Author: Bc. Dagmar Bakerová Supervisor: MUDr. Vít Řeháček Charles University, Faculty of Pharmacy in Hradec Králové Title of diploma thesis: RhD antigen screening by molecular genetic methods This thesis deals with the genotyping of weak and partial antigens using molecular genetic methods. The main aim is to evaluate the rate of the representation of individual types of variant and weak RhD antigens in first-time blood donors, patients and pregnant women. Testing took place at the Transfusion Department of University Hospital Hradec Králové between October 2015 and February 2019. The PCR-SSP method was used for RHD genotyping using commercially supplied BAGene SSP kits from BAGene Health Care. The study includes 32 samples from first-time blood donors in the reference period to determine the specific type of RhD antigen, and 188 samples from patients and pregnant women, for whom serological methods could not be used to unequivocally identify the RhD antigen. For all pregnant women, moreover, the genotyping result was a factor in determining whether to administer anti-D immunoglobulin. This RHD genotyping for all serologically ambiguous samples has made it possible to determine a specific type of partial or weak RhD antigen. In the donor group, the weak RhD antigen was detected in 1.12 % of cases...

Introdução: O sistema de grupo sanguíneo Rh é altamente complexo e polimórfico sendo considerado, depois do sistema ABO, o sistema de maior significado clínico na medicina transfusional. Os anticorpos dirigidos contra os seus antígenos estão envolvidos em reações hemolíticas transfusionais, anemia hemolítica autoimune e doença hemolítica do feto e neonatos. O antígeno D é o mais imunogênico dos antígenos do sistema Rh e sua conformação na superfície das hemácias está disposta como um mosaico de diferentes epítopos. Alterações no gene RHD, que expressa a proteína RhD, podem ser detectadas pela variação na intensidade da reação sorológica, utilizando-se diferentes reagentes anti-D. As alterações ocorrem por diversos mecanismos genéticos e são responsáveis pelo aparecimento dos fenótipos D fraco e D parcial. Essas variantes podem apresentar mudanças qualitativas e/ou quantitativas na proteína RhD e estão frequentemente envolvidas em casos de aloimunização anti-D. A identificação e classificação dos fenótipos RhD variantes possuem alta relevância clínicae, portanto, requerem uma rigorosa investigação molecular, uma vez que os testes sorológicos não são capazes de distinguir entre fenótipos D fraco e D parcial. Dessa forma, esclarecer os resultados fracos ou discrepantes encontrados na sorologia e determinar as variantes RhD têm grande importância para a comunidade científica e, principalmente, para a medicina transfusional. Objetivos: Caracterizar, por métodos moleculares, antígenos RhD variantes em amostras de doadores de sangue da Fundação Hemocentro de Brasília que apresentaram fraca expressão do antígeno RhD. Métodos: Foram selecionadas para extração de DNA e investigação molecular de antígenos RhD variantes 103 de 7983 amostras de doadores de sangue que apresentaram tanto resultados negativo, inconclusivo ou fraco (menor que 2 cruzes) na fenotipagem RhD, realizada por técnica em microplacas, como resultado positivo na confirmação de D fraco. Inicialmente, as amostras foram confirmadas quanto à presença do gene RHD por PCR multiplex RHD regiões íntron4/éxon7. Na sequência, técnicas de PCR alelo específico e RFLP foram utilizadas para triar as variantes D fraco tipos 1, 2, 3 e 4 ou DAR, seguido do sequenciamento de éxons específicos do gene RHD para investigação das demais variantes. As amostras foram avaliadas quanto à zigosidade por dosagem do gene RHD, por qPCR, e quanto à presença do Pseudogene (RHD?) e da deleção do gene RHD, por PCR-SSP. Os resultados encontrados foram interpretados em conjunto com os fenótipos RhCE também analisados. Resultados: Das amostras estudadas, 68,93% foram caracterizadas como RhD parcial; 21,36% como RhD fraco; 1,94% não apresentaram polimorfismos nos éxons do gene RHD e 2,91% apresentaram ausência de éxons RHD indicando a presença de um gene híbrido RHD-CE-D não definido. Entre as amostras RhD fraco, 16,5% eram RHD*fraco tipo 3; 5,8% RHD*fraco tipo 2; 1,94% RHD*fraco tipo 1; 0,97% RHD*fraco tipo 38 e 0,97% RHD*fraco tipo 145. Entre as amostras RhD parcial, 33,01% eram RHD*DAR 3.1; 32,04% RHD*DAR 1.2; 1,94% RHD*DVII; 0,97% RHD* DOL 1; 0,97% RHD* DOL 2. Discussão e conclusão: Nossos resultados demonstraram que as reações atípicas nos testes sorológicos para o antígeno RhD são indicativas da presença de variantes RhD. Os alelos RHD*DAR subtipos foram os mais frequentemente encontrados nas amostras dos doadores de Brasília-Distrito Federal. Esses alelos estão associados à aloimunização anti-D. A caracterização de antígenos RhD variantes por meio da associação de testes sorológicos e métodos moleculares visa, principalmente, determinar os fenótipos/genótipos associados à aloimunização anti-D. Essa caracterização é muito importante para aumentar a segurança transfusional, diminuir a administração desnecessária de imunoprofilaxia anti-D em gestantes e pode, também, colaborar com a preservação dos estoques escassos de unidades de sangue RhD negativo. Além disso, o conhecimento sobre a frequência e distribuição das variantes Rh contribui para a compreensão da origem multirracial da região estudada e auxilia no desenvolvimento de futuros protocolos de genotipagem RHD que estabeleçam estratégias de buscas de unidades de sangue compatíveis para pacientes portadores de variantes RhD. / Introduction: The Rh blood group system is highly complex and polymorphic, and considered, after the ABO system, the system of greater clinical significance in transfusion medicine. Antibodies directed against its antigens are involved in hemolytic transfusion reactions, autoimmune hemolytic anemia and hemolytic disease of the fetus and newborn. Antigen D is the most immunogenic of the Rh system and its conformation on the surface of red blood cells is a mosaic of different epitopes. Changes in the RHD gene, which expresses the RhD protein, can be detected by variations in the intensity of the serological reaction by using different anti-D reagents. The changes occur as a result of several genetic mechanisms and are responsible for the appearance of weak D and partial D phenotypes. These variants may exhibit qualitative and/or quantitative changes in RhD protein and are often involved in anti-D alloimmunization. The identification and classification of variant RhD phenotypes are of high clinical relevance. Therefore, they require a rigorous molecular investigation, since serological tests are not able to distinguish between weak D and partial D phenotypes. Thus, clarifying the weak or discrepant results found in serology and determining RhD variants are of great importance to the scientific community and especially to transfusion medicine. Objectives: To characterize, by molecular methods, variant RhD antigens in donor blood samples from the Blood Center Foundation of Brasília which showed poor expression of the RhD antigen. Methods: A total of 103 out of 7983 samples from blood donors who had negative, inconclusive or weak results (less than 2 crosses) in the microplate technique and also tested positive in the weak D confirmation test were selected for DNA extraction and molecular investigation of the RhD antigen. Initially, the presence of the RHD gene was confirmed in the samples by PCR multiplex RHD intron4/exon7 regions. Then, allele specific PCR and RFLP techniques were used to screen for weak D variant types 1, 2, 3 and 4 or DAR, followed by sequencing of specific exons of the RHD gene to investigate the other variants. Samples were evaluated for zygosity by RHD gene dosage by qPCR and for the presence of Pseudogene (RHD?) and RHD gene deletion by PCR-SSP. The results were interpreted in conjunction with the RhCE phenotypes also analyzed. Results: Of all samples studied, 68.93% were characterized as partial RhD; 21.36% as weak RhD; 1.94% had no polymorphisms in the RHD gene exons and 2.91% had no RHD exons indicating the presence of an undefined RHD-CE-D hybrid gene. Among the weak RhD samples, 16.5% were weak RHD*type 3; 5.8% RHD * weak type 2; 1.94% RHD*weak type 1; 0.97% RHD*weak type 38 and 0.97% RHD* weak type 145. Among the partial RhD samples, 33.01% were RHD*DAR 3.1; 32.04% RHD*DAR 1.2; 1.94% RHD*DVII; 0.97% RHD*DOL 1; 0.97% RHD*DOL 2. Discussion and conclusion: Our results demonstrated that atypical reactions in serological tests for the RhD antigen are indicative of the presence of RhD variants. The RHD*DAR subtype alleles were the most frequently found in donor samples from Brasília - Distrito Federal. These alleles are associated with anti-D alloimmunization. The characterization of variant RhD antigens through the association of serological tests and molecular methods mainly aims to determine the phenotypes/genotypes associated with anti-D alloimmunization. This characterization is very important to increase transfusion safety, reduce unnecessary administration of anti-D immunoprophylaxis in pregnant women and may also contribute to the preservation of scarce RhD negative blood units. In addition, knowledge about the frequency and distribution of Rh variants contributes to the understanding of the multiracial origin of the studied region, and assists in the development of future RHD genotyping protocols that establish compatible blood unit search strategies for RhD variant patients.

Submitted by Fabíola Silva (fabiola.silva@famerp.br) on 2016-10-03T18:10:48Z No. of bitstreams: 1 karinadeoliveirayounan_dissert.pdf: 994368 bytes, checksum: d0380b444a2b69e0b3248499e6a74c26 (MD5) / Made available in DSpace on 2016-10-03T18:10:48Z (GMT). No. of bitstreams: 1 karinadeoliveirayounan_dissert.pdf: 994368 bytes, checksum: d0380b444a2b69e0b3248499e6a74c26 (MD5) Previous issue date: 2014-08-22 / Introduction: The parasite Toxoplasma gondii infects a high percentage of individuals worldwide and disturbances resulting from this infection contribute to the aggravations of health conditions and may affect the intellectual development of children and adults. It has been suggested that the D antigen (Rh0) a glycoprotein that is the biochemical basis Rh but is absent in the nervous tissue, influence the motor response in the presence of T. gondii infection. Objectives: This study aims to evaluate the motor response and the reaction time for visual stimulus in the presence and in the absence of infection by the parasite T. gondii in individuals with good visual acuity, Rh positive and Rh negative. Methods: 212 volunteers from both sexes underwent visual acuity testing and measurement of average response time to visual stimulus (ART) by using a specific software. The collected blood samples were used to identify the erythrocyte RH phenotypes (positive and negative) and antibodies of IgG class anti-T. gondii (presence or absence). Average response times were compared according to sex, presence (reagents) and absence (non-reagent) infection and erythrocyte Rh phenotypes (positive and negative). The t test for comparison of average and the values of Odds Ratio (OR) and 95% confidence interval were calculated using the GraphPad Instat (version 6.3) software. The p-value equal to or less than 0.05 was considered significant. Results: The differences between the average age of reagents individuals (n = 134) and non-reagent (n = 38) to T. gondii were considered statistically significant (54.1 ± 18.7 vs 34.4 ± 18.9; p = 0.0001). The Rh phenotype positive (n = 189) was present in 89% of individuals, while the Rh-negative (n = 23) in 11%. The ART of reagents individuals for T. gondii was lower in males (0.672 ± 0.303) than in females (0.819 ± 0.270) (p = 0.0036). This same difference was observed between the non-reagent (0.475 ± 0.140 vs 0.791 ± 0.323), respectively (p <0.0001). Infected men (0.658 ± 0.282) had higher ART xi than uninfected men (0.488 ± 0.129) for T. gondii, both Rh positive (p = 0.0004). Women, infected or not, did not differ for ART even when compared by phenotype (positive or negative) Rh. Conclusions: Rh positive men infected with T. gondii have a higher ART than uninfected Rh positive men. Infected women do not differ in ART compared to women uninfected by T. gondii. / Introdução: O parasito Toxoplasma gondii infecta elevado percentual de indivíduos em todo o mundo e os distúrbios resultantes da infecção contribuem para os agravos da saúde e podem acometer o desenvolvimento intelectual de crianças e adultos. Tem sido proposto que o antígeno D (Rh0), uma glicoproteína que constitui a base bioquímica sistema Rh mas que se encontra ausente no tecido nervoso, influencia a resposta motora na presença de infecção por T. gondii. Objetivos: O objetivo deste estudo foi avaliar a resposta motora e o tempo de reação a estímulos visuais na presença e na ausência de infecção pelo parasito T.gondii em indivíduos com boa acuidade visual, Rh positivos e Rh negativos. Métodos: foram analisados 212 indivíduos voluntários, de ambos os sexos, submetidos a exame de acuidade visual e teste de medição de tempo médio de reação a estímulos visuais (TMR) com o uso de um software específico. As amostras de sangue coletadas foram utilizadas na identificação dos fenótipos eritrocitários Rh (positivo e negativo) e dos anticorpos da classe IgG, anti-T. gondii (presença ou ausência). Os tempos médios de reação foram comparados de acordo com o sexo, presença (reagentes) e ausência (não reagentes) de infecção e fenótipos eritrocitários Rh (positivo e negativo). O teste t para comparação das médias e os valores de Odds Ratio (OR) e do intervalo de confiança a 95% foram calculados com o uso do software GraphPad Instat (versão 3.06). O valor p igual ou menor que 0,05 foi considerado significante. Resultados: As diferenças entre as médias de idade de indivíduos reagentes (n=134) e não reagentes (n=78) ao T. gondii foram consideradas estatisticamente significante (54,1 ± 18,7 vs 34,4 ± 18,9; p=0,0001). O fenótipo Rh positivo (n=189) esteve presente em 89% dos indivíduos, enquanto o Rh negativo (n=23) em 11%. O TMR dos indivíduos reagentes para o T. gondii foi menor no sexo masculino (0.672 ± 0.303) que no feminino (0.819 ± 0.270) (p=0,0036). Esta mesma diferença foi observada entre os não reagentes (0.475 ± 0.140 vs 0.791 ± 0.323), respectivamente (p<0,0001). Homens infectados (0.658 ± 0.282) apresentam TMR maiores que homens não infectados (0.488 ± 0.129) por T. gondii, ambos Rh positivo (p=0,0004). Mulheres, infectadas ou não, não diferiram quanto ao TMR mesmo quando comparadas pelo fenótipo Rh (positivo ou negativo). Conclusões: Homens Rh positivos infectados por T. gondii apresentam TMR maior que homens Rh positivos não infectados. Mulheres infectadas não diferem quanto ao TMR em comparação a mulheres não infectadas por T. gondii.

Made available in DSpace on 2014-02-26T19:13:30Z (GMT). No. of bitstreams: 2 license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) 56122.pdf: 943164 bytes, checksum: 31ab7a412fa0e24ec2743d0b364e47f6 (MD5) Previous issue date: 2013-07-22 / Fundação Oswaldo Cruz. Instituto Fernandes Figueira. Departamento de Ensino. Programa de Pós-Graduação em Saúde da Criança e da Mulher. Rio de Janeiro, RJ, Brasil. / Introdução: a Doença Hemolítica Perinatal pelo fator Rh é causada pela incompatibilidade entre o sangue da mãe e do recém-nascido, levando a destruição de hemácias fetais e, sem tratamento os fetos mais severamente afetados podem morrer intra-útero. No recém-nascido, a doença pode resultar em icterícia,anemia, dano cerebral, falência cardíaca e morte.Desde introdução da profilaxia anti-Rh D o número de recém-nascidos com doença hemolítica tem caído drasticamente em países desenvolvidos, porém essa não é a realidade nacional. Objetivo Geral:descrever as práticas usadas para tratar os pacientes com doença hemolítica perinatal pelo fator Rh, nascidos no Instituto Fernandes Figueira nos últimos 10 anos e apresentar dados clínicos,laboratoriais, o tipo de abordagem terapêutica oferecida e o perfil imunohematológico de suas mães. Material e métodos:Foi realizada uma cohort de 300 recém-nascidos de gestantes Aloimunizadas Rh, nascidos no Instituto Fernandes Figueira no período de janeiro de1995 a dezembro de 2004. Foram coletados dados do pré-natal,nascimento e acompanhamento do Follow-up até 1 ano de idade. Resultados: a maioria de nossas gestantes possuía um anticorpo que foi o anti-D, sendo que a gravidade da doença hemolítica não teve relação com o tipo de anticorpo. O início do pré-natal em nossa unidade é tardio, mas mesmo assim a maioria dos recém-nascidos nasce bem. Nosso índice de óbitos e hidropisialmente está em torno de 7%. Foi evidenciada uma queda de 66 para 35,8% do número de pacientes submetidos à exsangüineotransfusão após o ano 2000 coincidindo com a introdução biliberço e uso da imunoglobulina humana inespecífica, sem comprometimento do prognóstico. Nosso índice de mortalidade relacionado à exsangüineotransfusão foi de 0,7% e de eventos adversos foi de 61%, sendo os mais comuns a plaquetopenia (mais ou menos 50.000) e distúrbios hidroeletrolíticos (hipocalcemia).Os eventos mais graves foram os distúrbios cardiológicos e de sangramento foram estatisticamente maiores nos pacientes cujas condições clínicas eram mais instáveis antes do procedimento. Fatores como níveis críticos de bilirrubina(mais ou menos 20 mg/dl), a prematuridade, hidropisia e asfixia pioram o prognóstico tardio (surdez e encefalopatia bilirrubínica)apesar de intervenção terapêutica precoce. Conclusões: Novas terapias têm sido desenvolvidas para abordagem do recém-nascido com Doença Hemolítica Perinatal como as fototerapias de alta intensidade e a imunoglobulina humana inespecífica, levando a uma diminuição no uso da exsangüineotransfusão, porém esta ainda é uma técnica usada em casos graves de hiperbilirrubinemia.Vários eventos adversos são descritos em conseqüência deste procedimento e são na maioria das vezes assintomáticos e passiveis de correção, mas não podemos deixar de levar em consideração a gravidade do recém-nascido antes do procedimento,além da experiência clínica do profissional que realizará o procedimento. Apesar da intervenção terapêutica precoce os pacientes com fatores de risco(Bt máx mais ou menos 20mg/dl,asfixia,hipoproteinemia e prematuridade) tiveram um prognóstico neurológico pior. / Introduction: The hemolytic disease secondary to rhesus alloimmunization is caused by the incompatib ility between the mother's and the newborn’s blood, leading to the destruction of fetal r ed blood cells and without treatment the fetuses more severely affected can di e intra-uterus. Afte r the delivery the newborn’s disease can result in j aundice, anemia, cerebral damage, heart failure and death. Since the introducti on of the prophylaxis anti-Rh D the number of newborn with hemolytic dis ease has been falling drastically in developed countries, however that is not the Brazilian reality. Objective : Describe the practices used to tr eat the patients with the hemolytic disease secondary to rhesus alloimmunizati on, who were born at IFF in the last 10 years. Describing clinical data, lab abnormalities, therapeutic approach and immunohematologic characteristic of their mothers. Material and methods: Its was done a cohort of 300 newborns of pregnant women’s with alloimmunization by Rh ant ibody, with babies Instituto Fernandes Figueira in the period of January 1995 to December 2004. The program EPI 6 made the statistical analyses. Results: The mostly found antibody in the pregnant women was the anti-D, and the severity of the hemolytic diseas e didn't have relationship with the types of antibodies. The beginning of the prenatal in our unit is late, but even so most are healthy. Deaths or hydrops ar e around 7%. It was evidenced a newborns fall of 50% in patients undergoing the exchange transfusion after the year 2000, coinciding with the introduction of the Biliberço® and use of the intravenous immunoglobulin, without affecting their prognos tic. Our mortality rate related to the exchange transfusion was of 0,7% and the one related to adverse events was of 61% , being the most co mmon thrombocytopenia (< 50.000) and hypocalcemia. The most serious events were bradycardia or heart arrhythmia and bleeding. These disturbances were mo re prevalent in the patients whose clinical conditions were unstable bef ore exchange transfusion. Factors as critical levels of bilirubin ( ≥ 20 mg/dl), prematurity, hydrops fetalis and asphyxia, worsen the neurological prognostic (deafness and bilirubin encephalopathy). Conclusions: New therapies have been developed for the approach of the newborns with hemolytic disease as the phototherapy of high intensity and the intravenous immunoglobulin, leading to a dec rease in the use of the exchange transfusions, but this is still a saving life technique in the serious cases of hiperbilirrubinemia. Several adverse ev ents are described as a consequence of this procedure and most of the ti me they show no symptoms and are susceptible to correction, but we have consider the severity of the patient’s clinical conditions and the professional's skill. Besides the early therapeutic intervention in patients with risk factors (BT máx ≥ 20 mg/dl, the preterm infants, hydrops fetalis and asphyxia) it had a worse neurological prognostic.

Made available in DSpace on 2014-07-11T16:47:19Z (GMT). No. of bitstreams: 2 Sá_Cynthia_iff_dou_2013.pdf: 4245727 bytes, checksum: 621887ac992f6d17a60eb59fd4d8f036 (MD5) license.txt: 1914 bytes, checksum: 7d48279ffeed55da8dfe2f8e81f3b81f (MD5) Previous issue date: 2013 / Fundação Oswaldo Cruz. Instituto Nacional de Saúde da Mulher, da Criança e do AdolescenteFernandes Figueira. Departamento de Ensino. Programa de Pós-Graduação em Saúde da Criança e da Mulher. Rio de Janeiro, RJ, Brasil. / Introdução: A Doença Hemolítica Perinatal RhD (DHPN-RhD) é decorrente da passagem transplacentária de anticorpos maternos anti Rh positivo causando hemólise no feto e recém-nascido. Este processo pode ser prevenido pela administração de imunoglobulina anti-Rh D, no entanto, quando instalada, é irreversível. Os pacientes afetados poderão desenvolver anemia e icterícia que se não tratadas adequadamente, levam a dano cerebral irreversível, clinicamente conhecido como Kernicterus ou morte. Apesar da existência de profilaxia adequada, a DHPN-RhD ainda é prevalente no Brasil, mas não é considerada para cálculo nos Estudos de Carga de Doença. Considerando que ela possa representar uma fração importante da morbidade e mortalidade perinatal e neonatal este trabalho propõe o cálculo da carga da DHPN-RhD no Brasil Objetivo: Calcular a Carga da DHPN-RhD no Brasil e Regiões do País Método: O indicador utilizado neste estudo foi o número de anos de vida perdidos ajustados por incapacidade DALY (DisabilityAdjusted Life Years). O número de DALY foi calculado a partir da soma de duas parcelas: Anos de Vida Perdidos por Morte Prematura (YLL -Years of Life Lost,) e os Anos de Vida Perdidos devido à Incapacidade (YLD - Years Lived with Disability. Os dados para o cálculo do YLL foram obtidos através do Sistema de Informação sobre Mortalidade (SIM/DATASUS). No processo de estimação do YLD, foram utilizados, como parâmetros clínicos epidemiológicos, os casos incidentes, a duração e o peso médio das incapacidades. O considerada foi de até 30 dias. Devido à gravidade do Kernicterus, considerou-se como duração 50% da expectativa de vida estimada para o País e para as macrorregiões. Para avaliar as estimativas dos pesos das incapacidades optou-se utilizar o peso 0,894 para os casos de DHPN-RhD sem sequelas e 0,459 para os casos de Kernicterus, considerando as sequelas neurológicas relacionadas ao quadro. Resultados: A DHPN-RhD possui as menores taxas de DALY em todas as regiões do País comparando com os outros eventos perinatais. As regiões Norte e Nordeste tiveram as maiores taxas para todos os eventos neonatais com exceção da DHPN-RhD cuja segunda maior taxa foi a da região Sul. Quando analisados o componente YLL, as maiores taxas estão nas regiões Norte e Nordeste e a menor no Sudeste. Em relação ao YLD, observa-se uma inversão em relação aos valores encontrados para o componente YLL, isto é, as maiores taxas foram aquelas das regiões Sudeste e Sul. Conclusão: Apesar de a Carga da DHPN-RhD no Brasil ser muito inferior aos outros eventos perinatais ele demonstra uma herança histórica de ausência de investimentos no Norte e Nordeste como demonstrado em nosso trabalho, onde o risco de morrer por DHPN-RhD é maior que nas regiões Sul e Sudeste. Assim, para o declínio da DHPN-RhD no nosso país há necessidade de melhorar a assistência perinatal e também de um reconhecimento político da contingência dessas desigualdades regionais e da necessidade de priorizar a profilaxia ao invés de tratamento. / Introduction: Rhesus Haemolytic Disease (RHD) occurs due passage of maternal antibodies anti RhD by placenta causing hemolysis in fetus and newborn. This can be prevented by administration of anti-Rh D immunoglobulin, however, when installed, is irreversible. Affected patients may develop anemia and jaundice which if not treated, lead to irreversible brain damage known as kernicterus or death. Despite the existence of appropriate prophylaxis to RhD-DHPN is still prevalent in Brazil, but is not considered for calculating the Burden of Disease Study. Whereas it may represent an important fraction of perinatal morbidity and mortality and neonatal this paper proposes calculation the burden of Rhesus Haemolytic Disease in Brazil Objective: To calculate burden of Rhesus Haemolytic Disease in Brazil and Macroregions Methods: The indicator used in this study was the number of years of life lost disability-adjusted DALY (Disability Adjusted Life Years). The number of DALYs was calculated from the sum of two components: Years of Life Lost to Premature Death (YLL-Years of Life Lost) and Years of Life Lost due to Disability (YLD - Years Lived with Disability. Data for the calculation of YLL was obtained through the Information System (SIM / DATASUL.) In the process of estimation of YLD were used as clinical epidemiological incident cases, the length and weight of disabilities. The number of incident cases calculated through analysis of the Hospital Information System of the Unified Health System (SIH-SUS). In the case of RhD without sequelae was considered the duration of up to 30 days due but to the severity of kernicterus it was considered as 50% of the duration estimated life expectancy. To evaluate the estimates of the weights of disabilities we use the weight to 0,894 cases of RHD without sequelae and 0.459 for cases of kernicterus considering neurological sequelae. Results: RHD has the lowest rates of DALYs in all regions of the country compared to other perinatal events. The North and Northeast had the highest rates for all events with the exception in the South were the rates RHD DALYS was the second highest. When analyzed the component YLL rates are the highest in the North and Northeast and the lowest rate in the Southeast. Regarding the YLD observed a reversal of the values found for the YLL component is the highest rates were those from Southeast and South Conclusion: Despite the burden of RhD Hemolytic Disease Perinatal in Brazil is much lower than the other perinatal events there is a historical legacy of lack of investment in the North and Northeast as demonstrated in our work where the risk of dying from DHPN-RhD is higher than in the South and Southeast. So for the decline of DHPN-RhD in our country there is a need to improve perinatal care and also a political recognition of the contingency of these regional inequalities and the need to prioritize the prevention rather than treatment.

Proteins of the conserved Mep-Amt-Rh superfamily, including mammalian Rhesus factors,<p>mediate ammonium transport. Ammonium is an important nitrogen source for the<p>biosynthesis of amino acids for instance but its accumulation is also known as cytotoxic in<p>animals. Nevertheless, the controlled disposal of ammonium in urine plays a critical role in<p>the regulation of the acid-base homeostasis. Alteration in ammonium transport via human Rh<p>proteins could have clinical outcomes. In this work, we addressed aspects of structurefunction<p>analysis of altered human Rhesus proteins using a heterologous expression system<p>and further characterized aspects of the patho-physiological roles of Rh proteins using<p>knockout mice models available in the laboratory.<p>Using a yeast-based expression assay, we characterized human Rh variants resulting from non<p>synonymous single nucleotide polymorphisms (nsSNPs) with known or unknown clinical<p>phenotypes. The HsRhAG variants (I61R, F65S) associated to overhydrated hereditary<p>stomatocytosis (OHSt), a disease affecting erythrocytes, proved affected in intrinsic<p>bidirectional ammonium transport, suggesting altered ammonium transport as a potential<p>hallmark of the disease. Moreover, these variants showed trans-dominant negative effects on<p>the activity of their native HsRhAG counterpart, suggesting altered cooperation of the<p>subunits in “heteromeric” transport complexes. On the other hand, we revealed that the<p>R202C variant of HsRhCG, the orthologue of mouse Rhcg required for optimal urinary<p>ammonium excretion and blood pH control, shows an impaired inherent ammonium transport<p>activity. HsRhCGR202C may potentially confer susceptibility to disorders leading to metabolic<p>acidosis for instance. <p>MmRhcg has been shown to be expressed in the male mice epididymal tract, its absence<p>leading to a more acidic luminal fluid and to a reduced male fertility. Using mice<p>models, we further investigated the role of Rhcg and Rhbg proteins in the male<p>reproductive function. <p> / Doctorat en Sciences / info:eu-repo/semantics/nonPublished

Ce travail a pour finalité d'analyser l'évolution de la GRH au sein des entreprises marocaines vers l'avènement d'une nouvelle tendance « Talents », en prenant le cas du secteur bancaire. Ce secteur connaît actuellement un contexte concurrentiel rude, notamment en présence d'une conjoncture économique difficile, une crise financière internationale, et un turn-over important. Nous avons choisi une méthodologie qualitative qui fait appel à des échanges, des entretiens en face à face, et aussi téléphoniques, réalisés sur le terrain. Cette thèse vise à comprendre l'approche « Talents » non seulement du point de vue de l'entreprise, mais également de la discerner telle que nous pouvons l'apercevoir chez le salarié. En effet, l'évolution actuelle de la mondialisation peut être repérée dans plusieurs domaines, et principalement dans les marchés financiers. Cela entraine certes des changements dans le fonctionnement de ce secteur. D'où l'apparition des nouvelles pratiques RH. L'objectif principal de la présente recherche est de voir si la gestion des talents peut s'imposer au sein des entreprises marocaines comme une nouvelle pratique de la GRH. Pour ce faire, nous allons tout d'abord déterminer la politique actuelle mise en place par les banques en termes de GRH, puis nous allons essayer de discerner la place de la nouvelle tendance « Talents » au sein de celles-ci, et enfin, nous allons analyser les résultats obtenus, et confirmer ou infirmer les hypothèses formulées à la lumière de notre étude empirique. Les résultats de ce travail peuvent faire l'objet de recommandations pratiques aux banques marocaines, afin de revoir leur politique RH, et de faire face aux enjeux actuels. / The purpose of this work is to analyze the evolution of HRM in the Moroccan companies to the advent of a new trend "Talents", taking the case of the banking sector. This sector is currently experiencing a severe competitive environment, particularly in the presence of a difficult economic environment, international financial crisis, and high turnover. We chose a qualitative methodology that involves exchanges, face-to-face discussion or phone interview. This thesis aims to understand the "Talents" not only in terms of business approach, but also to discern it as we can perceive it from the employee. Indeed, the current evolution of globalization can be spotted in several areas, especially in the financial markets. This certainly leads to changes in the functioning of this sector. Hence the appearance of new HR practices. The main objective of this research is to see if the talent management may be required in Moroccan companies as a new practice of HRM. To do this, we will first determine the current policy implemented by banks in terms of HRM, then we will try to discern the place of the new trend "Talents" in them, and finally, we will analyze the results and confirm or refute the hypotheses that have been mad of our empirical study. The results of this work may be of practical recommendations to Moroccan banks to review their HR policies, and cope the current issues.

RH 2000 är Sveriges nationella höjdsystem och det bygger på den tredje precisionsvägningen som genomfördes i Sverige mellan 1979 och 2003. Nätet för RH 2000 har en starkare geometri och är mer homogent än vid de tidigare två precisionsavvägningarna och höjdnäten (RH 00, RH 70). Under de senaste 14 åren har mycket arbete lagts ned på att få kommuner, myndigheter och andra samhällsaktörer att byta till RH 2000, detta för att få enhetlighet och främja datautbyte. Nu har de flesta aktörer anslutit sig till det nya nätet, men det finns fortfarande de som använder de äldre referenssystemen från den de två tidigare precisionsavvägningarna.  Högskolan i Gävle har länge använt sig av ett höjdnät som anslutits till RH 70. Man har visserligen gjort en preliminär anslutning till RH 2000, men denna har gjorts genom mätning med Global Navigation Satellite System (GNSS) och den nationella geoidmodellen. Höjdnätet skall ligga till grund för högskolan inom utbildning och forskning inom lantmäteriteknik, det är därför ett bra höjdnät behövs vid HiG. Nätet bör vara av hög kvalité, och det är därför viktigt att etablera nätet genom avvägning. Höjdbestämning med GNSS har högre osäkerhet jämfört med den traditionella metoden för etablering av höjdnät (avvägning). Ett syfte med denna studie är att etablera ett nytt stomnät i höjd som är hållbart över tid vid Högskolan i Gävles campus och genom finavvägning ansluta detta till riksnätet för det nationella höjdsystemet RH 2000 på ett så bra och tillförlitligt sätt som möjligt. Ett annat syfte är också att undersöka och jämföra skillnad i höjd mellan de nya och äldre höjdnätsrealiseringarna vid skolan, samt även att undersöka hur de nya avvägda RH 2000-höjderna stämmer med geoidmodellen lokalt med hjälp av höjder bestämda från GNSS- mätning och SWEPOS tjänst för Nätverks Real Time Kinematic (NRTK).  I detta examensarbete har finavvägning genomförts med det digitala avvägningsinstrument Leica DNA03 för att etablera ett anslutningsnät för samhällsbyggnad (klass A2 enligt Handbok i mät- och kartfrågor,HMK). Utvärdering av mätosäkerhet har gjorts i enlighet med de styrdokument som examensarbetet följer, nämligen HMK och SIS-TS 21143:2016. Stegvis utförda utjämningar av nätet resulterade i bra skattade höjder med standardosäkerheter på millimeternivå i RH 2000. Genom det nya höjdnätet anslutet till RH 2000 har Högskolan i Gävle erhållit ett nytt höjdnät med låga osäkerheter som möter kraven för anslutningsnät och framtida övningar på högskolan kommer att göras i en högkvalitativ realisering av RH 2000. / RH 2000 is the national height system/frame of Sweden. It is based on the third precision precise levelling that was carried out in Sweden between 1979 and 2003. The network for RH 2000 has a stronger geometry and is more homogeneous than for the previous two Swedish precise levellings and the height networks (RH00, RH70). During the last 14 years, a lot of work has been put into getting municipalities, state authorities and other community operators to switch to RH 2000, in order to achieve uniformity and promote data exchange. Most have now joined the new network, but some still use the older reference systems of the two previous precise levellings.  The University of Gävle has for a long time used a height network that has been connected to RH 70. Although a preliminary connection has been made to RH 2000, it has been made through Global Navigation Satellite System (GNSS) measurements and with the national geoid model. The height network shall form the basis for the university in education and research in surveying, which is why a good height network is needed at HiG. The network should have a high quality; therefore, it is important to establish the network by levelling. The determination of height with GNSS has higher uncertainty compared with the traditional method for establishing a height network (levelling). A purpose of this study is to establish a new geodetic control network in height that is sustainable over time at the Campus of the University of Gävle and through to connect it to the national height network/system RH 2000 in the best and most reliable way. Another purpose is also to investigate and compare differences in height between the new and older height networks, and it is also investigated whether the levelled RH 2000 heights match with the national geoid model locally by using heights determined from GNSS measurements and SWEPOS service for Network Real Time Kinematic (NRTK).  In this thesis, digital levelling has been carried out with the digital level instrument Leica DNA03 to establish a control network for urban management (class A2 according to Handbook of measurement and map issues,HMK). Evaluation of measurement uncertainty has been made in accordance with the governing documents that the thesis follows, namely Swedish HMK and SIS-TS 21143: 2016. Step-by-step adjustments of the network resulted in well estimated heights with standard uncertainties at the millimeter level in RH 2000. Through the heights in RH 2000 for the new network, the University of Gävle has received a new height network with low uncertainties that meets the requirements for connection networks and future exercises at the university can be made in a high-quality realization of RH 2000.

Urbane Räume sind aufgrund ihrer hohen Bevölkerungsdichtes sowie gesellschaftlichen und wirtschaftlichen Bedeutung besonders exponiert gegenüber äußeren Einflüssen und Umweltbelastungen. Sie sind klimatische Ungunsträume, in welchen sich besonders bei starken Hitzeereignissen eine hohe gesundheitliche Belastung entwickelt. Zudem sind Städte durch eine beträchtliche Lärmbelastung und Luftverschmutzung belastet. In der vorliegenden Dissertation wurde eine umweltbezogene Risikoanalyse anhand von Landschaftsstrukturmaßen umgesetzt, in dem Leipziger Stadtstrukturtypen hinsichtlich ihrer Belastung durch Verkehrslärm, Feinstaub und Oberflächentemperaturen untersucht wurden. Die höchsten Belastungen an Lärm und Feinstaub, als auch die höchsten Oberflächen-temperaturen treten in den Wohngebieten auf. Grünflächen und Kleingartenanlagen bilden dagegen Erholungsräume mit geringeren Oberflächentemperaturen und hohen Anteilen gering belasteter Flächen durch Lärm und Feinstaub. Eine gleichzeitige Analyse der vorhandenen Strukturmerkmale, Bebauungshöhe und Anteil an bebauter Fläche, ermöglichte die Betrachtung der Beeinflussung durch bestimmte Baustrukturen und deren Anordnung. Der Einsatz von Landschaftsstrukturmaßen ermöglicht eine kostengünstige und effiziente Analyse von Umweltbelastungen wie Lärm, Feinstaub und Hitze von unterschiedlichen Stadtstrukturtypen. Anhand von Landschaftsstrukturmaßen können die mit Stadtumbau und Neubau einhergehenden Verbesserungen oder Verschlechterungen der Luftschadstoff- und Lärmbelastung sowie Oberflächentemperaturen identifiziert werden. / In cause of their high population-density as well as social and economic importance, urban areas are particularly sensitive to external influences and environmental pollution. Under climate change and high noise and air pollution, green spaces, such as parks and urban forests, become increasingly important. The identification of highly polluted areas within the city or its residential districts can be helpful for city planners to proactively plan these areas and create open spaces. Sustainable effects on well-being and human health will be the outcome. The dissertation implemented an environmental risk analysis has been based on the quantitative concept of the landscape metrics. Typical structure types in Leipzig have been analysed for their exposure to traffic noise, air pollution and surface temperatures. The highest exposures of noise and airborne particles, as well as the highest surface temperatures were found in residential areas. In contrast green spaces and allotments form recreation areas with lower surface temperatures and high percentages of low exposured areas of noise and air pollution. A simultaneous analysis of existing structural features, building height and proportion of built area, allowed the consideration of the influence of certain structural conditions. The use of landscape metrics offered a cost-efficient analysis of the structure types and the prevailing exposure of the three environmental stressors. Bases on metrics such as edge and patch density and diversity indicés, land use structure changes going along with improvements or worsening of air and noise pollution as well as surface temperatures can be straightforward identified.

O desenvolvimento industrial e urbano tem causado aumento mundial das emissões de poluentes atmosféricos. Nas áreas metropolitanas o problema da deterioração da qualidade do ar tem se constituído numa das mais graves ameaças à qualidade de vida dos seus habitantes e os veículos automotores contribuem diretamente com o aumento do material particulado (MP). Neste trabalho foram descritas as etapas metodológicas para validar a Tibouchina granulosa como biomonitor ambiental. Assim, foram abordados a caracterização das folhas, categorização do MP, protocolo de remoção de MP e determinação dos EGPs (Pd, Pt e Rh) na deposição seca das folhas. Para tanto foram realizadas quatro coletas anuais (2011-2014) de folhas, entre os meses de agosto e setembro, em pontos específicos. Os resultados da caracterização mostraram que as folhas permanecem residentes nos ramos por até 6 meses e ocorre o desenvolvimento duas novas folhas por nó a cada mês, indicando que o biomonitoramento pode ser realizado com distribuição temporal e espacial. Os caracteres anatômicos foliares mais relevantes são os tricomas, sendo caracterizados quatro tipos (glandular, adpresso-escabro, base ramificada e estrigoso) que adsorvem o MP. No protocolo de remoção da deposição seca, o número de MP variou de acordo com os diferentes reagentes analíticos utilizados, sendo os mais significativos o ALCONOX&reg e a água régia, que apresentaram valores de remoção na faixa de 99-98% e de 94-99%. As estimativas das incertezas analíticas dos EGPs apresentam valores de uCPt=5% (Pt), uCPd=12% (Pd) e uCRh=5% (Rh) e as incertezas de amostragem, os valores de 57% para o Pd, 24% para a Pt e 27% para o Rh. Portanto, a incerteza expandida foi da Pt U=48%, Pd U=86% e Rh U=9%, a incerteza do Rh apresentou valor mais baixo por ser o elemento minoritário. A elevada sensibilidade do método para determinação dos EGPs apresentou limite de detecção de 0,1 pg g-1 para o Pd, 1,3 pg g-1 para Pt e 0,3 pg g-1 para o Rh e acompanhada boa reprodutibilidade. As concentrações dos EGPs encontradas na deposição seca nos vários pontos de coletas indicaram a clara diferença de acúmulo destes elementos entre o ponto de referência e os locais impactados, sugerindo que a liberação dos EGPS pelos catalisadores veiculares pode ser considerada alta. A evidência da presença dos EGPs na deposição seca foi confirmada por meio da análise da distribuição, que mostrou claramente a similaridade com o material de referência certificado Used Auto Catalystc-2557. As distribuições espaciais dos EGPs foram semelhantes para a Coleta 2, indicando os hot points da RMSP. As concentrações do EGPs foram ordenadas em Pt>Pd>Rh e foram mais baixas no ponto de coleta para controle das amostragens em comparação com os outros locais amostrados. Pode ser concluído que as folhas de T. granulosa foram validadas como biomonitor passivo dos EGPs constituintes de catalisadores veiculares. / Industrial and urban development has caused worldwide increase in emissions air pollutants. In metropolitan areas, the problem of deterioration air quality has been one the most serious threats to quality life its inhabitants, motor vehicles contribute directly increase pollutants. This work describes the methodological steps to validate Tibouchina granulosa as environmental biomonitor, which involved the characterization the leaves, PM categorization, PM removal protocol and determination PGEs in dry deposition, for which four annual collections (2011-2014) were performed between August and September of each year. The of results leaf characters showed that leaves in the branches remain for up to 6 months and the development two new leaf occurs every month. The most relevant foliar characters anatomical are trichomes, being characterized five types. The highest particle concentrations adsorbed to stray trichomes and star-based trichomes. In dry deposition removal protocol, MP number varied according to different analytical reagents used, the most significant being ALCONOX&reg and aqua regia, which presented range removal values of 99-98% and 94-99%, respectively. The estimates analytical uncertainties PGEs show de uCPt=5% (Pt), uCPd=12% (Pd) e uCRh=5% (Rh) and sampling uncertainties values were 57% (Pd), 24% (Pt) and 27% (Rh). Therefore, the expanded uncertainty was Pt u=48%, Pd u=86% e Rh u=9%, in case Rh the uncertainties should be reevaluated by presenting minority values. The high sensitivity of the method for determination of PGEs showed a detection limit of 0.1 pg g-1 for Pd, 1.3 pg g-1 for Pt and 0.3 pg g-1 for Rh and good reproducibility of the results. The concentrations PGEs found in dry deposition in various collection points indicated the clear difference accumulation these elements between reference point and impacted sites, suggesting that release PGEs by the vehicle catalysts can be considered high. Confirming this evidence, through the ternary graphs, which clearly showed similar distributions in the environmental samples and equality with MRC (Used Auto Catalysts). The spatial distributions of Pt, Pd and Rh are similar for Collection 2. Concentrations of the PGEs were ordered in Pt>Pd>Rh and were lower at the collection points for control samplings compared to other sites sampled. In view of the above, it can be concluded that the leaves of T. granulosa can be used as environmental biomonitor of vehicular emissions of PGEs constituent of vehicular catalysts.