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Contextualização: As complicações agudas do diabetes, embora em grande parte evitáveis, apresentavam considerável mortalidade em diversas localidades do mundo no século passado. No Brasil, a organização do Sistema Único de Saúde pode ter resultado em importante queda na mortalidade por esta causa. Objetivos: Descrever a mortalidade por complicações agudas do diabetes no Brasil entre 1991 e 2010. Métodos: Os óbitos declarados no Sistema de Informações sobre Mortalidade por complicações agudas do diabetes (CID-9 249 e 250, seguidos pelos dígitos 1, 2 ou 3, e CID-10 E10 a E14, seguidos pelos dígitos 0 ou 1) foram corrigidos para causas mal definidas e sub-registro. A partir da população obtida do Instituto Brasileiro de Geografia e Estatística, foram calculadas taxas de mortalidade padronizadas de acordo com a população mundial. Correlações lineares foram realizadas para descrever a relação entre mortalidade e idade, e regressões Joinpoint foram utilizadas para descrever tendências. Resultados: Houve queda de 70,9% na mortalidade por complicações agudas do diabetes no Brasil entre 1991 e 2010, de 8,42 para 2,45 óbitos por 100.000 habitantes. A redução ocorreu em ambos os sexos, todas as faixas etárias, todas as regiões e quase todas as unidades federativas. O declínio foi menor nos últimos anos, quando as taxas já estavam bem mais baixas. A mortalidade aumentou exponencialmente com a idade e foi maior nas regiões Norte e Nordeste. Conclusões: A marcante redução na mortalidade por complicações agudas do diabetes no Brasil nas últimas duas décadas indica que a cobertura ampla e gratuita adotada pelo sistema nacional de saúde do Brasil, com disponibilização de insulina e organização do cuidado, foi capaz de reduzir substancialmente as complicações agudas dessa doença. Entretanto, considerando especialmente as iniquidades regionais existentes, ainda há espaço para redução na mortalidade por essas complicações no Brasil. / Background: Acute complications of diabetes, though largely preventable, presented considerable mortality in various locations around the world in the 20th Century. In Brazil, the organization of the national health system may have resulted in an important decline in this cause of mortality. Objectives: To describe mortality rates from acute complications of diabetes in Brazil from 1991 to 2010. Methods: The deaths reported in the Mortality Information System for acute complications of diabetes (ICD-9 249 and 250, followed by the digits 1, 2 or 3, and ICD-10 E10 to E14, followed by the digits 0 or 1) were corrected for ill-defined and under-reporting. Using the population obtained from national censuses, we calculated mortality rates standardized to the world population. Linear correlations were performed to describe the relationship between mortality and age, and Joinpoint regressions were used to characterize trends. Results: Mortality from acute complications of diabetes decreased 70.9%, from 8.42 to 2.45 deaths / 100000 inhabitants, in Brazil from 1991 to 2010. The reduction occurred in both sexes, all ages, all regions and almost all states. The decline was less marked in recent years. Mortality rates increased exponentially with age and were higher in the North and Northeast regions. Conclusions: The marked reduction in mortality from acute complications of diabetes in Brazil over the last two decades suggests that the universal coverage adopted by the national health system of Brazil, provided without charge and in an increasingly organized fashion, coupled with greater availability of insulin, was able to substantially reduce deaths due to the acute complications of diabetes. However, especially considering regional inequities, much room still exists for further reduction in mortality from these complications in Brazil.

Contextualização: As complicações agudas do diabetes, embora em grande parte evitáveis, apresentavam considerável mortalidade em diversas localidades do mundo no século passado. No Brasil, a organização do Sistema Único de Saúde pode ter resultado em importante queda na mortalidade por esta causa. Objetivos: Descrever a mortalidade por complicações agudas do diabetes no Brasil entre 1991 e 2010. Métodos: Os óbitos declarados no Sistema de Informações sobre Mortalidade por complicações agudas do diabetes (CID-9 249 e 250, seguidos pelos dígitos 1, 2 ou 3, e CID-10 E10 a E14, seguidos pelos dígitos 0 ou 1) foram corrigidos para causas mal definidas e sub-registro. A partir da população obtida do Instituto Brasileiro de Geografia e Estatística, foram calculadas taxas de mortalidade padronizadas de acordo com a população mundial. Correlações lineares foram realizadas para descrever a relação entre mortalidade e idade, e regressões Joinpoint foram utilizadas para descrever tendências. Resultados: Houve queda de 70,9% na mortalidade por complicações agudas do diabetes no Brasil entre 1991 e 2010, de 8,42 para 2,45 óbitos por 100.000 habitantes. A redução ocorreu em ambos os sexos, todas as faixas etárias, todas as regiões e quase todas as unidades federativas. O declínio foi menor nos últimos anos, quando as taxas já estavam bem mais baixas. A mortalidade aumentou exponencialmente com a idade e foi maior nas regiões Norte e Nordeste. Conclusões: A marcante redução na mortalidade por complicações agudas do diabetes no Brasil nas últimas duas décadas indica que a cobertura ampla e gratuita adotada pelo sistema nacional de saúde do Brasil, com disponibilização de insulina e organização do cuidado, foi capaz de reduzir substancialmente as complicações agudas dessa doença. Entretanto, considerando especialmente as iniquidades regionais existentes, ainda há espaço para redução na mortalidade por essas complicações no Brasil. / Background: Acute complications of diabetes, though largely preventable, presented considerable mortality in various locations around the world in the 20th Century. In Brazil, the organization of the national health system may have resulted in an important decline in this cause of mortality. Objectives: To describe mortality rates from acute complications of diabetes in Brazil from 1991 to 2010. Methods: The deaths reported in the Mortality Information System for acute complications of diabetes (ICD-9 249 and 250, followed by the digits 1, 2 or 3, and ICD-10 E10 to E14, followed by the digits 0 or 1) were corrected for ill-defined and under-reporting. Using the population obtained from national censuses, we calculated mortality rates standardized to the world population. Linear correlations were performed to describe the relationship between mortality and age, and Joinpoint regressions were used to characterize trends. Results: Mortality from acute complications of diabetes decreased 70.9%, from 8.42 to 2.45 deaths / 100000 inhabitants, in Brazil from 1991 to 2010. The reduction occurred in both sexes, all ages, all regions and almost all states. The decline was less marked in recent years. Mortality rates increased exponentially with age and were higher in the North and Northeast regions. Conclusions: The marked reduction in mortality from acute complications of diabetes in Brazil over the last two decades suggests that the universal coverage adopted by the national health system of Brazil, provided without charge and in an increasingly organized fashion, coupled with greater availability of insulin, was able to substantially reduce deaths due to the acute complications of diabetes. However, especially considering regional inequities, much room still exists for further reduction in mortality from these complications in Brazil.

Les accidents sont la cause la plus fréquente de décès chez l’enfant, la plupart du temps à cause d’un traumatisme cranio-cérébrale (TCC) sévère ou d’un choc hémorragique. Malgré cela, la prise en charge de ces patients est souvent basée sur la littérature adulte. Le mannitol et le salin hypertonique (3%) sont des traitements standards dans la gestion de l’hypertension intracrânienne, mais il existe très peu d’évidence sur leur utilité en pédiatrie. Nous avons entrepris une revue rétrospective des traumatismes crâniens sévères admis dans les sept dernières années, pour décrire l’utilisation de ces agents hyperosmolaires et leurs effets sur la pression intracrânienne. Nous avons établi que le salin hypertonique est plus fréquemment utilisé que le mannitol, qu’il ne semble pas y avoir de facteurs associés à l’utilisation de l’un ou l’autre, et que l’effet sur la pression intracrânienne est difficile à évaluer en raison de multiples co-interventions. Il faudra mettre en place un protocole de gestion du patient avec TCC sévère avant d’entreprendre des études prospectives. La transfusion sanguine est employée de façon courante dans la prise en charge du patient traumatisé. De nombreuses études soulignent les effets néfastes des transfusions sanguines suggérant des seuils transfusionnels plus restrictifs. Malgré cela, il n’y a pas de données sur les transfusions chez l’enfant atteint de traumatismes graves. Nous avons donc entrepris une analyse post-hoc d’une grosse étude prospective multicentrique sur les pratiques transfusionnelles des enfants traumatisés. Nous avons conclu que les enfants traumatisés sont transfusés de manière importante avant et après l’admission aux soins intensifs. Un jeune âge, un PELOD élevé et le recours à la ventilation mécanique sont des facteurs associés à recevoir une transfusion sanguine aux soins intensifs. Le facteur le plus prédicteur, demeure le fait de recevoir une transfusion avant l’admission aux soins, élément qui suggère probablement un saignement continu. Il demeure qu’une étude prospective spécifique des patients traumatisés doit être effectuée pour évaluer si une prise en charge basée sur un seuil transfusionnel restrictif serait sécuritaire dans cette population. / Trauma is the leading cause of death of children, with the burden of mortality related both to traumatic brain injury and hemorrhagic shock. Despite the frequency of trauma in the pediatric population, the management of these patients is often based on adult literature due the sparse amount of literature in pediatric trauma. The studies presented below were intended to establish current practice, and prepare for future prospective studies in pediatric trauma. The management of raised intracranial pressure (ICP) following traumatic brain injury (TBI) involves intracranial monitoring and the escalation of care to prevent secondary insults to the brain. Hyperosmolar therapy with mannitol (20%) and hypertonic saline (3%) are standard of care for the reduction of ICP, despite little evidence for their use. Our retrospective, single center study aimed to describe the clinical practice of hyperosmolar therapy in pediatric severe TBI, and its effect on ICP. We found that both mannitol and hypertonic saline are frequently used without a clear indication for one agent over another. There was insufficient power to confirm an effect on ICP, and multiple co-interventions given after boluses of hyperosmolar therapy may have contributed this lack of effect. In order to prospectively evaluate the effect of hyperosmolar therapy on ICP, a standardized approach to TBI care and hyperosmolar agents is necessary. Red blood cell transfusion is a key component of the management of the unstable trauma patient. Literature now suggests that transfusion is associated with increased mortality, and practices have shifted toward restrictive transfusion strategies in many clinical populations. We sought to describe the transfusion practices in pediatric trauma patients based on a secondary analysis of a large prospective study on blood loss in pediatric intensive care unit (PICU) patients. Compared to non-trauma patients, trauma patients were more likely to be transfused and transfused early in their course of stay. Younger age, higher PELOD and mechanical ventilation were associated with receiving a red blood cell transfusion in the PICU. Receiving a blood transfusion prior to PICU admission was most strongly associated with receiving a transfusion after PICU admission, suggesting ongoing bleeding in those transfused early. Future prospective studies geared specifically for trauma patients are necessary to determine whether osmotherapy for high ICP, and restrictive transfusion strategies can be applied to them, in order to improve the quality of the evidence based care provided to children.

Στην παρούσα διπλωματική εργασία έγινε εφαρμογή της Στερικής Μονοφασικής Χρωματογραφίας Χρωματογραφίας βαρυτικού Πεδίου (Μ.Χ.Β.Π.), στη μελέτη της επίδρασης της θερμοκρασίας και του pH, στην καταλυτική δραστικότητα εμπορικών στελεχών ζύμης Saccharomyces Cerevisiae. Η τεχνική αυτή είναι απλή, αλλά ευρέως διαδεδομένη τα τελευταία χρόνια, κυρίως για τον προσδιορισμό μεγέθους διαφόρων μορίων και σωματιδίων. Σε αντίθεση με την κλασική χρωματογραφία, στην οποία είναι απαραίτητη η ύπαρξη στατικής φάσης για να επιτευχθεί ο διαχωρισμός των σωματιδίων, στην μονοφασική χρωματογραφία ο διαχωρισμός επιτυγχάνεται με την εφαρμογή κάποιου εξωτερικού πεδίου, που στην προκειμένη περίπτωση είναι το βαρυτικό πεδίο. Η τεχνική αυτή έχει μεγάλο εύρος εφαρμογών, όπως στο διαχωρισμό κολλοειδών σωματιδίων, σωματιδίων αμύλου, κυττάρων ζυμών, καθώς και στην ανάλυση ουσιών με περιβαλλοντικό και φαρμακευτικό ενδιαφέρον. Στην κανονική Μ.Χ.Π όσο μεγαλύτερη μάζα έχουν τα σωματίδια, τόσο πιο αργά θα εκλούονται από την στήλη. Μετά όμως από ένα κρίσιμο όριο η ισορροπία αυτή αντιστρέφεται και τα μεγαλύτερα σωματίδια εκλούονται πρώτα. Σε αυτό το σημείο αρχίζει η εφαρμογή της στερικής Μ.Χ.Β.Π. Ανάλογα με το είδος των κυττάρων που θέλουμε να διαχωρίσουμε καθορίζεται και το εξωτερικό πεδίο που θα εφαρμόσουμε. Με αποτέλεσμα να προκύπτουν και τα διαφορετικά ήδη της μονοφασικής χρωματογραφίας. Στην παρούσα εργασία η Μ.Χ.Β.Π χρησιμοποιήθηκε για την μελέτη και τον χαρακτηρισμό κυττάρων ζύμης, αλλά και για τη συγκριτική μελέτη πάνω στον χρόνο ζύμωσης αλλά και τρόπο ανάπτυξης τους σε θρεπτικά διαλύματα διαφορετικών θερμοκρασιών και pH. Στην παρούσα εργασία χρησιμοποιήθηκαν τα στελέχη Zymaflore F-10 και Zymaflore X-5 της ζύμης Saccharomyces cerevisiae. Οι θερμοκρασίες οι οποίες μελετήθηκαν είναι οι 15οC, 20οC, 25 οC και 30 οC , ενώ οι τιμές pH είναι 3,0 , 4,0 , 5,0 και 6,0. Με βάση τα πειραματικά αποτελέσματα καταλήξαμε στο συμπέρασμα ότι τα κύτταρα Zymaflore X-5 παρουσιάζουν μικρότερους χρόνους ζύμωσης σε όλες τις τιμές pH και θερμοκρασίας, σε σχέση με τα κύτταρα Zymaflore F-10. Επίσης, βρέθηκε ότι το βέλτιστο pH και για τα δύο στελέχη είναι το pH 5,0, το οποίο είναι και το pH του θρεπτικού, ενώ η βέλτιστη θερμοκρασία ζύμωσης είναι αυτή των 30 οC / In this study the analytical technique of Gravitational Field- Flow Fractionation (Gr-FFF), which is a type of Field Flow Fractionation ( F.F.F. ), was used for the study of the influence of the temperature and pH on the catalytic activity of varying commercial yeast strains of Saccharomyces Cerevisiae. It is a relatively new, simple, low cost and high accuracy technique, which allows the separation of samples according to their size. The F.F.F. technique has been applied for the separation and characterization of colloids, such as yeast cells, proteins, starch granules, polymers, etc. In F.F.F. the separation take place by applying an external field. According to the type of external field which is used for the separation, the different types of the F.F.F. are result. The Gg.F.F.F. separates the particles based on their mass. When the separation takes part in particles of the same chemical composition, which have the same density, the separation is based to their size. In normal F.F.F. the bigger particles take more time to elute, although under a critical size the separation overbalanced and bigger particles do not react to the external force, so they eluted first from the column. This type of F.F.F. is called steric F.F.F, and is the type of FFF we used in the present study The aim of this study was the separation, categorize and the distinction of the phases of yeast cells, during the alcoholic fermentation at different pH and temperature values. The yeast we study, were the Zymaflore F-10 and Zymaflore X-5, two different parts of Saccharomyces Cerevisiae yeast. The pH scale was 3,0 , 4,0, 5,0 and 6,0 and the temperatures were 15οC, 20οC, 25 οC and 30 οC. From the experimental results we concluded that Zymaflore X-5 cells, have the ability to complete the fermentation process, in smaller time periods at all pH and temperature values compared with Zymaflore F-10 cells. Also, we concluded that the optimum pH value for both strains is pH 5,0 , which is the pH of the medium, while the optimum fermentation temperature is 30 ° C