Introdução: Este estudo prospectivo, randomizado, duplo-cego investigou, em valvopatas, alterações hemodinâmicas durante o tratamento odontológico com o uso do anestésico local contendo adrenalina e sem a mesma. Métodos: O estudo foi conduzido na Unidade de Odontologia do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Brasil 2004-2005). Os pacientes foram alocados em dois grupos através de tabela de números aleatórios: LSA (lidocaína a 2% sem adrenalina, n= 31, 42.2 ± 10.3 anos) e LCA (lidocaína a 2% com adrenalina 1:100.000, n= 28, 40.3 ± 10.9 anos). O volume anestésico foi registrado. Um monitor multiparamétrico DIXTAL (São Paulo- Brasil) registrou os valores da pressão arterial sistêmica, freqüência cardíaca, saturação de oxigênio e traçado eletrocardiográfico. Registrou-se também o volume anestésico aplicado em cada procedimento realizado. Resultados: 22 homens e 37 mulheres foram incluídos. Valores da pressão arterial sistêmica, freqüência cardíaca e saturação de oxigênio, antes, durante e após administração da anestesia local não mostraram diferenças estatísticas entre os dois grupos (P > 0.05). Arritmias observadas em alguns pacientes antes do início do tratamento odontológico não sofreram alterações de morfologia ou gravidade após injeção anestésica. Relatos de dor durante a realização do procedimento odontológico foram mais freqüentes no grupo LSA com conseqüente aumento no volume de anestésico local administrado. Conclusão: lidocaína 2% com adrenalina 1:100.000 mostrou maior eficácia anestésica em comparação com a lidocaína 2% sem adrenalina sem causar alterações hemodinâmicas em pacientes portadores de valvopatias. / Introduction: This prospective, randomized double-blinded study investigated hemodynamic changes in valvular cardiac patients during dental treatment with the use of a local anesthesia containing epinephrine. Methods: The study was conducted in the Dental Department of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Brazil 2004- 2005). Patients were allocated into two groups through an aleatory numbered table: PL (plain 2% lidocaine, n= 31) and LE (2% lidocaine with 1:100.000 epinephrine, n= 28). The anesthetic amount was registered. DIXTAL monitor (São Paulo- Brazil) captured blood pressure, heart rate, oxygenation and electrocardiogram records. Results: 22 men and 37 women were included (LE age 40.3 ± 10.9 and PL age 42.2 ± 10.3). Blood pressure, heart rate and pulse oximetry values before, during and after local anesthesia injection did not show any difference between the two groups (P > 0.05). Any arrhythmias observed in some patients prior to dental anesthesia did not suffer alterations of shape or gravity after it. Complains of pain during dental procedure were more often in the PL group with a higher amount of local anesthesia needed. Conclusion: 2% lidocaine with epinephrine 1:100.000 showed a superior anesthetic efficiency without leading to hemodynamics changes in patients with cardiac valvular compromise.

The extreme elevation in plasma levels of norepinephrine (NE) and epinephrine (EP) which occurs during forced diving of ducks (Anas platyrhynchos) was studied before and after denervation of the adrenal glands. Elevated PaCO₂, decreased arterial pH, decreased blood glucose as well as low PaO₂ have been described as causal factors in this response. These variables, as well as blood pressure, heart rate and breathing frequency were measured in ducks dived after breathing air or pure 0₂ to clarify and quantify the mechanism involved and its physiological function. Both NE and EP concentration increased by up to 2 orders of magnitude in the 4 minute dive period, but by a significantly lesser amount if the duck breathed 0₂, before the dive. While pH and PaCO₂ were well correlated with the changes in plasma NE and EP levels during both air and 0₂ dives, both pH and PaCO₂ changed more in the 0₂ trials, indicating that they are not the primary cause of the response. Plasma glucose levels were variable. PaO₂ values less than normal correlated well with increasing NE and EP concentrations, but at high PaO₂s, there was no correlation, suggesting that hypoxia is the permissive state for the full response. Compared with breathing air, breathing O₂ before the dive attenuated the diving bradycardia, eliminated the decrease in blood pressure normally observed during dives, and caused more extreme changes in pH, PaC0₂, and of course, PaO₂. Denervating the adrenals decreased the amounts of both catecholamines released during dives after breathing air and 0₂, EP significantly more than NE. Adrenal denervation per se did not cause a significant change in heart rate, blood pressure, arterial gas tensions, pH, or plasma glucose changes during dives although the operation caused increased variation in some of the parameters. In ducks, the cause for the catecholamine release is decreasing PaO₂ and full expression of the response is dependent on intact innervation of the adrenal gland, although there is a component that is unaffected by denervation. While possible roles for this response are discussed, the true physiological function of this response remains cast in shadows. / Science, Faculty of / Zoology, Department of / Graduate

Catecholamines are elaborated in stress responses to mediate vasoconstriction, and elevate systemic vascular resistance and blood pressure. They are elaborated in disorders such as sepsis, cocaine abuse, and cardiovascular disease. The aim of the study was to determine whether catecholamines affect nitric oxide (NO) production, as NO is a vasodilator and counteracts the harmful effects of catecholamines. RAW264.7 macrophage cells were cultured with lipopolysaccharide (LPS)±epinephrine, norepinephrine, and dopamine at 5×10-6M concentrations for 24h. Supernatants were harvested for measuring NO by spectrophotometry using the Greiss reagent and cells were harvested for detecting inducible NO synthase (iNOS) by Western blot. NO production in RAW 264.7 macrophages was increased significantly by addition of LPS (0.5-10ng/ml) in a dose-dependent fashion. The NO production induced by LPS was further enhanced by epinephrine and norepinephrine, and to a lesser extent by dopamine. These increases in NO correlated with expression of iNOS protein in these cells. The enhancing effect of iNOS synthesis by epinephrine and norepinephrine on LPS-induced macrophages was down regulated by β-adrenoceptor antagonist, propranolol, and dexamethasone. The results suggest that catecholamines have a synergic effect on LPS in induction of iNOS synthesis and NO production, and this may mediate some of the vascular effects of infection. These data support a novel role for catecholamines in disorders such as septic shock and cocaine use, and indicate that β-adrenoceptor antagonists and glucocorticoids may be used therapeutically for modulation of the catecholamine-NO axis in disease states.

We tested the hypothesis that oxytocin-induced labor augmented IL-1β-induced/-stimulated lung fluid absorption in preterm guinea pig fetuses. IL-1β was administered subcutaneously daily to timed-pregnant guinea pigs for 3 days with and without simultaneous cortisol synthesis inhibition by metyrapone. At day 3, oxytocin was administered, and fetuses were delivered by abdominal hysterotomy at 61 and by oxytocin-induced birth at 68 days gestation. Delivered fetuses were instilled with isosmolar 5% albumin into the lungs, and lung fluid movement was measured over 1 h by mass balance. Lung fluid absorption was induced in 61-day and stimulated in 68-day gestation lungs by IL-1β. Labor induction by oxytocin augmented IL-1β-induced/- stimulated lung fluid absorption. Metyrapone pretreatment did not affect oxytocin-induced/-stimulated lung fluid absorption, while completely blocking IL-1β-induced/-stimulated fluid absorption. Fetal lung fluid absorption, when present, was always propranolol and amiloride sensitive, suggesting that β-adrenoceptor stimulation and amiloride-sensitive sodium channels were critical for fluid absorption. Epithelial sodium channel and Na-K-ATPase subunit expressions were both increased by IL-1β, but not further by oxytocin. Our results indicate that IL-1β release into the maternal blood circulation positively affects lung maturation due to the IL-1β-induced release of cortisol and thus prepares the lungs for the epinephrine surge associated with labor.

Stress plays a significant role in neural development and brain function. To better understand the mechanisms underlying the impact of stress on brain development and neuroendocrine function, this study focuses on the phenylethanolamine-N-methyltransferase (Pnmt) enzyme as a key mediator of stress hormone signaling. Pnmt is activated as part of a positive feedback mechanism during stress to convert norepinephrine to epinephrine and amplify the sympathetic response. Most of our knowledge about Pnmt is derived from its role in the systemic production of epinephrine from adrenal chromaffin cells, but it is also known to be expressed in the central nervous system, including the brainstem, retina, hypothalamus, and cerebellum. Given the importance of the central nervous system in modulating stress responses, this project sought to investigate cellular Pnmt expression in the central nervous system using a genetic-marking strategy with a Pnmt-Cre-recombinase knock-in driver strain (Pnmt+/Cre) and a β-galactosidase (βGal) reporter strain (R26R+/βGal) in parallel with Pnmt-specific immunofluorescent histochemical staining to identify Pnmt+ cells in the adult mouse cerebellum, hypothalamus, and cerebral cortex. The results show extensive patterns of active and historical Pnmt protein expression throughout the cerebellum and hypothalamus, with significant neuropeptide Y co-expression in the hypothalamus and considerable historical Pnmt expression throughout the cerebral cortex. To quantify baseline Pnmt mRNA levels across embryonic and postnatal neural development and elucidate differential Pnmt isoform expression through tissue-specific regulation in the developing brain, quantitative polymerase chain reaction (qPCR) was performed in the brainstem, cerebellum, and cerebral cortex with isoform-specific primers. Initial results show a developmental, tissue-specific Pnmt isoform shift between embryonic and postnatal neural development by an intron-retention alternative splicing mechanism. Ultimately, these findings provide an anatomical "blueprint" for investigating the role of central nervous system Pnmt expression in health and disease, and emphasize the role of Pnmt in early neural development, illustrating how stress impacts the formation of neural connections during formative periods of brain maturation.

The LKB1/STRAD/MO25 complex (LSMK) has been identified as the major upstream kinase for AMP-activated protein kinase (AMPK). PKA phosphorylates LKB1 at the Ser428 residue in humans and Ser431 residue in mice. We investigated PKA as an upstream kinase for LSMK. LKB1 that had been incubated with PKA prior to incubation with AMPK experienced up to a 51% increase in AMPK Kinase activity compared to LKB1 alone (p < 0.05). When blocked with a PKA Inhibitor, the kinase effect of PKA on LKB1 was eliminated. Rat epitrochlearis muscle tissue incubated with epinephrine experienced no increase in AMPK activity compared with controls indicating that epinephrine does not cause AMPK activity in this type of tissue. In conclusion, phosphorylation by PKA can increase the AMPKK activity of LKB1-STRAD-MO25 in vitro. Because LKB1 has been found to be constitutively active, it is postulated that phosphorylation by PKA may act to enhance LKB1-AMPK interaction and thus achieve its effect.

Children with life threatening food allergies live with the constant threat of a fatal reaction, and caregivers must always be prepared to treat with an epinephrine auto-injector (EAI). This interpretive phenomenological study explored parents’ perceptions and lived experiences with prescribed EAI use for their child. The purposive sample included 10 parents of five children under 12 years of age, diagnosed with a food allergy and prescribed with an EAI who recently experienced anaphylaxis. Eight main themes emerged: perception of anaphylaxis, life challenges, isolation, anxiety, hesitation, guilt, influence of health care, and lessons learned. Parents described multiple life challenges and feelings of isolation, anxiety and hesitation during a reaction that lead to subsequent guilt. Handling reactions correctly provided parents with confidence to treat subsequent reactions. Witnessing the effects of an EAI and receiving positive feedback from health care providers further strengthened their confidence to quickly and competently intervene in future reactions. / February 2017

Opioid/adrenergic interactions were studied to evaluate two hypotheses: (1) naloxone potentiates the effect of epinephrine on cardiac contractility by increasing circulating epinephrine concentrations; and (2) endogenous and exogenous opioids alter left cardiac nerve stimulationinduced norepinephrine release and cardiac function. A canine isolated heart-lung preparation was used for the first study. Plasma epinephrine was determined and myocardial epinephrine uptake was calculated during intravenous epinephrine infusion. Naloxone (4 mg) was given and the epinephrine infusion was repeated. Naloxone increased cardiac contractility, coronary blood flow, and the coronary sinus epinephrine concentration. When coronary blood flow was subsequently held constant (100% above resting), naloxone increased only contractility. This result indicated that the previously observed increase in coronary sinus epinephrine was flow dependent. Corticosterone (an uptake II blocker) was employed as a positive control. Corticosterone increased the contractile response to epinephrine, but unlike naloxone, corticosterone was accompanied by a clear decrease in myocardial epinephrine uptake. The stereospecificity of the response to naloxone was investigated and (+) naloxone equaled or exceeded (-) naloxone in potentiating the inotropic effect of epinephrine. In the second study, the left cardiac nerve was isolated and electrically stimulated in intact dogs. Norepinephrine overflow gradually declined during successive control stimulations. Pretreatment with naloxone (100 Mg/kg) prevented or delayed the decline. An intracoronary dynorphin 1-9 infusion (2 nmol/min/kg for 20 minutes) reduced both norepinephrine overflow and cardiac performance, and both effects were prevented by pretreatment with naloxone (100 /xg/kg) . To summarize, naloxone potentiated the inotropic effect of infused epinephrine without altering circulating epinephrine concentrations or myocardial epinephrine uptake. This effect of naloxone was not stereospecific and probably not mediated through a traditional opiate receptor. Endogenous and exogenous opioids inhibited the left cardiac nerve stimulation-induced norepinephrine overflow, suggesting that opiate receptors may regulate cardiac excitability by modulating norepinephrine release.

O presente trabalho teve como objetivo avaliar e comparar a reatividade vascular de agentes vasoconstritores presentes nas soluções anestésicas locais (Adrenalina - vasoconstrição e vasodilatação; Felipressina - vasoconstrição), nas doses de 80, 160, 320, 640 e 1280ng (adrenalina) ou 0,25; 0,5; 1; 2 e 4 x10-3UI (felipressina), em leito arterial mesentérico deratos normotensos, diabéticos, hipertensos renais um-rim, um-clip (1R-1C) e hipertensos1R-1C-diabéticos. E correlacionar tal reatividadecom expressão de RNAm dos receptores 1A e 2- adrenérgicos, V1A para vasopressina e AT1A, AT1Be AT2 para angiotensina II visando verificar se a hipertensão arterial e o diabetes mellitus provocam alteração em modelo indutivo e isogênico. Ratos Wistar pesando 110-160g, foram anestesiados com mistura de quetamina e xilazina (50+10mg/ml/kg de peso), tiveram seu abdômen aberto e receberam um clip de prata com abertura 0,25mm na artéria renal esquerda, removendo-se cirurgicamente o rim direito (ratos 1R-1C). Após 14 dias, receberam injeção subcutânea de estreptozotocina (50 e 60mg/kg de peso) para indução do diabetes mellitus sendo a glicemia testada pela veia caudal previamente aos experimentos (diabéticos). Após 30-42 dias da implantação do clip, todos os grupos foram novamente anestesiados e implantou-se cânula de polietileno (PE-50) na artéria carótida esquerda para registro direto da pressão arterial. Após registro da pressão os animais tiveram a artéria principal mesentérica exposta e canulada. O leito arterial mesentérico foi então isolado e colocado em banho com solução nutritiva de Krebs a 37ºC. O cateter foi conectado ao sistema de registro computadorizado (PowerLab®) utilizando software específico (Chart 5Pro ®). Analisaram-se: a pressão máxima (vasoconstrição) e mínima (vasodilatação), o tempo necessário para atingir esse valor, duração total da resposta, integral e integral sobre a linha de base. Os dados foram submetidos à análise de variância de medidas repetidas (ANOVA), seguida do teste de Holm-Sidak (distribuição normal) ou de Mann-Whitney (nãoparamétrico), quando apropriado, nível de significância de 5%. Todas as respostas máximas de vasoconstrição apresentaram comportamento dose-dependente, contudo, para os quatro grupos estudados, a resposta vasoconstritora para adrenalina foi significativamente superior à felipressina (p<0,05). Diabetes e hipertensão reduziram a resposta vasoconstritora da adrenalina e da felipressina, valores de integral sobre a linha de base, respectivamente para grupo controle, diabético, hipertenso e hipertenso-diabético: 2462±465; 1511±236; 2542± 5456 e 3749±819mmHg.s (p<0,05) para adrenalina e 3749 ± 708; 746 ± 103; 1647 ± 422; 1359 ± 591 mmHg.s (p<0,05) para felipressina. Tanto o diabetes quanto a hipertensão, associadas ou não, aumentaram significativamente o tempo para atingir a pressão máxima de vasoconstrição e a duração (p<0,05). As artérias mesentéricas de ratos diabéticos, hipertensos e diabéticos-hipertensos apresentaram expressão significativamente aumentada dos receptores 1Aadrenérgico, AT1B e AT2 para angiotensina II (p<0,05), enquanto receptor AT1A estava com a expressão aumentada apenas nos grupos diabéticos. A expressão do receptor 1A-adrenérgico é discrepante com os achados funcionais, o que pode ser justificado pela fase crônica da doença em que a PCR foi realizada. É possível correlacionar os dados obtidos com a menor atividade vasoconstritora da felipressina observada clinicamente. A maior sensibilidade às moléculas vasoconstritoras pode explicar a maior tendência de pacientes diabéticos desenvolverem hipertensão. A partir dos dados obtidos pode-se concluir que a adrenalina é o vasoconstritor mais potente que a felipressina e ambas as moléculas tem seus efeitos reduzidos em pacientes hipertensos e diabéticos, o que reforça a indicação de se utilizar anestésicos locais associados a vasoconstritores nestas populações. / The main goal of this study wasto evaluate and compare vasoconstrictor agents present in local anesthetic solutions (Epinephrine - vasoconstriction and vasodilation, Felypressin - vasoconstriction) vascular reactivity on mesenteric artery bed of normotensive, diabetic, renal hypertensive one-kidney-one-clip (1K1C) and hypertensive 1K1C diabetic rats. Dosagesstudied were 80, 160, 320, 640 and 1280ng (epinephrine) or 0,25; 0,5;1; 2 and 4 x 10-3UI (felypressin). Also, we aimed to correlate artery response with RNAm expression of 1A and 2-adrenoceptors, V1A vasopressin receptor and AT1A, AT1B e AT2 angiotensin receptors, in order to verify if arterial hypertension and diabetes can lead to alterations on a inductive and isogenic model. Wistar male rats weighing 110-160g were anaesthetized with a mixture of ketamine and xylazine (50+10mg/ml/kg), had their abdominal cavity opened and a silver clipwith 0.25-mm gap was implanted in the main left kidney artery, the right kidney was surgically removed (1K1C-rats). After 14 days, they received a subcutaneous injection of streptozotocin (50 and 60 mg/ml/kg) for inducing diabetes, whereas the glycemia was tested via the tail vein prior to surgery (diabetic rats). Around 30-42 after the clip was implanted, all the groups were anaesthetized again and a polyethylene (PE-50) cannula was implanted on the left carotid artery for direct arterial pressure register. After registering the pressure, the animals had their main mesenteric artery exposed and cannulated. The mesenteric artery bed was then isolated and transferred to a bath with Krebs nutritive solution at 37ºC. The catheter was connected to the computer register system (PowerLab®) using a specific software (Chart 5Pro ®). The following parameters were analyzed: maximum (vasoconstriction) and minimal pressure (vasodilating), the amount of time necessary to achieve this number, total duration of the reaction, integral and integral over baseline. The data was submitted to analysis of variance of repeated measures (ANOVA), followed by a Holm-Sidak (normal distribution) test or Mann Whitney (parametrics) test when suitable, with a significance level of 5%. All maximum vasoconstriction results presented dosage-dependant behavior, however, for the four groups tested, the vasoconstrictive result for epinephrine was significantly superior to felypressin (p<0,05). Diabetes and hypertension significantly reducedepinephrine and felypressin vasoconstrictor responses, integral above baseline, respectively, for control, diabetic, hypertensive and hypertensive-diabetic groups:2462±465; 1511±236; 2542± 5456 e 3749±819 mmHg.s (p<0.05, epinephrine) and 3749 ± 708; 746 ± 103; 1647 ± 422; 1359 ± 591 mmHg.s (p<0.05, felypressin). Both diabetes and hypertension, associated or not, significantly increased time necessary to achieve maximum vasoconstrictor response and its duration (p<0,05). Diabetic, hypertensive and hypertensive-diabetic mesenteric arteries presented 1A-adrenoceptor, AT1B and AT2 angiotensin II-receptor gene expression significantly increased when compared with control group (p<0,05), while AT1Areceptor presented this pattern only in diabetic groups.1A-adrenoceptor gene expression did not confirm functional data, probably due to chronic disease state in wich PCR was performed. A partir dos dados obtidos pode-se concluir que a adrenalina é o vasoconstritor mais potente que a felipressina e ambas as moléculas tem seus efeitos reduzidos em ratos hipertensos e diabéticos não tratados, o que reforça a indicação de se utilizar anestésicos locais associados a vasoconstritores nestas populações.Its possible to correlate our datawith reducedvasoconstrictor activity of felypressinin clinical use. Increased sensibility and receptor population for vasoconstrictor endogenous molecules could explain diabetic populations tendency to develop arterial hypertension. Our results suggest that epinephrine is more potent than felypressin and both vasoconstrictors presents reduced effects on diabetic and hypertensive patients, what reinforces vasoconstrictor associated with local anesthetic use in this population.

O objetivo deste estudo foi avaliar os efeitos cardiovasculares da infiltração maxilar usando lidocaína 2% associada à epinefrina 1:100.000, articaína 4% associada à epinefrina 1:100.000 e 1:200.000 em diferentes etapas da consulta odontológica para realização de procedimento restaurador. Vinte voluntários receberam, aleatoriamente, 1,8 ml dos três anestésicos locais. A pressão arterial sistólica, diastólica e média e a freqüência cardíaca foram avaliadas pelos métodos oscilométrico e fotopletismográfico em sete etapas da consulta odontológica. A análise estatística dos parâmetros cardiovasculares através dos testes ANOVA e Tukey não mostrou diferenças significativas entre as três soluções anestésicas. Houve diferença estatisticamente significante para os parâmetros cardiovasculares entre as diferentes etapas clínicas da consulta odontológica. A variação dos parâmetros cardiovasculares é semelhante para as soluções de articaína e lidocaína associadas à epinefrina e é influenciada pelas etapas da consulta odontológica. / The aim of this study was to evaluate cardiovascular effects by maxillary infiltration using 2% lidocaine with 1:100.000 epinephrine, 4% articaine with 1:100.000 and 1:200.000 epinephrine in different stages of dental appointment for restorative procedures. Twenty healthy patients randomly received 1,8 ml of the three local anesthetics. Systolic blood pressure, average blood pressure, diastolic blood pressure and heart rate were evaluated by the oscillometric and photoplethysmograph methods in seven stages of the appointment. Statistical analysis by ANOVA and Tukey tests of cardiovascular parameters did not show significant differences between the anesthetic associations. There were significant differences for the parameters among different clinical stages of the dental appointment. The variation of cardiovascular parameters is similar for articaine and lidocaine solutions and it is influenced by the stages of the dental appointment.