O uso do cateter venoso periférico intermitente em pacientes hospitalizados pode lhes trazer grandes benefícios, proporcionando maior liberdade com a higiene pessoal, alimentação, deambulação, além melhorias para a equipe de enfermagem com redução das rotinas diárias. No entanto, obstrução do cateter é algo que vem na contramão de uma assistência adequada, causando desconforto para o paciente e aumento do trabalho de enfermagem. Para evitar tal evento e garantir a perviedade do cateter intravascular, deve-se realizar o flushing com solução salina ou solução de heparina, após a administração de medicamentos ou em horários programados de acordo com o protocolo interno das instituições de saúde. Nesse contexto, surge o questionamento de qual é a melhor solução para manter a perviedade do cateter venoso periférico intermitente. Este estudo trata-se de uma revisão sistemática da literatura, com o objetivo de avaliar a efetividade do uso da solução salina comparada à solução de heparina na manutenção da perviedade dos cateteres venosos periféricos. Foi realizada a busca nas bases de dados eletrônicas Cinahl, Cochrane Central, Embase, Lilacs, Pubmed e Web of Science. Das 372 referências identificadas, 12 estudos foram selecionados após a análise de título e resumo para serem lidos na íntegra, sendo que 04 constituíram a amostra final. A extração e análise dos dados foram realizadas por dois revisores independentes e as divergências entre eles foram solucionadas por um terceiro revisor. Os 04 estudos foram publicados no período de 1995 a 2015. Ao todo, foram investigados 975 dispositivos endovenosos mantidos com uma das soluções estudadas em 420 participantes. Os estudos testaram a solução de heparina em dosagens que variaram de 10UI/mL a 100UI/mL versus a solução salina e investigaram as complicações relacionadas ao cateter venoso periférico em uso intermitente, sendo uma delas a obstrução do cateter a qual denominamos como ausência e/ou diminuição da perviedade do cateter venoso, que pode ser evitada com o flushing de forma adequada. As intervenções foram testadas em diferentes populações e não foram concordantes em suas conclusões; dois estudos recomendaram a solução de heparina, um estudo, a solução salina, e um recomenda o uso das duas soluções. Os quatro estudos discutem que as duas soluções são seguras e eficazes para a manutenção da perviedade do cateter venoso periférico. Porém, os autores afirmam que o tamanho da amostra não é suficiente para generalizar os resultados para todos os pacientes hospitalizados. Assim, essa revisão sistemática sugere a necessidade de que novos ensaios clínicos randomizados sejam realizados e que as instituições de saúde devem fomentar as investigações clínicas para validar uma assistência de enfermagem alicerçada em práticas seguras e de qualidade / The using of intermittent peripheral venous catheter in a hospitalized patient can bring to them important benefits, providing more freedom concerning to the personal hygiene, feeding, ambulation, and a lot of another improvements for the nursing team, reducing the daily routines. However, catheter obstruction it is something that disturb an appropriate assistence, provoking discomfort to the patient and increasing the need of job of the nursing team. To avoid this fact and to ensure the patency of the intervascular catheter, must to do the flushing process with saline solution or hepamin, after the application of drugs or in pre established time according to the protocol of procedure of the health institutions. In this regard, it emerges the questioning about what is the best solution to keep the patency of the intermittent peripheral venous catheter. This research is a systematic review about the litetature on this subject, and it aims to evaluate the effectiveness of the using of the saline solution in comparison to the heparin in the maintenance of the patency of the peripheral venous catheter. It has been done a research in the electronic databases Cinahl, Cochrane Central, Embase, Lilacs, Pubmed and Web of Science. An amount of 372 references was identified, but just 12 research were selected after the analysis of their titles and abstracts to be fully read. In the end, 04 of them were picked as definitive samples.The data collect and the anlysis were done by two independent reviewers, and the divergences between them were solved by a third reviewer. The 04 research were publicized in the 1995 to 2015 period. Altogheter, were searched 975 intravenous devices, keeping them with one of the studied solutions in 420 patients. Th estudies tried the heparin in dosages that vary from 10UI/mL to 100UI/mL versus the saline solution and investigated the complications related to the peripheral venous catheter in a intermittent using. One of these complications was the catheter obstruction, wich were designated as lack or the decrease of the patency of the venous catheter, that can be avoided with an appropriate flushing process. The interventions were tried in different populations, and they were not concordant in their conclusions. Two research recommended the heparin, one, the saline solution, and one of them recommend to use both. The four research affirm that the heparin and the saline solution are safety and effective for the maintenance of the patency of the peripheral venous catheter. However, the authors say point out that the quantity of the simple is not enough to to generalize the results regarding to all hospitalized patients. Thus, this systematic review suggest the necessity of new randomized clinical testings. In addition, the health institutions must promote clinical research in order to validate a solid nursing assistance based on safety and appropriated practices

Purpose:The stability of sildenafil in combination with heparin and dopamine was evaluated. Methods:A stability-indicating high-performance liquid chromatography method with ultraviolet detection was developed for sildenafil citrate and validated. The method was applied to the investigation of sildenafil alone, sildenafil with heparin, sildenafil with dopamine, and sildenafil with heparin and with dopamine, all in 5% dextrose injection at room temperature and under refrigeration for 30 days. Samples of 100 μL were pulled from each storage bottle on each sampling day, diluted in mobile phase, and assayed in duplicate. Samples were tested on days 0, 1, 2, 3, 4, 5, 7, 9, 12, 14, 21, and 30. Each preparation was visually inspected for precipitation and color change. The percent recovery in each study sample was determined by comparing the peak area of sildenafil in the sample with the peak area of sildenafil from a freshly prepared 100-μg/mL standard in mobile phase. Results:The sildenafil alone, sildenafil with heparin, and sildenafil with dopamine remained within 90–110% of the expected sildenafil potency for at least 30 days at both temperatures. The preparation of sildenafil with both heparin and dopamine fell below 90% potency after 3 days at room temperature and 21 days in the refrigerator. Conclusion:Sildenafil prepared in 5% dextrose injection alone, with heparin, and with dopamine retained over 90% potency after 30 days of storage at room temperature and under refrigeration. Sildenafil prepared with both heparin and dopamine had a potency of

Anhand einer umfassenden Falldarstellung einer jungen Patientin mit einem lebensbedrohlichen Gesichtsschmerzsyndrom, das nach septischer Thrombose der periorbitalen venösen und arteriellen Gefäße aufgetreten war, wurde die Bedeutung einer medikamentösen Antikoagulation für die erfolgreiche Schmerztherapie herausgearbeitet. An diesem Fallbeispiel konnte aber auch gezeigt werden, dass keine sicheren Parameter für die Indikation einer solchen Gerinnungstherapie vorlagen. Die Bedeutung dieses Falls lag unzweifelhaft in der Erkenntnis, dass in einer anhaltenden Aktivierung des Kontaktsystems der Gerinnung ein bislang unterschätztes Potential für die Entstehung und Unterhaltung ungeklärter Schmerzen liegen könnte und nicht zuletzt auch daran, dass sich diese ätiologische Komponente in der Komplexität der Erkrankung diagnostisch nicht eindeutig sichern ließ. Mit der Translokation von LPS aus der intestinalen Mukosa in endothelial vorgeschädigte Gefäßabschnitte wurde eine Hypothese vorgetragen, die neben einer schwer detektierbaren inflammatorischen Komponente auch das prokoagulatorische Potential der Schmerzentstehung erklären könnte. Die prokoagulatorische Komponente dieses hypothetischen Entstehungs-mechanismus chronischer Schmerzen müsste, so die Arbeitshypothese, umso dominanter sein, wenn prokoagulatorisch wirksame genetische Faktoren bei den Patienten hinzukommen. Unter der Annahme, dass eine solche zusätzliche Diathese nicht nur eine Schrittmacherfunktion haben, sondern auch einen diagnostischen Beitrag liefern könnte, wurde dieses diagnostische Pilotprojekt mit der empirisch begründeten Heparintherapie von 97 Schmerzpatienten verbunden. Alle Pa-tienten wurden mit dem niedermolekularen Heparin Enoxaparin behandelt und nach zehn Behandlungstagen in vier verschiedene Respondergruppen (Gruppe 1 bis 4) eingeteilt. Diese Gruppen wurden auf fünf prothrombotische Parameter untersucht. Dazu wurden die Allelprävalenzen des Plasminogen Aktivator Inhibitor-(PAI-1 4G/5G) Polymorphismus, der Faktor V-Leiden-Mutation, der Prothrombin (G20210A) Genmutation sowie die Prävalenzen der Hyperfibrinogenämie und des Protein S-Mangels ermittelt. Mit Hilfe des exakten Fisher Tests wurden jeweils die Allelprävalenzen und Parameter sowohl der Respondergruppen 1 bis 3 mit einem Kollektiv der Allgemeinbevölkerung als auch mit dem Kollektiv der Non-Responder (Gruppe 4) verglichen. Die Prävalenz des Allels A der Faktor V-Leiden-Mutation G1691A war im Enoxaparin-Kollektiv bei den Respondern der Gruppen 1 bis 3 im Vergleich zur Allgemeinbevölkerung und zur Non-Respondergruppe (Gruppe 4) signifikant erhöht. Die Allelprävalenzen und Parameter der übrigen prokoagulatorischen Faktoren unterschieden sich von denen der Kontrollgruppen nicht. Anhand des Kallikrein-Kinin-Systems als möglichem Effektor des Hämosta-sesystems konnten Hinweise auf die kausale Wirksamkeit des nieder-molekularen Heparins Enoxaparin bei der Behandlung chronischer Schmerzen gegeben werden. / We showed that low molecular heparins (enoxaparin) may help as a remedy in chronic pain syndromes. In our findings the inherited disorder Factor V Leiden was significantly higher in patients with chronic pain that had a benefit from enoxaparin in comparison to non-responders and to common population. The effect was proven by the Kallikrein-kinin-system.

<p>In 101 patients with ST-elevation myocardial infarction treated with streptokinase the additional effects of lmw-heparin (dalteparin) were investigated. The prognostic value of troponin-T (TnT) was elucidated and the development of myocardial damage was investigated with Positron Emission Tomography (PET).</p><p>Dalteparin tended to provide a higher rate of TIMI grade 3 flow in the infarct-related artery at 24 h compared to placebo. In patients with signs of early reperfusion there was a higher rate of TIMI grade 3 flow in the dalteparin group compared to placebo. There were significantly fewer patients with ischemic episodes at 6-24 h in the dalteparin compared to placebo group.</p><p>The increase in coagulation activity was attenuated in the dalteparin group. There was a tendency to more ischemic episodes and lower frequency of TIMI grade 3 flow in patients with persistent elevation of coagulation activity at 18 h. Among deceased patients the coagulation activity was significantly higher than in survivors. </p><p>The association between elevated TnT on admission and long-term mortality might be explained by longer delay, episodes of chest pain during the last 24 h, less non-invasive signs of reperfusion at 90 minutes, and lower patency in the infarct-related artery at 24 h. </p><p>Eight patients were investigated with PET at 3h, 24 h and after 3 weeks. PET outlines the infarct region with reduced perfusion and metabolism. The oxidative metabolism in the infarct region at 3 h correlated with the water-Perfusable Tissue Fraction (PTF) and its improvement over time.</p><p>Dalteparin seems to improve maintenance of coronary patency, which can be explained by attenuation of the increased coagulation activity. Elevated TnT level on admission is associated with a worse outcome, which can partly be explained by less successful fibrinolytic treatment. PET investigations might to be a useful method in future trials evaluating new agents in the treatment of acute myocardial infarction.</p>

<p>This thesis describes a new <i>in vitro</i> slide chamber model that makes it possible to conduct studies of molecular and cellular interactions between whole blood and biomaterials. The model proved to be a suitable tool for detection of cell and platelet binding to a biomaterial surface. It was possible to monitor activation of the blood cascade systems and cells in the fluid phase and detect surface-bound molecules.</p><p>One finding was that thrombin generation is primarily triggered by FXII on a biomaterial surface since corn trypsin inhibitor, inhibited thrombin generation in blood.</p><p>Another finding was that thrombin generation was dependent on variety types of blood cells, since thrombin generation was almost negligible in platelet-rich plasma. When various preparations of blood cells were used to reconstitute platelet-rich and platelet-poor plasma, erythrocytes were shown to be the most efficient cell type in triggering thrombin generation. Inhibition of platelet aggregation with aspirin and Ro44-9883 was associated with a decrease in thrombin generation, confirming that platelet activation is necessary for normal coagulation activation. These findings suggest that the central events consist of an initial low-grade generation of thrombin that involves erythrocytes and possibly leukocytes which leads to activation of platelets; and a second platelet-dependent amplification loop that produces most of the thrombin.</p><p>Titanium exposed to whole blood produced high amounts of thrombin. Stainless steel and PVC, generated lower amounts. This indicates that titanium might be less suitable as a biomaterial in devices that are in direct contact with blood for prolonged time. Considering the superior osteointegrating properties of titanium and titanium's response to blood, a correlation between high thrombogenicity and good osteointegration seems to exist.</p><p>Compstatin, that binds to complement component C3, effectively inhibited the generation of C3a and sC5b-9 and the binding of C3/C3 fragments to the surface. Our results suggest that a biomaterial is able to activate complement through both the classical and alternative pathways and that the classical pathway alone is able to maintain a substantial bioincompatibility reaction. The results show that complement activation is a prerequisite for activation and binding of PMNs to the surface in the <i>in vitro</i> model.</p>

<p>During the past decade clinical islet transplantation has become a viable strategy for curing type 1 diabetes. The limited supply of organs, together with the requirement for islets from multiple donors to achieve insulin independence, has greatly limited the application of this approach. </p><p>The islets are infused into the liver via the portal vein, and once exposed to the blood, the grafted tissue has been shown to be damaged by the instant blood-mediated inflammatory reaction (IBMIR), which is characterized by coagulation and complement activation as well as leukocyte infiltration into the islets. Islet revascularization is a subsequent critical step for the long-term function of the transplanted graft, which may partially be impeded by the IBMIR. </p><p>In this thesis, we have explored novel strategies for circumventing the effects of the IBMIR and facilitating islet revascularization.</p><p>Systemic inhibitors of the IBMIR are typically associated with an increased risk of bleeding. We therefore evaluated alternative strategies for modulating the islets prior to transplantation. We demonstrated, using an adenoviral vector, that a high level of expression and secretion of the anticoagulant hirudin could be induced in human islets. An alternative approach to limiting the IBMIR was developed in which anticoagulant macromolecular heparin complexes were conjugated to the islet surface. This technique proved effective in limiting the IBMIR in both an in vitro blood loop model and an allogeneic porcine model of islet transplantation. An increased adhesion of endothelial cells to the heparin-coated islet surface was demonstrated, as was the capacity of the heparin conjugate to bind the angiogenic factors VEGF and FGF; these results have important implications for the revascularization process.</p><p>The outcome of the work in this thesis suggests that modulation of the islet surface is an attractive alternative to systemic therapy as a strategy for preventing the IBMIR. Moreover, the same techniques can be employed to induce revascularization and improve the engraftment of the transplanted islets. Ultimately, improved islet viability and engraftment will make islet transplantation a more effective procedure and increase the number of patients whose diabetes can be cured.</p>

This thesis describes a new in vitro slide chamber model that makes it possible to conduct studies of molecular and cellular interactions between whole blood and biomaterials. The model proved to be a suitable tool for detection of cell and platelet binding to a biomaterial surface. It was possible to monitor activation of the blood cascade systems and cells in the fluid phase and detect surface-bound molecules. One finding was that thrombin generation is primarily triggered by FXII on a biomaterial surface since corn trypsin inhibitor, inhibited thrombin generation in blood. Another finding was that thrombin generation was dependent on variety types of blood cells, since thrombin generation was almost negligible in platelet-rich plasma. When various preparations of blood cells were used to reconstitute platelet-rich and platelet-poor plasma, erythrocytes were shown to be the most efficient cell type in triggering thrombin generation. Inhibition of platelet aggregation with aspirin and Ro44-9883 was associated with a decrease in thrombin generation, confirming that platelet activation is necessary for normal coagulation activation. These findings suggest that the central events consist of an initial low-grade generation of thrombin that involves erythrocytes and possibly leukocytes which leads to activation of platelets; and a second platelet-dependent amplification loop that produces most of the thrombin. Titanium exposed to whole blood produced high amounts of thrombin. Stainless steel and PVC, generated lower amounts. This indicates that titanium might be less suitable as a biomaterial in devices that are in direct contact with blood for prolonged time. Considering the superior osteointegrating properties of titanium and titanium's response to blood, a correlation between high thrombogenicity and good osteointegration seems to exist. Compstatin, that binds to complement component C3, effectively inhibited the generation of C3a and sC5b-9 and the binding of C3/C3 fragments to the surface. Our results suggest that a biomaterial is able to activate complement through both the classical and alternative pathways and that the classical pathway alone is able to maintain a substantial bioincompatibility reaction. The results show that complement activation is a prerequisite for activation and binding of PMNs to the surface in the in vitro model.

In 101 patients with ST-elevation myocardial infarction treated with streptokinase the additional effects of lmw-heparin (dalteparin) were investigated. The prognostic value of troponin-T (TnT) was elucidated and the development of myocardial damage was investigated with Positron Emission Tomography (PET). Dalteparin tended to provide a higher rate of TIMI grade 3 flow in the infarct-related artery at 24 h compared to placebo. In patients with signs of early reperfusion there was a higher rate of TIMI grade 3 flow in the dalteparin group compared to placebo. There were significantly fewer patients with ischemic episodes at 6-24 h in the dalteparin compared to placebo group. The increase in coagulation activity was attenuated in the dalteparin group. There was a tendency to more ischemic episodes and lower frequency of TIMI grade 3 flow in patients with persistent elevation of coagulation activity at 18 h. Among deceased patients the coagulation activity was significantly higher than in survivors. The association between elevated TnT on admission and long-term mortality might be explained by longer delay, episodes of chest pain during the last 24 h, less non-invasive signs of reperfusion at 90 minutes, and lower patency in the infarct-related artery at 24 h. Eight patients were investigated with PET at 3h, 24 h and after 3 weeks. PET outlines the infarct region with reduced perfusion and metabolism. The oxidative metabolism in the infarct region at 3 h correlated with the water-Perfusable Tissue Fraction (PTF) and its improvement over time. Dalteparin seems to improve maintenance of coronary patency, which can be explained by attenuation of the increased coagulation activity. Elevated TnT level on admission is associated with a worse outcome, which can partly be explained by less successful fibrinolytic treatment. PET investigations might to be a useful method in future trials evaluating new agents in the treatment of acute myocardial infarction.

Heparan sulfate proteoglycans are proteins with long, unbranched heparan sulfate (HS) polysaccharide chains attached to them. They are found on cell surfaces and in basement membranes where they exert their action by interacting with a wide range of enzymes and signaling molecules and are thereby involved in a range of various processes both during embryonic development and in adult physiology. A great part of the biological functionality of proteoglycans can be directly related to the polysaccharide part. HS chains display very variable sulfation patterns where highly sulfated regions are responsible for a large part of the biological activity. The biosynthesis of HS is a complex process in which a number of enzymes are involved. Better comprehension of how this process is regulated could reveal clues to how formation of HS sulfation patterns occurs, and thereby how HS functionality is controlled. This thesis is focusing on regulation of one of the enzymes responsible for HS sulfation, glucosaminyl N-deacetylase/N-sulfotransferase (NDST), in an attempt to understand these mechanisms better. Different aspects of NDST regulation were studied in three projects: I) “Heparin/heparan sulfate biosynthesis: Processive formation of N-sulfated domains”, where the sulfate donor PAPS is shown to influence the manner in which NDST modifies the substrate, affecting the domain structure of the polysaccharide. II) “Heparan sulfate biosynthesis: Characterization of an NDST1 splice variant”, where a splice variant of NDST1 which appears to influence NDST1 protein levels and affect HS structure is described. III) “Heparan sulfate biosynthesis in zebrafish: Five NDST genes with distinct expression patterns during embryonic development”, in which five zebrafish NDSTs were cloned and shown to be expressed in a temporally and spatially regulated manner.

Heparan sulfate (HS) is a sulfated glycosaminoglycan expressed by all cells in the body. It is found at the cell surface and in the extracellular matrix where it binds a large amount of various ligands including growth factors and morphogens. HS is important for building up morphogen gradients during embryonic development and to act as coreceptors for signaling molecules. Many different Golgi enzymes are involved in the biosynthesis of HS. It is known that some of these enzymes interact with each other but not how the whole biosynthesis machinery works or how the cell regulates the structure of the HS that it produces. In this thesis, cells and mice deficient in two of these biosynthetic enzymes, glucosaminyl N-deacetylase/N-sulfotransferase-1 (NDST1) and the isoform NDST2 have been studied. NDSTs perform the first modifications during biosynthesis where they replace N-acetyl groups on N-acetyl-glucosamine units with sulfate groups. It is known that deficiency of NDST1 is lethal, while lack of NDST2 only results in abnormal connective tissue type mast cells. Here it is shown that deficiency of both NDST1 and NDST2 is embryonically lethal. The embryonic stem (ES) cells extracted from the inner cell mass of double knockout blastocysts show in addition an impaired differentiation capacity compared to wild-type ES cells and fail completely to differentiate into cardiac muscle cells which NDST1-/-, NDST2-/- and wild-type ES cells all do. Cultured mast cells that lack NDST2 produce heparin that is low-sulfated compared to wild-type HS. To our surprise, we could show that mast cells deficient in NDST1 instead produce a more highly sulfated heparin than wild-type cells. We use a model that predicts that the biosynthesis enzymes work together in a multienzyme complex, the GAGosome, to explain our results. We hypothesize that NDST1 has a higher affinity for the GAGosome than NDST2 which only in the absence of NDST1 gets incorporated into the enzyme complex. When all GAGosomes contain NDST2, a more highly sulfated glycosaminoglycan chain will be synthesized. A splice variant of NDST1, NDST1S, has also been studied. We could show that NDST1S lacks enzyme activity but that it probably has the capacity to incorporate into GAGosomes. Overexpression of NDST1S results in altered structure of the HS produced by the cells. We speculate that expression of the splice variant during development may be one way to regulate HS structure.