With over a billion people infected world wide, hookworms are considered as important human pathogens, particularly in developing countries which have the highest rates of infections. Hookworms reside in the gastrointestinal tract of the host where they continuously feed on blood, leading to conditions such as chronic irondeficiency anaemia. The majority of blood-feeding parasites rely on proteins found in blood to provide many of their nutritional requirements for growth, reproduction and survival. Of the numerous proteins found in blood, haemoglobin (Hb) is one of the most abundant. In order to acquire amino acids for protein synthesis, it is thought that haematophagous parasites degrade Hb using various classes of endo- and exoproteases, in a manner similar to that which occurs in catabolism of proteins in mammalian cellular lysosomes. This study identified and characterised proteases involved in the Hb degradation process in the human hookworm, Necator americanus, in order to identify potential candidate antigens for a vaccine that interrupts blood-feeding. Red blood cells ingested by hookworms are lysed to release Hb, which is cleaved by various proteases into dipeptides or free amino acids and these are taken up through the gut membrane by amino acid transporters. Proteases expressed in the intestinal tract of hookworms are thought to play a major role in this process and would therefore make good targets for vaccine candidates aimed at interrupting blood-feeding. To identify these proteases, adult hookworms (both N. americanus and Ancylostoma caninum) were sectioned and intestinal tissue was dissected via laser microdissection microscopy. RNA extracted from the dissected tissue was used to generate gut-specific cDNA, which then was used to create plasmid libraries. Each library was subjected to shotgun sequencing, and of the 480 expressed sequence tags (ESTs) sequenced from each species, 268 and 276 contigs were assembled from the N. americanus and A. caninum libraries, respectively. Nine percent of N. americanus and 6.5% of A. caninum contigs were considered novel as no homologues were identified in any published/accessible database. The gene ontology (GO) classification system was used to categorise the contigs to predicted biological functions. Only 17% and 38% of N. americanus and A. caninum contigs, respectively, were assigned GO categories, while the rest were classified as being of unknown function. The most highly represented GO categories were molecular functions such as protein binding and catalytic activity. The most abundant transcripts encoded fatty acid binding proteins, C-type lectins and activation associated secreted proteins, indicative of the diversity of functions that occur in this complex organ. Of particular interest to this study were the contigs that encoded for cysteine and metalloproteases, expanding the list of potential N. americanus haemoglobinases. In the N. americanus cDNA library, four contigs encoding for cathepsin B cysteine proteases were identified. Three contigs from the A. caninum and one contig from the N. americanus cDNA libraries encoded for metalloproteases, including astacin-like and O-sialoglycoprotein endopeptidases, neither of which had previously been reported from adult hookworms. Apart from haemoglobinases, other mRNAs encoding potential vaccine candidate molecules were identified, including anti-clotting factors, defensins and membrane proteins. This study confirmed that the gut of hookworms encodes a diverse range of proteases, some of which are likely to be involved in Hb digestion and have the potential to be hidden (cryptic) vaccine antigens. Four cysteine proteases (Na-CP-2, -3, -4 and -5) were identified from the gut cDNA library of N. americanus. All four proteases belong to the clan CA, family C1, share homology with human cathepsin B and possess a modified occluding loop. Real-time PCR indicated that all transcripts were up-regulated in the adult stage of the hookworm parasite with high levels of mRNA expression detected in gut cDNA. All four proteases were expressed in recombinant form, but only Na-CP-3 was successfully expressed in soluble form in the yeast Pichia pastoris. Proteolytic activity for Na-CP-3 was detected on a gelatin zymogen gel, however no catalytic activity was detected against the class-specific fluorogenic peptides Z-Phe-Arg-AMC and Z-Arg-Arg-AMC. Mass spectrometry analysis of the purified protein suggested that the pro-region had not been processed in trans when the protein was secreted by yeast. Incubation of Na-CP-3 in salt buffers containing dextran sulfate resulted in autoprocessing of the pro-region as detected by Western blot and catalytic activity was detected against Z-Phe-Arg-AMC. Activated Na-CP-3 did not digest intact tetrameric human Hb. The other three cysteine proteases (Na-CP-2, -4, and -5) were expressed in insoluble form in Escherichia coli. Antibodies to all four proteins (Na- CP-2 to 5) immunolocalised to the gut region of the adult worm, supporting mRNA amplification results and strongly indicated that they might play a role in nutrient acquisition. Hb digestion in blood feeding parasites such as schistosomes and Plasmodium spp. occurs via a semi-ordered cascade of proteolysis involving numerous enzymes. In Plasmodium falciparum, at least three distinct mechanistic classes of endopeptidases have been implicated in this process, and at least two classes have been implicated in schistosomes. A similar process is thought to occur in hookworms. An aspartic protease, Na-APR-1, was expressed in P. pastoris and purified protein was shown to cleave the class-specific fluorogenic peptide 7- Methoxycoumarin-4-Acetyl-GKPILFFRLK(DNP)-D-Arg-Amide. Recombinant Na- APR-1 was able to cleave intact human Hb and completely degrade the 16 kDa monomer and 32 kDa dimer within one hour. Recombinant Na-CP-3 was not able to cleave intact Hb, but was able to further digest globin fragments that had previously been digested with Na-APR-1. A clan MA metalloprotease, Na-MEP-1, was identified in gut tissue of N. americanus and was expressed in recombinant form in Hi5 insect cells using the baculovirus expression system. Recombinant Na-MEP-1 displayed proteolytic activity when assessed by gelatin zymography, but was incapable of cleaving intact Hb. However, Na-MEP-1 did cleave globin fragments which had previously been incubated with Na-APR-1 and Na-CP-3. Hb digested with all three proteases was subjected to reverse phase HPLC and peptides were analysed using Liquid Chromatography-Mass Spectrometry (LC-MS). A total of 74 cleavage sites were identified within Hb ƒ¿ and ƒÀ chains. Na-APR-1 was responsible for cleavage of Hb at the hinge region, probably unravelling the molecule so that Na- CP-3 and Na-MEP-1 could gain access to globin peptides. All three proteases were promiscuous in their subsite specificities, but the most common P1-P1Œ residues were hydrophobic and/or bulky in nature, such as Phe, Leu and Ala. Antibodies to all three proteins (Na-APR-1, -CP-3, -MEP-1) immunolocalised to the gut region of the worm, further supporting their roles in Hb degradation. These results suggest that Hb degradation in N. americanus follows a similar pattern to that which has been described in Plasomdium falciparum. Studies conducted in this project have identified a number of potential haemoglobinases and have demonstrated that the gut region of the hookworm contains a multitude of proteases which could be targeted for production of new chemotherapies or as vaccine candidates. Results presented here also suggest that the Hb degradation process occurs in an ordered cascade, similar to those which have been reported in other haematophagous parasites. More importantly, it has been confirmed that Na-APR-1 plays a crucial role in the initiation of the Hb degradation process and therefore targeting this molecule as a vaccine candidate could provide high levels of protection against hookworm infection.

Recent statistics show that approximately 415 million people worldwide have diabetes. Glycated haemoglobin (HbA1c) measurements were introduced many years ago as the gold standard tool for detecting and monitoring treatment as well as making management decisions for diabetic patients. Glycated haemoglobins are formed by the non-enzymatic glycation of haemoglobin molecules. This non-enzymatic glycation process has been strongly related to pathogenesis of chronic complications associated to diabetes. It was suggested that this glycation process may be moderated by an enzymatic deglycation process thought to involve a deglycating enzyme known as Fructosamine-3-kinase (FN3K), an enzyme that deglycates the glycated haemoglobin in erythrocytes and other glycated proteins in other tissues. FN3K acts through phosphorylation of fructosamines on the third carbon of their sugar moiety, making them unstable and consequently causing them to detach from the protein. The degree of deglycation is thought to depend on the activity of the FN3K enzyme. Moreover, variation in the activity of FN3K between individuals is hypothesised to lead to apparent differences in glycated haemoglobin levels: some individuals have high rates of deglycation so that they tend to have lower average glycaemia than actually the case, while others with low rates of deglycation appear to have higher than actual glycaemia (known as the glycation gap, G-gap). The G-gap has been reported to be associated with alteration of diabetic complications risk. The G-gap reflects the discrepancy between average glycaemia as determined from glycated haemoglobin (measured as HbA1c) and that from the determination of fructosamine. The positive G-gap is defined as a higher level of glycation of proteins than expected whereas a negative G-gap means a lower level of glycation than expected. To explore the role of FN3K in diabetes and other associated morbidities, we decided to divide our research into 3 studies. Each study was categorised according to the type and the source of samples involved. The first study explored the correlation between FN3K activity and protein level with G-gap data; it involved 148 diabetic patients who were recruited at New Cross Hospital, Wolverhampton, selected as having a consistent positive G-gap > +0.5 and a consistent negative G-gap > -0.5 over a minimum of 2 estimations. Age, gender, race and BMI were collected from patients in this study. Blood samples were also 3 collected to measure FN3K activity, protein levels, and markers of CVD in relation to G-gap. The second study involved 23 AECOPD patients who were recruited from St George’s Hospital (London) and were treated with either metformin or a placebo. Serum samples were collected from these patients for a larger study: we assayed those 23 serum samples for FN3K protein levels to explore any possible correlation between FN3K with metformin therapy in COPD patients. The third study utilised 36 human peripheral lung samples from healthy individuals, asymptomatic smokers and stable COPD patients (GOLD 2) who were recruited at The Section of Respiratory Medicine, University Hospital of Ferrara, Italy. Those samples were assessed for FN3K expression by means of immunohistochemistry to explore the difference in FN3K activity between those three categories. It was found that the intracellular activity and protein expression of the FN3K enzyme in diabetic patients negatively correlated with the values of G-gaps where FN3K activity was high in patients with negative G-gap. FN3K serum protein levels were shown to be enhanced with metformin administration in COPD diabetic patients, suggesting a protective role for FN3K enzyme against protein damaged caused by the non-enzymatic glycation of proteins. Therefore, patients with positive G-gap have lower FN3K activity than those with negative G-gap, and in turn they are more susceptible to diabetes related complications. Our data also indicate that metformin has a beneficial effect in reducing damage caused by carbonyl stress from cigarette smoking in COPD patients by the action of FN3K. Our research has demonstrated that FN3K contributes to the protein repair system which protects against damage caused by non-enzymatic glycation. The high activity for the FN3K enzyme was associated with low levels of AGEs and low carbonyl stress levels in observed among patients with diabetes and COPD. In contrast, COPD patients tend to have low FN3K-mediated protection against protein damage in comparison to the normal population. These patients tend to be at risk for developing more complications, particularly CVD complications, than normal, healthy individuals. Treatment with metformin enhances FN3K action in COPD diabetic patients, possibly as a protective enzyme against the damaged caused by the non-enzymatic glycation.

A doença falciforme é uma síndrome hematológica genética que faz parte das hemoglobinopatias de grande abrangência na população mundial. Estima-se que 4,5% da população apresente algum tipo de hemoglobinopatia, cujos aspectos clínicos oscilam de leve à grave. O principal fator que pode influenciar o fenótipo das doenças falciformes é o genótipo da doença; homozigose para HbS ou genótipos compostos do tipo HbSC, HbS/beta-talassemia, HbSD. Este pode desenvolver distúrbios como dislipidemia, colelitíase e transtornos cardiovasculares que podem causar o óbito. O presente estudo visa correlacionar o perfil lipídico de pacientes portadores de doença falciforme. Foram avaliados 52 pacientes do Serviço de Hematologia Clínica do Hospital Universitário Pedro Ernesto HUPE-UERJ, portadores da doença falciforme confirmada pela técnica de HPLC realizada no Laboratório de Análises Clínicas da Faculdade de Farmácia (LACFAR)-UFRJ. As análises hematológicas compostas pelo hemograma completo e dosagens bioquímicas do perfil lipídico formado pela dosagem de triglicerídeos, colesterol total, colesterol HDL, colesterol LDL e colesterol VLDL. A população estudada é composta por 52 pacientes, sendo 22 pacientes do sexo masculino, representando 42% do total de pacientes e 30 do sexo feminino, definindo 58% do total. E com objetivo comparativo, foi constituído um grupo controle de 52 pessoas com média de idade 26 anos, variando entre 5 e 63 anos. A população de Doença Falciforme apresenta grupos etários que oscilam entre 6 e 60 anos de idade, tendo média de 28 anos. Baseada nas características fenotípicas definidas por HPLC, a classificação de hemoglobina demonstra um grupo de 83% de portadores de Hemoglobina SS (n=43), 13% portadores de Hemoglobina SC (n=7) e 4% com Hemoglobina SB0 (n=2). Em relação às dosagens bioquímicas, a análise do perfil lipídico demonstra hipocolesterolemia, cuja média da população é definida por 122mg/dL quando comparada com o grupo controle (GC) com média de 201mg/dL (p<0,001). A taxa do colesterol-HDL situa-se na média de 29mg/dL e do GC 54 mg/dL (p<0,001) e do colesterol-LDL 69mg/dL enquanto o GC 120mg/dL (p<0,001). A sistematização dos resultados hematológicos define uma média de hematimetria de 2,7. 106/mm3. Na dosagem de hemoglobina obteve-se média de 8,4g/dL. Tais resultados caracterizam que é predominante neste grupo a hipocromia sem expressão de microcitose. Dentre os processos patológicos mais comuns, a litíase biliar se destacou nos pacientes com doença falciforme, onde 25% dos pacientes estudados (n=13) apresentaram este comprometimento hepatobiliar, na qual grande parte desses pacientes foram submetidos à colecistectomia. A doença Falciforme cursa com hiperplasia medular principalmente às custas da hiperproliferação dos precursores eritróides na medula óssea. O estado hiperproliferativo nessa doença possivelmente causa redução do colesterol plasmático para atender à maior demanda deste elemento para síntese de novas membranas. Esta redução na produção endógena de colesterol pode ser entendida pela disfunção hepática que habitualmente está presente em pessoas com doença falciforme. Logo se concluiu que existe uma correlação de hipocolesterolemia total e de HDL-c baixo em pacientes com doença falciforme. / The sickle cell disease is an hematologic genetic syndrome, a genetic part of hemoglobinopathies -reaching in the world population. It is estimated that 4.5 % of population present some type of hemoglobinopathy, whose clinical features ranging from mild to severe. The main factor that can influence the phenotype of sickle cell disease is the disease genotype, homozygous or compound HbS genotypes of type HbSC, HbS / beta- thalassemia, HbSD. This can develop disorders such as dyslipidemia, gallstones and cardiovascular disorders that can cause death. This study aims to correlate the lipid profile of patients to sickle cell disease. 52 patients of the Department of Clinical Hematology, University Hospital Pedro Ernesto HUPE - UERJ with sickle cell disease confirmed by HPLC technique performed in the Laboratory of Clinical Analysis, Faculty of Pharmacy ( LACFAR) -UFRJ were evaluated. Hematological analyzes made by complete blood count and biochemical measurements of the lipid profile formed by a triglyceride, total cholesterol, HDL cholesterol, LDL cholesterol and VLDL cholesterol were. The study population consists of 52 patients, 22 male patients, representing 42 % of patients and 30 female, defining 58 % of the total group. And with the comparative purpose, a control group was composed of 52 people with mean age 26 years, ranging between 5 and 63 years. The population of sickle cell disease presents age groups ranging from 6 to 60 years of age, with a mean of 28 years. Based on phenotypic characteristics defined by HPLC rankings hemoglobin shows a group of 83 % of patients with SS ( n = 43 ) Hemoglobin, 13 % patients with hemoglobin SC ( n = 7 ) and 4 % with hemoglobin SB0 ( n = 2 ). Regarding biochemical measurements, the lipid profile analysis demonstrates hypocholesterolemia, whose average population is defined by 122mg/dL compared with the control group (CG ) with an average of 201mg/dL ( p < 0.001 ). The rate of HDL cholesterol lies in the middle of 29mg/dL and CG 54 mg / dL (p <0.001) and LDL-cholesterol while CG 69mg/dL 120mg/dL (p < 0.001). The systematization of hematological results defines a weighted average of hematimetria 2,7.106 / mm3. The measurement of hemoglobin was obtained an average of 8.4 g / dL. These results characterize that is prevalent in this group hypochromic without the expression of microcytosis. Among the most common pathological processes, gallstones stood in patients with sickle cell disease, where 25 % of patients ( n = 13) had this hepatobiliary involvement, in which many of these patients underwent cholecystectomy. The sickle Cell Disease progresses with medullary hyperplasia mainly due to a hyperproliferation of erythroid precursors in the bone marrow. The hyperproliferative state in this disease possibly causes reduction of plasma cholesterol to meet the increased demand of this element for synthesis of new membranes. This decrease in endogenous production of cholesterol, can be understood by hepatic dysfunction that is usually present in people with sickle cell disease. Therefore it was concluded that there is a correlation total hypocholesterolemia and low HDL-C in patients with sickle cell disease.

A doença falciforme é uma síndrome hematológica genética que faz parte das hemoglobinopatias de grande abrangência na população mundial. Estima-se que 4,5% da população apresente algum tipo de hemoglobinopatia, cujos aspectos clínicos oscilam de leve à grave. O principal fator que pode influenciar o fenótipo das doenças falciformes é o genótipo da doença; homozigose para HbS ou genótipos compostos do tipo HbSC, HbS/beta-talassemia, HbSD. Este pode desenvolver distúrbios como dislipidemia, colelitíase e transtornos cardiovasculares que podem causar o óbito. O presente estudo visa correlacionar o perfil lipídico de pacientes portadores de doença falciforme. Foram avaliados 52 pacientes do Serviço de Hematologia Clínica do Hospital Universitário Pedro Ernesto HUPE-UERJ, portadores da doença falciforme confirmada pela técnica de HPLC realizada no Laboratório de Análises Clínicas da Faculdade de Farmácia (LACFAR)-UFRJ. As análises hematológicas compostas pelo hemograma completo e dosagens bioquímicas do perfil lipídico formado pela dosagem de triglicerídeos, colesterol total, colesterol HDL, colesterol LDL e colesterol VLDL. A população estudada é composta por 52 pacientes, sendo 22 pacientes do sexo masculino, representando 42% do total de pacientes e 30 do sexo feminino, definindo 58% do total. E com objetivo comparativo, foi constituído um grupo controle de 52 pessoas com média de idade 26 anos, variando entre 5 e 63 anos. A população de Doença Falciforme apresenta grupos etários que oscilam entre 6 e 60 anos de idade, tendo média de 28 anos. Baseada nas características fenotípicas definidas por HPLC, a classificação de hemoglobina demonstra um grupo de 83% de portadores de Hemoglobina SS (n=43), 13% portadores de Hemoglobina SC (n=7) e 4% com Hemoglobina SB0 (n=2). Em relação às dosagens bioquímicas, a análise do perfil lipídico demonstra hipocolesterolemia, cuja média da população é definida por 122mg/dL quando comparada com o grupo controle (GC) com média de 201mg/dL (p<0,001). A taxa do colesterol-HDL situa-se na média de 29mg/dL e do GC 54 mg/dL (p<0,001) e do colesterol-LDL 69mg/dL enquanto o GC 120mg/dL (p<0,001). A sistematização dos resultados hematológicos define uma média de hematimetria de 2,7. 106/mm3. Na dosagem de hemoglobina obteve-se média de 8,4g/dL. Tais resultados caracterizam que é predominante neste grupo a hipocromia sem expressão de microcitose. Dentre os processos patológicos mais comuns, a litíase biliar se destacou nos pacientes com doença falciforme, onde 25% dos pacientes estudados (n=13) apresentaram este comprometimento hepatobiliar, na qual grande parte desses pacientes foram submetidos à colecistectomia. A doença Falciforme cursa com hiperplasia medular principalmente às custas da hiperproliferação dos precursores eritróides na medula óssea. O estado hiperproliferativo nessa doença possivelmente causa redução do colesterol plasmático para atender à maior demanda deste elemento para síntese de novas membranas. Esta redução na produção endógena de colesterol pode ser entendida pela disfunção hepática que habitualmente está presente em pessoas com doença falciforme. Logo se concluiu que existe uma correlação de hipocolesterolemia total e de HDL-c baixo em pacientes com doença falciforme. / The sickle cell disease is an hematologic genetic syndrome, a genetic part of hemoglobinopathies -reaching in the world population. It is estimated that 4.5 % of population present some type of hemoglobinopathy, whose clinical features ranging from mild to severe. The main factor that can influence the phenotype of sickle cell disease is the disease genotype, homozygous or compound HbS genotypes of type HbSC, HbS / beta- thalassemia, HbSD. This can develop disorders such as dyslipidemia, gallstones and cardiovascular disorders that can cause death. This study aims to correlate the lipid profile of patients to sickle cell disease. 52 patients of the Department of Clinical Hematology, University Hospital Pedro Ernesto HUPE - UERJ with sickle cell disease confirmed by HPLC technique performed in the Laboratory of Clinical Analysis, Faculty of Pharmacy ( LACFAR) -UFRJ were evaluated. Hematological analyzes made by complete blood count and biochemical measurements of the lipid profile formed by a triglyceride, total cholesterol, HDL cholesterol, LDL cholesterol and VLDL cholesterol were. The study population consists of 52 patients, 22 male patients, representing 42 % of patients and 30 female, defining 58 % of the total group. And with the comparative purpose, a control group was composed of 52 people with mean age 26 years, ranging between 5 and 63 years. The population of sickle cell disease presents age groups ranging from 6 to 60 years of age, with a mean of 28 years. Based on phenotypic characteristics defined by HPLC rankings hemoglobin shows a group of 83 % of patients with SS ( n = 43 ) Hemoglobin, 13 % patients with hemoglobin SC ( n = 7 ) and 4 % with hemoglobin SB0 ( n = 2 ). Regarding biochemical measurements, the lipid profile analysis demonstrates hypocholesterolemia, whose average population is defined by 122mg/dL compared with the control group (CG ) with an average of 201mg/dL ( p < 0.001 ). The rate of HDL cholesterol lies in the middle of 29mg/dL and CG 54 mg / dL (p <0.001) and LDL-cholesterol while CG 69mg/dL 120mg/dL (p < 0.001). The systematization of hematological results defines a weighted average of hematimetria 2,7.106 / mm3. The measurement of hemoglobin was obtained an average of 8.4 g / dL. These results characterize that is prevalent in this group hypochromic without the expression of microcytosis. Among the most common pathological processes, gallstones stood in patients with sickle cell disease, where 25 % of patients ( n = 13) had this hepatobiliary involvement, in which many of these patients underwent cholecystectomy. The sickle Cell Disease progresses with medullary hyperplasia mainly due to a hyperproliferation of erythroid precursors in the bone marrow. The hyperproliferative state in this disease possibly causes reduction of plasma cholesterol to meet the increased demand of this element for synthesis of new membranes. This decrease in endogenous production of cholesterol, can be understood by hepatic dysfunction that is usually present in people with sickle cell disease. Therefore it was concluded that there is a correlation total hypocholesterolemia and low HDL-C in patients with sickle cell disease.

The routines for blood testing were changed during 2010 at the blood bank in UAS. At first, the blood test was taken before the donation and now it is taken after donation. Along with this, the blood bank increased the lowest level for allowance of blood donation with 10 g/L both for men and women. The level is now on 125 g/L and 135 g/L for women respectively men. After the increase, it was noticed that the amount of blood donors were deferred due to low Hb levels in creased. A study made in year 2013, investigated how much the Hb-levels actually was changed during a blood donation. It showed that it was lowered in means by 6 g/L and not 10 g/L as previously thought.The aim of this study was to see if the sitting position of the blood donor during waiting time and the supine position during the time of blood donation may had any effect on the difference of the Hb-level during the blood donation.Data from the 120 blood donors in the earlier study was collected. Hb values, before and after blood donation, were taken from the earlier study and registered times were taken from the database Prosang. The waiting time, time of blood donation and the difference of Hb-levels were calculated and correlated with Spearmanns correlation coefficient.The results did not show any correlation between the times and the difference in Hb-levels. One of the reasons may be that the blood donor physiology differ and thus the change in Hb-level can vary.

Thesis (MSportSc)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: There are a growing number of men and women world-wide who are suffering strokes due to poor lifestyle-related habits. While there is evidence of the differences in cerebral haemodynamics between stroke patients and both elderly and young healthy individuals, limited evidence has examined the effect of rehabilitation on cerebral haemodynamics. Furthermore, most studies have examined changes in cerebral haemodynamics during cognitive and functional tasks in isolation, with no literature published on them simultaneously. The primary aim of this study was to examine whether differences in cerebral haemodynamics exist between stroke patients and healthy elderly individuals while performing a simple and complex cognitive task. Thirty two men and women (age 75 ± 8 years) volunteered to participate in the study and were split into an experimental (n = 14) group consisting of stroke patients and a control (n = 18) group consisting of healthy individuals. Each participant was required to attend one testing session where measurements of oxyhaemoglobin (O2Hb), deoxy-haemoglobin (HHb), tissue oxygenation index (TOI) and total haemoglobin index (THI) were obtained. Measurements were obtained with the participants at rest, while performing the Mini Mental State Exam (MMSE) and the modified Stroop Task as cognitive tests, and the Timed Up-and-Go (TuG) and six minute walk test (6MWT) or Toe Taps (TT) as the functional tests. Furthermore, the outcome scores of the various tests were also recorded. Change in O2Hb levels were lower in the experimental group than in the control group, especially in the left prefrontal cortex (LPFC) while HHb values were higher in the right prefrontal cortex (RPFC) (p > 0.05). There were almost no differences in TOI between the two groups in either the LPFC or RPFC, however, statistically significant differences were seen in THI in the RPFC during the MMSE (p = 0.03), rest period 2 (p = 0.03), the first modified Stroop Task (p = 0.04), as well as the TuG (p = 0.02). Furthermore, significant differences were seen between the two groups with respect to the time taken to complete the TuG, with the experimental group completing it much faster (p = 0.04). The experimental group participants who had received regular rehabilitation performed consistently better across most of the testing phases, with a number of practically significant findings. The results show that definite differences exist between stroke patients and healthy elderly individuals when performing a simple and complex task. The positive effect of low intensity exercise on task performance was clearly seen in both groups, and holds a great deal of practical significance for the development of exercise programmes for healthy individuals, as well as stroke patients. Furthermore, rehabilitation following a stroke has obvious benefits as shown by the positive results of the current study, however, limited research exists to validate these findings, highlighting the need for further research in this area. / AFRIKAANSE OPSOMMING: Daar is ʼn wêreld wye toename in die aantal mans en dames wat beroertes ondervind as gevolg van swak lewenstyl-verwante gewoontes. Alhoewel baie navorsing beskikbaar is oor die verskille in serebrale hemodinamika tussen beroerte pasiënte en bejaardes, asook jong gesonde individue, is daar ʼn beperkte aantal studies oor die effek van rehabilitasie op serebrale hemodinamika. Meeste van hierdie studies het die veranderinge in serebrale hemodinamika tydens kognitiewe of funksionele take in isolasie ondersoek, met geen literatuur waar die effek van albei gesamentlik gemeet word nie. Die hoofdoel van hierdie studie was om die verskille in serebrale hemodinamika tussen beroerte pasiënte en gesonde bejaardes, tydens die uitvoering van ʼn eenvoudige en komplekse kognitiewe taak, te ondersoek. Twee-en-dertig mans en vroue (ouderdom 75 ± 8 jaar) het aan die studie deelgeneem. Die eksperimentele groep (n = 14) het bestaan uit die beroerte pasïente en die kontrole groep (n = 18) was gesonde bejaardes. Elke deelnemer het een toets sessie bygewoon waartydens oksihemoglobien (O2Hb), deoksihemoglobien (HHb), weefsel oksigenasie indeks (TOI) en totale hemoglobien indeks (THI) gemeet is. Metings is tydens rus geneem, asook tydens die kognitiewe toetse, die “Mini Mental State Exam” (MMSE) en die gewysigde Stroop taak gemeet, en die funksionele toetse, naamlik die “Timed Up-and-Go” (TuG) en die ses minute loop toets (6MWT) of “Toe Taps” (TT). Die eksperimentele groep se O2Hb was laer as die kontrole groep, veral in die linker voor frontale korteks (LPFC), en die eksperimentele groep se HHb waardes was hoër in die regter voor frontale korteks (RPFC) (p > 0.05). Daar was geen statisties betekenisvolle verskille in TOI tussen die twee groepe nie, maar wel in die THI in die RPFC tydens die MMSE (p = 0.03), rusperiode twee (p = 0.03), die eerste gewysigde Stroop Taak (p = 0.04) en die TuG toets (p = 0.02). Die kontrole groep was statisties betekenisvol vinniger as die eksperimentele groep in die TuG toets (p = 0.04). Deelnemers in die eksperimentele groep wat gereelde rehabilitasie ontvang het, het konsekwent beter gevaar tydens die toets sessie, en ʼn aantal prakties betekenisvolle verskille is in sekere veranderlikes gevind. Die resultate dui aan dat daar wel ʼn verskil in serebrale hemodinamika bestaan tussen beroerte pasiënte en gesonde bejaardes terwyl hulle eenvoudige en komplekse take verrig. Die positiewe effek van lae intensiteit oefening op prestasie was duidelike sigbaar van beide groepe. Hierdie resultate is prakties betekenisvol as dit kom by die ontwikkeling van oefenprogramme vir gesonde individue asook beroerte pasiënte. Rehabilitasie na ʼn beroerte hou ooglopende voordele in soos aangedui deur die positiewe bevindinge van die huidige studie, hoewel daar beperkte navorsing beskikbaar is om hierdie bevindinge te staaf. Daar is dus ʼn behoefte vir verdere navorsing in hierdie gebied.

L'anémie de l'enfant reste un problème d'importance pour la santé mondiale, malgré les décennies de recherche visant à comprendre son étiologie et à développer des interventions efficaces pour réduire sa prévalence et ses conséquences. Bien que les facteurs de risque individuels de l'anémie soient connus, y compris les facteurs liés à la malnutrition et à la morbidité, l'interaction entre lesdits facteurs est moins documentée dans des contextes où les enfants sont fréquemment exposés à plusieurs facteurs en même temps. Cette étude vise à documenter les efforts de lutte contre l'anémie du programme MICAH qui a été mis en oeuvre au Ghana, au Malawi et en Tanzanie. Ensuite, en utilisant les données relatives à la fois au processus et à l'évaluation colligées au cours du programme, elle vise à mieux comprendre les facteurs de risque d'anémie chez les jeunes enfants dans ces contextes et à comprendre comment les relations entre ces facteurs peuvent avoir changé au fil du temps lors de l'intervention. Spécifiquement, cette étude vérifie s‘il y a des preuves d'une réduction de la vulnérabilité des enfants aux facteurs de risque associés à l'anémie dans chaque contexte. Un examen de la documentation a été réalisé afin de caractériser le contexte du programme et des interventions, leur l'intensité et étendue. Les données transversales sur la nutrition et l'état de santé des enfants âgés de 24 à 59 mois (N = 2405) obtenues en 2000 et 2004 à partir des enquêtes d'évaluation du programme MICAH au Ghana, au Malawi et en Tanzanie, ont été utilisées pour décrire la prévalence de l'anémie. Les modèles polynomiaux de régression logistique et linéaire ont été utilisés pour estimer les risques d'anémie légère et d'anémie modérée / sévère et les niveaux d‘hémoglobine associés à des groupes de variables. Les estimations du risque attribuable à une population (RAP) ont aussi été calculées. Une anémie (Hb <110 g/L) a touché au moins 60% des enfants dans les trois pays; l'anémie modérée / sévère (<100 g/L) constituait la majorité des cas. Une forte diminution de l'anémie a été observée entre 2000 et 2004 au Ghana, mais seulement une légère baisse au Malawi et en Tanzanie. Le risque d'anémie modérée / sévère était associé au retard de croissance chez les enfants du Ghana (OR 2,68, IC 95% 1,70-4,23) et du Malawi (OR 1,71; 1,29-2,27) mais pas de la Tanzanie (OR 1,29; 0,87- 1,92). Le paludisme et les maladies récentes étaient associées à une hémoglobine plus basse. Une atténuation de cette association en 2004 a été observée seulement au Malawi pour le paludisme et au Ghana pour les maladies récentes. Le risque d'anémie modérée / sévère était 44% moindre chez les enfants âgés de 48 à 59 mois comparativement aux enfants de 24 à 35 mois dans les trois pays et cela n'a pas changé entre 2000 et 2004. Les RAP estimés ont montré qu‘environ un cinquième des cas d‘anémie modérée à sévère était attribuable au retard de croissance au Ghana et Malawi, mais pas en Tanzanie. Des RAP moindres et dépendants des contextes ont été trouvés pour le paludisme et les maladies récentes. Dans ces zones d‘intervention intégrées de santé et de nutrition la relation de certains facteurs de risque à l'anémie se modifia avec le temps. Le retard de croissance est resté toutefois un facteur de risque indépendant et non mitigé de l'anémie. Une réduction efficace des causes de la malnutrition chronique est nécessaire afin de réduire la vulnérabilité des enfants et de garantir un impact maximum des programmes de lutte contre l'anémie. Une mitigation de l'impact du paludisme peut par contre être visée dans les régions endémiques. / Childhood anaemia remains a problem of global health importance, despite decades of research to understand its aetiology and develop effective interventions to reduce its prevalence and consequences. While the individual risk factors for anaemia in young children are known, including factors related to undernutrition and morbidity, much less is known about the interaction amongst these in contexts where children are frequently exposed to several at the same time. This study seeks to document the anaemia control efforts of the Micronutrient and Health (MICAH) program implemented in Ghana, Malawi and Tanzania and use both process and evaluation data collected during the program to better understand the risk factors for anaemia in young children in these contexts and how these risk relationships may have changed over time during the intervention. Specifically, this study tests whether there is evidence of a reduction in child vulnerability to the risk factors associated with anaemia in each context. A review of program documentation was conducted to characterize the program contexts and interventions, including estimates of intensity and reach. Cross-sectional data on the nutrition and health status of children 24-59 mo (N=2405) obtained in 2000 and 2004 from community-based program evaluation surveys in Ghana, Malawi and Tanzania, were used to describe the prevalence of anaemia. Multinomial logistic and linear regression models were used to estimate the risk of mild and moderate/severe anaemia and low haemoglobin, respectively, associated with groups of variables. Population attributable risk (PAR) estimates were also calculated. Anaemia (haemoglobin <110 g/L) affected at least 60% of children in all three countries; moderate/severe anaemia (<100 g/L) accounted for the majority of cases. A large decrease in anaemia was observed between 2000 and 2004 in Ghana, but only a small decrease in Malawi and Tanzania. The risk of moderate/severe anaemia was associated with stunting in children from Ghana (OR 2.68; 95% CI 1.70, 4.23) and Malawi (OR 1.71; 1.29, 2.27) but not Tanzania (OR 1.29; 0.87, 1.92). Malaria and recent illness was associated with lower Hb overall; attenuation of this association in 2004 was observed only in Malawi for malaria and Ghana for illness. Children 48-59 mo were at least 44% less likely than those 24-35 mo to have moderate/severe anaemia in all three countries and this did not change between 2000 and 2004. PAR estimates showed that roughly one fifth of moderate/severe anaemia cases were attributable to stunting in Ghana and Malawi but not Tanzania. Lower and context-variable PAR estimates were found for malaria and recent illness. Integrated health and nutrition interventions altered the relationship of some but not all risk factors for anaemia. Stunting remained an independent and non-buffered risk factor for anaemia. Effectively reducing the causes of chronic undernutrition is required in order to reduce child vulnerability and ensure maximum impact of anaemia control programs. Some buffering of malaria impact may be achieved in endemic settings.

Magister Public Health - MPH (Public Health) / The prevalence of diabetes in Africa has been on the increase. A prevalence of 1%- 10% has been reported by different authors in different regions in Nigeria. The International Diabetes Federation estimates that 1.9% of Nigerians are diabetic and most of them have complications at the time of diagnosis. Laboratory measurement of Glycosylated hemoglobin (HbA1c) is the method of choice for monitoring glycaemic control but due to its cost and limited availability, most developing countries use fasting plasma glucose (FPG) measurement (which is less reliable) to assess glycaemic control. Most diabetic patients in Nigeria have poor glycaemic control and several factors have been implicated especially socio-economic, behavioral and treatment-related factors. Understanding the reasons for poor glycaemic control is essential in order to reduce the rate of diabetes complications.

Submitted by Geyciane Santos (geyciane_thamires@hotmail.com) on 2015-06-11T15:24:38Z No. of bitstreams: 1 Dissertação - Raissa Afonso da Costa.pdf: 2822299 bytes, checksum: 2bef6491accd0173c49963abed1e3e86 (MD5) / Approved for entry into archive by Divisão de Documentação/BC Biblioteca Central (ddbc@ufam.edu.br) on 2015-06-11T20:39:40Z (GMT) No. of bitstreams: 1 Dissertação - Raissa Afonso da Costa.pdf: 2822299 bytes, checksum: 2bef6491accd0173c49963abed1e3e86 (MD5) / Approved for entry into archive by Divisão de Documentação/BC Biblioteca Central (ddbc@ufam.edu.br) on 2015-06-11T20:42:26Z (GMT) No. of bitstreams: 1 Dissertação - Raissa Afonso da Costa.pdf: 2822299 bytes, checksum: 2bef6491accd0173c49963abed1e3e86 (MD5) / Made available in DSpace on 2015-06-11T20:42:26Z (GMT). No. of bitstreams: 1 Dissertação - Raissa Afonso da Costa.pdf: 2822299 bytes, checksum: 2bef6491accd0173c49963abed1e3e86 (MD5) Previous issue date: 2015-04-24 / Não Informada / Periodontal disease (PD) and diabetes mellitus (DM) are high prevalent chronic diseases in the adult population worldwide. There is evidence of bidirectional relationship between both diseases, i.e., DM represents a risk factor for PD and PD can impair diabetes control, resulting in a cycle of cause and effect with harmful consequences to the health of individuals. This cross-sectional study aimed to determine the socioeconomic profile of the diabetic population registered in Hiperdia program in the city of Manaus, Amazonas and to measure their periodontal status, looking for a possible relationship between periodontal and glycemic control parameters. A total of 209 type 2 diabetic patients participated of the survey, which consisted of three stages: interview, physical and periodontal examination and laboratorial tests. Data were analysed using the software Stata SE version 10.1. Chi-square tests, Spearman’s correlation, bivariate analysis and multivariate logistic regression were applied. The study population presented a mean age of 55 years, with majority of females, mixed race, income of 1-3 times the minimum wage, complete high school, average of 8 years of DM, most of them were hypertensive and 37.8% had other comorbidities, such as nephropathy and retinopathy; the average fasting plasma glycemia (FPG) and glycated hemoglobin (HbA1c) were 181.96 mg/dL and 7.92%, respectively. There was a significant positive correlation between HbA1c and plaque index - PI (r = 0.31; p <0.001), gingival index - GI (r = 0.24; p <0.001), probing depth - PD (r = 0, 19; p = 0.007) and clinical attachment level - CAL (r = 0.23; p <0.001) and between the FPG and PI (r = 0.42; p <0.001), GI (r = 0.37; p <0.001), PD (r = 0.30; p <0.001), CAL (r = 0.26 p <0.001) and dental mobility (r = 0.14; p = 0.031). Individuals diagnosed with periodontitis (208) were divided into two groups: mild/moderate periodontitis and severe periodontitis. In the bivariate analysis, it was verified association between the variables: age ≥ 50 years (p = 0.019), more than 2 years of no dental care (p = 0.021), not flossing (p = 0.039), time with DM> 4 years (p = 0.013), GI and PI ≥ 50% (p <0.001 and p = 0.003), HbA1c ≥ 9% (p <0.001) and FPG> 110 mg/dL (p <0.001) like risk factors and sex female (p = 0.025), ), 9-12 years of study (p = 0.025), ), not using insulin (p = 0.032) like protection factors in the severe periodontitis outcome. After multivariate logistic regression, it was observed that age ≥ 50 years (OR = 2.36; CI: [1.10 to 5.04]; p = 0.027) and HbA1c ≥ 9% (OR = 9.05; CI: [2.98 to 27.51 ]; p <0.001) are risk factors and female gender (OR = 0.47; CI: [from 0.23 to 0.99]; p = 0.047), 9-12 years of education (OR = 0.51; CI: [0.17 to 1.69]; p = 0.287) and no use insulin (OR = 0.33; CI: [from 0.12 to 0.85]; p = 0.023) are protector factors for severe periodontitis. It was concluded that individuals with HbA1c ≥ 9% are 9.05 times more likely to have severe periodontitis and that, considering the high prevalence of PD in diabetics and the significant correlation between periodontal and glycemic control parameters, it is required greater attention on the oral health of diabetics. / Doença Periodontal (DP) e Diabetes Mellitus (DM) são patologias crônicas de alta prevalência na população adulta e idosa em todo o mundo. Há evidências da relação bidirecional entre ambos os agravos, ou seja, o DM constitui-se como fator de risco para a DP e a DP pode dificultar o controle do diabetes, resultando em um ciclo de causas e efeitos com consequências danosas à saúde dos indivíduos. Esse estudo transversal almejou traçar o perfil socioeconômico da população diabética cadastrada no programa Hiperdia na cidade de Manaus, Amazonas e mensurar a condição periodontal desses usuários, buscando uma possível relação entre os parâmetros periodontais e de controle glicêmico. Um total de 209 diabéticos tipo 2 provenientes dos 4 distritos urbanos de saúde participou da pesquisa que consistiu de três etapas: entrevista, exame físico e periodontal e exame laboratorial. Os dados foram analisados no software estatístico Stata SE versão 10.1. Foram aplicados os testes de qui-quadrado, correlação de Spearman, análise bivariada e regressão logística multivariada. A população do estudo apresentou idade média de 55 anos, com prevalência do sexo feminino, raça parda, renda de 1 a 3 salários mínimos, ensino médio completo, média de 8 anos de DM, sendo a maioria hipertensa e 37,8% tinham outras comorbidades, como nefropatia e retinopatia; as médias de glicemia (GJ) e hemoglobina glicada (HbA1c) foram 181,96 mg/dL e 7,92%, respectivamente. Houve correlação positiva significativa entre HbA1c e índice de placa - IP (r = 0,31; p < 0,001), índice gengival - IG (r = 0,24; p < 0,001), profundidade de sondagem - PS (r = 0,19; p = 0,007) e nível de inserção clínica - NIC (r = 0,23; p < 0,001) e entre a GJ e IP (r = 0,42; p < 0,001), IG (r = 0,37; p < 0,001), PS (r = 0,30; p < 0,001), NIC (r = 0,26 p < 0,001) e mobilidade (r = 0,14; p = 0,031). Os indivíduos com diagnóstico periodontite (208) foram divididos em dois grupos: periodontite leve/moderada e periodontite severa. Na análise bivariada foi constatada associação entre as variáveis idade ≥ 50 anos (p = 0,019), tempo sem assistência odontológica maior que 2 anos (p = 0,021), não uso do fio dental (p = 0,039), tempo de experiência com o DM > 4 anos (p = 0,013), IP e IG ≥ 50% (p < 0,001 e p = 0,003), HbA1c ≥ 9% (p < 0,001) e GJ > 110 mg/dL (p < 0,001) como fatores de risco e sexo feminino (p =0,025), 9 a 12 anos de estudo (p = 0,025) e não uso de insulina (p = 0,032) como fatores de proteção para o desfecho periodontite severa. Após a regressão logística multivariada, observou-se que idade ≥ 50 anos (RC = 2,36; IC: [1,10-5,04]; p = 0,027) e HbA1c ≥ 9% (RC = 9,05; IC: [2,98-27,51]; p < 0,001) eram fatores de risco e sexo feminino (RC = 0,47; IC: [0,23-0,99]; p = 0,047), 9 a 12 anos de estudo (RC = 0,51; IC: [0,17-1,69]; p = 0,287) e não uso de insulina (RC = 0,33; IC: [0,12-0,85]; p = 0,023) eram fatores protetores para periodontite severa. Concluiu-se com os resultados obtidos que indivíduos com HbA1c ≥ 9% têm 9,05 vezes mais chance de ter periodontite severa e que, considerando a alta prevalência da DP nos diabéticos e a correlação significativa entre os parâmetros periodontais e de controle glicêmico, faz-se necessária uma maior atenção quanto à saúde bucal dos diabéticos.

The aim of this thesis was to study maternal and infant effects of delayed cord clamping (≥180 seconds, DCC) compared to early (≤10 seconds, ECC) in a randomised controlled trial. Practice and guidelines regarding when to clamp the cord vary globally, and different meta-analyses have shown contradictory conclusions on benefits and disadvantages of DCC and ECC. The study population consisted of 382 term infants born after normal pregnancies and randomised to DCC or ECC after birth. The primary objective was iron stores and iron deficiency at 4 months of age, but the thesis was designed to investigate a wide range of suggested effects associated with cord clamping. Paper I showed that DCC was associated with improved iron stores at 4 months (45% higher ferritin) and that the incidence of iron deficiency was reduced from 5.7% to 0.6%. Neonatal anaemia at 2-3 days was less frequent in the DCC group, 1.2% vs. 6.3%. There were no differences between the groups in respiratory symptoms, polycythaemia, or hyperbilirubinaemia. In paper II we demonstrated that DCC versus ECC was not associated with higher risk for maternal post partum haemorrhage and rendered a comparable ratio of valid umbilical artery blood gas samples. In paper III, the Ages and Stages Questionnaire was used to assess neurodevelopment at 4 months. The total scores did not differ, but the DCC group had a higher score in the problem-solving domain and a lower score in the personal-social domain. Immunoglobulin G level was 0.7 g/L higher in the DCC group at 2–3 days, but did not differ at 4 months. Symptoms of infection up to 4 months were comparable between groups. Finally, in paper IV, iron stores and neurodevelopment were similar between groups at 12 months. Gender specific outcome on neurodevelopment at 12 months was discovered, implying positive effects from DCC on boys and negative on girls. We conclude that delaying umbilical cord clamping for 180 seconds is safe and associated with a significantly reduced risk for iron deficiency at 4 months, which may have neurodevelopmental effects at a later age.