Made available in DSpace on 2015-04-11T13:41:12Z (GMT). No. of bitstreams: 1 Marcos Giovanni Santos Carvalho.pdf: 4299748 bytes, checksum: 026ddef622b0abee7f254cf45582e0de (MD5) Previous issue date: 2012-11-23 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Introduction: Prematurity is a serious problem for health services across the world, and the respiratory distress syndrome (RDS) is the largest lung problem during the neonatal period. The deployment of new technologies such as prenatal corticosteroids has shown an important role in reducing neonatal morbidity and mortality, in spite of few studies conducted in Brazil. Purpose: Evaluate the impact of antenatal corticosteroid on clinical outcomes of premature newborns. Methodology: Retrospective study of medical data collection of 24 newborns to 34 weeks of gestational age and their respective mothers, during the year of 2010 at Maternity "Balbina Mestrinho" in Manaus/AM. The sample was divided into four groups, considering the exposure of newborns to prenatal corticosteroid and the gestational age of them [Corticosteroids Groups (CG) ≤ 30 and 31 weeks ≥; and groups without Corticosteroid (GS) ≤ and ≥ 30 31semanas]. The GC and GS ≤ 30; GC and GS ≥ 31 were compared, considering the variables: incidence of RDS and its severity, use of exogenous surfactant, ventilatory support requirement, length of hospital stay and neonatal morbidity and mortality. The Generalized Fisher exact test and the binomial test and the Mann-Whitney were used by statistical software R2 .14 .1 with the packages and Deducer Rcmdr, considering a significance level of 5%. Results: the frequency of use of corticosteroid was 43,91% among pregnant women. The prenatal corticosteroids reduced the RDS diagnosis, but not its severity, in the GC ≥ 31 (p = 0.0028), as well as the need for exogenous surfactant administration (p = 0.0175), what was not seen in the GC ≤ 30. The corticosteroid did not reduce the use of ventilatory support or the number of days of its use, nor the time of hospitalization. There was no difference in the diagnosis of morbidity and mortality among newborns of same gestational range exposed to antenatal corticosteroid (p > 0.05). Conclusions: there was repercussion in favour of the use of antenatal corticosteroid in RDS reduction and the use of exogenous surfactant for newborns with a gestational age ≥ 31 weeks; on the other hand, such therapy did not influence the use and duration of ventilatory support, length of hospital stay and mortality rates between newborns of similar gestational range. / Introdução: A prematuridade representa um sério problema para serviços de saúde através do mundo, sendo a síndrome do desconforto respiratório neonatal (SDRN) o maior problema pulmonar durante o período neonatal. A implantação de novas tecnologias como a corticoterapia pré-natal têm mostrado importante papel na redução da morbimortalidade neonatal, apesar dos poucos estudos realizados no Brasil. Objetivo: Avaliar as repercussões da corticoterapia pré-natal sobre variáveis de evolução clínica e desfecho de recém-nascidos (RN´s) prematuros. Metodologia: Estudo retrospectivo, de coleta de dados de prontuários de neonatos de 24 a 34 semanas de idade gestacional (IG) e de suas respectivas mães, durante o ano de 2010 na Maternidade Balbina Mestrinho em Manaus/AM. A amostra foi dividida em quatro grupos, considerando-se a exposição dos RN´s à corticoterapia pré-natal e a IG dos mesmos [Grupos Corticoides (GC) ≤ 30 e ≥ 31 semanas; e Grupos Sem Corticoide (GS) ≤ 30 e ≥ 31semanas]. Os GC e GS ≤ 30; GC e GS ≥ 31 foram comparados, considerando-se as variáveis: incidência de SDRN e sua severidade, uso de surfactante exógeno, necessidade de suporte ventilatório, tempo de internação e morbimortalidade neonatal, utilizando-se os testes Exato de Fisher Generalizado e o Teste binominal bem como o de Mann-Whitney por meio do software estatístico R2,14,1 com os pacotes Deducer e Rcmdr, considerando um nível de significância de 5%. Resultados: A frequência de utilização do corticoide foi de 43,91% entre as gestantes. A corticoterapia pré-natal reduziu o diagnóstico da SDRN, mas não a sua severidade, no GC ≥ 31 (p=0,0028), bem como a necessidade de administração do surfactante exógeno (p=0,0175), fato não ocorrido no GC ≤ 30. O corticoide não reduziu o uso de suporte ventilatório nem o número de dias de sua utilização, tampouco o tempo de internação. Não houve diferença no diagnóstico de morbimortalidade entre os RN´s de mesma faixa gestacional expostos à corticoterapia pré-natal (p>0,05). Conclusões: Verificou-se repercussão favorável ao uso do corticoide pré-natal na redução da SDRN e na utilização de surfactante exógeno para RN´s com IG ≥ 31 semanas; por outro lado, tal terapia não apresentou influência no uso e tempo de suporte ventilatório, tempo de internação e morbimortalidade entre RN´s de faixa gestacional similar.

Background: Intra-articular corticosteroid injections (IACI) are a commonly used treatment for painful knee osteoarthritis (OA). Response to treatment varies the reason for which is unclear. Further there are no data concerning the impact of accuracy of injection and psychological factors including illness perceptions, pain catastrophizing and depression on outcome following IACI.Objectives: i) to undertake a systematic review looking at predictors of response to IACI in patients with symptomatic knee OA and, ii) to determine the role of psychological factors and accuracy of injection in predicting response to IACI.Methods: A systematic review was conducted using electronic databases for randomised trials and observational studies looking at predictors of response to IACI in knee and hip OA. An observational study of 141 consenting patients (105 primary OA and 36 secondary OA in the context of well controlled rheumatoid arthritis) receiving routine IACI as part of clinical care for knee OA was conducted including baseline assessment and outcome assessments at 3 and 9 weeks. Response was defined as at least 40% reduction of pain from baseline, using the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Assessment included ultrasound (US) for features of synovial inflammation), radiographs, and assessment of psychological factors including the revised illness perception questionnaire (IPQR). Accuracy of injection was assessed using US. Characteristics of responders and non-responders to IACI at 3 and 9 weeks were determined using univariate statistics and significant factors entered into logistic regression models. Results: The systematic review found no consistent evidence for any disease or non-disease related predictor of response and no systematic exploration of the effects of psychological factors or accuracy of injection on treatment response. In the observational study, 83 (53%) of 141 subjects were responders to IACI at 3 weeks and 56 (44%) at 9 weeks. In univariate analysis, responders to treatment had higher scores for the IPQR domain treatment control and lower scores for IPQR consequences, depression and pain catastrophizing at both 3 and 9 weeks. Physical and patient related factors, including accuracy of injection and US features, were not associated with outcome, with the exceptions of higher baseline pain and previous experience of injection being associated with non-response at 9 weeks. In multiple regression, treatment control was the only independent predictor of response at 3 weeks. At 9 weeks, treatment control, consequences and depression were independent predictors of treatment outcome. Conclusion: In this observational study illness perceptions and depression predicted the outcome of IACI at 3 and 9 weeks. By contrast, physical factors including accuracy of injection did not influence outcome. Further work is needed to replicate these findings and elucidate mechanisms for these effects.

Topical treatment containing undeclared corticosteroids and illegal topical treatment with corticosteroid content have been seen on the Swedish market. In creams and ointments corticosteroids in the category of glucocorticosteroids are used to reduce inflammatory reactions and itchiness in the skin. If the inflammation is due to bacterial infection or fungus, complementary treatment is necessary. Side effects of corticosteroids are skin reactions and if used in excess suppression of the adrenal gland function. Therefore the Swedish Medical Products Agency has published related warnings to make the public aware. There are many similar structures of corticosteroids where the anti-inflammatory effect is depending on substitutions on the corticosteroid molecular skeleton. In legal creams and ointments they can be found at concentrations of 0.025 ‑ 1.0 %, where corticosteroids with fluorine substitutions usually are found at concentrations up to 0.1 % due to increased potency. At the Medical Products Agency 19F-NMR and 1H-NMR have been used to detect and quantify corticosteroid content in creams and ointments. Nuclear Magnetic Resonance, NMR, is an analytical technique which is quite sensitive and can have a relative short experimental time. The low concentration of corticosteroids makes the signals detected in NMR small and in 1H‑NMR the signals are often overlapped by signals from the matrix. With 1H‑NMR characteristic signals could be detected in a less crowded spectral window between 5.96 ‑ 6.40 ppm where overlapping signals from the matrix often are absent. Since fluorine is less common in molecules, the option of using 19F‑NMR increases the possibility of finding fluorine-containing corticosteroids in creams and ointments. The corticosteroid signals in 19F‑NMR are detected at -165 ppm and -187 ppm, depending on where fluorine is located on the structure. Quantifying with 1H-NMR and 19F-NMR gave similar result with an accuracy of 98‑116 % and 89-106 % respectively, and RSD values between 2‑35 %, depending on the kind and amount of corticosteroid. Relations between the structure and some signals in 1H‑NMR were found, making it easier to determine the basic structure of unknown corticosteroids in creams and ointments. Screening experiments were performed on creams and ointments with known concentration corticosteroid in order to find minimum NS for analyzing products which might contain corticosteroids. In order to detect a corticosteroid concentration of 0.05 % 19F‑NMR needed 64 NS with an experimental time of 2 min and 1H-NMR needed 160 NS with an experimental time of 17 min. Concentrations of 0.025 % could for some corticosteroids be detected with these parameters. The possibility of spiking samples in order to discriminate between corticosteroids was also investigated. The corticosteroids available at the MPA could be discriminated from each other with at least one of the methods 1H‑NMR or 19F-NMR, and in most cases with both. A market research was done in order to search for counterfeits and salespersons in different health food stores were asked to recommend the best product to treat eczema or psoriasis. Nine recommended products were bought where one was found illegally containing a corticosteroid. In previous experiments at the MPA there had been occurrences of a split signal in 19F-NMR when analyzing creams. The split 19F‑NMR signal was shown to be related both to the presence of water and structural effects of the corticosteroid

Chronic stress and dysfunction of the serotonergic system in the brain have been considered two of the major risks for development of depression. In this study, adult Fischer 344 rats were subjected to a regimen of chronic social defeat (CSD). To mimic stressful conditions, some rats were not exposed to CSD, but instead treated with corticosterone (CORT) in oral solution while maintained in their home cage. Protein levels of the serotonin transporter (SERT) in the dorsal raphe nucleus (DRN), hippocampus, frontal cortex, and amygdala were examined by Western blotting or immunofluorescence staining. The results showed that CSD up-regulated SERT protein levels in the DRN, hippocampus, frontal cortex, and amygdala regions. This up-regulation was abolished or prevented by adrenalectomy, or treatment with antagonists of corticosteroid receptors mifepristone and spironolactone, alone or in combination. Similarly, up-regulated SERT protein levels in these brain regions were also observed in rats treated with oral CORT ingestion, which was analogously prevented by treatment with mifepristone and spironolactone. Furthermore, both CSD- and CORT-induced up-regulation of SERT protein levels in the DRN and three brain regions were attenuated by simultaneous treatment with fluoxetine, an antidepressant that specifically inhibits serotonin reuptake. The results indicate that up-regulation in SERT protein levels in the DRN and forebrain limbic structures caused by CSD regimen was mainly motivated by CORT through corticosteroid receptors. The present findings demonstrate that chronic stress is closely correlated with the serotonergic system by acting on the regulation of the SERT expression in the DRN and its projection regions, which may contribute to the development of depression. Chronic stress and dysfunction of the serotonergic system are etiologically related to depression. In an attempt to explore their interaction, we found that chronic social defeat upregulated expression of serotonin transporter in the DRN and the projection regions, which may induce an alteration of serotonin transformation in the brain. This interaction may account for the development of this disease.

Stress has been reported to activate the locus coeruleus (LC)-noradrenergic system. However, the molecular link between chronic stress and noradrenergic neurons remains to be elucidated. In the present study adult Fischer 344 rats were subjected to a regimen of chronic social defeat (CSD) for 4 weeks. Measurements by in situ hybridization and Western blotting showed that CSD significantly increased mRNA and protein levels of the norepinephrine transporter (NET) in the LC region and NET protein levels in the hippocampus, frontal cortex and amygdala. CSD-induced increases in NET expression were abolished by adrenalectomy or treatment with corticosteroid receptor antagonists, suggesting the involvement of corticosterone and corticosteroid receptors in this upregulation. Furthermore, protein levels of protein kinase A (PKA), protein kinase C (PKC), and phosphorylated cAMP-response element binding (pCREB) protein were significantly reduced in the LC and its terminal regions by the CSD paradigm. Similarly, these reduced protein levels caused by CSD were prevented by adrenalectomy. However, effects of corticosteroid receptor antagonists on CSD-induced down-regulation of PKA, PKC, and pCREB proteins were not consistent. While mifeprestone and spironolactone, either alone or in combination, totally abrogate CSD effects on these protein levels of PKA, PKC and pCREB in the LC and those in the hippocampus, frontal cortex and amygdala, their effects on PKA and PKC in the hippocampus, frontal cortex and amygdala were region-dependent. The present findings indicate a correlation between chronic stress and activation of the noradrenergic system. This correlation and CSD-induced alteration in signal transduction molecules may account for their critical effects on the development of symptoms of major depression.

http://olabout.wiley.com/WileyCDA/Section/id-820227.html / 京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第19590号 / 医博第4097号 / 新制||医||1014(附属図書館) / 32626 / 京都大学大学院医学研究科医学専攻 / (主査)教授 山田 亮, 教授 清水 章, 教授 小池 薫 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Binding parameters of soluble Type I and Type II receptors were assessed in hippocampus of adult, adrenalectomized, male and female rats. No sex differences in the number of either Type I or Type II receptors could be demonstrated between gonadally intact animals. When females treated with 17β-estradiol benzoate (10 μg/day) were compared with males, a statistically significant reduction in Type II receptors was observed in the females; progesterone produced no further decrease in receptor numbers. The amount of tissue-associated corticosteroid-binding globulin in gonadally intact animals (perfused with dextran-saline) was twice as great in females as males. Sex-dependent differences in these gonadally intact rats were found in the affinity, measured as the dissociation constant (Kd), of both the Type I and Type II receptors. For both receptors, affinity in cytosols from females was reduced. The difference for the Type II receptor was slight, but the Kd value of the type I receptor was several-fold higher in females. The difference in affinity was evident with both natural and synthetic steroid ligands. There appears to be little, if any, difference in affinity between the hippocampal Type I and the Type II receptors in females. This suggests that the occupancy of Type I receptors in females is substantially less than that of males at low circulating concentrations of corticosteroids.

Although glucocorticoids are often used as an adjunct to epinephrine to treat anaphylactic shock, glucocorticoids can also be a rare cause of anaphylactic shock. Only through the administration of a challenge dose of different glucocorticoids and different substrates that glucocorticoids are delivered in can the determination be made about which glucocorticoid or accompanying solvent may be the culprit which caused the anaphylactic reaction. These challenge tests should only be performed in a controlled environment as repeat anaphylaxis is a risk, especially if the patient has a history of glucocorticoid-induced anaphylaxis.

There were three objectives of this study. The first was to determine if commercially available fluorochromes could be used to determine the glucocorticoid receptor (GR) density and binding affinity (BA) in equine peripheral blood mononuclear cells. The second was to determine if there was a correlation between elevated plasma cortisol and GR density or binding affinity in healthy adult horses. The third objective was to evaluate the HPA axis in adult horses presenting with systemic inflammatory response syndrome (SIRS), and to determine where any alterations in HPA axis function occur in these patients compared to healthy adults. For the first part of the study, peripheral venous blood was collected from 3 healthy research horses on 3 days. Peripheral blood mononuclear cells were isolated using Ficoll gradient centrifugation. Phycoerythrin (PE)-CD44 was then used to extracellularly label leukocytes, and then an intracellular GR antibody was used to determine a baseline measurement of GR density and fluorescein isothiocyanate (FITC)-dexamethasone was used to determine binding affinity via flow cytometric analysis. Comparison of control samples to those for CD44, GR density, and GR binding affinity showed a statistically significant difference for all samples (P<0.0001, P<0.0001, and P<0.0001 respectively). This showed that the CD44, GR antibody, and FITC-dexamethasone could successfully be used to analyze equine peripheral blood mononuclear cells for GR activity. For the second part of the study, an ACTH stimulation test was performed on 8 healthy horses in order to induce an increase in endogenous cortisol production. Plasma cortisol levels, GR density, and GR binding affinity were measured at baseline, 4, 8, and 24 hours after treatment. Median basal cortisol concentration was 4.9, range 3.2-6.1 μg/dl. This initially increased following ACTH stimulation to 5.6, range 4.8-7.4 μg/dl, then showed a significant decrease by 8 hours post ACTH administration to 1.4, range 1.1-2.7 μg/dl (P=0.0221). No correlation was observed between plasma cortisol concentration in healthy horses and GR density or binding affinity (r=-0.145, P=0.428 and r=0.046, P=0.802, respectively). For the third phase of the study, horses (N=10) with systemic inflammatory response syndrome (SIRS) were compared to healthy, age and sex matched controls (N=10) presenting for lameness evaluation or ophthalmologic examination. Blood was collected from SIRS cases and controls on presentation to the Equine Medical Center. A CBC, serum biochemistry, and serum ACTH and cortisol measurements were performed. GR density and binding affinity were also determined. Nonsurvivors had a significantly decreased GR binding affinity (P=0.008) and demonstrated a trend towards an increase in the ACTH:cortisol ratio. ROC analysis was performed for serum ACTH and cortisol concentrations, the ACTH:cortisol ratio, GR density and GR binding affinity, and triglycerides to determine cut-off values associated with nonsurvival. These were then used to analyze this population using Fischer's exact test to determine the odds ratio (OR) associated with nonsurvival for each variable. This revealed that a serum triglyceride concentration greater than 28.5 mg/dl was associated with nonsurvival (OR=117, 95% CI, 1.94-7060). The other variables were not found to be significantly associated with nonsurvival, although a Delta BA% of less than 35.79% was found to be closely associated with nonsurvival (OR=30.33, 95% CI, 0.96-960.5). Additionally, a significant negative correlation was detected between the plasma ACTH concentration and Delta BA% (r=-0.685, P=0.029) and the ACTH:cortisol ratio and the Delta BA% (r=-0.697, P=0.025). This study showed that nonsurviving horses with SIRS had a significantly decreased GR binding affinity compared to survivors, and a tendency toward an increase in their ACTH:cortisol ratios. This confirms that HPA axis dysfunction occurs in adult horses with SIRS as tissue resistance to glucocorticoids, and potentially relative adrenal insufficiency as well. These results suggest that there are horses with SIRS that might benefit from "physiologic" doses of synthetic glucocorticoids to complement their relative adrenal insufficiency in addition to their poor tissue sensitivity. Further research should focus on methods to more rapidly determine which horses might benefit from treatment with glucocorticoids on presentation, as well as to more accurately determine prognosis for survival. / Master of Science

Bakgrund: Subakromiell smärta är ett vanligt förekommande muskuloskeletalt besvär. Behandlingen består ofta av antingen styrketräning, kortisoninjektion eller en kombination av behandlingsformerna.  Syfte: Att undersöka effekten av kombinerad behandling (styrketräning och kortisoninjektion) jämfört med enbart styrketräning som behandling för subakromiell smärta samt att utföra en kvalitetsgranskning och en bedömning av den sammanvägda tillförlitligheten. Metod: En systematisk litteraturöversikt utifrån formulerat PICO. Systematiska sökningar utfördes i databaserna AMED, CINAHL, PEDro, PubMed och Web of Science. Genomförande av kvalitetsgranskning enligt granskningsmallen PEDro och bedömning av den sammanvägda tillförlitligheten enligt ”Bedömning av den sammanvägda tillförlitligheten i systematiska översikter”. Resultat: Motstridiga resultat visades gällande effekten av kombinerad behandling. Totalt 8 studier inkluderades till kvalitetsgranskningen där resultatet varierade från medel till hög kvalitet. Av dessa bedömdes den sammanvägda tillförlitligheten i 6 studier. För funktion var den måttligt hög till att ingen effekt kan ses av interventionen. För smärta och rörelseomfång var tillförlitligheten låg respektive mycket låg till att effekt ses av interventionen. Konklusion: Det har inte varit möjligt att fastslå vilken effekt en kombinerad behandling jämfört med styrketräning har på smärta, funktion och rörelseomfång på kort sikt då resultaten har varit motstridiga. Inga långsiktiga effekter har observerats. Tillförlitligheten för funktion var måttligt hög till att ingen effekt ses av interventionen. För smärta bedömdes den som låg och för rörelseomfång som mycket låg till att effekt ses av interventionen. Framtida forskning bör fokusera på att utföra studier med mer likvärdiga interventioner för att kunna utvärdera effekten av kombinerad behandling jämfört med styrketräning för personer med subakromiell smärta. / Background: Subacromial pain syndrome is a common musculoskeletal condition. The treatment consists of either physiotherapy, corticosteroid injection or a combination of the two. Objective: To research the effects of a combined treatment compared to exclusively resistance training in individuals with subacromial pain syndrome and to assess the quality of the evidence as well as the overall reliability.  Method: A systematic review. Systematic searches were conducted using the databases AMED, CINAHL, PEDro, PubMed and Web of Science. The quality of the evidence was assessed using the PEDro scale. The overall reliability was assessed using “Bedömningen av den sammanvägda tillförlitligheten i systematiska översikter”.  Results: Contradictory results were found regarding the effect of combined treatment. A total of 8 studies were included in the quality assessment, with results varying from moderate to high quality. Of these, the overall reliability was assessed in 6 studies. The reliability for the outcome measure of function was assessed as moderately high that no effect of the intervention could be observed. Effects from the intervention on pain and range of motion were found to have low and very low reliability, respectively.  Conclusion: It has not been possible to determine the effect of combined treatment compared to resistance training on pain, function and range of motion in the short term, as the results have been conflicting. No long term effects have been observed. Overall reliability for the outcome measure of function was assessed as moderately high that no effect could be seen from the intervention. Effects on pain and range of motion from the intervention were found to have low and very low reliability, respectively. Future research should focus on conducting studies with more comparable interventions to evaluate the effect of combined treatment compared to resistance training for individuals with subacromial pain.