontaali-infektion vaikeusasteen välillä vallitsi tilastollisesti merkittävä käänteinen yhteys ja taso nousi merkittävästi infektion hoidon jälkeen. Myös seerumin PTH taso nousi parodontaali-infektion hoidon jälkeen; nousu oli tilastollisesti merkittävä (p = 0.016) pitkälle edennyttä parodontiittia sairastavilla. Interventiotutkimuksen tulokset viittaavat kausaaliseen yhteyteen 1,25(OH)2D:n ja parodontaali-infektion välillä. Alhainen seerumin 1,25(OH)2D pitoisuus infektion vallitessa voi selittyä sen suurella käytöllä immuunipuolustukseen infektion aikana tai lisääntyneellä hajoamisella. Tason nousu hoidon jälkeen tukee edellä mainittua. PTH on 25(OH)D:n hydroksylaation pääsäätelijä ja 1,25(OH)2D:n nousua hoidon jälkeen voi osittain selittää myös seerumin PTH tason kohoaminen. Seerumin 25(OH)D:n ja parodontaali-infektion välillä havaittu yhteys oli heikko, mutta ei täysin sulje pois 25(OH)D:n suojaavaa vaikutusta. Käänteinen yhteys löytyi vain interventiotutkimuksen alkutilanteessa T1DM potilailla. Infektion hoito ei vaikuttanut 25(OH)D tasoon. Terveys 2000 tutkimuksen osa-aineistossa havaittiin hyvän suuhygienian omaavilla jonkin verran alhaisempi määrä syventyneitä ientaskuja ylemmissä kuin alemmissa 25(OH)D kvintiileissä.

Le traitement des patients avec une coronarographie après un SCA est l'aspirine et les thiénopyridines. La réponse aux thiénopyridines est variable, cette variabilité, multifactorielle, a des répercutions cliniques. Leur efficacité a été évaluée sur la réduction de la survenue d'évènements cliniques et peu sur le risque d'hémorragie qui est un effet indésirable majeur. Les plaquettes, jouent un rôle dans l'athérosclérose et les SCA notamment par le CD40L.J'ai étudié les facteurs plaquettaires conditionnant le risque hémorragique chez ces patients et apporté un éclairage sur des fonctions plaquettaires peu connues comme l'inflammation. Les génotypes du cytochrome P450 CYP2C19*2 et *17 ont une influence sur la réponse plaquettaire aux thiénopyridines et il existe une relation entre les complications hémorragiques et la réactivité plaquettaire.Une très faible réactivité plaquettaire (VASP<10%) est un facteur prédictif du risque hémorragique et les valeurs de VASP < 10 % sont plus fréquentes chez les patients traités par prasugrel. Nous avons ensuite ciblé un marqueur de l'état inflammatoire plaquettaire, le CD40L. Sa libération plaquettaire dépend de la voie du P2Y12, son expression, elle, dépend moins de cette voie. Une faible expression du CD40L est associée à des évènements hémorragiques chez les patients traités par thiénopyridines.Ainsi le déterminisme génétique de l'efficacité du traitement par thiénopyridines a un impact sur le risque hémorragique et d'autres paramètres plaquettaires influencent ce risque indépendamment de l'inhibition de l'agrégation plaquettaire. Le CD40L, serait un lien entre l'inflammation et l'équilibre saignement/thrombose. / Aspirin and thienopyridine are the therapy for patients with percutaneous coronary intervention after ACS. The level of platelet inhibition by thienopyridine varies between patients, this variability, multifactorial, is associated with adverse clinical outcomes. Treatment efficacy was evaluated mainly on the association between poor thienopyridine response and thrombotic events but less on the principal side effect: bleeding complications. Platelet play a key role in atherosclerosis and thrombosis, notably via CD40L.I studied platelet factors that influence the bleeding risk in these patients and brought a new highlight on platelet function less known such as inflammation.P450 cytochrome genetic variants (2C19*2 and 2C19*17) influence platelet response to thienopyridines. There is a relation between platelet reactivity and bleeding events. A very low on-treatment platelet reactivity (VASP<10 %) is a predictor of bleeding and is mainly observed with prasugrel treatment. We then focussed on a marker of platelet inflammatory status, CD40L. Its release by platelets depends on P2Y12 signalling, whereas its surface expression is less dependent on this signalling pathway. A low platelet-CD40L surface expression is associated with bleeding events in these patients We show that genetic background on thienopyridine treatment efficacy is related to bleeding risk and that other platelet parameters influence the bleeding risk independently of platelet aggregation inhibition. Thus, a molecule of inflammation, CD40L, would be a link between inflammation and bleeding/thrombosis equilibrium.

Bei Anwendung reversibler Betäubungsmethoden erfolgt die Tötung von Schlachttieren durch Blutentzug. Findet dieser nicht oder nicht in ausreichendem Maße statt, besteht die Gefahr, dass die Tiere ihre Wahrnehmungs- und Empfindungsfähigkeit wiedererlangen, bevor sie weiteren Verarbeitungsschritten zugeführt werden. Dies ist aus Tierschutzsicht keinesfalls hinnehmbar und steht im Widerspruch sowohl zum Tierschutzschlachtrecht, als auch zu Verbrauchererwartungen im Hinblick auf einen tierschutzgerechten Schlachtablauf. Es ist deshalb dringend erforderlich den Todeseintritt jedes Einzeltieres zu verifizieren. Dies kann durch direkte Kontrolle der Schlachttiere (klinische Untersuchung, Prüfung der Hirnstammreflexe) nach Eintritt des Todes erfolgen oder bereits frühzeitiger, über eine Erfassung von Parametern, die eine Aussage über die Wahrscheinlichkeit des kurz bevorstehenden Todeseintritts erlauben (TROEGER 2011). Hierfür eignet sich insbesondere die Stichblutmenge, bzw. die Blutflussrate, da ab einer bestimmten Blutmenge pro Zeiteinheit vom kurz bevorstehenden Tod des Tieres ausgegangen werden kann (TROEGER 2010). Zielsetzung dieser Arbeit war zum einen, ein geeignetes Messsystem zur Erfassung des Entbluteverlaufs zu finden und dieses in das Stechkarussell zu integrieren, zum anderen sollte der Zusammenhang zwischen Stichblutmengenanstieg und Todeseintritt der Tiere untersucht werden. In einem ersten Schritt wurden vier verschiedene Messsysteme zur Erfassung des Entbluteverlaufs unter Zuhilfenahme eines Prototyps geprüft: Stichblutwaage (Fa. Bizerba), Füllstandsmesssonde (Fa. Sick), Infrarotkamera „thermoIMAGER TIM“ (Fa. Micro-Epsilon) und Infrarotsensoren „thermoMETER CSmicro“ (Fa. Micro-Epsilon). Als Messparameter und Maß für die Qualität der Entblutung bzw. des Entblutestichs, wurde die Steigung des Blutanstiegs im Blutauffangbehälter verwendet. Das Messsystem „Infrarotsensoren“ erwies sich als am besten geeignetes System und wurde nachfolgend in die Stechkarussellanlage des Partnerschlachthofes integriert und der Messvorgang automatisiert. Um den Zusammenhang zwischen Stichblutmengenanstieg und Todeseintritt der Schweine auf der Nachentblutestrecke zu untersuchen, wurde der Entbluteverlauf in den ersten Sekunden nach dem Stich sowohl mit dem Prototyp (Messsystem Waage) als auch mit dem integrierten IR-Sensor-Messsystem bei einer Stichprobe von 1034 (Prototyp) bzw. 1500 (integriertes System) Schweinen erfasst und anschließend der Eintritt des Hirntodes der Tiere klinisch überprüft (u.a. Untersuchung der Hirnstammreflexe). Im Rahmen eines Vorversuchs wurde eine Status quo-Erhebung von Stichblutmenge- und anstieg durchgeführt und die ersten fünf Sekunden nach dem Entblutestich als geeigneter Messzeitraum festgelegt. Es konnte gezeigt werden, dass der Anstieg der Entblutekurve in diesem Zeitraum annähernd linear verläuft, unabhängig von Lebendgewicht und Geschlecht der Tiere ist, und zudem eine gewisse Voraussage über den weiteren Verlauf der Entblutung bzw. die am Ende der Entblutung absolut entzogene Blutmenge zulässt. In der Hauptuntersuchung waren bei keinem Tier deutliche Anzeichen für Empfindungs- und Wahrnehmungsvermögen (gerichtete Augenbewegungen, Vokalisation) vorhanden. 3,6 Prozent (Prototyp-Untersuchung) bzw. 3,7 Prozent (integriertes IR-Sensor-Messsystem) der Tiere zeigten jedoch bei der Verifizierung des Todeseintritts noch bzw. wieder Reaktionen, die zumindest auf eine gewisse (Rest-)Hirnfunktion hindeuteten. Ein signifikanter Zusammenhang zwischen Steigung der Entblutekurve und nachfolgendem Todeseintritt der Tiere konnte weder in der Untersuchung mit dem Prototyp, noch in der Untersuchung mit dem integrierten IR-Sensor-Messsystem dargestellt werden. Die Ursache dafür wird in einer Beeinflussung der Ergebnisse durch tierindividuell unterschiedliche Betäubungstiefen vermutet (irreversibel betäubte Tiere, deren Entblutekurven eine geringe Steigung aufwiesen, die aber trotzdem keine Reaktionen auf der Nachentblutestrecke zeigten). Im Rahmen der vorliegenden Arbeit wurde ein vollständig automatisiertes, mit herkömmlichen Stechkarussellanlagen kompatibles, Entblutekontrollsystem auf Grundlage der Infrarotsensor-Technik entwickelt. Durch die Fokussierung auf die ersten fünf Sekunden nach Setzen des Entblutestichs, ist das Ergebnis bereits verfügbar, wenn sich die Tiere noch in der Reichweite des Stechpersonals befinden, wodurch eine sofortige Nachbearbeitung betroffener Schweine, ohne zusätzlichen Personaleinsatz, ermöglicht wird. Weiterhin erlaubt das berührungslos arbeitende System eine Einzeltierkontrolle, inklusive automatischer Dokumentation der Entblutedaten, bei der sowohl unzureichend als auch versehentlich überhaupt nicht entblutete Schweine erkannt werden. Die Entwicklung des automatisierten Entblutekontrollsystems trägt dazu bei, den Tierschutz bei der Schweineschlachtung zu verbessern und gesetzliche Vorgaben sowie Verbrauchererwartungen im Hinblick auf tierschutzgerechte Fleischgewinnung als Teil der Lebensmittelqualität zu erfüllen.