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Submitted by jose de souza andrade neto andrade (neto.jsa@hotmail.com) on 2018-01-09T15:51:07Z No. of bitstreams: 1 José Andrade Neto - Doutorado em Anestesiologia.pdf: 670032 bytes, checksum: b5c727b9c523ebb565c09234ac9ba901 (MD5) / Approved for entry into archive by Luciana Pizzani null (luciana@btu.unesp.br) on 2018-01-10T12:53:05Z (GMT) No. of bitstreams: 1 andrade neto_js_doc_int.pdf: 670032 bytes, checksum: b5c727b9c523ebb565c09234ac9ba901 (MD5) / Made available in DSpace on 2018-01-10T12:53:05Z (GMT). No. of bitstreams: 1 andrade neto_js_doc_int.pdf: 670032 bytes, checksum: b5c727b9c523ebb565c09234ac9ba901 (MD5) Previous issue date: 2017-10-16 / Introdução: a lesão renal aguda (LRA) é prevalente em pacientes hospitalizados e responsável por alta morbimortalidade. No entanto, ainda não há um marcador precoce e acurado para seu diagnóstico. Pacientes idosos estão em risco de desenvolver LRA no pós-operatório de grandes cirurgias. Objetivos: avaliar o biomarcador cistatina C plasmática como preditor precoce de LRA no período pós-operatório de cirurgia para correção de fratura de fêmur em idosos. Método: cinquenta e nove pacientes idosos submetidos à cirurgia de correção de fratura de fêmur foram estudados prospectivamente por 48 horas do pós-operatório. Amostras de sangue foram coletadas para análise de cistatina C plasmática nos seguintes tempos: logo ao término da cirurgia, no período de 4 e 24 horas depois. Amostras da creatinina foram coletadas na admissão hospitalar, ao término da cirurgia, 4, 24 e 48 horas no pós-operatório. Para a determinação do diagnóstico e estadiamento de LRA foi utilizado o critério KDIGO (Kidney Disease Improve Global Outcomes Acute Kidney Injury Workgroup). Foi analisada a precocidade e acurácia, esta última por meio da área sob a curva receiver operating characteristic (AUC ROC), da molécula de cistatina C plasmática para diagnóstico de LRA (KDIGO ≥1). Resultados: vinte e um pacientes (35,5%) apresentaram LRA. A cistatina C plasmática foi um marcador precoce de LRA elevando-se 4 horas após o fim da cirurgia (p < 0,003). Obteve uma AUC ROC em 4 horas de 0,750 (IC 95% de 0,610 a 0,860) e de 0,778 (IC 95% de 0,640 a 0,870) em 24 horas do pós-operatório. Conclusão: a molécula de cistatina C plasmática é um marcador precoce e com boa acurácia (apresentou AUC ROC > 0,70) para LRA, além de possuir elevado valor preditivo negativo para o ponto de corte de 0,92mg/L após 4 horas do término da cirurgia.

La prédiction du devenir du greffon et de sa survie permettrait d’optimiser la prise en charge des patients transplantés. Le suivi des patients transplantés rénaux inclue des mesures répétées de marqueurs longitudinaux tels que la créatinine sérique et l’exposition aux médicaments immunosuppresseurs. L’approche statistique récemment proposée des modèles conjoints permet d’analyser la relation entre un processus longitudinal et la survenue d’un événement clinique. Dans la première partie de ce travail de thèse, nous avons utilisé les modèles conjoints à classes latentes pour étudier l’impact du profil de créatinine sérique au cours des 18 premiers mois post-greffe sur la survie du greffon à long terme. Dans la cohorte étudiée, trois groupes homogènes caractérisés par une trajectoire spécifique de l’évolution de la créatinine sérique en fonction du temps et un risque d’échec de greffe spécifique ont été identifiés. Les probabilités individuelles de l’échec de greffe pendant les 10 premières années post-transplantation ont été calculées sur la base du modèle conjoint développé. Chez les patients qui n’avaient pas développé d’anticorps anti-HLA spécifiques du donneur, le risque d’échec de greffe en fonction du temps était prédit avec un niveau de performance satisfaisant en termes de spécificité, sensibilité et précision.L’utilité clinique de cet outil devra être évaluée avec une approche dynamique. Dans une seconde partie, les modèles non linéaires à effets mixtes combinés avec l’approche des modèles de mélange a été utilisée pour analyser (i) l’association entre la variabilité de l’exposition au tacrolimus au cours du temps et l’adhésion au traitement rapportée par le patient et (ii) l’impact de cette variabilité d’exposition sur le risque de rejet aigu. Ce modèle a montré un effet significatif de la variabilité de l’exposition au cours du temps du tacrolimus sur la survenu de rejet aigu au-delà de 3 mois post-transplantation. Au contraire, aucune association entre l’adhésion et la variabilité de l’exposition au tacrolimus d’une part, et le risque de rejet aigu d’autre part n’a été observée dans cette étude qui n’incluait que des patients modérément non-adhérents. Ce résultat pose la question de l’impact d’une non adhésion modérée sur le devenir du greffon. / Prediction of graft outcome would be useful to optimize patient care. Follow-up of kidneytransplant patients include repeated measurements of longitudinal markers, such as serum creatinine and immunosuppressive drug exposure. Recently proposed joint models areappropriate to analyze relationship between longitudinal processes and time-to-event data. In the first part of present work, we used the approach of joint latent class mixed models tostudy the impact of time-profiles of serum creatinine collected within the first 18 months after kidney transplantation on long-term graft survival. The studied cohort was parted into three homogenous classes with a specific time-evolution of serum creatinine and a specific risk of graft failure. The individual predicted probabilities of graft failure up to 10 years posttransplantation, calculated from this joint model were satisfying in terms of sensitivity, specificity and overall accuracy, for patients who had not developed de novo donor specificanti-HLA antibodies. The clinical usefulness of developed predictive tooI needs to beevaluated with a dynamic approach. In the second part, non-linear mixed effects models witha mixture of distribution for random effects were used to investigate (i) the associationbetween variability over time of tacrolimus exposure and self-reported drug adherence and(ii) the impact of this variability on the acute rejection risk. This model found a significantimpact of tacrolimus time-exposure variability on acute rejection onset beyond 3 months posttransplantation. On the contrary, no association between adherence and (i) variability oftacrolimus time-exposure and (ii) acute rejection was observed in our study which included moderate non-adherent patients only. This result questions the impact of moderate nonadherence on graft outcome.

Foi realizado um estudo de farmacocinética da polimixina B em pacientes críticos com desenvolvimento de um modelo populacional. Os critérios de inclusão foram pacientes internados em Unidade de Terapia Intensiva, com idade igual ou superior a 18 anos e em uso de polimixina B intravenosa por um período mínimo de 48 horas. Amostras de sangue, urina e dialisato foram coletadas durante um intervalo de doses no estado de equilíbrio. A concentração de polimixina B no plasma foi medida por meio de cromatografia líquida de alta performance associada à espectrometria de massas acoplada à espectrometria de massas, sua ligação às proteínas plasmáticas foi determinada por meio de diálise de equilíbrio rápido e a fração livre foi calculada. Foram realizadas análise farmacocinética populacional e Simulações de Monte Carlo. Foram incluídos 24 pacientes, dos quais dois estavam em hemodiálise contínua; 54,2% eram do sexo masculino e as medianas da idade, do escore APACHE e do peso corporal total foram de 61,5 anos, 21,5 e 62,5kg, respectivamente. As doses de polimixina B, conforme prescrição do médico assistente, variaram entre 0,45-3,38mg/kg/dia. O clearance estimado da creatinina nos 22 pacientes sem hemodiálise variou entre 10-143mL/min. A mediana da fração livre plasmática da polimixina B foi de 0,42 e a média (± desvio padrão) da fração livre da área sob a curva ao longo de um dia (fAUC0-24h) da polimixina B foi de 29,2±12,0mg•h/L, incluindo os pacientes em hemodiálise. A polimixina B foi excretada predominantemente por vias não renais e as medianas de sua recuperação urinária de forma inalterada foi de 4,04% e do seu clearance renal foi de 0,061L/hora. Nos pacientes 1 e 2 em hemodiálise foram identificados, respectivamente, clearance corporal total de 0,043 e 0,027L/h/kg, clearance da hemodiálise de 0,0052 e 0,0015L/h/kg; no dialisato foram recuperados 12,2% e 5,62% da dose como polimixina B não modificada. O clearance corporal total da polimixina B não mostrou nenhuma relação com o clearance da creatinina, escore APACHE II ou idade. A disposição da polimixina B no tempo foi adequadamente descrita pelo modelo de dois compartimentos com eliminação linear. O modelo farmacocinético populacional proporcionou ajustes excelentes para os perfis observados de concentração-tempo para pacientes individuais e as concentrações individuais e populacionais ajustadas foram precisas. O ajuste dos clearances e dos volumes de distribuição para o peso corporal total reduziu a variabilidade intersujeitos em 3,4% para o clearance e 41,7% para o volume de distribuição central; nos pacientes em diálise, após esse ajuste, os parâmetros estimados se assemelharam aos dos demais pacientes. As Simulações de Monte Carlo foram feitas com seis diferentes regimes de doses clinicamente relevantes escalonados pelo peso corporal total. O regime de doses de 1,5mg/kg 12/12h forneceu uma AUC0-24h de polimixina B no dia 4 de 90.4mg•hora/L para 50% dos pacientes, adequada para erradicação bacteriana em infecções graves por Pseudomonas aeruginosa ou Acinetobacter baumannii com concentração inibitória mínima para a polimixina B ≤2mg/L. Nas Simulações de Monte Carlo também foi possível identificar que uma melhor área sob a curva só foi atingida no dia 4 de tratamento. Este estudo mostrou que a dose de polimixina B intravenosa deve ser ajustada ao peso corporal total, que o melhor regime de doses é o de 1,5mg/kg 12/12h precedido de dose de ataque de 2,5mg/kg e que não há indicação de ajuste para a função renal, mesmo em pacientes em hemodiálise contínua. / A polymyxin B pharmacokinetics study in critically ill patients was conducted with the development of a population modeling. The inclusion criteria were patients from Intensive Care Unit, aged ≥18 years who received intravenous polymyxin B for ≥ 48 hours. Blood, urine and dialysate samples were collected over a dosing interval at steady state. Polymyxin B concentrations was measured by liquid chromatography- tandem mass spectrometry, its plasma protein binding was determined by rapid equilibrium dialysis and unbound fraction was calculated. Population pharmacokinetic analysis and Monte Carlo Simulations were conducted. Twenty four patients were enrolled, two of whom on continuous hemodialysis; 54.2% were male; the median of age, APACHE II score and total body weight were 61.5years, 21.5 and 62.5kg, respectively. The physician-selected dose of polymyxin B was 0.45- 3.38mg/kg/day. The creatinine clearance of the 22 patients without hemodialysis ranged from 10 to 143mL/min. The median unbound fraction in plasma of polymyxin B was 0.42 and the mean (± standard deviation) of the area under the curve over a day for unbound (fAUC0-24h) polymyxin B was 29.2±12.0mg•hour/L, including hemodialysis patients. Polymyxin B was predominantly nonrenally cleared with median unchanged urinary recovered of 4.04%; the median renal clearance was 0.061L/hour. Patients 1 and 2 in hemodialysis presented, respectively, total body clearance of 0.043 and 0.027L/h/kg, hemodialysis clearance of 0.0052 and 0.0015L/h/kg; 12.2% and 5.62% of the polymyxin dose were recovered intact in the dialysate. Polymyxin B total body clearance did not show any relationship with creatinine clearance, APACHE II score, or age. The time course of polymyxin B concentrations was well described by a 2-compartment disposition model with linear elimination. The population pharmacokinetics model provided excellent fits to the observed concentration-time profiles for individual patients and the individual-fitted and population-fitted concentrations were adequately precise. Linear scaling of clearances and volumes of distribution by total body weight reduced the between subject variability in 3.4% for clearance and 41.7% for the central volume of distribution; after this scaling, the estimated parameters in hemodialysis patients were within the range of estimates from the other patients. The population mean of the total body clearance of polymyxin B when scaled by total body weight (0.0276L/hour/kg) showed remarkably low interindividual variability. The Monte Carlo Simulations were performed for six different clinically relevant dosage regimens scaled by total body weight. The regimen of 1.5mg/kg/12 hours provided an AUC0- 24h of polymyxin B of 90.4 mg•h/L in day 4 for 50% of patients which is appropriate considering severe infections by Pseudomonas aeruginosa or Acinetobacter baumannii with minimal inhibitory concentration for polymyxin B ≤2mg/L. In Monte Carlo Simulations we also identified that the best area under the curve was attained only in the day 4 of the treatment. This study showed that doses of intravenous polymyxin B are best scaled by total body weight, that the best regimen of doses is 3mg/kg/day with a loading dose of 2.5mg/kg and that its dosage selection should not be based on renal function, even in patients in continuous hemodialysis.

Made available in DSpace on 2015-03-26T13:46:45Z (GMT). No. of bitstreams: 1 texto completo.pdf: 246842 bytes, checksum: f7b7371c8cb299837b636e055567a1b8 (MD5) Previous issue date: 2005-03-02 / This trial was carried out to evaluate the effect of periods of urine and feces collection on urinary excretion of creatinine, urea and purine derivatives, absorbed purine, microbial nitrogen compounds production (Nmic), apparent digestibility of dry matter (DM), organic matter (OM), crude protein (CP), ether extract (EE), neutral detergent fiber (NDF) and nonfiber carbohydrates (CNF) and total digestible nutrients contents (TDN) of Nelore bovines four categories (heifers, steers, bulls and lactating cows) fed 25 or 50% concentrate, total dry matter basis. The plasma N-urea concentrations (NUP) were evaluated and the Nmic obtained in urine spot samples was compared with that of total collection. The experiment was divided in two experimental periods of 28 days each, when the feces and urine total collection were performed at 22nd and 28th day of each experimental period. Feces were colleted directly from the floor after excretion and the urine was obtained using catheters in females and funnels in males. A 25% concentrate-based diet was fed to the animals in the first period and a 50% concentrate-based diet in the second one, all of them with 12% CP. Sixteen Nelore bovines, under feedlot, housed in individual pens, were assigned to a completely randomized design, in a split plot scheme, where the treatments were represented by the plots (2 x 4 factorial scheme), with two levels of concentrate (25 or 50%) and four Nelore categories, and the split plots were represented by the urine collections. The comparisons for digestibility evaluation were made by regression analyses, that were performed considering 4 days of feces collection of each period. The equations were obtained by comparing the nutrients digestibility referent to one (24h), two (48h) or three days (72h) compared to four days (96h of collection). Comparison with six days of total feces collection, using equations (second experimental period [50% concentrate]) was considered reference (144h total feces collection). No interaction (P>0.05) among concentrate levels, Nelore categories and collection days for the urinary volume, the creatinine excretion and Nmic production was observed. Urinary volume was not affected (P>0.05) by the concentrate levels and collection days, but significant effect (P<0.05) was observed for cows. Creatinine excretion was not affected (P>0.05) by treatments and collection days, considering average of 27.1 mg/kg0.75. Absorbed purines and microbial nitrogen compounds production were also not influenced (P>005) by the treatments and collection days. Nmic production estimated by the urinary spot collection differed (P>0.05) neither from that obtained by total collection total, nor among the concentrate levels and Nelore categories. No significant difference (P>0.05) was observed for any evaluated digestibility and TDN contents during the total feces collection period. The results suggest that the coefficients of variation decresed as the period of collection days increased. Considering the results of creatinine excretion and of microbial protein production, it was concluded that a 24-h period is enough for researchs with Nelore, independently of the category, and that urinary spot sample collection can be used to estimate microbial protein production in all Nelore bovines (heifers, steers, bulls and lactating cows). Total feces collection from 1 to 6 days to evaluate nutrients apparent digestibility are precise, but better results could be obtained by increasing the collection period. / O presente trabalho foi conduzido com o objetivo de avaliar o efeito da duração do período de coletas de urina e de fezes sobre a excreção urinária de creatinina, de uréia e de derivados de purinas, as purinas absorvidas, a produção de compostos nitrogenados microbianos (Nmic), as digestibilidades aparentes da matéria seca (MS), matéria orgânica (MO), proteína bruta (PB), extrato etéreo (EE), fibra em detergente neutro (FDN) e de carboidratos não-fibrosos (CNF) e os teores de nutrientes digestíveis totais (NDT) em Nelores de quatro categorias (novilhas, machos castrados, machos inteiros e vacas em lactação) alimentados com 25 ou 50% de concentrado na base da matéria seca total das dietas. Avaliou-se ainda as concentrações de N-uréia plasmática (NUP) e comparou-se também a produção de Nmic obtida em amostras spot de urina com aquela da coleta total. O experimento foi conduzido em dois períodos experimentais com duração de 28 dias cada, sendo as coletas totais de urina e de fezes efetuadas do 22o ao 28o dias de cada período experimental. As fezes foram retiradas do piso imediatamente após excreção e a urina obtida com sondas em fêmeas e funis nos machos. Utilizou-se dieta com 25% de concentrado no primeiro período e com 50% no segundo experimental. Todas as dietas continham aproximadamente 12% de PB. Utilizaram-se 16 animais da raça Nelore, mantidos em confinamento, alojados em baias individuais, distribuídos em delineamento inteiramente casualizado, em esquema de parcelas subdivididas, tendo nas parcelas os tratamentos em esquema fatorial 2 x 4, sendo dois níveis de concentrado (25 ou 50%) e quatro categorias de Nelores e nas subparcelas os seis dias de coletas de urina. Já para a avaliação das digestibilidades, as comparações foram feitas através de análises de regressão, que foram efetuadas considerando quatro dias de coletas de fezes em cada período, sendo as equações obtidas sempre comparando as digestibilidades dos nutrientes referentes a um dia (24 h), 2 dias (48 h) ou 3 dias (72 h) em relação aos 4 dias (96 h de coleta). Foram feitas também comparações através de equações, utilizando os seis dias de coleta total de fezes, referentes ao segundo período experimental (50% de concentrado), sendo nesse caso utilizado como referência os seis dias de coleta total (144 h de coleta total de fezes). Não houve interação (P>0,05) entre níveis de concentrado, categorias de Nelore e dias de coleta para o volume urinário, a excreção de creatinina e a produção de Nmic. O volume urinário não foi influenciado (P>0,05) pelos níveis de concentrado e dias de coleta, contudo foi significativamente maior (P<0,05) para as vacas. A excreção de creatinina não foi afetada (P>0,05) pelos tratamentos e dias de coletas, observando-se média de 27,1 mg/kg0,75. As purinas absorvidas e a produção de compostos nitrogenados microbianos também não foram influenciadas (P>0,05) pelos tratamentos e dias de coleta. A produção de Nmic estimada através de amostra spot de urina não diferiu (P>0,05) daquela obtida pela coleta total, nem entre os níveis de concentrados e categorias de Nelore. Não houve diferença significativa (P>0,05) para nenhuma das digestibilidades avaliadas e também para os teores de NDT entre os dias de coleta total de fezes, contudo, observou-se que os coeficientes de variação diminuíram à medida que se aumentou o número de dias de coleta. Concluiu-se considerando as respostas obtidas para excreção de creatinina e a produção de proteína microbiana, que um período de coletas de urina de 24 horas é suficiente para trabalhos com Nelores, independente de serem novilhas, machos castrados ou inteiros e vacas em lactação e que a coleta de amostra spot de urina também pode ser utilizada para estimar a produção de proteína microbiana em novilhas, machos inteiros ou castrados e vacas lactantes da raça Nelore. Concluiu-se também que para avaliar a digestibilidade aparente dos nutrientes, coletas totais de fezes feitas durante um a seis dias são exatas. Contudo, a precisão é melhorada com o aumento dos dias de coleta.

This thesis provides an appraisal of the structure of clustering of metabolic phenotypes and evaluates the pathophysiological mechanisms underlying the relationship between urinary uric acid and albumin excretion. Two population-based studies were involved. In the first part, we used data obtained in a large representative cross-sectional survey in the Czech Republic (Czech post-MONICA study). We showed that the urinary albumin/creatinine ratio (uACR) was an independent factor for an increase in serum uric acid (SUA) levels in adults without manifest metabolic syndrome (MetS), but with 1-2 MetS component(s). Furthermore, SUA levels increased by the synergistic interaction of uACR with visceral adiposity and blood pressure, which may suggest obesity-related hypertension with altered renal hemodynamics as the primary mechanism. In the second part, we analyzed data captured in a representative population sample of French Canadians (CARTaGENE study) with more detailed urine biochemical analyses available. This study yielded two novel observations. First, we showed that the rs13129697 major T allele, which has been associated with increased SUA levels in our analysis as well as in prior publications, was associated with a paradoxical decrease in uACR. The reason for this discrepant finding is the...

Foi realizado um estudo de farmacocinética da polimixina B em pacientes críticos com desenvolvimento de um modelo populacional. Os critérios de inclusão foram pacientes internados em Unidade de Terapia Intensiva, com idade igual ou superior a 18 anos e em uso de polimixina B intravenosa por um período mínimo de 48 horas. Amostras de sangue, urina e dialisato foram coletadas durante um intervalo de doses no estado de equilíbrio. A concentração de polimixina B no plasma foi medida por meio de cromatografia líquida de alta performance associada à espectrometria de massas acoplada à espectrometria de massas, sua ligação às proteínas plasmáticas foi determinada por meio de diálise de equilíbrio rápido e a fração livre foi calculada. Foram realizadas análise farmacocinética populacional e Simulações de Monte Carlo. Foram incluídos 24 pacientes, dos quais dois estavam em hemodiálise contínua; 54,2% eram do sexo masculino e as medianas da idade, do escore APACHE e do peso corporal total foram de 61,5 anos, 21,5 e 62,5kg, respectivamente. As doses de polimixina B, conforme prescrição do médico assistente, variaram entre 0,45-3,38mg/kg/dia. O clearance estimado da creatinina nos 22 pacientes sem hemodiálise variou entre 10-143mL/min. A mediana da fração livre plasmática da polimixina B foi de 0,42 e a média (± desvio padrão) da fração livre da área sob a curva ao longo de um dia (fAUC0-24h) da polimixina B foi de 29,2±12,0mg•h/L, incluindo os pacientes em hemodiálise. A polimixina B foi excretada predominantemente por vias não renais e as medianas de sua recuperação urinária de forma inalterada foi de 4,04% e do seu clearance renal foi de 0,061L/hora. Nos pacientes 1 e 2 em hemodiálise foram identificados, respectivamente, clearance corporal total de 0,043 e 0,027L/h/kg, clearance da hemodiálise de 0,0052 e 0,0015L/h/kg; no dialisato foram recuperados 12,2% e 5,62% da dose como polimixina B não modificada. O clearance corporal total da polimixina B não mostrou nenhuma relação com o clearance da creatinina, escore APACHE II ou idade. A disposição da polimixina B no tempo foi adequadamente descrita pelo modelo de dois compartimentos com eliminação linear. O modelo farmacocinético populacional proporcionou ajustes excelentes para os perfis observados de concentração-tempo para pacientes individuais e as concentrações individuais e populacionais ajustadas foram precisas. O ajuste dos clearances e dos volumes de distribuição para o peso corporal total reduziu a variabilidade intersujeitos em 3,4% para o clearance e 41,7% para o volume de distribuição central; nos pacientes em diálise, após esse ajuste, os parâmetros estimados se assemelharam aos dos demais pacientes. As Simulações de Monte Carlo foram feitas com seis diferentes regimes de doses clinicamente relevantes escalonados pelo peso corporal total. O regime de doses de 1,5mg/kg 12/12h forneceu uma AUC0-24h de polimixina B no dia 4 de 90.4mg•hora/L para 50% dos pacientes, adequada para erradicação bacteriana em infecções graves por Pseudomonas aeruginosa ou Acinetobacter baumannii com concentração inibitória mínima para a polimixina B ≤2mg/L. Nas Simulações de Monte Carlo também foi possível identificar que uma melhor área sob a curva só foi atingida no dia 4 de tratamento. Este estudo mostrou que a dose de polimixina B intravenosa deve ser ajustada ao peso corporal total, que o melhor regime de doses é o de 1,5mg/kg 12/12h precedido de dose de ataque de 2,5mg/kg e que não há indicação de ajuste para a função renal, mesmo em pacientes em hemodiálise contínua. / A polymyxin B pharmacokinetics study in critically ill patients was conducted with the development of a population modeling. The inclusion criteria were patients from Intensive Care Unit, aged ≥18 years who received intravenous polymyxin B for ≥ 48 hours. Blood, urine and dialysate samples were collected over a dosing interval at steady state. Polymyxin B concentrations was measured by liquid chromatography- tandem mass spectrometry, its plasma protein binding was determined by rapid equilibrium dialysis and unbound fraction was calculated. Population pharmacokinetic analysis and Monte Carlo Simulations were conducted. Twenty four patients were enrolled, two of whom on continuous hemodialysis; 54.2% were male; the median of age, APACHE II score and total body weight were 61.5years, 21.5 and 62.5kg, respectively. The physician-selected dose of polymyxin B was 0.45- 3.38mg/kg/day. The creatinine clearance of the 22 patients without hemodialysis ranged from 10 to 143mL/min. The median unbound fraction in plasma of polymyxin B was 0.42 and the mean (± standard deviation) of the area under the curve over a day for unbound (fAUC0-24h) polymyxin B was 29.2±12.0mg•hour/L, including hemodialysis patients. Polymyxin B was predominantly nonrenally cleared with median unchanged urinary recovered of 4.04%; the median renal clearance was 0.061L/hour. Patients 1 and 2 in hemodialysis presented, respectively, total body clearance of 0.043 and 0.027L/h/kg, hemodialysis clearance of 0.0052 and 0.0015L/h/kg; 12.2% and 5.62% of the polymyxin dose were recovered intact in the dialysate. Polymyxin B total body clearance did not show any relationship with creatinine clearance, APACHE II score, or age. The time course of polymyxin B concentrations was well described by a 2-compartment disposition model with linear elimination. The population pharmacokinetics model provided excellent fits to the observed concentration-time profiles for individual patients and the individual-fitted and population-fitted concentrations were adequately precise. Linear scaling of clearances and volumes of distribution by total body weight reduced the between subject variability in 3.4% for clearance and 41.7% for the central volume of distribution; after this scaling, the estimated parameters in hemodialysis patients were within the range of estimates from the other patients. The population mean of the total body clearance of polymyxin B when scaled by total body weight (0.0276L/hour/kg) showed remarkably low interindividual variability. The Monte Carlo Simulations were performed for six different clinically relevant dosage regimens scaled by total body weight. The regimen of 1.5mg/kg/12 hours provided an AUC0- 24h of polymyxin B of 90.4 mg•h/L in day 4 for 50% of patients which is appropriate considering severe infections by Pseudomonas aeruginosa or Acinetobacter baumannii with minimal inhibitory concentration for polymyxin B ≤2mg/L. In Monte Carlo Simulations we also identified that the best area under the curve was attained only in the day 4 of the treatment. This study showed that doses of intravenous polymyxin B are best scaled by total body weight, that the best regimen of doses is 3mg/kg/day with a loading dose of 2.5mg/kg and that its dosage selection should not be based on renal function, even in patients in continuous hemodialysis.

abstract: A mule deer herd exists on the northern rim of the Grand Canyon, located on the North Kaibab Plateau. Historical references to this indigenous mule deer herd presented reports of periodic population irruption and collapse. Partially funded by the Arizona Game and Fish Department and the Arizona Deer Association, examination of herd nutritional and metabolic status from the Fall 2005 - Spring 2008 was completed at the request of AzGFD and ADA. Habitat analysis included forage micro-histological, protein, and caloric content plus whole blood and plasma assays gauging herd metabolic response. Modelling was completed using best management practices wildlife energy demand calculations and principal component analysis. Forage quality analysis and modelling suggest a sufficient amount of nitrogen (N) available (DPI) to the deer for protein synthesis. Energy analysis (MEI) of forage suggest caloric deficiencies are widely prevalent on the north Kaibab plateau. Principal component analysis integrates forage and metabolic results providing a linear regression model describing the dynamics of forage utilization, energy availability, and forage nitrogen supply with metabolic demand and response of the mule deer herd. Most of the plasma and blood metabolic indicators suggest baseline values for the North Kaibab mule deer. Albumin values are in agreement with albumin values for mule deer in the Southwest. I suggest that the agreed values become a standard for mule deer in the Southwestern U.S. As excess dietary N is converted to a caloric resource, a continual state of under-nutrition exists for the deer upon entering the N. Kaibab winter range. The population is exceeding the nutritional resource plane that the winter habitat provides. Management recommendations include implementation of multiple small-scale habitat rehabilitation efforts over time, including invasive juniper (Juniperous osteosperma) and piñon (Pinus edulis) management, prescribed burning to control big sage (Artemesia tridentata) populations, and reseeding treated areas with a seed mix of native shrubs, grasses and forbs. I recommended that the population size of the North Kaibab deer herd is maintained at the current size with natural selection controlling growth, or the population be artificially reduced through increased hunting opportunities. / Dissertation/Thesis / Ph.D. Environmental Design and Planning 2014

Foi realizado um estudo de farmacocinética da polimixina B em pacientes críticos com desenvolvimento de um modelo populacional. Os critérios de inclusão foram pacientes internados em Unidade de Terapia Intensiva, com idade igual ou superior a 18 anos e em uso de polimixina B intravenosa por um período mínimo de 48 horas. Amostras de sangue, urina e dialisato foram coletadas durante um intervalo de doses no estado de equilíbrio. A concentração de polimixina B no plasma foi medida por meio de cromatografia líquida de alta performance associada à espectrometria de massas acoplada à espectrometria de massas, sua ligação às proteínas plasmáticas foi determinada por meio de diálise de equilíbrio rápido e a fração livre foi calculada. Foram realizadas análise farmacocinética populacional e Simulações de Monte Carlo. Foram incluídos 24 pacientes, dos quais dois estavam em hemodiálise contínua; 54,2% eram do sexo masculino e as medianas da idade, do escore APACHE e do peso corporal total foram de 61,5 anos, 21,5 e 62,5kg, respectivamente. As doses de polimixina B, conforme prescrição do médico assistente, variaram entre 0,45-3,38mg/kg/dia. O clearance estimado da creatinina nos 22 pacientes sem hemodiálise variou entre 10-143mL/min. A mediana da fração livre plasmática da polimixina B foi de 0,42 e a média (± desvio padrão) da fração livre da área sob a curva ao longo de um dia (fAUC0-24h) da polimixina B foi de 29,2±12,0mg•h/L, incluindo os pacientes em hemodiálise. A polimixina B foi excretada predominantemente por vias não renais e as medianas de sua recuperação urinária de forma inalterada foi de 4,04% e do seu clearance renal foi de 0,061L/hora. Nos pacientes 1 e 2 em hemodiálise foram identificados, respectivamente, clearance corporal total de 0,043 e 0,027L/h/kg, clearance da hemodiálise de 0,0052 e 0,0015L/h/kg; no dialisato foram recuperados 12,2% e 5,62% da dose como polimixina B não modificada. O clearance corporal total da polimixina B não mostrou nenhuma relação com o clearance da creatinina, escore APACHE II ou idade. A disposição da polimixina B no tempo foi adequadamente descrita pelo modelo de dois compartimentos com eliminação linear. O modelo farmacocinético populacional proporcionou ajustes excelentes para os perfis observados de concentração-tempo para pacientes individuais e as concentrações individuais e populacionais ajustadas foram precisas. O ajuste dos clearances e dos volumes de distribuição para o peso corporal total reduziu a variabilidade intersujeitos em 3,4% para o clearance e 41,7% para o volume de distribuição central; nos pacientes em diálise, após esse ajuste, os parâmetros estimados se assemelharam aos dos demais pacientes. As Simulações de Monte Carlo foram feitas com seis diferentes regimes de doses clinicamente relevantes escalonados pelo peso corporal total. O regime de doses de 1,5mg/kg 12/12h forneceu uma AUC0-24h de polimixina B no dia 4 de 90.4mg•hora/L para 50% dos pacientes, adequada para erradicação bacteriana em infecções graves por Pseudomonas aeruginosa ou Acinetobacter baumannii com concentração inibitória mínima para a polimixina B ≤2mg/L. Nas Simulações de Monte Carlo também foi possível identificar que uma melhor área sob a curva só foi atingida no dia 4 de tratamento. Este estudo mostrou que a dose de polimixina B intravenosa deve ser ajustada ao peso corporal total, que o melhor regime de doses é o de 1,5mg/kg 12/12h precedido de dose de ataque de 2,5mg/kg e que não há indicação de ajuste para a função renal, mesmo em pacientes em hemodiálise contínua. / A polymyxin B pharmacokinetics study in critically ill patients was conducted with the development of a population modeling. The inclusion criteria were patients from Intensive Care Unit, aged ≥18 years who received intravenous polymyxin B for ≥ 48 hours. Blood, urine and dialysate samples were collected over a dosing interval at steady state. Polymyxin B concentrations was measured by liquid chromatography- tandem mass spectrometry, its plasma protein binding was determined by rapid equilibrium dialysis and unbound fraction was calculated. Population pharmacokinetic analysis and Monte Carlo Simulations were conducted. Twenty four patients were enrolled, two of whom on continuous hemodialysis; 54.2% were male; the median of age, APACHE II score and total body weight were 61.5years, 21.5 and 62.5kg, respectively. The physician-selected dose of polymyxin B was 0.45- 3.38mg/kg/day. The creatinine clearance of the 22 patients without hemodialysis ranged from 10 to 143mL/min. The median unbound fraction in plasma of polymyxin B was 0.42 and the mean (± standard deviation) of the area under the curve over a day for unbound (fAUC0-24h) polymyxin B was 29.2±12.0mg•hour/L, including hemodialysis patients. Polymyxin B was predominantly nonrenally cleared with median unchanged urinary recovered of 4.04%; the median renal clearance was 0.061L/hour. Patients 1 and 2 in hemodialysis presented, respectively, total body clearance of 0.043 and 0.027L/h/kg, hemodialysis clearance of 0.0052 and 0.0015L/h/kg; 12.2% and 5.62% of the polymyxin dose were recovered intact in the dialysate. Polymyxin B total body clearance did not show any relationship with creatinine clearance, APACHE II score, or age. The time course of polymyxin B concentrations was well described by a 2-compartment disposition model with linear elimination. The population pharmacokinetics model provided excellent fits to the observed concentration-time profiles for individual patients and the individual-fitted and population-fitted concentrations were adequately precise. Linear scaling of clearances and volumes of distribution by total body weight reduced the between subject variability in 3.4% for clearance and 41.7% for the central volume of distribution; after this scaling, the estimated parameters in hemodialysis patients were within the range of estimates from the other patients. The population mean of the total body clearance of polymyxin B when scaled by total body weight (0.0276L/hour/kg) showed remarkably low interindividual variability. The Monte Carlo Simulations were performed for six different clinically relevant dosage regimens scaled by total body weight. The regimen of 1.5mg/kg/12 hours provided an AUC0- 24h of polymyxin B of 90.4 mg•h/L in day 4 for 50% of patients which is appropriate considering severe infections by Pseudomonas aeruginosa or Acinetobacter baumannii with minimal inhibitory concentration for polymyxin B ≤2mg/L. In Monte Carlo Simulations we also identified that the best area under the curve was attained only in the day 4 of the treatment. This study showed that doses of intravenous polymyxin B are best scaled by total body weight, that the best regimen of doses is 3mg/kg/day with a loading dose of 2.5mg/kg and that its dosage selection should not be based on renal function, even in patients in continuous hemodialysis.

Les biocapteurs sont des moyens d'analyse en plein essor à la fois rapides, sélectifs et peu coûteux, applicables à des domaines très variés (environnement, santé, agroalimentaire…). La capacité de reconnaissance moléculaire extraordinaire de biomolécules telles que les enzymes ou les anticorps a été exploitée avec succès pour la réalisation de nombreux biocapteurs. Cependant, l'inconvénient majeur de ces récepteurs biologiques est qu'ils sont difficiles à produire et fragiles. Une manière de surmonter ces inconvénients consiste à les remplacer par des récepteurs artificiels présentant des propriétés de reconnaissance similaires. Parmi les matériaux biomimétiques prometteurs figurent les polymères à empreintes moléculaires (MIPs). Dans ce travail, nous nous sommes intéressés au développement de deux capteurs biomimétiques impédimétriques, le premier basé sur l'utilisation de poly(éthylène co-alcool vinylique) imprimé pour la détection de la créatinine et le deuxième sur des MIPs de polyméthacrylate pour la détection de la testostérone. Dans le premier cas, le polymère imprimé a été produit et déposé à la surface d'électrodes en or, soit par drop-coating, soit sous forme de nanofibres par la technique d'électrofilage. Dans le deuxième, le MIP a été synthétisé par polymérisation radicalaire de l'acide méthacrylique en présence d'éthylèneglycol diméthacrylate (réticulant), d'initiateur et de testostérone en utilisant la méthode du « grafting from » qui consiste à greffer d'abord l'initiateur sur la surface du transducteur mais pour la polymérisation on a utilisé deux approches (spin-coating d'une solution de prépolymérisation sur la surface du transducteur ou l'immersion de ce dernier dans la solution de monomère plus testostérone) suivie de l'exposition à une source d'energie pour effectuer la polymérisation. Les performances des capteurs (limite de détection, sélectivité, reproductibilité) ont ensuite été évaluées / Biosensors are rapid, selective and low-cost analytical devices of growing interest for a wide range of application fields (e.g. environment, food, health). The extraordinary molecular recognition capabilities of sensing biomolecules such as enzymes and antibodies have been successfully exploited in the elaboration of a number of biosensors. However, these biorecognition elements are often produced via complex and costful protocols and require specific handling conditions because of their poor stability. To circumvent these limitations, artificial receptors of similar recognition properties are now proposed as alternatives to natural receptors in sensor technology. Molecular imprinted polymers are among the most promising biomimetic materials reported. In this work, we developed two impedimetric biomimetic sensors. The first one is based on imprinted poly(ethylene co-vinyl alcohol) for creatinine detection and the second on polymethacrylate MIPs for testosterone analysis. In the first case, MIP was produced and deposited onto gold microelectrodes, either by spin-coating of a pre-polymerization solution, or by electrospinning. In the second case, MIPs were synthetized by photopolymerization of methacrylic acid in presence of ethyleneglycoldimethacrylate (cross-linker), an azo-initiator and testosterone as template using the “grafting from” method in which the initiator is first attached to the transducer surface but to effect polymerization we used two different approaches (dip-coating of a prepolymerization solution on the transducer surface functionalized with the initiator or immersing it in the solution of monomers and testosterone) followed by exposure to an energy source to effect polymerization. Then, analytical performances (linear range, detection limit, selectivity and reproducibility) of both creatinine and testosterone sensors were determined and compared