Com o objetivo de analisar a evolução dos níveis de glicose e dos hormônios insulina, glucagon e cortisol de cadelas com piometra e sepse grave durante o tratamento intensivo, foram estudadas 13 cadelas que apresentaram duas alterações na resposta inflamatória sistêmica e no mínimo uma disfunção orgânica. Antes do procedimento cirúrgico foram colhidas amostras para realização de exames laboratoriais e avaliação dos níveis dos hormônios insulina, glucagon e cortisol. Durante o período de internação, os animais foram avaliados diariamente por meio da análise de perfis bioquímicos renal e hepático, hemograma, sódio, potássio, insulina, glucagon e cortisol. O nível de glicose foi avaliado antes do procedimento cirúrgico, a cada 3 h nas primeiras 6 h e a cada 6 h até a alta ou óbito dos pacientes. Após o procedimento cirúrgico, os animais obtiveram a inserção do aparelho de CGMS no subcutâneo, para avaliação da glicose subcutânea. Um grupo controle com nove animais foram submetidos às mesmas dosagens de glicose do grupo sepse. Para a análise estatística da comparação dos valores obtidos para o grupo controle foi utilizado o teste não paramétrico Wilcoxon. Para avaliação da glicose, glucagon, cortisol, insulina, sódio e potássio para o grupo sepse, utilizou-se abordagem de modelos mistos com medidas repetidas. Os animais do grupo sepse apresentaram 7,37±1,66 anos de idade e 23,88±8,5 kg de peso corpóreo. No primeiro dia de internação, 23 % dos animais apresentaram hiperglicemia e estes animais permaneceram maior período de internação quando comparado com os demais animais. Nenhum animal apresentou hipoglicemia; apenas a técnica utilizada com Medsense Optium® apresentou valores superiores quando comparado com os valores de referência. Os animais apresentaram valores elevados de glucagon no primeiro dia quando comparado com o último dia de internação; o mesmo comportamento foi apresentado pelo cortisol e insulina. Como conclusão do estudo os animais com sepse grave apresentaram hiperglicemia e elevação dos hormônios glucagon, cortisol e insulina que tenderam a normalização na alta. / Aiming the analysis of glucose, insulin, glucagon and cortisol hormones levels in female dogs with pyometra and severe sepsis during intensive treatment. It was studied 13 female dogs with pyometra diagnosis and severe sepsis, which, the animals presented two alterations on the systemic inflammation response and at least one organic dysfunction. Before surgical procedure, samples were collected to laboratory exams realization and evaluation of hormones levels (insulin, glucagon and cortisol). During the interning time, the animals were evaluated daily through the renal and hepatic biochemical profile analysis, hemogram, sodium, potassium, insulin, glucagon and cortisol. The level of glucose was evaluated before the surgical procedure, every 3 hours in the first 6 hours and every 6 hours until patient discharge or patient death. After the surgical procedure, the animals received the CGMS introduction in subcutaneous, for glucose subcutaneous evaluation. A control group of nine animals were submitted to the same dosages of glucose from sepsis group. For statistical analysis of values comparison obtained to the control group was utilized the non parametric testing of Wilcoxon. For glucose evaluation, glucagon, cortisol, insulin, sodium and potassium to the sepsis group, was utilized the mixed model approach with repeated measurements. The animals of sepsis group presented 7,37±1,66 years and 23,88±8,5 Kg of body weight. At the first interning day, 23% of animals presented hyperglycemia and these animals remained with a longer interning period when compared with other animals. None of animals presented hypoglycemia; there was a difference only related to the utilized technique (Medsense Optium® presented higher values when compared to the reference values). The animals presented high values if glucagon at the first day when compared to the last interning day; the same was noticed with cortisol and insulin. As conclusion to this study, the animals with severe sepsis presented hyperglycemia and increase of hormones levels of glucagon, cortisol and insulin, which tendered to normalization on their discharge.

A insuficiência renal aguda (IRA) em cadelas com piometra foi avaliada retrospectivamente em 147 animais e prospectivamente em 351 animais selecionando 27 e 132 cadelas respectivamente, mediante os seguintes critérios de inclusão, creatinina ≥ 2,4 mg/dL e ou uréia ≥ 80 mg/dL e ou aumentos relativos de 100% da creatinina e ou uréia séricas em relação a qualquer mensuração anterior, aplicados em 3 momentos estratégicos, o diagnóstico, 24 horas após a ovário-salpingo-histerectomia e na retirada dos pontos. Os animais do estudo retrospectivo foram utilizados como controle, enquanto que os animais selecionados do estudo prospectivo receberam tratamento conservador com solução de Ringer Lactato até 90 ml/kg/h, durante 4 horas. Os parâmetros avaliados antes e após a terapia, peso, pressão arterial sistólica, freqüência cardíaca, função renal, hemogasimetria arterial, bioquímica sérica e urinária e "clearance" da creatinina endógena. Os animais que não responderam adequadamente a terapia convencional e apresentavam-se em "síndrome urêmica" foram submetidos à hemodiafiltração (N=5 animais) e prescrito sessões de 2 horas, durante 3 dias, soluções apropriadas para hemodiafiltração (HDF) e reposição e capilar de polissulfona. Durante a HDF 2 animais vieram a óbito, 1 animal morreu com 18 dias e outro 12 dias após a última sessão de diálise e 1 animal sobreviveu. A taxa de mortalidade para os animais selecionados retrospectivamente foi de 40,7% e 20,4% prospectivamente. Entretanto os animais selecionados do estudo prospectivo que não sobreviveram foram comparados com os animais selecionados que sobreviveram, mediante análise univariada da uréia e creatinina séricas, fração de excreção de eletrólitos, bicarbonato arterial e "clearance" da creatinina e foram significativamente diferentes (p<0,05). Porém quando estes dados foram submetidos a uma análise multivariada e realizada a curva ROC (Receiver Operating Characteristic), detectou-se que a área sob a curva era de 0,867 (p<0,0001) IC: 0,769 ? 0,966. Desta forma foi possível concluir que a creatinina maior que 2,6 mg/dL prediz a morte da cadela com piometra e IRA, com 93% de sensibilidade e 77% de especificidade. Quanto aos animais que receberam a HDF e morreram apresentavam uma sobrevida de 7 dias em relação aos animais que receberam o tratamento conservador apenas, podendo a HDF ser um método de aumentar a sobrevida, dando tempo para o animal se recuperar. / Acute renal failure (ARF) was evaluated retrospectively in 147 and prospectively in 351 female dogs with piometra. 27 and 132 animals were respectively selected for this study, fulfilling the following criteria, measured in three moments (immediately after the diagnosis, 24 hours after the hysterectomy and when the suture was removed): creatinine ≥ 2,4mg/dl and/or urea ≥ 80mg/dl and/or relative increases of 100% in comparison with values previously obtained. The animals of the retrospective study were used as control. The animals selected for the prospective study received conservative treatment consisting in Lactated Ringer Solution, with the maximum dose of 90ml/kg/h, during 4 hours. The factors evaluated before and after the therapy were weight, systolic arterial pressure, heart rate, renal function, arterial hemogasometry, serum and urinary biochemistry and the endogenous renal creatinine clearance. Five animals that did not respond adequately to the conservative treatment and showed uremic syndrome were randomly chosen and submitted to hemodiafiltration (HDF), given in 3 sessions of 2 hours each, during 3 days, with appropriate solutions for HDF and polissulfona membrane. During the HDF two animals died after the last session of HDF, one animal remained alive for 18 days, another animal for 12 days and one animal survived. The rate of death for the animals in the retrospective study was 40.7% and 20.4% for the prospective group. The animals of the prospective study that died were compared with the alive animals that were selected from the total population for that group, using univariada analysis of the values of serum urea and creatinine, electrolyte rate of excretion, arterial bicarbonate and creatinine clearance and it was observed that there was significative difference (p<0.05), however when this data was submitted to a multivariated analysis and the ROC curve were plotted it was detected that the area under it was of 0,867 (p<0.0001), IC:0,769-0,966. Therefore it was possible to conclude that a creatinine value higher than 2,6mg/dl predicted the death of the animals with piometra and ARF, with 93% of sensibility and 77% of specificity. Regarding the animals that were submitted to HDF and died, it was observed that they presented a -7days prolonged life in relation with the animals that received only the conservative treatment, suggesting that the HDF is a method to increase lifetime, offering extra time for the animal to recover.

O avanço da terapia intensiva na medicina veterinária vem permitindo a realização de um melhor suporte e monitorização dos animais com sepse grave. Esta é uma síndrome clínica caracterizada por alterações inflamatórias sistêmicas (SIRS) associadas a disfunções orgânicas, como, por exemplo, lesão pulmonar aguda (LPA) e síndrome do desconforto respiratório agudo (SARA). No homem, esta síndrome resulta em uma significante taxa de mortalidade, porém, na medicina veterinária ainda faltam estudos sobre este assunto. Assim, o objetivo deste estudo foi avaliar a ocorrência de complicações respiratórias em animais com sepse grave submetidos à terapia intensiva. Neste estudo foram incluídos 14 animais com sepse grave secundária à piometra. Durante o período de tratamento intensivo os pacientes foram monitorados por meio de: freqüências cardíaca e respiratória, pressão arterial sistólica, débito urinário, pressão venosa central, lactato, saturação venosa central de oxigênio, hemogasometria arterial e radiografias torácicas. Todos os animias (100%) apresentaram alterações respiratórias, destes três cadelas vieram a óbito (21,42%) e 11 (78,57%) receberam alta do tratamento intensivo.Os animais submetidos à terapia intensiva devido ao desenvolvimento de sepse grave secundária à piometra, necessitam de um acompanhamento radiográfico torácico diário, a fim de se estabelecer medidas de suporte respiratório adequadas e, consequentemente, obter menores taxas de mortalidade. / The advances in intensive care has allowed to offer better support to animals with severe sepsis. This is a clinical syndrome characterized by systemic inflammatory response associated with organic dysfunction, such as acute pulmonary injury (ALI) and acute respiratory distress syndrome (ARDS). In humans, this syndrome results in significant mortality, but, in veterinary medicine there are not many studies about this. The aim of this study was to evaluate the development the pulmonary complications in animals submitted to intensive care. In this study were included 14 animals with severe sepsis secondary to pyometra. During the period of intensive care the animals were evaluated: heart and respiratory rates, systolic blood pression, urine output, central venous pression lactate, lactate, central venous saturation, arterial hemogasometric and thoracic x-ray. All animals (100%) had abnormal breathing, three of these dogs eventually died (21.42%) and 11 (78.57%) out of intensive care. Animals with severe sepse secondary to pyometra underwent intensive therapy, requiring a chest radiographic daily in order to establish adequate respiratory support, and thus achieve lower mortality rates.

Orientador: Sisi Marcondes Paschoal / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-23T22:06:04Z (GMT). No. of bitstreams: 1 Lopes-Pires_MariaElisa_D.pdf: 1241899 bytes, checksum: a13986c42dd2369a280228a76009db4c (MD5) Previous issue date: 2013 / Resumo: A sepse e ainda causa de muitos óbitos em hospitais do mundo todo. A gravidade da sepse esta relacionada ao estado de ativação de plaquetas. Trabalho prévio do nosso grupo mostrou que o tratamento de ratos com lipopolissacarideo (LPS) leva a inibição da agregação plaquetaria e aumento da formação de espécies reativas de oxigênio (EROs) via NADPH oxidase. Entretanto, o efeito inibitório do LPS na agregação não e dependente da liberação de EROs. Portanto, o objetivo do presente trabalho foi investigar as vias de sinalização envolvidas na inibição da agregação e na ativação da NADPH oxidase em plaquetas de ratos tratados com LPS. Para tanto, ratos Wistar machos foram injetados com LPS (1 mg/kg, i.p.) e apos 6h ou 48h o sangue foi coletado. A agregação plaquetaria foi induzida por ADP (10 ?M) na ausência e na presença de diferentes inibidores enzimáticos. A formação de EROs em plaquetas foi determinada por citometria de fluxo utilizando a sonda fluorescente DCFH-DA e a concentração intraplaquetaria de GMPc por imunoensaio. Também foram realizados ensaios de western blotting para a analise da ativação das enzimas c-Src, AKT e NADPH oxidase, bem como para a detecção de proteínas contendo resíduos de nitrotirosina. A analise do western blotting mostrou que a fosforização da c-Src quinase no resíduo Tyr 416, que indica ativação da enzima, foi semelhante em plaquetas de ratos injetados com salina ou LPS em 6h ou 48h. Alem disso, a inibição de Src com PP2 (10 ?M) não modificou a agregação plaquetaria de ratos tratados com LPS. Nos verificamos que a inibição da agregação foi acompanhada por um aumento significativo dos níveis de GMPc, bem como da nitracao de proteínas, em plaquetas de ratos 6h ou 48h apos o tratamento com LPS. A incubação das plaquetas com o sequestrador de peroxinitrito -(-) epigalocatequina gallato (10 ?M) aumentou significativamente a agregação de ratos injetados com LPS em 48h, mas não alterou a agregação em 6h. Entretanto, a inibição da agregação plaquetaria em ratos tratados com LPS em 6h foi revertida pelo inibidor da enzima guanilil ciclase ODQ (25 ?M) ou pelo inibidor de PKG Rp-8-Br (25 ?M). De forma semelhante, o inibidor nao seletivo de PKC GF109203X (10 ?M) reverteu o efeito inibitório do LPS em 6h na agregação e reduziu os niveis de GMPc em plaquetas. Nos mostramos que a fosforização da AKT no resíduo Thr308 foi significativamente maior em plaquetas de ratos tratados com LPS quando comparado com ratos injetados com salina. A incubacao das plaquetas de ratos tratados com LPS com o inibidor de PI3K wortmannin (100 nM) nao modificou a agregação. Entretanto, o inibidor da AKT PPI-1 (20 ?M) aumentou a agregação para níveis semelhantes aos observados nos ratos injetados com salina. A agregação plaquetaria de ratos 48h apos o tratamento com LPS não foi afetada por nenhum dos inibidores enzimáticos utilizados neste trabalho. O aumento da geração de EROs em plaquetas de ratos tratados com LPS em 6h ou 48h foi acompanhado pelo aumento significativo da fosforização do resíduo Ser345 na subunidade p47-phox da NADPH oxidase. A incubação de plaquetas de ratos tratados com LPS com GF109203X inibiu a fosforização da p47-phox bem como reduziu a geração de EROS. A produção aumentada de EROs em plaquetas de ratos tratados com LPS em 6h também foi reduzida em 42% por PP2. A inibição de PI3K ou AKT não modificou a produção de EROS em plaquetas de ratos tratados com LPS. A incubação de plaquetas com ODQ ou com Rp-8-Br (5?M) reduziu significativamente a produção de EROS somente em plaquetas de ratos 48h apos o tratamento com LPS. Portanto, no presente trabalho podemos concluir que a inibição da agregação plaquetaria observada 6h apos a injeção de LPS e mediada pela via NO/GMPc/PKG e também e modulada pela PKC e AKT, enquanto que, o efeito inibitório do LPS em 48h e essencialmente dependente da formação de peroxinitrito. A produção aumentada de EROs em plaquetas de ratos tratados com LPS envolve a fosforização da subunidade p47-phox da NADPH oxidase pela PKC. Alem da PKC, são importantes no aumento da liberação de EROs em plaquetas a Src em 6h e a via GMPc/PKG em 48h apos a injeção de LPS / Abstract: Sepsis is still a cause of high mortality in hospitals all over the world and its severity is directly related to platelet activity. A previous work of our group showed that the treatment of rats with lipopolysaccharide (LPS) inhibited platelet aggregation and also increased reactive oxygen species (ROS) production which was mediated especially by NADPH oxidase. However, the inhibitory effect of LPS on platelet aggregation is independent of ROS formation. Therefore, in the present work we investigated the signaling pathways involved in the aggregation inhibition as well as in the increased ROS formation in platelets of LPS-treated rats. Male Wistar rats were injected with LPS (1 mg/kg, i.p.) and blood was collected after 6h or 48h. Platelet aggregation was induced by ADP (10 ?M) in the absence or in the presence of different enzymatic inhibitors. ROS formation in platelets was determined through flow cytometry using 2',7'-dichlorofluorescein diacetate (DCFHDA) and cGMP intraplatelet levels by enzyme immunoassay kit. Western blotting assays were carried out to analyze AKT and NADPH oxidase activation and the presence of nitrated proteins in platelets. In the present work, we observed that the inhibition of aggregation was accompanied by a significant increase of cGMP levels as well as protein nitration in platelets of LPS-treated rats. Incubation of platelets with the peroxynitrite scavenger -(-) epigallocatechingallate (10 ?M) significantly increased aggregation of LPS-treated rats at 48h, but did not modify it at 6h. However, the inhibitory effect of LPS at 6h on platelet aggregation was reversed by the guanylyl cyclase (sGC) inhibitor ODQ (25 ?M) or by the PKG inhibitor Rp-8-Br (25 ?M). Likewise, the PKC inhibitor GF109203X (10 ?M) reversed the inhibition of aggregation and the increased cGMP levels in platelets of LPS-treated rats at 6h. We demonstrated that AKT phosphorylation at Thr308 was significantly higher in platelets of LPS-injected rats than in the saline group. The AKT inhibitor PPI-1 (20 ?M) increased platelet aggregation of rats 6h after LPS-injection to the levels comparable to the saline group, despite of the PI3K inhibitor wortmannin (100 nM) has had no effect. Platelet aggregation of rats 48h after LPS injection was not affected by any enzymatic inhibitors used in this work. Increased ROS formation in platelets of LPS injected rats at 6h or 48h was followed by a marked increase of the NADPH oxidase subunit p47-phox phosphorylation at Ser345. Incubation of platelets of LPS-injected rats with GF109203X inhibited the p47-phox phosphorylation as well as ROS generation. The increased ROS production in platelets of rats 6h after LPS-injection was reduced 42% by PP2. Inhibition of both PI3K and AKT did not change ROS production in platelets of LPS-injected rats. Incubation of either ODQ or Rp-8-Br (5 ?M) reduced significantly the ROS production just in platelets of rats 48h after LPS-injection. Therefore, our results show that the inhibition of ADP-induced platelet aggregation of rats 6h after LPS injection is mediated by NO/cGMP/PKG-dependent mechanisms, and PKC and AKT probably act upstream upregulating this pathway. On the other hand, the inhibitory effect of LPS at 48h on platelet aggregation is essentially dependent on ONOO- production. In addition, our results show that the augmented ROS production in platelets of LPS-treated rats is mediated by PKCdependent phosphorylation of p47-phox. Besides PKC, the increased ROS formation in platelets is also modulated by Src at 6h after LPS injection, while NO/cGMP/PKG pathway takes part of this effect at 48h / Doutorado / Farmacologia / Doutora em Farmacologia

Orientador: Carlos Emilio Levy / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-18T23:13:59Z (GMT). No. of bitstreams: 1 Fiolo_Kateli_M.pdf: 2870883 bytes, checksum: 6e6dd0df208caa395482319a31dda8b1 (MD5) Previous issue date: 2011 / Resumo: Streptococcus agalactiae, conhecido como Estreptococo beta-hemolítico do grupo B (EGB), é classificado por diferenças capsulares que podem variar em dez sorotipos, alguns responsáveis por infecções materno-infantis sérias e debilitantes ou podendo ainda levar ao óbito. O EGB pode ocasionar também, infecções graves em adultos e idosos. OBJETIVO: Descrever e analisar o perfil epidemiológico dos sorotipos prevalentes de Streptococcus agalactiae, provenientes de infecção em recém-nascidos (RN), do Centro de Atenção Integral á Saúde da Mulher (CAISM /UNICAMP) e casos de infecção por EGB de diversos materiais do Hospital de Clínicas da Unicamp (HC UNICAMP) e de sete laboratórios que prestam serviços a outros hospitais maternidade na cidade de Campinas SP e região. MÉTODOS: Estudo transversal laboratorial realizado, no período de janeiro de 2007 a dezembro de 2010. As cepas de EGB foram triadas por provas laboratoriais manuais padronizadas, ou por automação microbiológica, Vitek®2 (BioMeriéux). A seguir foram tipadas por PCR, utilizando sucessivamente primers específicos para espécie e para nove sorotipos de Streptococcus agalactiae. RESULTADOS: Durante os anos de 2007 e 2008 o programa de triagem materna do CAISM coletou 2.022 amostras de secreção retovaginal com média de 20,5% de positividade. Entre janeiro de 2007 a dezembro de 2010, foram selecionadas 120 amostras de EGB, isoladas de pacientes do HC UNICAMP, de diferentes materiais: urina (72,5%), sangue (hemocultura) (15,8%), secreção de feridas e abscessos (4,1%), líquor (2,5%), secreção ferida cirúrgica (1,6%), outras secreções (3,3%). Foram também selecionados, entre setembro de 2008 a setembro de 2009, 383 amostras de EGB isolados por laboratórios que prestam serviço a hospitaismaternidade de Campinas e região em: urina (54,3%), secreção retovaginal (37,8%), esperma (3,4%), sangue (2,3%), secreções gerais (1,8%) e líquor (0,2%). Foram avaliados, por análise molecular os sorotipos de 70 destas amostras, sendo 22 isoladas de sangue, 5 de líquor e 43 de outros materiais clínicos, escolhidos aleatoriamente, revelando a predominância do sorotipo tipo V (61,4%), seguido pelo tipo Ia (24,3%), tipo III (10,0%), tipo Ib (2,8%) e o tipo IV (1,4%). Dentre as amostras analisadas apenas seis eram provenientes de processos infecciosos em RNs do CAISM, sendo 1, 2,1 e 2 casos, respectivamente para cada ano, de 2007 até 2010, estimando-se para este período uma incidência média 0,55 casos de EGB por 1.000 nascidos vivos. Apenas mais um caso de RN foi isolado no Hospital Estadual de Sumaré no ano de 2009. Entre esses sete casos de RN, em dois foram encontradas amostras pareadas de mãe-filho. Nas amostras de RNs houve predominância do sorotipo V com 42,8%, seguido pelo tipo III e Ia com 28,5% cada um, nas amostras das duas mães foram encontrados os mesmos sorotipos de seus recém-nascidos. CONCLUSÕES: O número de amostras obtidas de recém nascidos foi abaixo do esperado, possivelmente em conseqüência da eficiência do programa de triagem e profilaxia materna do EGB, não podendo ser excluída a possibilidade de limitações dos recursos laboratoriais utilizados. Os sorotipos encontrados são os mais prevalentes na literatura mundial e associados à maior virulência. A técnica de PCR revelou ser muito útil para estudos epidemiológicos e de elevada especificidade / Abstract: Streptococcus agalactiae, also known as beta-hemolytic streptococcus group B (GBS), is classified by capsular differences that can vary in ten serotypes, some responsible for maternal and infant debilitating or serious infections and can even lead to death. The GBS can also cause, serious infections in adults and elderly. OBJECTIVE: To describe and analyze the epidemiology of prevalent serotypes of Streptococcus agalactiae, isolated from newborns (NB), from the Center for Integral Attention to Women's Health (CAISM / UNICAMP) and cases of GBS infection of various materials from Hospital de Clinicas, Unicamp (HC UNICAMP) and seven laboratories that provide services to other maternity hospitals in Campinas, São Paulo, Brazil and region. Methods. It was a cross-sectional laboratory study conducted in the period from January 2007 to December 2010. GBS strains were screened by standard manual microbiological laboratory tests, or by automation by Vitek ® 2 (bioMérieux). Following, they were typed by PCR, using specific primers for species and nine serotypes of Streptococcus agalactiae. RESULTS: During the years of 2007 and 2008 the CAISM maternal screening program collected 2,022 rectovaginal secretion samples with an average of 20.5% positivity. From January 2007 to December 2010, were selected a total of 120 GBS strains isolated at the HC UNICAMP as follows: urine (72.5%) blood (15.8%), secretion from wounds and abscesses (4.1%), cerebrospinal fluid (2.5%), wound secretion (1.6%) and other secretions (3.3%). From September 2008 to September 2009, were also selected 383 samples of GBS isolated by laboratories that provide service for maternity hospitals of Campinas region as follows: urine (54.3%), rectovaginal secretion (37.8%), sperm (3.4%), blood (2.3%), general secretions (1.8%) and cerebrospinal fluid (0.2%). Of these samples 70 strains were evaluated by molecular typing analysis, 22 isolated from blood, 5 from cerebrospinal fluid and 43 randomly selected isolates from other clinical materials, revealing the predominance of serotype V (61.4%), followed by serotype Ia (24.3%), serotype III (10.0%), serotype Ib (2.8%) and serotype IV(1.4%). Among the 70 samples, six were from newborns of CAISM with infectious processes, with 1, 2, 1 and 2 cases occurred respectively in each year from 2007 to 2010. For this period were estimated an average incidence of 0.55 cases of GBS for 1,000 born alive. Only one additional case of NB infection was isolated in the Hospital Estadual de Sumaré in 2009. Among these seven cases of NB infections, for only two were found paired EGB isolates from mother and newborn. In the NB samples was found predominantly the serotype V ( 42.8%), followed by type Ia and III with 28.5% for each, and in two samples of mothers were found the same serotype of their newborns. CONCLUSIONS: The number of samples of newborns was lower than expected, possibly due to the efficiency of the maternal GBS screening program and prophylaxis, but can not be excluded the limitations of laboratory resources used. The founded serotypes are the most prevalent in the literature and associated with increased virulence. The PCR technique has proved to be very useful for epidemiological studies and a have a high specificity / Mestrado / Saude da Criança e do Adolescente / Mestre em Ciências

Orientador: Mário José Abdalla Saad / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-20T04:12:07Z (GMT). No. of bitstreams: 1 Silva_KellyLimaCalistoda_D.pdf: 12319373 bytes, checksum: 35117c7c04d7b9af2c03f2af293482d1 (MD5) Previous issue date: 2012 / Resumo: Na sepse o sistema imune torna-se hiperativo, levando a excessiva produção de mediadores pró-inflamatórios. Tanto componentes bacterianos, como o LPS, quanto citocinas pro-inflamatórias resultantes da resposta imune, podem ativar mecanismos intracelulares associados à resistência à insulina, como a via IKK'beta'/NF'capa'B e a via da JNK. Hiperglicemia e resistência à insulina ocorrem durante a sepse, como consequência dos efeitos metabólicos da excessiva produção de mediadores pró-inflamatórios. Sabe-se que a resistência à insulina pode agravar ainda mais o quadro da sepse, todavia a manutenção da normoglicemia com a insulinoterapia reduz os índices de morbidade e mortalidade. Por esta razão, o objetivo do presente estudo foi investigar o efeito de fármacos (atorvastatina e diacereína) sobre a sobrevivência, sinalização inflamatória e, paralelamente, a sua ação sobre a via de sinalização da insulina em ratos com sepse induzida por peritonite. Nossos dados demonstram que os tratamentos com atorvastatina e diacereína aumentam a sobrevida, com um efeito benéfico sobre a sensibilidade à insulina, melhorando a sinalização da insulina dos animais sépticos. Ademais, os tratamentos reduziram a ativação de JNK e IKK e consequente expressão de citocinas pró-inflamatórias, e em paralelo reduziram estresse do retículo endoplasmático induzido pela sepse. Com isso, podemos sugerir que a restauração da sinalização da insulina demonstrada pela reativação da via PI3K/Akt induzida pelos tratamentos, desempenhou um papel fundamental no aumento da sobrevida na sepse. Neste contexto, acreditamos que a melhora na via de sinalização da insulina, induzida pelos tratamentos com atorvastatina e diacereína, em paralelo com uma atenuação da inflamação nos tecidos, pode ajudar a predizer a eficácia destes tratamentos na sepse / Abstract: During the onset of sepsis, the inflammatory system becomes hyperactive, and the persistent activating stimuli induce cells to produce excessive amounts of cytokines and mediators that lead to tissue damage. Both bacterial components and proinflammatory cytokines can directly activate pro-inflammatory pathways as IKK'beta'/NF'kappa'B and JNK that seem to be associated to disruption on insulin signaling. Hyperglycemia and insulin resistance occur during sepsis, as a consequence of the metabolic effects of stress hormone and cytokine production. Studies indicate that insulin resistance may aggravate sepsis. Furthermore, it was demonstrated that the maintenance of normoglycemia with insulin therapy reduces morbidity and mortality rates in sepsis. The aim of the present study was to investigate the effect of drugs (atorvastatin and diacerhein) on survival, inflammatory signaling and insulin signaling pathway in rat model of CLP-induced sepsis. Our data demonstrate that atorvastatin and diacerhein treatment improves survival in septic rats and this improvement is accompanied by a marked improvement in insulin sensitivity. Sepsis induced an increase in JNK and IKK/NF-'kappa'B activation, and blunted insulin-induced insulin signaling in liver, muscle and adipose tissue; atorvastatin and diacerhein reversed all these alterations in parallel with a decrease sepsis-induced endoplasmic stress reticulum and circulating levels proinflammatory cytokines. The improvement insulin signaling pathway through PI3K/Akt induced by treatments with atorvastatin and diacerhein, in parallel with a decrease in tissue inflammation, may play a central role in regulation of insulin signaling and survival in sepsis insult / Doutorado / Clinica Medica / Doutor em Ciências Médicas

Au cours d’une infection, les cellules de l’immunité innée sont capables de reconnaître via les Toll-like receptors (TLR) des motifs appelés pathogen-associated molecular patterns. Les cellules natural killer (NK) contribuent au processus inflammatoire en produisant de nombreuses cytokines. Chez la souris, nous avons montré que l’expression du TLR2 et du TLR4 dans les cellules NK spléniques est intracellulaire, comme pour le TLR9. La réponse des NK aux agonistes des TLR2, 4 et 9 nécessite la présence de cytokines accessoires (IL-15 et IL-18), afin d’obtenir une production significative des cytokines pro-inflammatoires IFN- et GM-CSF. En revanche, dans un modèle de sepsis polymicrobial, les NK spléniques de souris présentent une diminution dramatique de leur production d’IFN- et de GM-CSF en réponse aux agonistes des TLR. Cette diminution est sous le contrôle des cellules T régulatrices (Treg) et due au TGF-1. L’analyse des voies de signalisation nous a permis de montrer que la production de GM-CSF est abolie chez les cellules NK de souris déficientes pour STING en réponse au CpG-DNA. Ces résultats mettent en lumière une voie alternative et cytoplasmique pour la détection de l’ADN bactérien dans les cellules NK, différente de la voie classique TLR9-MyD88 dépendante. De plus, nous avons montré un trafic du récepteur TLR2 depuis l’intérieur vers la surface des cellules NK. La migration du TLR2 à la surface des NK nécessite la molécule UNC93B1, précédemment décrite comme transporteur endosomal de TLR.Chez les cellules NK humaines circulantes (sous-populations CD3-CD56bright et CD3-CD56dim), nous avons montré que l’expression des TLR2 et 4 est majoritairement intracellulaire, comme pour le TLR9 et comme chez la souris. La production d’IFN- par les NK de sujets sains en réponse aux agonistes des TLR nécessite également la présence de cytokines accessoires. Nous montrons que cette production est fortement altérée pour les NK des patients admis en soins intensifs et ayant un sepsis ou un syndrome de réponse inflammatoire systémique (SIRS). De même nous avons trouvé des différences entre les patients et les sujets sains dans l’expression du CD69 (marqueur d’activation précoce) et des TLR eux-mêmes. Cette étude indique que les NK des patients sepsis et SIRS deviennent tolérants aux agonistes des TLR en terme de production d’IFN-, de manière similaire à ce qui a été décrit pour d’autres cellules comme les monocytes / As sensors of infection, innate immune cells are able to recognize pathogen-associated molecular patterns by receptors such as Toll-like receptors (TLR). NK cells contribute to inflammatory processes by the production of numerous cytokines. In mice, we have shown that the protein expression of TLR2 and TLR4 in naive NK cells from spleen is predominantly intracellular, similarly to TLR9. The responsiveness of purified NK cells to TLR2, 4 or 9 agonists in vitro requires the presence of accessory cytokines (IL-15 and 18) to trigger a significant production of IFN- and GM-CSF. In contrast, NK cells purified from a model of in vivo polymicrobial sepsis, showed a dramatic reduction in their capacity to respond to TLR agonists in terms of IFN- and GM-CSF release due an inhibitory cross talk with Treg cells mediated by TGF-1. Analyzing the signaling pathways involved in cytokine production in response to CpG-DNA, we found that GM-CSF production was abolished in NK cells from STING-deficient mice, revealing that this intracytoplasmic receptor acts as a TLR9/MyD88-independent alternative sensor to bacterial DNA in NK cells. Additionally we show that intracellularly expressed TLR2 traffics to the cell surface of NK cells, by a mechanism involving UNC93B1, a protein previous described as an endosomal TLR carrier.In human peripheral blood NK cells (CD3-CD56bright and CD3-CD56dim subsets), we show that TLR2 and 4 protein expression is primarily intracellular, similar to TLR9, and similar to our findings in murine NK cells. The ex vivo responsiveness of human blood NK cells to TLR2, 4 or 9 agonists also requires accessory cytokines, to promote secretion of IFN-. In intensive care patients diagnosed with systemic inflammatory response syndrome (SIRS) and sepsis, IFN- production was significantly decreased. We also discovered modulations in the expression of CD69 (early activation marker) and in that of TLR themselves. This study indicates that NK cells undergo tolerance in response to TLR agonists during SIRS or sepsis, similarly to other cells, such as monocytes.

Abstract Sepsis is a major challenge for healing responses maintaining homeostasis. Coagulation and inflammation are activated at the whole-body level, even in undamaged tissues. Despite constantly growing knowledge and advances in care, high mortality in severe sepsis remains. It was hypothesised that tissue regeneration processes may also be altered in severe sepsis. The study population consisted of 44 patients with severe sepsis and 15 healthy controls. Serum samples were obtained during ten days of severe sepsis and twice again, three months and six months later. Experimental suction blisters were performed twice during severe sepsis and at 3 and 6 months. Serum samples were obtained and suction blisters were induced once in controls. Biochemical analyses were performed to assess the level of procollagen I and III aminoterminal propeptides (PINP, PIIINP), reflecting the synthesis of corresponding collagens; in serum and suction blister fluid. In addition collagen I degradationproduct in serum was measured. Physiological measurements of transepidermal water loss and blood flow were done in order to evaluate the re-epithelisation rate and blood flow in an experimental wound. Levels of matrix metalloproteinases (MMPs) 2, 8 and 9 were measured from serum and suction blister fluid. Decrease in water evaporation from an experimental blister wound was slower in sepsis than in controls. On the fourth day the sepsis patients had higher blood flow in the blister wound than the controls (both in the healing wound and in the newly induced wound). The procollagen III aminoterminal propeptide (PIIINP) levels were increased in serum in severe sepsis, whereas procollagen I aminoterminal propeptide (PINP) levels were not, making up a pronounced PIIINP/PINP ratio. PIIINP and PINP levels were associated with disease severity and outcome. In addition, collagen I degradation measured with ICTP assay was increased in severe sepsis and PINP/ICTP ratio was lower. Furthermore, the overall protein concentration and PINP and PIIINP levels were low in suction blister fluid, which implies that the balance of the extracellular matrix consistence is disturbed in uninjured skin in severe sepsis. Then again in survivors the levels of PINP and PIIINP were up-regulated at three months but returned to normal by six months. MMP-9 levels in serum and skin blister fluid were lower in severe sepsis than in controls during the ten days studied. The MMP-2 levels were found to be increased both in serum and in skin blister fluid in severe sepsis in comparison to the controls and MMP-2 was associated with disease severity and outcome. MMP-8 was increased in serum and in skin blister fluid. In conclusion, the balance of collagen turnover is altered in severe sepsis in serum and skin and epidermal re-epithelisation is delayed. The levels of MMP-2 and MMP-8 are increased whereas levels of MMP-9 are depressed.

L'apport des biomarqueurs aux urgences est bien documenté. Depuis l'apparition de la myoglobine et de la troponine pour le diagnostic de syndrome coronaire aigu (SCA), de multiples marqueurs ont été développés pour l'aide au diagnostic de multiples pathologies aux urgences. Certains biomarqueurs sont même intégrés à la définition de syndromes ou pathologies comme le SCA avec la troponine, ou le sepsis sévère avec le lactate. Nous abordons dans ce travail l'approche multimarqueurs, qui consiste à combiner le dosage de plusieurs biomarqueurs pour améliorer les performances diagnostiques ou pronostiques. L'hypothèse de base de ce travail est que l'association d'un marqueur sensible, généraliste, avec un marqueur spécifique de pathologie ou de dysfonction d'organe, permettrait d'améliorer la prise en charge diagnostique ou la stratification du risque aux urgences. On illustre cette approche dans trois cas particuliers : la prédiction du sepsis sévère, le diagnostic du syndrome coronaire aigu, et l'évaluation du risque après une crise convulsive. Plusieurs méthodes sont envisagées pour combiner plusieurs biomarqueurs, et on développera ici la détermination de la meilleure combinaison linéaire pour obtenir une discrimination optimale. / The added value of biomarkers in the emergency settings is well reported, in various pathologies. Since the burst of myoglobin and troponine for the diagnosis of myocardial infarction (MI), various biomarkers have been developed and adopted for diagnostic purposes in different pathologies. Some of them are part of the very definition of specific syndrom or disease (MI with troponin, or severe sepsis with lactate). We present here the multimarker approach in the emergency department – a strategy that combines the results of several different biomarkers to enhance diagnostic or prognostic performances. We made the hypothesis that the association of a sensitive and generalist biomarker, with an organ or syndrome specific one, would result in better performances.We illustrate here this strategy in three particular cases: the prediction of severe sepsis, the diagnosis of acute coronary syndrome, and the risk stratification after a convulsive seizure. Several methods are considered for the combination of biomarkers, and we will focus on the determination of the best linear combination.

Reliable access to the circulation is paramount in most medical and surgical emergencies. When venous access cannot be expediently established, intraosseous (IO) access is indicated. This method has a high success rate even in relatively inexperienced hands and there is considerable clinical experience of IO administration of drugs and fluids. There is however limited evidence on the use of IO samples for laboratory analysis. Also, uptake of drugs during shock has not been extensively studied. Further, there have been concerns that analysis of IO samples may damage laboratory equipment. We have studied, in a porcine model, the use of IO samples for point of care analysis of blood gases, acid base parameters and blood chemistries in stable circulation, in experimental septic shock, and in hypovolemia after major hemorrhage, comparing IO samples with arterial and venous samples, and comparing IO samples from different sites. We have also studied coagulation assays on IO samples in stable circulation and after major hemorrhage. Furthermore, we have compared IO and intravenous administration of antibiotics in experimental sepsis. Average differences between IO and arterial/venous samples varied between the studied analytes. During stable circulation, average IO levels of blood gases, acid-base parameters, hemoglobin/hematocrit and several blood chemistries approximated venous levels relatively well. Differences in acid-base and blood gas parameters, and lactate, were more pronounced in hypovolemia, as well as in sepsis. The dispersion of the differences was often relatively large, indicating limited precision. Average differences between two intraosseous sites were small. Intraosseous samples were clinically hypercoagulable with a strong tendency to clot in vitro, and thromboelastography demonstrated shortened reaction times compared with venous samples. Major bleeding and hemodilution moderately affected the studied coagulation parameters. In endotoxemic animals with circulatory instability, concentrations of cefotaxime and gentamicin in samples from the pulmonary artery were comparable at 5 minutes after intraosseous and intravenous administration, and during a 3 hour observation period. In summary, agreement between analytes in intraosseous and conventional blood samples was variable and often unpredictable, especially during circulatory compromise. Intraosseous samples clinically appeared hypercoagulable, and thromboelastography confirmed this. High and comparable concentrations of cefotaxime and gentamicin were found after intraosseous and intravenous administration of equivalent doses, suggesting that uptake is acceptable during septic instability.