Introdução: A hipertensão arterial tem elevada prevalência em pessoas submetidas à cirurgia de revascularização do miocárdio. Contudo, em nosso meio, pouco se conhece sobre sua influência no resultado pós-operatório. Objetivos: Avaliar associação da hipertensão arterial com desfechos de morbidade e mortalidade após cirurgia de revascularização miocárdica e identificar os preditores de mortalidade nos pacientes hipertensos. Método: Estudo de coorte que utilizou banco de dados institucional de um hospital da cidade de São Paulo-SP incluindo 3010 pacientes submetidos à revascularização miocárdica cirúrgica com acompanhamento dos desfechos aos 30 dias e até um ano após a cirurgia. Os grupos de hipertensos e não hipertensos foram comparados quanto às características pré-operatórias e quanto à morbidade e mortalidade pós-operatórias. Os grupos de hipertensos controlados e hipertensos não controlados foram comparados quanto às características préoperatórias e à ocorrência de morbidade e mortalidade pósoperatória. Para identificação das variáveis preditoras de mortalidade no grupo dos hipertensos procedeu-se a análise multivariada com regressão logística. Resultados: A prevalência de hipertensão arterial foi de 82,8%. A média de idade dos hipertensos foi de 62,4 anos e 67,8% eram do sexo masculino. Os fatores associados, independentemente, à hipertensão foram (OR- Odds Ratio; ICIntervalo de Confiança 95%): idade (1,01; 1,00-1,02); sexo feminino (1,77; 1,39-2,25), raça parda (1,53; 1,07-2,19), obesidade (1,53;1,13- 2,06), diabetes (1,90; 1,52-2,39), dislipidemia (1,51;1,23-1,85) e creatinina>1,3mg/dL (1,37; 1,09-1,72). Não houve diferença estatisticamente significativa nos desfechos de morbidade e mortalidade entre os grupos de hipertensos e não hipertensos. Cerca da metade dos hipertensos (51,1%) apresentava pressão arterial controlada (PA<140/90 mmHg) na admissão hospitalar. O grupo de hipertensos não controlados apresentou risco significativamente maior do que hipertensos controlados de (Risco Relativo; Intervalo de Confiança 95%): acidente vascular encefálico (2,25; 1,13-4,56), insuficiência cardíaca (1,65; 1,04-2,63), parada cardíaca (1,54; 1,03- 2,31) e óbito (1,59; 1,20-2,10). Após regressão logística múltipla, as variáveis associadas ao óbito dos hipertensos em até 30 dias após a cirurgia foram (OR; IC 95%): idade, variável contínua (1,039; 1,012- 1,066), creatinina sérica, variável contínua (1,245; 1,062-1,459); história familiar de doença coronariana (0,491; 0,265-0,912), dislipidemia (0,512; 0,316-0,829), procedimento de revascularização isolado (0,289; 0,176-0,476) e índice de massa corporal, variável contínua, (0,944; 0,892-0,999). As variáveis associadas ao óbito dos hipertensos em até um ano após a cirurgia foram (OR; IC 95%): idade, variável contínua (1,049; 1,028-1,071), pressão arterial não controlada (1,768; 1,245-2,508), antecedentes de doença renal crônica (2,554; 1,481-4,404), acidente vascular encefálico (2,48; 1,403-4,203), insuficiência arterial periférica (1,894; 1,087-3,300), doença carotídea (3,050; 1,367-6,806), insuficiência cardíaca (4,623; 2,455-8,703), arritmia (1,811; 1,038-3,159), creatinina sérica préoperatória, variável contínua (1,201; 1,017-1,418), glicemia capilar pós-operatória, variável contínua (1,007; 1,002-1,012), história familiar de doença coronariana (0,613; 0,401-0,939), dislipidemia (0,658; 0,463-0,936) e cirurgia de revascularização isolada (0,306; 0,203-0,461) Conclusões: A hipertensão arterial apresentou alta prevalência e se associou a fatores modificáveis e não modificáveis. Entre hipertensos, a falta de controle da pressão arterial foi preditora de mortalidade na avaliação em longo prazo após a cirurgia. / Introduction: Hypertension is highly prevalent in people undergoing coronary artery bypass graft (CABG) surgery. However, in our field, little is known about its influence on postoperative results. Objectives: To evaluate the association of hypertension with morbidity and mortality outcomes after the coronary artery bypass graft surgery and identify predictors of mortality in hypertensive patients. Method: A cohort study which used the institutional database of a hospital in the city of São Paulo (state of São Paulo) and included 3010 patients undergoing CABG surgery, with monitoring of outcomes at 30 days and one year after surgery. The groups of hypertensive and nonhypertensive patients were compared regarding the preoperative characteristics and the postoperative morbidity and mortality. The groups of controlled hypertensive and uncontrolled hypertensive patients were compared in relation to preoperative characteristics and the occurrence of postoperative morbidity and mortality. A multivariate analysis with logistic regression was used to identify the predictors of mortality in the hypertensive group. Results: The prevalence of hypertension was 82.8%. The average age of hypertensive patients was 62.4 years and 67.8% were male. The factors independently associated with hypertension were the following (OR- odds ratio; CIconfidence interval 95%): age (1.01; 1.00-1.02); female gender (1.77; 1.39-2.25), multiracial (pardo) (1.53; 1.07-2.19), obesity (1.53; 1.13- 2.06), diabetes (1.90; 1.52-2.39), dyslipidemia (1.51; 1.23-1.85) and creatinine>1.3mg/dL (1.37; 1.09-1.72). There was no statistically significant difference in the outcomes of morbidity and mortality among hypertensive and non-hypertensive groups. About half of the hypertensive patients (51.1%) had controlled blood pressure (Pa<140/90 mmHg) at hospital admission. The group of uncontrolled hypertensive patients showed significantly higher risk than the group of controlled hypertensive of the following (RR-Relative Risk; CI 95%): cerebrovascular accident (2.25; 1.13-4.56), heart failure (1.65; 1.04- 2.63), cardiac arrest (1.54; 1.03-2.31) and death (1.59; 1.20-2.10). Using multiple logistic regression, the variables associated with death of hypertensive patients within 30 days after surgery were the following (OR; CI 95%): age, continuous variable (1.039; 1.012-1.066), serum creatinine, continuous variable (1.245; 1.062-1.459); family history of coronary artery disease (0.491; 0.265-0.912), dyslipidemia (0.512; 0.316-0.829), isolated revascularization procedure (0.289; 0.176- 0.476) and body mass index, continuous variable, (0.944; 0.892- 0.999). The following variables were associated to the death of hypertensive patients in up toan year after surgery (OR; CI 95%): age, continuous variable (1.049; 1.028-1.071), uncontrolled blood pressure (1.768; 1.245-2.508), history of chronic kidney disease (2.554; 1.481- 4404), stroke (2.48; 1.403-4.203), peripheral artery disease (1.894; 1.087-3.300), carotid artery disease (3.050; 1.367-6.806), cardiac failure (4.623; 2.455-8.703), arrhythmia (1,811; 1,038-3,159), preoperative serum creatinine, continuous variable (1.201; 1.017- 1.418), postoperative blood glucose, continuous variable (1.007; 1.002-1.012), family history of coronary disease (0.613; 0.401-0.939), dyslipidemia (0.658; 0.463-0.936) and isolated coronary artery bypass graft surgery (0.306; 0.203-0.461). Conclusions: Hypertension showed high prevalence and was associated to modifiable and nonmodifiable factors. Among hypertensive patients, the lack of blood pressure control was predictive of mortality in the long-term evaluation after surgery.

A perda da vitalidade pulpar, em consequência de injurias traumáticas, lesões cariosas profundas e malformações dentárias, pode interromper o desenvolvimento radicular em dentes permanentes jovens. O tratamento endodôntico em dentes com rizogênese incompleta constituise num desafio ao clínico para a realização de tratamentos convencionais, devido principalmente à dificuldade de debridamento das paredes dentinárias e do adequado selamento apical. Além disso, em função das paredes dentinárias delgadas e uma proporção coroa-raiz inadequada, a ocorrência de fraturas no trans e pós-operatório não é um evento raro. Existem diferentes estratégias terapêuticas para o manejo destes dentes com rizogênese incompleta, incluindo os procedimentos de apicificação e revascularização da polpa. O objetivo desta tese foi revisar sistematicamente a literatura para avaliar a efetividade dos procedimentos de apicificação e revascularização da polpa em relação aos desfechos clínicos, radiográficos e de retenção dentária. Dois revisores de maneira independente revisaram a literatura e avaliaram os artigos. A busca foi realizada na literatura via PubMed/MEDLINE e Embase até junho de 2017 para selecionar estudos de caso-controle e coorte. Um total 231 artigos foram localizados nas bases de dados, dos quais 3 permaneceram após a aplicação dos critérios de elegibilidade. Após a seleção dos artigos, os dados de cada estudo foram coletados e o risco de viés avaliado. Foram obtidas estimativas de efeito comparando o sucesso clínico e radiográfico e retenção dentária entre o plug apical de agregado de trióxido mineral (MTA) versus revascularização da polpa (BC) e hidróxido de cálcio (CH). As duas meta-análises comparando tanto o MTA vs BC para os desfechos clínicos e radiográficos (Z=0.164, p=0.869, RR=1.010, 95%CI:0.895-1.140, I=0%) e retenção dentária (Z=0.855, p=0.393, RR=1.050, 95%CI:0.939-1.173, I=0%) ou MTA vs CH para os desfechos clínicos e radiográficos e retenção dentária (Z=-1.596, p=0.110, RR=0.816, 95%CI:0.635-1.048, I=0%) não demonstraram diferenças estatisticamente significativas. Todos estudos incluídos na revisão sistemática foram considerados de alta qualidade metodológica. Em conclusão, a técnica de revascularização da polpa, por possibilitar o desenvolvimento radicular adicional, deve ser a primeira opção de tratamento em dentes permanentes com rizogênese incompleta que apresentem proporção coroa-raiz inadequada, entretanto, o plug apical de MTA parece apresentar resultados mais fidedignos em relação ao sucesso em geral, e assim, nos casos de dentes permanentes que apresentem proporção coroaraiz satisfatória, esta técnica de ser a primeira opção de tratamento. / The loss of pulp vitality, as a consequence of traumatic injuries, deep carious lesions and dental malformations, may interrupt the root development in young permanent teeth. The endodontic treatment in immature teeth constitutes a challenge to the practitioner to perform conventional treatments, mainly due to difficulty of dentinal walls debridement and adequate apical sealing. In addition, due to the thin dentinal walls and inadequate crown-root proportion, occurrence of trans and postoperative fractures is not a rare event. There are different therapeutic strategies to manage these immature teeth including apexification and pulp revascularization procedures. The aim of this thesis was to systematically review the literature to evaluate the effectiveness of apexification and pulp revascularization procedures regarding the clinical, radiographic and tooth retention outcomes. Two reviewers independently performed the screening and evaluation of articles. The literature was screened via PubMed/MEDLINE and Embase databases until June 2017 to select case-control and cohort studies. A total of 231 articles were retrieved from the databases, in which only 3 remained after the eligibility criteria. After the selection of the articles, the data of each study was extracted and bias risk assessed. Pooled-effect estimates were obtained comparing the clinical and radiographic success and retention rates among the mineral trioxide aggregate (MTA) apical plug vs pulp revascularization (BC) and calcium hydroxide (CH). The two meta-analysis comparing either MTA vs BC for clinical and radiographic outcomes (Z=0.164, p=0.869, RR=1.010, 95%CI:0.895-1.140, I=0%) and tooth retention rates (Z=0.855, p=0.393, RR=1.050, 95%CI:0.939-1.173, I=0%) or MTA vs CH for clinical and radiographic outcomes and tooth retention rates (Z=-1.596, p=0.110, RR=0.816, 95%CI:0.635-1.048, I=0%) showed no statistically significant differences. All studies included in the systematic review were classified as high quality. In conclusion, the revascularization treatment, as it allows additional root development may be the first treatment option in immature necrotic permanent teeth that have inadequate crown-root ratio, however, the MTA apical plug seems to provide more predictable outcomes regarding the overall success, and thus, in cases of permanent teeth having adequate crown-root proportion, it should be the first treatment option.

Submitted by Carvalho Dias João Paulo (joao.dias@famerp.br) on 2018-04-12T17:21:57Z No. of bitstreams: 1 fernandamssalves_dissert.pdf: 1008314 bytes, checksum: ef2fa02486e86b46225f993bb257984c (MD5) / Made available in DSpace on 2018-04-12T17:21:57Z (GMT). No. of bitstreams: 1 fernandamssalves_dissert.pdf: 1008314 bytes, checksum: ef2fa02486e86b46225f993bb257984c (MD5) Previous issue date: 2017-04-06 / Introduction: Coronary Artery Disease (CAD) is considered as one of the presentation forms of cardiovascular disease. Myocardial revascularization surgery (MRS) is one of the possible interventions for its treatment; however, it is an invasive procedure with postoperative complications. Objectives: To identify the pulmonary complications after MRS with extracorporeal circulation, determining the efficacy of non-invasive ventilation (NIV) in comparison with incentive spirometry (IS) in the postoperative management and to update knowledge related to the respiratory and motor Physiotherapy in pre and post MRS. Materials and Methods: A total of 105 patients were randomized into two groups (G0 - IS and G1 - CPAP). The blood gas values, chest X-ray and respiratory muscle strength were assessed before the pre, first and third postoperative day according to the incidence of pulmonary complications presented. Results: The complications presented in both groups were hypoxemia, atelectasis, pleural effusion, pneumonia and lung congestion, proportionately distributed with no statistically significant correlation with the technique used in the postoperative period. The maximum inspiratory pressure (MIP) was reduced in both groups in the pre and the first day after surgery, carrying on up to the third day after surgery only in the group 0. The maximum expiratory pressure (MEP) remained significantly reduced in both groups postoperatively when compared to predicted values. Conclusion: Respiratory physical therapy modalities used were effective in maintaining inspiratory muscle strength, however, no statistically significant difference in the proportion of expressed pulmonary complications between the groups, inferring non superiority of NIV technique compared to IS in the reversal of pulmonary complications post MRS. Further studies accomplished with stricter methodology, greater number of subjects studied and technical standardization are necessary. Moreover, to determine the appropriate method or protocol for restoring pulmonary and physical condition of these patients postoperatively. / Introdução: A doença arterial coronariana (DAC) é designada como uma das formas de apresentação da doença cardiovascular, e uma das intervenções possíveis para seu tratamento é a cirurgia de revascularização do miocárdio (CRM), porém, trata-se de um procedimento invasivo, acarretando complicações pós-operatórias. Objetivos: Identificar as complicações pulmonares pós CRM com circulação extracorpórea (CEC) determinando ,assim, a eficácia da ventilação não invasiva (VNI) em comparação à espirometria de incentivo (EI) no manejo pós-operatório e atualizar os conhecimentos relacionados à Fisioterapia respiratória e motora no pré e pósoperatório de CRM. Casuística: Foram incluídos 105 pacientes, randomizados em dois grupos (G0 – EI e G1 – CPAP). Os valores gasométricos, radiografia de tórax e força muscular respiratória foram avaliados no pré, primeiro e terceiro dia de pós-operatório quanto à incidência de complicações pulmonares apresentadas. Resultados: As complicações apresentadas em ambos os grupos foram hipoxemia, atelectasia, derrame pleural, pneumonia e congestão pulmonar, distribuídas proporcionalmente, sem correlação estatística significativa com a técnica utilizada no pós-operatório. A pressão inspiratória máxima (Pimáx.) apresentou-se reduzida em ambos os grupos no pré e primeiro dia de pós-operatório, perpetuando pelo terceiro dia de pós-operatório somente no grupo 0. A pressão expiratória máxima (Pemáx.) permaneceu significativamente reduzida em ambos os grupos no pós-operatório, quando comparada aos valores preditos. Conclusão: As modalidades de fisioterapia respiratória empregadas foram eficientes na manutenção da força muscular inspiratória, porém, sem diferença estatisticamente significativa na proporção de complicações pulmonares expressas entre os grupos, inferindo não superioridade da técnica de VNI em comparação à EI na reversão das complicações pulmonares pós CRM. São necessários novos estudos, idealizados com maior rigor metodológico, maior número de indivíduos estudados e padronização técnica para determinação da modalidade ou protocolo apropriado para restabelecimento da condição pulmonar e física destes pacientes no pós-operatório.

Made available in DSpace on 2016-08-19T18:15:54Z (GMT). No. of bitstreams: 1 Dissertacao NAYANA NAZARE PESSOA SOUSA XIMENES.pdf: 1995028 bytes, checksum: 3ae92b8f1b5e63655e1c2d926c972116 (MD5) Previous issue date: 2014-11-21 / Regular physical activity has been beneficial post - cardiac surgery. Early resistance exercise training improves functional capacity, clinical status, cardiac function and survival of patients, leading to a reduction of the harmful effects of prolonged bed rest, reduced care costs and hospital stay. Objective: To evaluate the effects of resistance exercise during hospital postoperative coronary artery bypass grafting (CABG). Methods: It was performed a randomized controlled trial with 37 patients subjected to isolated CABG between August 2013 and May 2014, distributed by simple drawing into two groups: control group (n = 20) that received conventional physiotherapy and intervention group (n = 17) underwent resistance exercise. Pulmonary function and functional capacity were assessed preoperatively, on discharge from the intensive care unit (ICU) and hospital discharge by spirometry and six minute walk test (6MWT). For statistical analyze were utilized Shapiro-Wilk, Mann-Whitney, Student's t, Fisher and G tests. Variables with p < 0.05 were considered significant. Results: The groups were homogeneous in terms of demographic, clinical, and surgical variables. No effect of resistance exercise on pulmonary function was observed when compared to control group. However, in intervention group it was maintained functional capacity during assessments periods when compared to the control group which was observed significant reducing (p < 0.0001). It was Observed a significant reduction in length of hospital stay (6.3 ± 1 2 vs. 7.6 ± 2.5 days) (p = 0.03). Conclusion: In this study, the resistance exercise during hospital CABG postoperative provided maintaining functional capacity and reduction of hospital stay when compared to conventional physiotherapy. / A prática de atividade física tem sido benéfica pós - cirurgia cardíaca. O exercício resistido precoce melhora a capacidade funcional, quadro clínico, função cardíaca e sobrevida dos pacientes, promovendo a diminuição dos efeitos prejudiciais do repouso prolongado no leito, redução dos custos com a assistência e tempo de internação hospitalar. Objetivo: avaliar os efeitos do exercício resistido na fase hospitalar do pós-operatório de revascularização do miocárdio (RM). Métodos: realizou-se um ensaio clínico controlado randomizado com 37 pacientes submetidos à RM isolada, com circulação extracorpórea entre agosto de 2013 e maio de 2014, distribuídos por sorteio simples em dois grupos: grupo controle (n = 20) que realizou fisioterapia convencional e grupo intervenção (n = 17) submetidos ao exercício resistido. A função pulmonar e a capacidade funcional foram avaliados no pré-operatório, alta da unidade de terapia intensiva (UTI) e alta hospitalar pela espirometria e teste de caminhada de seis minutos (TC6M). Para análise estatística empregaram-se os testes de Shapiro-Wilk, Mann-Whitney, t-Student, Fisher e G. variáveis com p < 0,05 foram consideradas significativas. Resultados: Os grupos apresentaram-se homogêneos quanto às variáveis demográficas, clínicas e cirúrgicas. Não se observou efeito do exercício resistido na função pulmonar quando comparado ao grupo controle. Entretanto, no grupo intervenção houve manutenção da capacidade funcional nos três períodos avaliados quando comparado ao grupo controle para o qual se observou queda significativa (p < 0,0001).Observou-se redução significativa do tempo de internação hospitalar (6,3 ± 1,2 vs. 7,6± 2,5 dias) , (p = 0,03) .Conclusão:No presente estudo, o exercício resistido na fase hospitalar do pós-operatório de RM proporcionou manutenção da capacidade funcional e redução do tempo de internação hospitalar quando comparado a fisioterapia convencional.

O objetivo desse estudo etnográfico foi descrever a realidade social vivenciada por pessoas durante o período de reabilitação da cirurgia de revascularização do miocárdio, para compreender os significados da experiência da enfermidade e da qualidade de vida. Os referenciais teóricos foram a antropologia interpretativa e o modelo conceitual de qualidade de vida do Centre for Health Promotion. Participaram do estudo onze sujeitos que realizaram a cirurgia em uma instituição filantrópica, na cidade de Goiânia, Goiás, e dez familiares. Para coleta de dados realizou-se observações diretas e entrevistas semi-estruturadas no domicílio dos participantes. A partir da análise e interpretação dos dados, constatou-se que os sentidos atribuídos pelos participantes à experiência do problema cardíaco e da cirurgia de revascularização do miocárdio estão relacionados à surpresa ao saber que o problema era no coração, ao medo da morte, à entrega da vida nas mãos de Deus e à conformação, pois sem a cirurgia não seria possível sobreviver. As explicações para a doença relacionaram-se a causas psicossociais, comportamentais, sobrenaturais e à presença de outras condições crônicas de saúde. Mencionaram que, apesar das conseqüências (difícil retorno ao trabalho, necessidade de adotar um novo estilo de vida, dependência de familiares; necessidade de tomar medicamento), a cirurgia trouxe a possibilidade de sobreviver e aliviar sintomas. Para os participantes, qualidade de vida significa ter saúde, trabalho e harmonia familiar. Essas foram consideradas as dimensões importantes para uma vida ?tranqüila e feliz?. Considerando-se o modelo conceitual de qualidade de vida, observou-se que a dimensão ?ser? relacionou-se a ter saúde do ponto de vista físico (alimentar bem, dormir, não sentir dor), psicológico (paz) e espiritual (ter fé em Deus). Na dimensão ?pertencer?, os participantes mencionaram o trabalho relacionado aos cuidados da família e, principalmente, o trabalho que envolve o desenvolvimento social e que gera condições financeiras para promover o desenvolvimento pessoal, a independência, o lazer e o bem-estar físico. A dimensão ?tornar-se? envolveu a harmonia familiar como aspecto importante para o crescimento no sentido de adaptações às mudanças que aconteceram em decorrência da cirurgia (desemprego, invalidez, dependência). De um modo geral, apesar de mencionarem que não estão satisfeitos com todas essas dimensões, as pessoas afirmam que são felizes, pois consideram que não podem reclamar do que têm apesar de tudo. O significado de qualidade de vida é construído a partir da interrelação entre essas dimensões, resultando no tema: qualidade de vida - ser feliz à medida do possível. Conclui-se que a compreensão do processo saúde e doença é permeada por subjetividade e o grande desafio para a busca de soluções e implementação de ações em saúde que tenham como objetivo promover saúde e melhorar a qualidade de vida das pessoas. A compreensão da experiência da doença e do significado de qualidade de vida contribui para que pesquisadores, profissionais que cuidam de seres humanos, com ou sem incapacidades ou uma condição crônica de saúde, possam repensar sua prática e, então, buscar modelos de atenção à saúde mais integralizadores em que a alteridade, o humanismo e a individualidade sejam aspectos valorizados e norteadores de suas ações / This ethnographic study aimed to describe the social reality experienced by patients during rehabilitation after myocardial revascularization, in order to understand the meanings of the disease experience and quality of life. The theoretical reference frameworks were interpretative anthropology and the Centre for Health Promotion?s conceptual model of quality of life. Study participants were eleven subjects, who were operated on at a philanthropic institution in Goiânia, Goiás, and ten relatives. Direct observations and semistructured interviews at participants? homes were used for data collection. Data analysis and interpretation revealed that the meanings participants attributed to the experience of the heart problem and the myocardial revascularization surgery are related to the surprise in knowing that they had a heart problem, to the fear of death, handing over their life to God and conformation, as they could not survive without the surgery. Explanations for the disease were related psychosocial, behavioral and supernatural causes, as well as to the presence of other chronic health conditions. They mentioned that, in spite of the consequences (difficult return to work, need to adopt a new lifestyle, dependence on relatives, need to take medication), the surgery opened up the possibility of surviving and relieving symptoms. According to the participants, quality of life means being healthy, having a job and a harmonious family. These were considered important dimensions for a ?tranquil and happy? life. With respect to the conceptual model of quality of life, we found that the dimension of ?being? was related to being healthy from a physical (eating well, sleeping, not feeling pain), psychological (peace) and spiritual perspective (believing in God). In the ?belonging? dimension, participants mentioned work related to care for the family and, mainly, work involving social development, independence, leisure and physical well-being. The dimension of ?becoming? involved family harmony as an important aspect for growth, in the sense of adaptations to the changes that occurred as a result of the surgery (unemployment, disability, dependence). In general, despite mentioning that they are not satisfied with all of these dimensions, people affirm that they are happy, as they consider that they cannot ?complain of what they have in spite of everything. The meaning of quality of life is constructed on the basis of the interrelation between these dimensions, resulting in the theme: Quality of life ? being happy as possible. We conclude that the understanding of the health and disease process is permeated by subjectivity and constitutes the main challenge in seeking solutions and implementing health actions aimed at promoting health and improving people?s quality of life. The contribution of understanding the disease experience and the meaning of quality of life is that is allows researchers, professionals who take care of human beings with or without disabilities or a chronic health condition to rethink their practice and, then, look for more comprehensive health care models in which alterity, humanism and individuality are valued and drive their actions

The islets of Langerhans are small and delicate spheroid organs scattered in the pancreas responsible for insulin production. Transplantation of isolated islets is a beneficial therapy for patients with a severe form of type 1 diabetes. The islets, which normally are richly vascularized in the pancreas, are completely disconnected from the vascular support by the enzymatic digestion during the isolation procedure. Islet viability is affected throughout all steps in this process, from donor death and isolation of islets to culturing and the transplantation process itself. In this thesis a novel strategy to promote islet survival and to re-establish islet vasculature is presented. We show endogenous expression of 51 different genes related to inflammation in cultured islets. Among these genes high expression of MCP-1, MIF, VEGF, thymosin b-10 and IL-8, IL-1β, IL-5R-a, IFN-γ antagonist were found in all donors during the 5- and the 2-day cultures, respectively. Protein expression of these genes can stimulate inflammatory immune responses but also promote tissue repair by attracting curative cells such as endothelial cells (EC) leading to re-establishment of the vasculature. We have established a novel technique by formation of composite islets using EC and mesenchymal stem cells (MSC). EC adhered on the surface of the islets and created a potential blood tolerant surface. The EC-islets showed a degree of protection from the detrimental effects of instant blood-mediated inflammatory reaction (IBMIR) with the major components of IBMIR being decreased in in vitro assays. We combined MSC to the EC-islets with success. The MSC were found to have proliferative effect on EC and the combination of these two cell types on the islets further increased the EC covered surface compared to EC-islets. The EC-MSC-islets in co-culture formed vessel-like structures both into the islets and out to the surrounding matrix. The MSC enhanced the exogenous EC to form vessel-like network in the EC-MSC-islets indicating vascular support by the MSC. The novel strategy and conditions presented herein could alleviate problems related to survival of the islets by promoting revascularization. This would open up a new era in islet transplantation and allow more patients to benefit from this therapy. / Clinical immunology, islet group

Despite the increasing clinical demand in reconstructive, cosmetic and correctional surgery there remains no optimal strategy for the regeneration or replacement of adipose tissue. Previous approaches to adipose tissue engineering have failed to create an adipose tissue depot that maintains implant volume in vivo long-term (>3 months). This is due to inadequate mechanical properties of the biomaterial and insufficient vascularization upon implantation. Modular tissue engineering is a means to produce large volume functional tissues from small sub-mm sized tissues with an intrinsic vascularization. We first explored the potential of a semi-synthetic collagen/poloxamine hydrogel with improved mechanical properties to be used as the module biomaterial. We found this biomaterial to not be suitable for adipose tissue engineering because it did not support embedded adipose-derived stem cell (ASC) viability, differentiation and human microvascular endothelial cell (HMEC) attachment. ASC-embedded collagen gel modules coated with HMEC were then implanted subcutaneously in SCID mice to study its revascularization potential. ASC cotransplantation was shown to drive HMEC vascularization in vivo: HMEC were seen to detach from the surface of the modules to form vessels containing erythrocytes as early as day 3; vessels decreased in number but increased in size over 14 days; and persisted for up to 3 months. Early vascularization promoted fat development. Only in the case of ASC-HMEC cotransplantation was progressive fat accumulation observed in the module implants. Although implant volume was not maintained, likely due rapid collagen degradation, the key result here is that ASC-HMEC cotransplantation in the modular approach was successful in creating vascularized adipose tissue in vivo that persisted for 3 months. The modular system was then studied in vitro to further understand ASC-EC interaction. Coculture with ASC was shown to promote an angiogenic phenotype (e.g. sprouting, migration) from HUVEC on modules. RT-PCR analysis revealed that VEGF, PAI-1 and TNFα was involved in ASC-EC paracrine signalling. In summary, ASC-HMEC cotransplantation in modules was effective in rapidly forming a vascular network that supported fat development. Future work should focus on further elucidating ASC-EC interactions and developing a suitable biomaterial to improve adipose tissue development and volume maintenance of engineered constructs.

Despite the increasing clinical demand in reconstructive, cosmetic and correctional surgery there remains no optimal strategy for the regeneration or replacement of adipose tissue. Previous approaches to adipose tissue engineering have failed to create an adipose tissue depot that maintains implant volume in vivo long-term (>3 months). This is due to inadequate mechanical properties of the biomaterial and insufficient vascularization upon implantation. Modular tissue engineering is a means to produce large volume functional tissues from small sub-mm sized tissues with an intrinsic vascularization. We first explored the potential of a semi-synthetic collagen/poloxamine hydrogel with improved mechanical properties to be used as the module biomaterial. We found this biomaterial to not be suitable for adipose tissue engineering because it did not support embedded adipose-derived stem cell (ASC) viability, differentiation and human microvascular endothelial cell (HMEC) attachment. ASC-embedded collagen gel modules coated with HMEC were then implanted subcutaneously in SCID mice to study its revascularization potential. ASC cotransplantation was shown to drive HMEC vascularization in vivo: HMEC were seen to detach from the surface of the modules to form vessels containing erythrocytes as early as day 3; vessels decreased in number but increased in size over 14 days; and persisted for up to 3 months. Early vascularization promoted fat development. Only in the case of ASC-HMEC cotransplantation was progressive fat accumulation observed in the module implants. Although implant volume was not maintained, likely due rapid collagen degradation, the key result here is that ASC-HMEC cotransplantation in the modular approach was successful in creating vascularized adipose tissue in vivo that persisted for 3 months. The modular system was then studied in vitro to further understand ASC-EC interaction. Coculture with ASC was shown to promote an angiogenic phenotype (e.g. sprouting, migration) from HUVEC on modules. RT-PCR analysis revealed that VEGF, PAI-1 and TNFα was involved in ASC-EC paracrine signalling. In summary, ASC-HMEC cotransplantation in modules was effective in rapidly forming a vascular network that supported fat development. Future work should focus on further elucidating ASC-EC interactions and developing a suitable biomaterial to improve adipose tissue development and volume maintenance of engineered constructs.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

A perda da vitalidade pulpar, em consequência de injurias traumáticas, lesões cariosas profundas e malformações dentárias, pode interromper o desenvolvimento radicular em dentes permanentes jovens. O tratamento endodôntico em dentes com rizogênese incompleta constituise num desafio ao clínico para a realização de tratamentos convencionais, devido principalmente à dificuldade de debridamento das paredes dentinárias e do adequado selamento apical. Além disso, em função das paredes dentinárias delgadas e uma proporção coroa-raiz inadequada, a ocorrência de fraturas no trans e pós-operatório não é um evento raro. Existem diferentes estratégias terapêuticas para o manejo destes dentes com rizogênese incompleta, incluindo os procedimentos de apicificação e revascularização da polpa. O objetivo desta tese foi revisar sistematicamente a literatura para avaliar a efetividade dos procedimentos de apicificação e revascularização da polpa em relação aos desfechos clínicos, radiográficos e de retenção dentária. Dois revisores de maneira independente revisaram a literatura e avaliaram os artigos. A busca foi realizada na literatura via PubMed/MEDLINE e Embase até junho de 2017 para selecionar estudos de caso-controle e coorte. Um total 231 artigos foram localizados nas bases de dados, dos quais 3 permaneceram após a aplicação dos critérios de elegibilidade. Após a seleção dos artigos, os dados de cada estudo foram coletados e o risco de viés avaliado. Foram obtidas estimativas de efeito comparando o sucesso clínico e radiográfico e retenção dentária entre o plug apical de agregado de trióxido mineral (MTA) versus revascularização da polpa (BC) e hidróxido de cálcio (CH). As duas meta-análises comparando tanto o MTA vs BC para os desfechos clínicos e radiográficos (Z=0.164, p=0.869, RR=1.010, 95%CI:0.895-1.140, I=0%) e retenção dentária (Z=0.855, p=0.393, RR=1.050, 95%CI:0.939-1.173, I=0%) ou MTA vs CH para os desfechos clínicos e radiográficos e retenção dentária (Z=-1.596, p=0.110, RR=0.816, 95%CI:0.635-1.048, I=0%) não demonstraram diferenças estatisticamente significativas. Todos estudos incluídos na revisão sistemática foram considerados de alta qualidade metodológica. Em conclusão, a técnica de revascularização da polpa, por possibilitar o desenvolvimento radicular adicional, deve ser a primeira opção de tratamento em dentes permanentes com rizogênese incompleta que apresentem proporção coroa-raiz inadequada, entretanto, o plug apical de MTA parece apresentar resultados mais fidedignos em relação ao sucesso em geral, e assim, nos casos de dentes permanentes que apresentem proporção coroaraiz satisfatória, esta técnica de ser a primeira opção de tratamento. / The loss of pulp vitality, as a consequence of traumatic injuries, deep carious lesions and dental malformations, may interrupt the root development in young permanent teeth. The endodontic treatment in immature teeth constitutes a challenge to the practitioner to perform conventional treatments, mainly due to difficulty of dentinal walls debridement and adequate apical sealing. In addition, due to the thin dentinal walls and inadequate crown-root proportion, occurrence of trans and postoperative fractures is not a rare event. There are different therapeutic strategies to manage these immature teeth including apexification and pulp revascularization procedures. The aim of this thesis was to systematically review the literature to evaluate the effectiveness of apexification and pulp revascularization procedures regarding the clinical, radiographic and tooth retention outcomes. Two reviewers independently performed the screening and evaluation of articles. The literature was screened via PubMed/MEDLINE and Embase databases until June 2017 to select case-control and cohort studies. A total of 231 articles were retrieved from the databases, in which only 3 remained after the eligibility criteria. After the selection of the articles, the data of each study was extracted and bias risk assessed. Pooled-effect estimates were obtained comparing the clinical and radiographic success and retention rates among the mineral trioxide aggregate (MTA) apical plug vs pulp revascularization (BC) and calcium hydroxide (CH). The two meta-analysis comparing either MTA vs BC for clinical and radiographic outcomes (Z=0.164, p=0.869, RR=1.010, 95%CI:0.895-1.140, I=0%) and tooth retention rates (Z=0.855, p=0.393, RR=1.050, 95%CI:0.939-1.173, I=0%) or MTA vs CH for clinical and radiographic outcomes and tooth retention rates (Z=-1.596, p=0.110, RR=0.816, 95%CI:0.635-1.048, I=0%) showed no statistically significant differences. All studies included in the systematic review were classified as high quality. In conclusion, the revascularization treatment, as it allows additional root development may be the first treatment option in immature necrotic permanent teeth that have inadequate crown-root ratio, however, the MTA apical plug seems to provide more predictable outcomes regarding the overall success, and thus, in cases of permanent teeth having adequate crown-root proportion, it should be the first treatment option.