Estudo observacional transversal que teve como objetivos caracterizar os pacientes com diabetes mellitus segundo as variáveis demográficas e clínicas; estimar a prevalência de infecção pelo vírus da hepatite B e C e a cobertura vacinal contra hepatite B em pacientes com diabetes mellitus e identificar potenciais fatores de risco relacionados. A amostra de conveniência foi constituída de 255 pacientes com diabetes mellitus que compareceram à consulta médica nos ambulatórios de Endocrinologia e de Clínica Médica Integrado de Unidade Distrital de Saúde de Ribeirão Preto-SP, no período de julho a dezembro de 2014. As variáveis demográficas selecionadas foram sexo, idade e escolaridade e, as clínicas o uso de insulina, monitoramento da glicemia capilar, história de intervenções médicas, cirúrgicas, diagnósticas e terapêuticas e situações e comportamentos de risco para hepatite B e C. Os marcadores sorológicos investigados foram HBsAg, Anti-HBc IgG, Anti-HBc IgM, Anti-HBs e Anti-HCV. Considerou-se vacinação completa três ou mais doses da vacina contra hepatite B registrada. Para a coleta de dados utilizou-se um questionário, consulta ao registro de vacinação no Sistema Informatizado de Gestão em Saúde da Secretaria Municipal de Saúde e coleta de sangue venoso. Os dados foram apresentados por meio de estatística descritiva. A análise univariada das possíveis associações entre as variáveis demográficas e clínicas e os desfechos infecção pelo vírus da hepatite B e C e cobertura vacinal contra hepatite B, foi determinada pelos testes de Qui-quadrado corrigido por Pearson ou Teste exato de Fisher bicaudal e Wilcoxon para amostras não pareadas. Para a análise multivariada, foi construído um modelo de regressão logística onde foram incluídas as variáveis que exibiram p<0,2 na análise univariada. Valores de \'p\' inferiores a 5% foram considerados significativos. Os resultados mostraram que 16,8% dos pacientes apresentaram marcador Anti-HBc total reagente, 8,2% Anti-HBs isolado e 75% foram não reagentes para todos os marcadores de hepatite B. Nenhum caso de HBsAg reagente foi encontrado na amostra estudada. Quanto à infecção pelo vírus da hepatite C, 3,3% dos pacientes apresentaram marcador anti-HCV reagente. A prevalência de infecção pelo vírus da hepatite B (Anti-HBc reagente) em pacientes com diabetes mellitus foi de 16,8%, superior à nacional e mostrou-se diretamente associado ao tempo da doença. A prevalência de infecção pelo vírus da hepatite C (Anti-HCV reagente) foi de 3,3%, superior à nacional, mas não teve associação com as variáveis demográficas e clínicas investigadas. A cobertura vacinal contra hepatite B mostrou-se baixa (15%) em pacientes com diabetes mellitus evidenciando a sua vulnerabilidade a essa doença grave e potencialmente fatal. Maior escolaridade e o trabalho na área da saúde foram associados à melhor cobertura vacinal. Estes resultados fornecem subsídios importantes para a avaliação da prática clínica dos enfermeiros na atenção primaria à saúde para a prestação de cuidados relacionados à cobertura vacinal a pessoas com diabetes mellitus. Assim, esforços devem ser empenhados pelos profissionais e serviços de saúde para enfrentar o desafio de prover ampla cobertura vacinal a essa população, garantindo a prevenção da infecção pelo vírus da hepatite B e C / A cross-sectional observational study aimed at characterizing patients with diabetes mellitus according to demographic and clinical variables; to estimate the prevalence of hepatitis B and C virus infection and vaccine coverage in patients with diabetes mellitus and to identify potential related risk factors. The convenience sample consisted of 255 patients with diabetes mellitus who attended the medical consultation in the outpatient clinics of Endocrinology and Integrated Medical Clinic of the District Health Unit of Ribeirão Preto-SP, from July to December 2014. The selected demographic variables the use of insulin, capillary blood glucose monitoring, history of medical, surgical, diagnostic and therapeutic interventions and risky situations and behaviors for hepatitis B and C. The serological markers investigated were HBsAg, Anti -HBc IgG, Anti-HBc IgM, Anti-HBs and Anti-HCV. Three or more doses of the registered hepatitis B vaccine were considered complete vaccination. To collect data, a questionnaire was used, consulting the vaccination record of the Health Management Computerized System of Health of the Municipal Health Department and venous blood collection. The data were presented by means of descriptive statistics. Univariate analysis of possible associations between demographic and clinical variables and outcomes of hepatitis B and C virus infection and vaccine coverage against hepatitis B was determined by the Pearson-corrected chi-square test or Wilcoxon\'s exact Fisher\'s test for Unpaired samples. For the multivariate analysis, a logistic regression model was constructed in which variables that exhibited p <0.2 were included in the univariate analysis. Values of \'p\' below 5% were considered significant. The results showed that 16.8% of the patients presented total anti-HBc marker reagent, 8.2% Anti-HBs alone and 75% were non-reactive for all hepatitis B markers. No case of HBsAg reagent was found in the sample studied. Regarding hepatitis C virus infection, 3.3% of the patients presented anti-HCV marker reagent. The prevalence of hepatitis B virus (Anti-HBc reagent) in patients with diabetes mellitus was 16.8% higher than the national level and was directly associated with the time of diabetes mellitus. The prevalence of hepatitis C virus infection (Anti-HCV reagent) was 3.3%, higher than the national level, but had no association with the demographic and clinical variables investigated. Hepatitis B vaccination coverage was shown to be low (15%) in patients with diabetes mellitus evidencing their vulnerability to this serious and potentially fatal disease. Higher schooling and work in the health area were associated with better vaccine coverage. These results provide important insights for the evaluation of nurses\' clinical practice in primary health care for care related to vaccination coverage for people with diabetes mellitus. Thus, efforts must be made by health professionals and services to meet the challenge of providing ample vaccination coverage to this population, ensuring the prevention of hepatitis B and C virus infection

Made available in DSpace on 2014-07-29T15:26:23Z (GMT). No. of bitstreams: 1 Tese Marcia Alves Dias Matos.pdf: 1405580 bytes, checksum: cff6253aff8dbc7e48a7a6c687cebfa0 (MD5) Previous issue date: 2007-12-18 / Hepatitis B virus (HBV) infection occurs throughout the world. In Africa, this infection is highly endemic, with the majority of individuals becoming infected during childhood. Although Brazil has been globally considered a country of HBV intermediate endemicity, variable rates have been found in all five Brazilian regions and even inside the same region. This study aimed to investigate the epidemiological and molecular profile of the HBV infection among the Kalunga population in Goiás, Central Brazil, which is considered the largest Afro-Brazilian isolated community. A total of 878 individuals were interviewed about sociodemographic characteristics, risk factors and HBV vaccination. Blood samples were collected from all participants and serum samples were screened by enzyme-linked immunosorbent assay for the presence of HBsAg, anti-HBc and anti-HBs serological markers. HBsAg-positive samples were submitted to HBeAg and anti-HBe detection. HBsAg and anti-HBc positive samples were tested for HBV DNA detection by polymerase chain reaction and genotyping by subsequent restriction fragment length polymorphism (RFLP) analysis and nucleotide sequencing of preS/S region. The overall prevalence of HBV infection was 35.4% (95% CI: 32.3-38.7). HBsAg carrier rate was 1.8% (95% CI: 1.1- 3.0). Multivariate analysis of risk factors showed that increased age, male gender, illiteracy and history of multiple sexual partners were associated with this infection. Isolated anti-HBs was found in 301 (34.3%) individuals who were immune for hepatitis B. HBV DNA was detected in 75% (12/16) of the HBsAg positive samples, in 100% (2/2) of the HBeAg and in 83.3% (10/12) of the anti-HBe positive samples. An occult HBV infection rate of 1.7% (5/295) was found among anti-HBc positive individuals. All genotyped isolates belonged to genotype A by RFLP analysis. Nucleotide sequencing of preS/S region confirmed the circulation of genotype A (subgenotype Aa) in this community. The epidemiological findings indicate that preventive measures, such as additional health education and HBV vaccination programs, are needed to control HBV infection in this population. In addition, the molecular results suggest the introduction of genotype A, subgenotype Aa in Brazil from Africa during the slave trade. / infecção pelo vírus da hepatite B (HBV) apresenta distribuição mundial. Na África, é altamente endêmica, sendo a maioria dos indivíduos infectada durante a infância. Embora o Brasil seja considerado um país de endemicidade intermediária, taxas variadas de prevalência têm sido encontradas nas cinco regiões geográficas e mesmo dentro de uma mesma região. Este estudo teve como objetivo investigar o perfil epidemiológico e molecular da infecção pelo HBV na população Kalunga em Goiás, Brasil Central, que é considerada a maior comunidade afro-descendente isolada no Brasil. Um total de 878 indivíduos foi entrevistado sobre características sócio-demográficas, fatores de risco e vacinação contra hepatite B. Amostras sanguíneas foram coletadas de todos os participantes e os soros triados para detecção dos marcadores HBsAg, anti-HBc total e anti-HBs por ensaio imunoenzimático. As amostras HBsAg positivas foram submetidos à detecção dos marcadores HBeAg e anti-HBe. O DNA viral foi detectado nas amostras HBsAg e anti-HBc reagentes pela reação da polimerase em cadeia, sendo as amostras HBV DNA positivas genotipadas pela análise do polimorfismo de comprimento dos fragmentos de restrição (RFLP) e sequenciamento da região Pré-S/S. A prevalência global da infecção pelo HBV foi de 35,4% (IC 95% 32,3-38,7), sendo de 1,8% (IC 95% 1,1-3,0) para o HBsAg. A análise multivariada mostrou que aumento da idade, gênero masculino, analfabetismo e história de múltiplos parceiros sexuais foram fatores associados a esta infecção. Em 301 (34,3%) indivíduos, verificou-se positividade isolada ao marcador anti-HBs, sugerindo imunidade ao HBV. O HBV DNA foi detectado em 75% (12/16) das amostras HBsAg reagentes, em 100% (2/2) das HBeAg e 83,3% (10/12) das anti-HBe positivas. Um índice de 1,7% (5/295) para infecção oculta pelo HBV foi encontrado nos indivíduos anti-HBc reagentes. Todas as amostras genotipadas por RFLP foram do genótipo A. O sequenciamento da região Pré-S/S confirmou a circulação do genótipo A (subgenótipo Aa) nesta comunidade. Os achados epidemiológicos indicam que medidas preventivas, como programas de educação em saúde e de vacinação contra hepatite B, são necessárias para o controle da infecção pelo HBV nesta população. Além disso, os resultados moleculares sugerem que o genótipo A, subgenótipo Aa foi introduzido no Brasil durante o tráfico de escravos da África.

As hepatites B e C constituem ainda importante problema de saúde pública no mundo, com cifras de portadores crônicos estimados em cerca de 350 milhões e de 170 milhões, respectivamente, fazendo com que número elevado de pessoas se encontrem sob risco de cronificação e evolução para cirrose hepática e hepatocarcinoma. Entre os fatores de risco mais conhecidos para hepatite B estão às transfusões de sangue e derivados, o contato com sangue e/ou com secreções, por relações sexuais desprotegidas, compartilhamento de seringas e/ou agulhas para uso de drogas injetáveis, tatuagem e piercing com material contaminado. A hepatite C é transmitida primordialmente por via parenteral e a sua prevenção faz-se de modo semelhante à hepatite B. Diversos fatores de risco para ambas parecem ser fazer presentes na população surda, a qual é historicamente marginalizada em termos de acesso a informações e serviços de saúde e sobre a qual não existem referências de investigações sobre hepatites virais. Esse trabalho teve como objetivos estimar a prevalência de sorologia positiva para hepatite B e C e investigar possíveis fatores de risco entre a população surda de Ribeirão Preto. Foram estudados 88 surdos, aos quais foi apresentado DVD explicativo sinalizado em Libras sobre características e riscos das hepatites B e C. Aos que concordaram em participar foi aplicado questionário padronizado e coletada uma amostra de sangue para realização de testes imunoenzimáticos para detecção dos marcadores HBsAg, anti-HBs, anti-HBc e anti-HCV, realizados no Laboratório de Sorologia do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto. A análise sorológica revelou presença de infecção atual ou pregressa por hepatite B em sete participantes, correspondendo a 8% de prevalência total de marcadores (IC95%: 2,3 13,7). Ao se analisar as possíveis variáveis de risco, encontrou-se associação entre a infecção e as variáveis: ser nascido em outra Unidade Federada que não São Paulo e antecedente de encarceramento. Os participantes mostraram grande desconhecimento sobre aspectos básicos relacionados à transmissão das hepatites virais, indicando necessidade de políticas de saúde pública voltadas para esta população, e que levem em consideração suas particularidades linguística e cultural. / Hepatitis B and C are still an important public health problem in the world, with chronic carriers estimated at around 350 million and 170 million, respectively, causing a large number of people to be at risk of chronic forms and progression to liver cirrhosis and hepatocellular carcinoma. Among the most well-known risk factors for hepatitis B are blood and derivatives transfusions, contact with blood and/or secretions by unprotected sex, sharing needles and/or syringes in injectable drug use, tattooing and piercing with contaminated material. Hepatitis C is transmitted primarily by parenteral way and its prevention is similar to hepatitis B. Several risk factors for both seem to be present in the deaf population, which is historically marginalized in terms of access to health information and services and on which there are no references to research on viral hepatitis. This work aimed to estimate the prevalence of positive serology for hepatitis B and C and to investigate possible risk factors among the deaf population of Ribeirão Preto. An explanatory DVD about the features and risks of hepatitis B and C was presented to them in Brazilian Sign Language. Eighty eight deaf agreed to participate, signed a free and informed consent form and were included in the investigation. A standardized questionnaire was applied and a sample of blood was collected. Immunoenzymatic tests for detection of HBsAg, anti-HBS, anti-HBC and anti-HCV markers were carried out at the Serum Laboratory of the University Hospital of the Ribeirão Preto Medical School, University of São Paulo. The serological analysis revealed the presence of current or previous infection by hepatitis B in seven participants, representing 8% of total prevalence of markers (CI95%: 2,3 13,7). When analyzing the possible risk factors, it was found association between infection and the variables being born in another State other than São Paulo and past history of imprisonment. No positive samples for hepatitis C were found. The participants showed great ignorance about basic aspects related to the transmission of viral hepatitis, indicating need for public health policies directed to this population that takes into account their linguistic and cultural singularities.

Este estudo, que envolveu todos os doadores de sangue (25.891) que compareceram pela primeira vez ao Hemocentro de Ribeirão Preto, de junho de 1996 a junho de 2001, teve os seguintes objetivos: 1) Estudar a positividade de marcadores sorológicos das hepatites B e C em testes da triagem dos doadores. 2) Analisar o fluxo dos doadores positivos para os marcadores das hepatites B e C ao Ambulatório de Hepatites (AH) do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto. 3) Estimar a prevalência de infecção atual ou pregressa pelos vírus das hepatites B e C entre os doadores, através da análise dos resultados de testes confirmatórios para essas doenças. 4) Avaliar a importância da determinação da transaminase glutâmico-pirúvica (TGP) como marcador indireto de infecção pelos vírus das hepatites B e/ou C. Foram levantados dados registrados no Hemocentro, no Núcleo de Vigilância Epidemiológica (NVE) e no AH, coletando-se informações referentes ao doador, ao tipo de doação e ao resultado de teste da triagem sorológica (HBsAg, anti-HBc, anti-HCV, TGP, anti-HIV, anti-HTLV, doença de Chagas e sífilis). Foram estudados ainda: os resultados dos testes de repetição – realizados no Hemocentro – dos doadores positivos para os marcadores das hepatites B e C na triagem sorológica; o comparecimento ao NVE; e a confirmação, no AH, dos resultados para esses marcadores. A população dos doadores foi composta majoritariamente por homens (83,6%) e indivíduos de 26 a 45 anos de idade (64,0%). Predominaram as doações vinculadas (85,4%), e as maiores motivações foram solicitação e estímulo familiar ou de amigos. Os valores da prevalência, nos testes da triagem sorológica, foram iguais a 0,63% (IC95%: 0,54 – 0,72), para o HBsAg e 1,15% (IC95%: 1,02 – 1,28), para o anti-HCV. O total de doadores positivos que deveriam ser avaliados no AH, sofreu uma perda de 55,5% entre os suspeitos de ter hepatite B e de 58,7% entre os suspeitos de ter hepatite C, totalizando 266 doadores perdidos quanto ao acompanhamento. Os valores da prevalência, nos testes confirmatórios, foram iguais a 0,22% (IC95%: 0,16 – 0,28), para a hepatite B, e 0,31% (IC95%: 0,24 – 0,38), para a hepatite C. As co-positividades entre os valores de TGP e os marcadores de hepatites, nos testes de triagem sorológica, foram de 8,8%, para o vírus C, e de 0,5%, para o vírus B, indicando que a determinação dessa enzima não auxilia na seleção de doadores em bancos de sangue. / This study, which involved all blood donors (25.891) that attended the Blood Center of Ribeirão Preto for the first time from June 1996 to June 2001 had the following objectives: 1) To study the positiveness for hepatitis B and C serologic markers in donors screening tests. 2) To analyze the flow of positive donors for hepatitis B and C markers to the Hepatitis Ambulatory (HA) in the Clinical Hospital of the Faculty of Medicine of Ribeirão Preto of the University of São Paulo. 3) To estimate the predominance of present or former infection by hepatitis B and C viruses among donors, by analyzing results of screening tests that confirm these diseases. 4) To evaluate the importance of determining the glutamic-piruvic transaminase (GTP) as an indirect marker of infection by hepatitis B and C viruses. Registered data from the Blood Center as well as from the Epidemiological Surveillance Nucleus (ESN) and HA were used with the purpose of collecting information about donors, type of donation and results in serologic screening tests (HBsAg, anti-HBc, anti-HCV, GTP, anti-HIV, anti-HTLV, Chagas disease and syphilis). In addition, a study was performed on the results in repetition tests – that took place in the Blood Center – of positive donors for hepatitis B and C markers in serologic tests as well as on their attendance at the ESN and the confirmation in the HA of the results for these markers. The population of donors was composed in its majority by men (83,6%) and individuals from 26 to 45 year-old (64,0%). Linked donations predominated (85,4%), and the greatest reasons for donation arose from solicitation and stimulus coming from family and friends. The value of prevalence in serologic screening tests was 0,63% (IC95%: 0,54 – 0,72) for HBsAg and 1,15% (IC95%: 1,02 – 1,28) for anti-HCV. The total of positive donors that should have been evaluated in the HA suffered a loss of 55,5% among the suspects of having hepatitis B and of 58,7% among the suspects of having hepatitis C, reaching a total of 266 donors lost during follow-up. The value of prevalence in confirmatory tests was 0,22% (IC95%: 0,16 – 0,28) for hepatitis B and 0,31% (IC95%: 0,24 – 0,38) for hepatitis C. The copositiveness between GPT and hepatitis markers in serologic screening tests was 8.8% for hepatitis C virus and 0.5% for hepatitis B virus, indicating that determination of this enzyme is not helpful in selection of donors in blood banks.

Yip, Wing Kit. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2009. / Includes bibliographical references (leaves 100-119). / Abstract also in Chinese. / Abstract (English version) --- p.i / Abstract (Chinese version) --- p.iii / Acknowledgments --- p.v / Table of Contents --- p.vii / List of Tables --- p.x / List of Figures --- p.xi / List of Abbreviations --- p.xiii / Chapter CHAPTER 1 --- INTRODUCTION --- p.1 / Chapter 1.1 --- Hepatocellular Carcinoma --- p.1 / Chapter 1.1.1 --- Epidermiology --- p.1 / Chapter 1.1.2 --- Etiology --- p.1 / Chapter 1.2 --- Hepatitis B Virus --- p.3 / Chapter 1.2.1 --- The Epidermiology of Hepatitis B Virus Infection --- p.3 / Chapter 1.2.2 --- The Morphology and Genome of Hepatitis B Virus --- p.4 / Chapter 1.2.3 --- HBV Genotypes and Their Significance --- p.8 / Chapter 1.3 --- Hepatitis B Virus X Protein --- p.9 / Chapter 1.3.1 --- HBx Alters Various Signal Transduction Pathways --- p.10 / Chapter 1.3.2 --- HBx Interacts with Various Transcription Factors and Co-activators --- p.12 / Chapter 1.3.3 --- HBx Induces Epigenetic Alterations --- p.14 / Chapter 1.3.4 --- Identification of COOH-terminal Truncated HBx in Liver Tumors --- p.15 / Chapter 1.4 --- MicroRNAs --- p.17 / Chapter 1.4.1 --- Transcriptional Regulation and Biogenesis of MicroRNAs --- p.18 / Chapter 1.4.2 --- MicroRNAs and Cancer --- p.21 / Chapter 1.4.3 --- MicroRNAs and HCC --- p.25 / Chapter 1.5 --- Hypothesis and Aims of the Study --- p.29 / Chapter CHAPTER 2 --- MATERIALS and METHODS --- p.30 / Chapter 2.1 --- Patients --- p.30 / Chapter 2.2 --- Cell Lines --- p.30 / Chapter 2.3 --- Cloning of Various HBx Constructs --- p.32 / Chapter 2.3.1 --- PCR Amplification of HBx Fragments --- p.32 / Chapter 2.3.2 --- Cloning of HBx Fragments into TA-vectos --- p.33 / Chapter 2.3.3 --- Heat Shock Transformation --- p.33 / Chapter 2.3.4 --- Sub-cloning of HBx Fragments into Lentiviral Vectors --- p.34 / Chapter 2.4 --- Generation of Lentivirus --- p.37 / Chapter 2.4.1 --- Lentivirus Infection --- p.37 / Chapter 2.5 --- RNA Extraction --- p.38 / Chapter 2.6 --- Western Blot Analysis --- p.39 / Chapter 2.7 --- MiRNA Microarray --- p.40 / Chapter 2.7.1 --- Cyanine3-pCp Labeling of RNA Samples --- p.40 / Chapter 2.7.2 --- Sample Hybridization --- p.41 / Chapter 2.7.3 --- Microarray Wash --- p.41 / Chapter 2.7.4 --- Array Slide Scanning and Processing --- p.41 / Chapter 2.8 --- Detection of HBx Gene Deletion by PCR --- p.43 / Chapter 2.9 --- Immunohistochemistry --- p.44 / Chapter 2.10 --- Quantitative Real-time PCR --- p.45 / Chapter 2.11 --- Proliferation Assay --- p.47 / Chapter 2.12 --- Cell Cycle Analysis --- p.48 / Chapter 2.13 --- Annexin V Apoptosis Assay --- p.49 / Chapter 2.14 --- Colony Formation Assay --- p.50 / Chapter 2.15 --- Statistical Analysis --- p.51 / Chapter CHAPTER 3 --- RESULTS --- p.52 / Chapter 3.1 --- Detection of Full-length and COOH-terminal Truncated HBx in HCC Tissues --- p.52 / Chapter 3.2 --- Confirmation of HBx Expression in HCC Tissues --- p.55 / Chapter 3.3 --- Comparison of HBx from Different HBV Genotypes for Study --- p.61 / Chapter 3.4 --- Functional Characterization of COOH-tterminal Truncated HBx --- p.64 / Chapter 3.4.1 --- Selection of COOH-terminal Truncated HBx --- p.64 / Chapter 3.4.2 --- Generation of Various HBx-expressing Hepatocyte Cell Lines --- p.66 / Chapter 3.4.3 --- Effect of Full-length and COOH-terminal Truncated HBx on Cell Proliferation --- p.69 / Chapter 3.4.4 --- Effect of Full-length and COOH-terminal Truncated HBx Cell Cycle --- p.34 / Chapter 3.4.5 --- Effect of Full-length and COOH-terminal Truncated HBx on Apoptosis --- p.45 / Chapter 3.5 --- MicroRNA Profiling of Various HBx-expressing Hepatocyte Cell Lines --- p.76 / Chapter 3.5.1 --- Identification of Deregulated MicroRNAs by Microarray --- p.76 / Chapter 3.5.2 --- Validation of Deregulated MicroRNAs by Real-time PCR Analysis --- p.80 / Chapter 3.5.3 --- Confirmation of Deregulated MiRNAs in HCC and Adjacent Non-tumor Tissues --- p.84 / Chapter 3.5.4 --- Potential Downstream Targets of the HBx-deregulated MiRNAs --- p.87 / Chapter CHAPTER 4 --- DISCUSSION --- p.91 / Chapter 4.1 --- The Impact of COOH-terminal Truncated HBx in HCC --- p.91 / Chapter 4.2 --- The Biological Significance of COOH-terminal Truncated HBx Induced MiRNAs --- p.94 / Chapter 4.3 --- Limitations of the Present Study --- p.97 / Chapter 4.4 --- Future Studies --- p.98 / Chapter CHAPTER 5 --- CONCLUSION --- p.99 / REFERENCES --- p.100

O contato pele a pele imediato entre mãe e recém-nascido (RN) constitui-se em procedimento indispensável no cuidado ao momento do nascimento, quando se trabalha sob o enfoque da humanização. Estudos atuais mencionam os efeitos proporcionados por esta terapêutica, no alívio da dor aguda em recém-nascidos (RN), porém, faz-se necessário estudar tais efeitos no momento do nascimento. O objetivo deste estudo é testar o efeito tardio do contato pele a pele ao nascer, no alívio à dor dos RN, durante a administração da vacina contra Hepatite B. Trata-se de estudo comparativo com delineamento quase-experimental. O projeto foi aprovado pelo Comitê de Ética em Pesquisa da EERPUSP. Os RN pertenceram a dois grupos, sendo que, o grupo A permaneceu em contato pele a pele com sua mãe por 15 minutos após o nascimento, e, o grupo B, foi diretamente encaminhado ao berço aquecido. Manifestações comportamentais como estado de sono-vigília, NFCS adaptada, tempo de choro e reflexos de Moro, foram filmados nas fases pré-injeção, procedimento (anti-sepsia, punção, injeção e compressão) e recuperação. A freqüência cardíaca (FC) foi registrada desde a fase préinjeção até o final da recuperação. A normalidade das distribuições foi testada pelo teste Kolmogorov- Smirnov. Nas comparações dos scores da NFCS e FC utilizou-se ANOVA com medidas repetidas, possibilitando a análise intra e entre grupos. Para a variável estado de sono-vigília, na comparação entre os grupos, utilizou-se o teste Mann-Whitney. Na comparação intragrupos foi utilizado o teste de Friedman seguido de Wilcoxon para comparações múltiplas, com valor ajustado para o nível de significância, segundo número de comparações. Para variáveis categóricas foi utilizado o teste Quiquadrado. Na análise da NFCS não houve efeito estatisticamente significativo da interação grupos e fases do estudo (p=0,357). Tal efeito também não foi observado na análise entre grupos, considerandose todas as fases (p=0,298). Por outro lado, constatou-se efeito estatisticamente significativo na análise intragrupos, sendo que o valor médio da NFCS na fase de procedimento, diferiu das médias nas fases pré-injeção e recuperação (p=0,000), considerando os grupos como um todo. Com relação ao estado de sono-vigília, não foi constatada diferença estatisticamente significante entre os valores medianos dos grupos durantes as três fases (p=0,29; p=1,0; p=0,14). Na análise intragrupo houve diferença significativa entre as fases de pré-injeção e procedimento (p=0,000), bem como entre as fases de procedimento e recuperação (p=0,000). Quanto ao tempo de choro, os testes não mostraram significância estatística para as diferenças constatadas entre grupos para todas as fases (p=0,18; p= 0,57; p=0,51). O grupo A apresentou mais episódios de reflexos de Moro durante todas as fases, sendo tal diferença, significativa entre os grupos (p=0,02; p=0,04; p=0,01). Na análise da FC, os valores médios foram maiores no grupo A em todas as fases. Não houve diferença estatisticamente significativa da interação grupos e fase do estudo (p=0,933), na análise intragrupos (p=0,075) e entre grupos (p=0,332). Não foi constatado estatisticamente o efeito tardio do contato pele a pele, na diminuição dos indicadores comportamentais e fisiológico de reatividade à dor, durante a administração da vacina contra Hepatite B. No entanto, os resultados apontam o momento de contato como de intensa modulação comportamental para os RN. Separados das mães após o período de contato, os RN choraram mais, apresentaram maiores escores do NFCS, de FC e de reflexos de Moro, sendo os últimos, estatisticamente significativos. Desta forma, ainda que o tratamento estatístico não tenha encontrado diferenças entre os grupos, clinicamente foram observadas mais alterações comportamentais e fisiológica no grupo que esteve em contato, sendo em seguida retirado da mãe. / Immediate skin-to-skin contact between mother and newborn is an essential procedure in birth care when ones work is focused on the humanization of care. Current studies address the effects of this therapeutic on the relief of acute pain in newborns, though further research on its effects at birth is needed. This study aimed to test the late effect of skin-to-skin contact at birth and on the relief of newborns pain during the administration of Hepatitis B vaccine. This is a comparative study with quasi-experimental design. The project was approved by the Research Ethics Committee at the University of Sao Paulo at Ribeirão Preto, College of Nursing. The newborns composed two groups. Group A had skin-to-skin contact with mothers for 15 minutes after birth and group B was directly sent to heated cribs. Behavioral manifestations as sleep-awake state, adapted NFCS, time spent crying and moro reflexes were video recorded in the pre-injection, procedure (antisepsis, puncture, injection and compression) and recovery stages. Cardiac frequency (FC) was registered from the pre-injection phase up to the total recovery. Normality of distributions was tested through Kolmogorov-Smirnov. ANOVA with repetitive measures was used to compare NFCS and FC scores, which permitted intra and between groups analysis. The Mann-Whitney test was used to compare the variable sleep-awake state in the comparison between groups. The Friedmans test followed by Wilcoxon for multiple comparisons with value adjusted for level of significance according to the number of comparisons were used for the intra-groups comparison. Chi-square test was used for the categorical variables. Statistically significant effect was not found for the NFCS in the groups interaction and phases of study (p=0.357). Such effect was not observed in the between groups analysis considering all phases (p=0.298). On the other hand, statistically significant effect was found in the intra-groups analysis and the average value of NFCS in the procedure phases differed from averages of the pre-injection and recovery phases (p=0.000) considering the groups as a whole. Statistically significant difference was not found in median values of groups during the three phases regarding the sleep-awake state (p=0.29; p=1.0; p=0.14). There was significant difference in the intra-groups analysis between pre-injection and procedure phases (p=0.000), and also between procedure and recovery (p=0.000). The tests did not evidence statistical significance for differences found between groups in all phases regarding time spent crying (p=0.18; p= 0.57; p=0.51). Group A presented more reflexes episodes during all phases and such difference was significant between groups (p= 0.02; p=0.04; p=0.01). In the FC analysis, the average values were higher for group A in all phases. There was no statistically significant difference of the groups interaction and phase of study (p=0.933), in the intra-groups analysis (p=0.075) and between groups (p=0.332). The effect of late skin-to-skin contact was not statistically evidenced in the reduction of behavioral indicators and physiological indicator of reactivity to pain during the administration of Hepatitis B vaccine. However, results appoint the moment of contact as intense behavioral modulation for newborns. Newborns separated from mothers after contact cried more, presented higher NFCS and FC scores and more reflexes, which were statistically significant. Therefore, even though the statistical analysis did not present differences between groups, it was possible to clinically observe more behavioral and physiological alterations in the group who was in contact with the mother and was then withdrawn.

Hepatitis B virus (HBV) infection is a global leading cause of death as a result of its role in the development of cirrhosis, hepatic decompensation, and hepatocellular carcinoma (HCC). In industrialized nations such as the United States, chronic hepatitis B infection represents a significant and disproportionate disease burden among the foreign-born population. A Markov cohort decision model was developed to determine the cost-effectiveness of HBV screening among new immigrants for the purposes of early detection and treatment, as compared to usual care. The incremental cost-effectiveness ratio for the screening strategy was $45,570 per quality adjusted life year saved. Given the potential for health gains for the immigrant cohort as well as the economic attractiveness of the intervention, some consideration should be given to the addition of a universal HBV screening program to U.S. immigration policy.

Hepatitis B virus (HBV) infection is a global leading cause of death as a result of its role in the development of cirrhosis, hepatic decompensation, and hepatocellular carcinoma (HCC). In industrialized nations such as the United States, chronic hepatitis B infection represents a significant and disproportionate disease burden among the foreign-born population. A Markov cohort decision model was developed to determine the cost-effectiveness of HBV screening among new immigrants for the purposes of early detection and treatment, as compared to usual care. The incremental cost-effectiveness ratio for the screening strategy was $45,570 per quality adjusted life year saved. Given the potential for health gains for the immigrant cohort as well as the economic attractiveness of the intervention, some consideration should be given to the addition of a universal HBV screening program to U.S. immigration policy.

Current progress in the development of vaccines has decreased the incidence of fatal and non-fatal infections and increased longevity. However, new technologies need to be developed to combat an emerging generation of infectious diseases. DNA vaccination has been demonstrated to have great potential for use against a wide variety of diseases. Alone, this vaccine technology does not generate a significant immune response for vaccination, but combined with delivery by electroporation (EP), can enhance plasmid expression and immunity against the expressed antigen. Most EP systems, while effective, can be invasive and painful making them less desirable for use in vaccination. Our lab recently developed a non-invasive electrode known as the multi-electrode array (MEA), which lies flat on the surface of the skin without penetrating the tissue. This study evaluated the use of the MEA for the development of DNA vaccines. We assessed the appropriate delivery conditions for gene expression and the development of humoral immunity. We used both B. anthracis and HBV as infectious models for our experiments. Our results indicated that the MEA can enhance gene expression in a mouse model with minimal to no tissue damage. Optimal delivery conditions, based on generation of antibodies, were determined to be 125-175V/cm and 150ms with 200ug and a prime boost protocol administered on Day 0 and 14. Under these conditions, end-point titers of 20,000-25,000 were generated. Neutralizing antibodies were noted in 40-60% of animals. Additionally, we utilized a guinea pig model to assess the translation potential of this electrode. The plasmid encoding HBsAg, pHBsAg, was delivered intradermally with the MEA to guinea pig skin. The results show increased protein expression resulting from plasmid delivery using the MEA as compared to injection alone. Within 48 hours of treatment, there was an influx of cellular infiltrate in the experimental groups. Humoral responses were also increased significantly in both duration and intensity as compared to the injection only groups. Results from both experimental models demonstrate that protective levels of humoral immunity can be generated and that this electrode should translate well to the clinic.

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences