Submitted by Rosivalda Pereira (mrs.pereira@ufma.br) on 2017-07-21T19:09:46Z No. of bitstreams: 1 CiceroAgostinho.pdf: 718364 bytes, checksum: 5b373c12916005349c74311789694b95 (MD5) / Made available in DSpace on 2017-07-21T19:09:46Z (GMT). No. of bitstreams: 1 CiceroAgostinho.pdf: 718364 bytes, checksum: 5b373c12916005349c74311789694b95 (MD5) Previous issue date: 2011-03-31 / The aim of this study was to evaluate the effect of two different concentrations (4 mg and 12 mg) of dexamethasone to control pain, swelling and trismus after third molar surgery inclusos. This clinical study was conducted with 16 adult patients of both sex, displaying mandibular third molar in the same position bilaterally, with an indication for surgical removal. Patients were treated with 4 mg or 12 mg of dexamethasone 1 hour before surgery on the first or second surgery. The choice of which side was operated first and which dose of dexamethasone would be taken first was performed randomly and double blind. The trismus was assessed by measuring the distance interincisal. Pain was assessed by the amount of tablets (paracetamol 750mg) taken after the surgery and the visual analogue pain scale (VAS). These data were obtained before surgery, 24 and 48 hours after surgery. Based on statistical analysis (Student's t test, Wilcoxon and Friedman), the results showed no differences in variables (swelling, pain and trismus) between the two doses of dexamethasone (4mg and 12mg). / O objetivo deste trabalho foi avaliar o efeito de duas concentrações diferentes (4mg e 12mg) de dexametasona no controle da dor, edema e trismo após a cirurgia de terceiros molares inferiores inclusos. Este estudo clínico foi realizado com 27 pacientes adultos, de ambos os sexos, que apresentavam terceiros molares inferiores inclusos na mesma posição bilateralmente, com indicação para remoção cirúrgica. Os pacientes foram medicados com 4mg ou 12mg de dexametasona uma hora antes do procedimento cirúrgico na primeira ou na segunda cirurgia. A escolha de qual lado foi operado primeiro e qual dose de dexametasona seria empregada inicialmente era realizada de forma randomizada e duplo-cega. O trismo foi avaliado pela medida da distância interincisal. A dor foi avaliada mediante a contagem da quantidade de comprimidos (paracetamol 750mg) ingerida após a cirurgia e da Escala Visual Analógica da dor (VAS). Esses dados foram obtidos antes da cirurgia, 24 horas e 48 horas depois do procedimento cirúrgico. Com base na análise estatística (teste t-student, Wilcoxon e Friedman), os resultados não mostraram diferença nas variáveis (edema, dor e trismo) entre as duas doses de dexametasona.

Le TRALI immunologique est un syndrome de détresse respiratoire aiguë rare, provoqué par la présence d’alloanticorps dans les produits transfusés. Il est classiquement étudié au moyen d’un modèle de souris qui reçoivent un anticorps monoclonal contre les molécules d’histocompatibilité de classe I, anti-H-2d. Or les mécanismes qui conduisent au TRALI restent encore largement incompris. Dans ce travail de thèse, je montre que l’inhibition des récepteurs P2X1 à l’ATP et du canal calcique TRPC6, diminue le développement des œdèmes péri-artériolaires pulmonaires lors d’un TRALI, suggérant un rôle des cellules musculaires lisses. Les expériences de déplétions cellulaires spécifiques montrent que les plaquettes et les neutrophiles ne sont pas nécessaires pour l’initiation du TRALI, contrairement à ce qui avait été montré par d’autres équipes. Les monocytes et/ou les macrophages sont par contre indispensables. J’ai aussi développé un modèle de TRALI immunologique utilisant des souris transgéniques pour le récepteur humain FcγRIIA, et un anticorps recombinant muni d’une partie Fc d’IgG1 humaine. Mes travaux montrent que le TRALI est plus sévère dans les souris transgéniques, accompagné d’une activation plus importante des plaquettes et des neutrophiles. Ce modèle permet d’envisager l’étude des mécanismes du TRALI sous un nouvel angle, plus proche de la physiopathologie humaine, ainsi que celle de la contribution des parties Fc des anticorps humains. / Immunological TRALI is a rare acute respiratory distress syndrome induced by the presence of alloantibodies in transfused products. A mouse model using a monoclonal antibody against the major histocompatibility complex class I, anti-H-2d, is usually used to study its mechanisms. Nevertheless, there is a lack in our understanding regarding the course of events. In this thesis, I show that the inhibitions of the ATP-gated receptor P2X1 and of the TRPC6 channel reduce the development of periarteriolar pulmonary edema occurring during TRALI, pointing to a role of smooth muscles cells. Specific cell depletions show that platelets and neutrophils are dispensable for TRALI initiation, in contrast to previous reports. Monocytes and/or macrophages are however necessary. I also developed a model of immune TRALI using transgenic mice expressing the human receptor FcγRIIA, and a recombinant antibody with a human IgG1-Fc fragment. My work reveal a more severe TRALI response in transgenic mice, with enhanced activation of platelets and neutrophils. This model allow a finer study of mechanisms underlying TRALI, moving towards the human actors of the pathology. We can also use this novel approach to assess the contribution of human Fc fragment.

The objective of this study was to investigate the intra-rater (within day & between days) and inter-rater reliability of foot/ankle water volumetry in healthysubjects.Study design: Repeated measures design with 2 raters.Background: Physiotherapists more often aim to reduce swelling in the acute phase of soft tissue injury. Reduction in swelling will hasten the healing process. Therefore swelling forms an important outcome measure that is worth studying during the healing process to determine the efficacy of the intervention. Though there are different methods available to measure extremity swelling, water displacement method is widely used in physiotherapy studies. Although water volumetry has been used to assess the reduction in swelling over time, there is paucity of reliability studies that have assessed the between-days reliability.Methods: Thirty normal subjects with asymptomatic ankles were measured by 2 raters. Three repeated foot volume measurements were performed by each of the rater using water volumetry during a single test session. The same procedure was repeated approximately at the same time on the 3rd day and 5th day following the 1st measurement day by the same raters on the same subjects. The raters were blinded to each other's measurements. The order for rater's volumetric measurement on each subject on each day was determined by a random chart produced by SPSS. The reliability was measured in terms of systematic bias (Paired t test & Bland & Altman's plot), absolute reliability (Limits of Agreement [LOA] & Standard Error of Measurement [SEM]) and relative reliability (Intraclass Correlation Coefficient [ICC]).Results: There was no systematic bias between any of the trials within day/between days or between raters. The intra-rater reliability within day as calculated by ICC; LOA and SEM were 0.99, ±10ml and ±3.5ml respectively and for between days reliability the values were 0.99 (ICC), ±20ml (LOA) and ±7ml (SEM) and for interrater reliability the values were 0.99 (ICC), ±13ml (LOA) and ±5ml (SEM). The results demonstrated that water volumetry method was highly reliable within day and between days for both the raters; and highly reliable between raters.Conclusion: Water volumetry is a highly reliable method for measuring foot/ankle volume repeatedly on different days. The random error range in milliliters (ml) as estimated by the absolute reliability indices provides the practical use of this method in a clinical/research setting.

Für die visuelle Wahrnehmung im Gehirn spielt die ungestörte Funktion von Neuronen und Gliazellen in der Netzhaut eine entscheidende Rolle. Viele schädigende Prozesse wie Entzündungen, Ischämien oder Traumata können zur Ödementstehung in der Netzhaut führen. Da die Netzhaut entwicklungsgeschichtlich einen vorverlagerten Teil des Zwischenhirns darstellt, lassen sich die pathophysiologischen Zusammenhänge, die zur Entstehung eines Netzhautödems führen, auch auf die Ödementstehung im Gehirn übertragen. Diese Arbeit beschäftigt sich mit dem Phänomen der Zellvolumenregulation von Müllerzellen – den hauptsächlich in der Netzhaut anzutreffenden Gliazellen – und leistet damit einen Beitrag zur Grundlagenerforschung der Ödementstehung in neuronalen Geweben. Die im Rahmen von Ödementstehungen regelmäßig zu beobachtenden Gefäßpermeabilitätserhöhungen führen in neuronalen Geweben auch zur Extravasation von Albumin. Unter diesem Gesichtspunkt untersucht die vorliegende Arbeit den Einfluss von bovinem Serumalbumin auf die Müllerzellen und die damit verbundenen Mechanismen am Modell der Netzhaut von Ratten.

Darbo tikslas: įvertinti šunų gerklų edemų etiotropinius faktorius, taikomas diagnostikos priemones bei gydymo ypatumus. Darbo uždaviniai: 1. Apžvelgti literatūroje pateikiamus duomenis apie gerklų edemų šunims etiologiją. 2. Išanalizuoti patologinio proceso pagrindinius ir pagalbinius diagnozavimo metodus. 3. Išanalizuoti gerklų edemų gydymui taikomas priemones, pateikti patologinio proceso prevencijos būdus. Buvo renkami duomenys 2005–2012 m. pacientų, kurie sirgo ligomis, sukeliančiomis gerklų edemą. Nuo 2005–2008 m. analizuotos tik pacientų ligos istorijos, kuriems buvo diagnozuota gerklų edema (n=133), o nuo 2008–2012 m. – gyvūnai (n=163) tirti kartu su veterinarijos gydytojais, dalyvauta atliekant diagnostines procedūras bei paskiriant gydymą. Išnagrinėti gerklų edemos etiologiniai veiksniai, jų diagnozavimo ir gydymo būdai. Tyrimų rezultatai ir išvados: išanalizavus surinktus duomenis apie pacientus, sergančius ligomis, kurios iššaukia gerklų edemą, nustatyta, kad pagrindiniai etiologiniai veiksniai, sukėlę gerklų edemą šunims, buvo laringitas (54 proc. arba 159 atvejai, p>0,05), laringotracheitas (27 proc. arba 78 atvejai, p>0,05), trachėjos kolapsas (11 proc. arba 34 atvejai, p<0,05), brachicefalinis sindromas (6 proc. arba 19 atvejų, p<0,05), navikai gerklų srityje (1 proc. arba 4 atvejai, p>0,05), vabzdžių įgėlimai (0,3 proc. arba 1 atvejis, p>0,05) ir šunidžių kosulys (0,3 proc. arba 1 atvejis, p>0,05). Gerklų edema dažniau diagnozuota patinams (58 proc. arba 17... [toliau žr. visą tekstą] / The objective of the research–to understand factors about dogs laryngeal oedema, laryngeal oedema diagnostic and treatment. Task of the research: 1. To analyze information about dogs laryngeal edema in literature. 2. To identify pathological process main and supporting diagnostic procedures. 3. To analyze treatment and ways of prevention of the laryngeal edema in dogs. 2005–2012 years, the information was picked about pacients, who had diseases, which stimulate laryngeal edema, from 2005–2008 information was picked about patients who has diseases which stimulate laryngeal edema, and from 2008–2012, the pacients were researched with vet doctor near abay. Were identifyied 296 pacients and their causes and treatment of laryngeal edema. Results and conclusions: main etiology factors of laryngeal edema in dogs were: laringytis (54 percent or 159 cases, p>0,05), laringotracheitis (27 percent or 78 cases, p>0,05), collapse of trachea (11 percent. or 34 cases, p<0,05), brachicefalic syndrome (6 percent. or 19 cases, p<0,05), tumours (1 percent or 1 case, p>0,05), bite of insect (0,3 % or 1 case, p>0,05) and kennel cough (0,3 % or 1 case, p>0,05). laryngeal edema,was identified more in males (58 percent or 172 cases), than females (42 percent or 124 cases). The patient average age was from 5,2±1,17 years old. Laryngeal edema diagnosed more in pedigreed dogs (72 percent or 214 cases) than in hybrids (28 percent or 82 cases). Major pedigreed dogs had ilnesses, who were from 1 to 5... [to full text]

The objective of this study was to investigate the intra-rater (within day & between days) and inter-rater reliability of foot/ankle water volumetry in healthysubjects.Study design: Repeated measures design with 2 raters.Background: Physiotherapists more often aim to reduce swelling in the acute phase of soft tissue injury. Reduction in swelling will hasten the healing process. Therefore swelling forms an important outcome measure that is worth studying during the healing process to determine the efficacy of the intervention. Though there are different methods available to measure extremity swelling, water displacement method is widely used in physiotherapy studies. Although water volumetry has been used to assess the reduction in swelling over time, there is paucity of reliability studies that have assessed the between-days reliability.Methods: Thirty normal subjects with asymptomatic ankles were measured by 2 raters. Three repeated foot volume measurements were performed by each of the rater using water volumetry during a single test session. The same procedure was repeated approximately at the same time on the 3rd day and 5th day following the 1st measurement day by the same raters on the same subjects. The raters were blinded to each other's measurements. The order for rater's volumetric measurement on each subject on each day was determined by a random chart produced by SPSS. The reliability was measured in terms of systematic bias (Paired t test & Bland & Altman's plot), absolute reliability (Limits of Agreement [LOA] & Standard Error of Measurement [SEM]) and relative reliability (Intraclass Correlation Coefficient [ICC]).Results: There was no systematic bias between any of the trials within day/between days or between raters. The intra-rater reliability within day as calculated by ICC; LOA and SEM were 0.99, ±10ml and ±3.5ml respectively and for between days reliability the values were 0.99 (ICC), ±20ml (LOA) and ±7ml (SEM) and for interrater reliability the values were 0.99 (ICC), ±13ml (LOA) and ±5ml (SEM). The results demonstrated that water volumetry method was highly reliable within day and between days for both the raters; and highly reliable between raters.Conclusion: Water volumetry is a highly reliable method for measuring foot/ankle volume repeatedly on different days. The random error range in milliliters (ml) as estimated by the absolute reliability indices provides the practical use of this method in a clinical/research setting.

Made available in DSpace on 2013-08-07T19:04:03Z (GMT). No. of bitstreams: 1 000438181-Texto+Completo-0.pdf: 3961885 bytes, checksum: 1a2e9a9bcf3838013c6755da613f5eb7 (MD5) Previous issue date: 2011 / INTRODUCTION : Posterior Reversible Encephalopathy Syndrome (PRES) is a clinico-radiological entity that presents with headache, altered mental status, seizure and visual disturbance and is associated with a reversible probably vasogenic edema, predominantly in occipital and parietal lobes. The precise physiopathology remains unclear and there isn’t an experimental model of this disorder. OBJECTIVES : The objectives of this paper were (1) the clinical and radiological evaluation of patients with PRES in the Hospital São Lucas-PUCRS and (2) the development of a translational model based on clinical features that mimetize this syndrome in pregnants Wistar rats. METHODS : It was performed a review of clinical data, neuroimage and blood basic test of 25 patients with PRES, that were followed in Hospital São Lucas-PUCRS in the period from March 15 of 2007 to September 15 of 2011. Based on clinical features and neuroimagem findings, we developed a rat model of PRES using pregnant Wistar rats, which were submitted to a reduction of uterine pressure perfusion (RUPP), measurement of arterial blood pressure with an invasive catheter and a brain anatomo-pathologic study, after Evans’s blue venous infusion to verify the permeability of the blood-brain-barrier. RESULTS : Our clinical sample consisted of 25 patients (4 men and 21 women) with mean age of 27,84 years old (range from 2 to 74 years old). The most common causes of PRES reported in this series were associated with pregnant situations that occurred in 11 cases (44%). The symptom more commonly reported was headache in 18 patients (72%). The occipital lobe was the most common topography of the magnetic ressonance abnormality (edema) and occurred in 23 cases (92%). The highest value of the systolic blood pressure presented the mean of 176 mmHg and the highest value of the diastolic blood pressure presented the mean of 95,2 mmHg. Animals submitted to RUPP to simulate the PRES presented increase of the blood-brain-barrier permeability and elevation of blood pressure, when compared with the control animals. CONCLUSION : In our series, PRES occurred predominantly in women and the most frequent triggers were obstetric causes; headache was the most common symptom and the neuroimage findings showed a predominance of posterior alteration suggesting a vasogenic edema due a breakdown of blood brain barrier. The experimental rat model was developed based on these clinical observations, so, we used pregnant rats submitted to reduction of uterine pressure perfusion. We identified in these animals increase of blood pressure and a breakdown of blood brain barrier corroborating to establish an experimental model of PRES. We believe that an experimental model of PRES could be important for future studies allowing a better comprehension of this syndrome. / INTRODUÇÃO : A Síndrome Encefalopatia Reversível Posterior (Posterior Reversible Encephalopathy Syndrome – PRES) é uma entidade clinico-radiológica caracterizada por cefaléia, alteração do nível de consciência, crises convulsivas e alteração visual e está associado a um edema provavelmente vasogênico na substância branca encefálica, predominantemente afetando os lobos occipitais e parietais. A fisiopatogenia do PRES permanece desconhecida e não existe um modelo experimental de tal distúrbio. OBJETIVOS : O objetivo desse trabalho é avaliar apresentação clínica juntamente com os exames de neuroimagem realizados por pacientes com Síndrome da Encefalopatia Reversível Posterior no Hospital São Lucas-PUCRS e baseado nos achados clínicos desenvolver um modelo translacional que mimetize essa síndrome em ratos Wistar.MÉTODOS : Foram revisados os prontuário juntamente com os exames de neuroimagem e laboratoriais de 25 pacientes portadores da síndrome da encefalopatia reversível posterior, os quais foram atendidos no Hospital São Lucas-PUCRS no período de 15 de março de 2007 à 15 de setembro de 2011. A partir das características clínicas e de neuroimagem analisadas nesta pesquisa desenvolvemos modelo experimental de PRES com o uso de ratas Wistar gestantes, as quais foram submetidas à redução da pressão de perfusão uterina (RUPP do inglês Reduction of Uterine Pressure Perfusion), medida de pressão arterial invasiva e estudo anatomopatológico dos encéfalos dos animais, após infusão venosa de azul de Evans para avaliação da permeabilidade da barreira hemato-encefálica. RESULTADOS : Dos 25 pacientes com PRES analisados com idade média de 27,84 anos (variando de 2 anos a 74 anos), 4 eram homens e 21 mulheres. As causas e/ou desencadeadores mais comumente encontrados foram de origem obstétricas em 11 casos (44%). O sintoma mais freqüentemente referido foi cefaléia em 18 pacientes (72%). A topografia mais comumente acometida pelo edema gerado pelo PRES foi occipital em 23 pacientes (92%). O valor da pressão arterial sistólica máxima em média foi de 176 mmHg e a pressão arterial diastólica máxima em média foi de 95,2 mmHg. Os animais submetidos ao modelo experimental proposto através do procedimento RUPP para mimetizar o PRES apresentaram alterações de permeabilidade da barreira hematoencefálica e elevação da pressão arterial quando comparado aos animais controles. CONCLUSÃO : Na nossa casuística o PRES foi nitidamente predominante em mulheres, os fatores desencadeantes/causais mais frequentes foram os de origem obstétrica, predominando a cefaleia como sintoma; os exames de neuro-imagem confirmaram o predomínio posterior das alterações estruturais e sugerem serem decorrentes de edema vasogênico com quebra da barreira hematoencefálica. O modelo experimental em ratos Wistar foi desenvolvido baseado nestas observações clínicas motivo pelo qual utilizamos ratas gestante submetidas a redução da pressão de perfusão uterina. Identificamos nestes animais a quebra da barreira hematoencefálica corroborando para o estabelecimento do modelo experimental do PRES, o qual pensamos que possa ser de fundamental importância para estudos posteriores que permitam uma melhor compreensão desta síndrome.

Made available in DSpace on 2015-05-14T12:59:24Z (GMT). No. of bitstreams: 1 arquivototal.pdf: 1952542 bytes, checksum: cbb5dfafac619fd1f5d9b4ef4efbccf2 (MD5) Previous issue date: 2011-02-28 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Enantiomers are asymmetric compounds that present mirror images of each other, not overlapping and different behaviors in chiral environments, resulting in esterioseletiva discrimination and different biological effects. The carvone is a monoterpene, a constituent of many essential oils found in nature as two enantiomers, (S)-(+)-carvone and (R)-(−)-carvone. The inflammation, a physiological response of the organism, when it occurs exaggerated or inappropriated ways may promote tissue damage and associated pathologies. An example of inflammatory disease is asthma, an immediate hypersensitivity process of the airways and the conventional treatments have significant adverse effects. The aim of this study was to evaluate the carvone enantiomers in experimental models of inflammation and hypersensitivity of the airways. To investigate the effect anti-inflammatory the following parameters were evaluated: NO production by cells J774.A1, paw oedema formation induced by carrageenan, zymosan, compound 48/80 and histamine, cell migration and cytokines production (TNF-α and IL-1β) in the experimental model of peritonitis induced by zymosan in Swiss mice. To evaluate the anti-asthmatic activity of these enantiomers, it was used the experimental model of asthma induced by ovalbumin and the following parameters were analyzed: bronchoalveolar lavage (BAL), mucus production, OVA-specific IgE synthesis, cytokine production (IL-13, IFN-γ and IL-10). The results showed that both enantiomers were able to reduce NO production, inhibit the paw oedema induced by phlogistic agents and inhibit cell migration to the peritoneum, but only the (R)-(−)-carvone was able to reduce levels of TNF-α. In the murine model of asthma, the (R)-(−)-carvone, was able to reduce the cellularity of the BAL, modulate the OVA-specific IgE production, reduce the cell infiltration and mucus in the lungs and further increase the IL-10. However, although the (S)-(+)-carvone has reduced the BAL cellularity and increased IFN-γ levels, it was unable to reduce the cell infiltration in the lung and increase the mucus production. Therefore, both enantiomers of carvone showed anti-inflammatory effect, although only the (R)-(−)-carvone showned potential anti-asthmatic. Additionally, the results presented by (S)-(+)-carvone, revealed a potential adverse effect of this enantiomer in the experimental model of asthma. / Enantiômeros são compostos assimétricos que apresentam a particularidade de serem imagens especulares um do outro, não sobreponíveis e por terem comportamentos diferentes em ambientes quirais, resultando frequentemente na discriminação esterioseletiva e diferentes efeitos biológicos. A carvona é um monoterpeno, constituinte de muitos óleos essenciais e encontrada na natureza na forma de dois enantiômeros: (S)-(+)-carvona e (R)-(-)-carvona. A inflamação uma resposta fisiológica do organismo, quando ocorre de forma exacerbada ou inapropriada pode promover dano tecidual e patologias associadas. Um exemplo de doença inflamatória importante é a asma, um processo hipersensibilidade imediata nas vias aéreas e que tratamentos convencionais apresentam efeitos colaterais importantes. O objetivo desse trabalho foi avaliar os enantiômeros da carvona em modelos de inflamação e de hipersensibilidade das vias aéreas. Para investigar a atividade anti-inflamatória das substâncias os seguintes parâmetros foram avaliados: produção de NO por células J774.A1, formação de edema de pata induzido por carragenina, zimosan, composto 48/80 e histamina, migração de células e produção das citocinas (TNF-α e IL-1β) no modelo de peritonite induzida por zimosan, em camundongos Swiss. Para avaliar a atividade anti-asmática dos enantiômeros, foi utilizado o modelo de asma experimental induzido por ovalbumina e analisado os seguinte parâmetros: celularidade do lavado bronco alveolar (BAL), produção de muco, síntese de IgE OVA-específica, produção de citocinas (IL-13, IFN-γ e IL-10). Os resultados demonstraram que ambos os enantiômeros foram capazes de reduzir a produção de NO, inibir o edema de pata induzido pelos agentes flogísticos utilizados e inibir a migração de células para o peritônio, porém apenas a (R)-( )-carvona foi capaz de reduzir os níveis de TNF-α. No modelo murino de asma alérgica, a (R)-(−)-carvona, foi capaz de reduzir a celularidade do BAL, modular a produção de IgE OVA-específica, reduzir o infiltrado de células e muco no pulmão e ainda, aumentar os níveis de IL-10. Porém, embora a (S)-(+)-carvona, tenha reduzido a celularidade do BAL e aumentado os níveis de IFN-γ, ela não foi capaz de reduzir o infiltrado de células no pulmão e ainda, aumentou a produção de muco. Portanto, ambos enantiômeros da carvona apresentaram efeito anti-inflamatório, embora apenas a (R)-(-)-carvona tenha apresentado potencial anti-asmático e ainda, os resultados apresentados pela (S)-(+)-carvona, revelaram um potencial efeito adverso desse enantiômero em modelo experimental de asma.

Introdução: Descontinuação prematura ou tardia da ventilação mecânica invasiva (VM) associa-se a maior morbimortalidade. Redução da pressão intratorácica durante o teste de respiração espontânea (TRE) pode precipitar disfunção cardíaca através da elevação abrupta do retorno venoso e da pós-carga do ventrículo esquerdo. Da mesma maneira, alterações na demanda respiratória e cardíaca que ocorrem ao longo do TRE também podem manifestar-se à ultrassonografia pulmonar. O padrão B é um artefato sonográfico que se correlacionada com edema intersticial. Um ensaio clínico randomizando concluiu que a ultrassonografia pulmonar foi capaz de prever insuficiência ventilatória pós extubação através de variações na aeração pulmonar observadas durante o procedimento de desmame; contudo, a ferramenta não pôde rastrear pacientes antes da submissão ao TRE. O impacto do balanço hídrico (BH) e de sinais radiológicos de congestão pulmonar antes do TRE sobre os desfechos no desmame também precisam ser determinados. Métodos: Cinquenta e sete indivíduos elegíveis para o desmame ventilatório foram recrutados. Traqueostomizados foram excluídos. Realizou-se avaliação ultrassonográfica de seis zonas pulmonares imediatamente antes e ao final do TRE. Predominância B foi definida como qualquer perfil com padrão B presente bilateralmente em região torácica anterior. Os pacientes foram seguidos por até 48 horas depois da extubação. Após esse estudo piloto, foi conduzido um estudo observacional, prospectivo, multicêntrico em duas unidades de terapia intensiva (UTIs) clínico-cirúrgicas ao longo de dois anos. Os mesmos critérios de inclusão e de exclusão foram aplicados; contudo, a ultrassonografia foi realizada apenas antes do TRE. O desfecho primário foi falha no TRE, definido como incapacidade de tolerar o teste T durante 30 a 120 minutos e, nesse caso, o paciente não era extubado. Dados demográficos e fisiológicos, BH das 48 horas antecedendo o TRE (entrada de fluidos menos débitos durante 48 horas) e desfechos foram coletados. Em uma análise post hoc de 170 procedimentos de desmame, um radiologista aplicou um escore radiológico na interpretação de radiografias digitais de tórax realizadas previamente ao TRE – o exame mais recente disponível foi avaliado em termos de congestão pulmonar. Resultados: No estudo piloto, 38 indivíduos foram extubados com sucesso, 11 falharam no TRE e 8 necessitaram de reintubação em até 48 horas após a extubação. No início do teste T, padrão B ou consolidação já estava presente em porções inferiores e posteriores dos pulmões em mais da metade dos casos, e tais regiões mantiveram-se não aeradas até o final do teste. Perda de aeração pulmonar durante o TRE foi observada apenas no grupo que falhou no mesmo (p= 0,07). Esses pacientes também demonstraram maior predominância B ao final do teste (p= 0,019). Antes do procedimento de desmame, todavia, não foi possível discernir indivíduos que falhariam no TRE, tampouco aqueles que necessitariam de reintubação dentro de 48 horas. Posteriormente, de 2011 a 2013, 250 procedimentos de desmame foram avaliados. Falha no TRE ocorreu em 51 (20,4%). Cento e oitenta e nove pacientes (75,6%) foram extubados na primeira tentativa. Indivíduos que falharam no TRE eram mais jovens (mediana de 66 versus 75 anos, p= 0,03) e apresentaram maior duração de VM e maior prevalência de doença pulmonar obstrutiva crônica (DPOC) (19,6 versus 9,5%, p= 0,04). Predominância B mostrou-se um preditor muito fraco para falha no TRE, exibindo sensibilidade de 47%, especificidade de 64%, valor preditivo positivo de 25% e valor preditivo negativo de 82%. Não houve diferença estatisticamente significativa no BH das 48 horas antecedendo o TRE entre os grupos (falha no TRE: 1201,65 ± 2801,68 ml versus sucesso no TRE: 1324,39 ± 2915,95 ml). Entretanto, em pacientes portadores de DPOC, ocorreu associação estatisticamente significativa entre BH positivo nas 48 horas antes do TRE e falha no TRE (odds ratio= 1,77 [1,24 – 2.53], p= 0,04). O escore radiológico, obtido em 170 testes T, foi similar entre os pacientes com falha e sucesso no TRE (mediana de 3 [2 – 4] versus 3 [2 – 4]), p= 0, 15). Conclusão: Maior perda de aeração pulmonar observada à ultrassonografia durante o TRE pode sugerir disfunção cardiovascular e aumento na água extravascular, ambos induzidos pelo processo de desmame. BH, sinais radiológicos de congestão pulmonar ou padrão B documentado através de um protocolo ultrassonográfico simplificado não devem contraindicar o TRE em pacientes estáveis hemodinamicamente e adequadamente oxigenados, haja vista o fato de tais variáveis não terem predito maior probabilidade de falha de desmame em pacientes críticos clínico-cirúrgicos. Ainda assim, evitar BH positivo em pacientes com DPOC parece otimizar os desfechos do desmame. / Introduction: Both delayed and premature liberation from mechanical ventilation (MV) are associated with increased morbi-mortality. Inspiratory fall in intra-thoracic pressure during spontaneous breathing trial (SBT) may precipitate cardiac dysfunction through abrupt increase in venous return and in left ventricular afterload. Changes in respiratory and cardiac load occurring throughout SBT might manifest with dynamic changes in lung ultrasound (LUS). B-pattern is an artifact that correlates with interstitial edema. A randomized controlled trial concluded that bedside LUS could predict post extubation distress due to changes in lung aeration throughout weaning procedure; however, it could not screen patients before submission to SBT. The impact of fluid balance (FB) as well as of radiological signs of pulmonary congestion prior to SBT on weaning outcomes must also be determined. Methods: Fifty-seven subjects eligible for ventilation liberation were enrolled. Patients with tracheostomy were excluded. LUS assessment of six thoracic zones was performed immediately before and at the end of SBT. B-predominance was defined as any profile with anterior bilateral B-pattern. Patients were followed up to 48 hours after extubation. After this pilot report, we conducted a 2-year prospective, multicenter, observational study in two adult medical surgical intensive care units (ICUs). Same inclusion and exclusion criteria were applied; however, LUS was performed only immediately before SBT. The primary outcome was SBT failure, defined as inability to tolerate a T-piece trial during 30 to 120 minutes, in which case patients were not extubated. Demographic, physiologic, FB in the preceding 48 hours of SBT (fluid input minus output over the 48-hour period), and outcomes data were collected. As a post hoc analysis in 170 weaning procedures performed in one of the ICUs, an attending radiologist applied a radiological score on interpretation of digital chest x-rays performed before SBT - the most recent available exam was analyzed regarding degree of lung fluid content. Results: In the pilot study, 38 subjects were successfully extubated, 11 failed the SBT and 8 needed reintubation within 48 hours of extubation. At the beginning of T-piece trial, B-pattern or consolidation were already found at lower and posterior lung regions in more than half of the individuals and remained nonaerated at the end of the trial. Loss of lung aeration during SBT was observed only in SBT-failure group (p= 0.07). These subjects also exhibited higher B-predominance at the end of trial (p= 0.019). Prior to weaning procedure, however, we were not capable to discriminate individuals who would fail SBT, nor who would need reintubation within 48 hours. Afterwards, from 2011 to 2013, 250 weaning procedures were evaluated. SBT failure occurred in 51 (20.4%). One hundred eighty-nine patients (75.6%) were extubated at first attempt. Individuals who failed SBT were younger (median 66 versus 75 years, p= 0.03), had higher duration of MV (median 7 versus 4 days, p< 0.0001) and higher prevalence of chronic obstructive pulmonary disease (COPD) (19.6 versus 9.5%, p= 0.04). B-predominance was a very weak predictor for SBT failure, showing 47% sensitivity, 64% specificity, 25% positive predictive value, and 82% negative predictive value. There were no statistically significant differences in 48 hour-FB prior to SBT between groups (SBT failure: 1201.65 ± 2801.68 mL versus SBT success: 1324.39 ± 2915.95 mL). However, in COPD subgroup, we found significant association between positive FB in the 48 hours prior to SBT and SBT failure (odds ratio = 1.77 [1.24 – 2.53], p= 0.04). Radiological score, obtained in 170 T-piece trials, was similar between SBT failure and success subjects (median 3 [2 - 4] vs 3 [2 - 4], p= 0.15). Conclusion: Higher loss of lung aeration observed by LUS during SBT might suggest cardiovascular dysfunction and increases in extravascular lung water, both induced by weaning. Neither FB, nor radiological findings of pulmonary congestion, nor B-pattern detected by a simplified LUS protocol should preclude hemodynamically stable, sufficiently oxygenated patients from performing an SBT, since such variables did not predict greater probability of weaning failure in medical-surgical critically ill population. Notwithstanding, avoiding positive FB in COPD patients might improve weaning outcomes.

Submitted by Rodrigo Martins Cruz (rodrigo.cruz@ufvjm.edu.br) on 2015-01-23T16:14:42Z No. of bitstreams: 5 carlos.pdf: 1077384 bytes, checksum: 83eb6b248c6848161b2017a683c19682 (MD5) license_url: 52 bytes, checksum: 3d480ae6c91e310daba2020f8787d6f9 (MD5) license_text: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) license_rdf: 23898 bytes, checksum: e363e809996cf46ada20da1accfcd9c7 (MD5) license.txt: 2109 bytes, checksum: aa477231e840f304454a16eb85a9235f (MD5) / Approved for entry into archive by Rodrigo Martins Cruz (rodrigo.cruz@ufvjm.edu.br) on 2015-02-10T11:09:38Z (GMT) No. of bitstreams: 5 carlos.pdf: 1077384 bytes, checksum: 83eb6b248c6848161b2017a683c19682 (MD5) license_url: 52 bytes, checksum: 3d480ae6c91e310daba2020f8787d6f9 (MD5) license_text: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) license_rdf: 23898 bytes, checksum: e363e809996cf46ada20da1accfcd9c7 (MD5) license.txt: 2109 bytes, checksum: aa477231e840f304454a16eb85a9235f (MD5) / Made available in DSpace on 2015-02-10T11:09:38Z (GMT). No. of bitstreams: 5 carlos.pdf: 1077384 bytes, checksum: 83eb6b248c6848161b2017a683c19682 (MD5) license_url: 52 bytes, checksum: 3d480ae6c91e310daba2020f8787d6f9 (MD5) license_text: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) license_rdf: 23898 bytes, checksum: e363e809996cf46ada20da1accfcd9c7 (MD5) license.txt: 2109 bytes, checksum: aa477231e840f304454a16eb85a9235f (MD5) Previous issue date: 2013 / O objetivo do presente estudo foi realizar uma avalia??o comparativa do efeito da dexametasona e da metilprednisolona no controle da dor, edema e limita??o da abertura bucal ap?s a extra??o de terceiros molares impactados. Dezesseis pacientes saud?veis (3 homens e 13 mulheres) com m?dia de 20,3 (DP= 1,25) anos de idade foram submetidos ? extra??o bilateral dos terceiros molares com intervalo de tr?s a quatro semanas entre as duas cirurgias. Uma hora antes de cada procedimento cir?rgico foi administrada em dose ?nica, por via oral, dexametasona 8 mg ou metilprednisolona 40 mg. Durante os intervalos p?s-operat?rios de 24, 48 e 72 horas e sete dias, o edema linear foi determinado utilizando medidas na face e o trismo atrav?s da abertura bucal m?xima. A dor p?s-operat?ria foi auto-registrada pelo paciente utilizando escala anal?gica visual durante as 72 horas iniciais, em intervalos de oito horas. A an?lise estat?stica envolveu an?lise descritiva, teste McNemar, Teste T pareado e Wilcoxon (p<0,05). A dexametasona apresentou melhor controle do edema em todos os per?odos p?s-operat?rios (p <0,02) e da abertura bucal dois dias ap?s a cirurgia (p = 0,029). Com rela??o ? dor n?o foi observada diferen?a estatisticamente significativa entre os medicamentos. A administra??o pr?-perat?ria de 8 mg de dexametasona apresentou melhor controle do edema e da limita??o da abertura bucal do que a metilprednisolona na dose de 40 mg, muito embora os medicamentos n?o diferiram no controle da dor. / Disserta??o (Mestrado) ? Programa de P?s-Gradua??o em Odontologia, Universidade Federal dos Vales do Jequitinhonha e Mucuri, 2012. / ABSTRACT The?aim of this study?was to make a comparative assessment of the effect of?dexamethasone and methylprednisolone?to control pain, swelling?and limitation?of mouth opening after extraction of?impacted third molars.?Sixteen healthy patients (3 men and 13 women)?with a mean age?of 20.3 (SD = 1,25) years underwent bilateral extraction?of?third molars with na interval of three to four weeks between the two surgeries. One hour?before each?surgical procedure?a single oral dose?of?dexamethasone 8?mg or methylprednisolone?40?mg was administered.?During the postoperative?intervals?of 24,?48?and 72?hours and?seven days, the swelling was determined using?linear?measures?in the?face and trismus?by?maximum mouth opening. The?postoperative pain?was self-recorded?by the patient using?visual analogue scale?in?72 hours with an interval of eight hours. Statistical analysis involved descriptive analysis, McNemar test, Wilcoxon?and paired T test (p?<0.05). Dexamethasone showed better control of swelling in all?postoperative periods (p?<0.02) and of mouth opening two days after surgery (p = 0.029). Regarding pain there was no statistically significant difference between the drugs. Preemptive dexamethasone?8 mg showed better control of swelling?and limitation?of mouth opening than methylprednisolone 40 mg, but there was no difference?in pain control.