Alterações macro e microvasculares ocorrem no Diabetes Mellitus (DM). A Retinopatia Diabética (RD) é uma complicação bem prevalente do DM e resulta de microangiopatia generalizada no tecido retiniano que, em diferentes estágios da doença, se observa como edema local, exsudatos, formação de neovasos e hemorragias, sendo a principal causa de cegueira na faixa etária de 20 a 74 anos. Alguns fatores angiogênicos são apontados como possíveis mediadores no desenvolvimento das alterações microvasculares no DM. Dentre eles, a Eritropoietina (EPO), hormônio glicoproteico, possui expressão mediada por alelos específicos do gene EPO. Determinados perfis genéticos para três SNPs-single nucleotide polymorphisms do gene EPO (rs1617640, rs507392, rs551238) encontram-se associados com maiores concentrações de EPO no humor vítreo de pacientes diabéticos com RD, o que pode ser indicativo da relação entre determinado genótipo de risco (TTA) e o desenvolvimento de tal comorbidade. O presente trabalho pretendeu investigar a associação entre o genótipo considerado de risco para o desenvolvimento de RD e alterações funcionais na visão de cores de pessoas com diagnóstico de DM. Tal estudo contou com uma amostra de 95 diabéticos (49 mulheres e 46 homens, média de idade: 48,33 anos; DP: 16,90), com um total de 31 DM tipo 1 e 64 tipo 2 e 114 controles (73 mulheres e 41 homens, média de idade: 38,38 anos; DP: 12,81). Foi realizada avaliação através de teste psicofísico (Cambridge Colour Test CCT), que visou medir o limiar de discriminação nos três eixos de confusão de cores e sequenciamento genético, a partir de amostras de sangue. Para os diabéticos, no eixo de confusão protan, os resultados mostraram uma piora de desempenho para o genótipo TTA/GCC (p= 0,048), com relação aos controles. No eixo de confusão deutan, não houve diferença para qualquer dos genótipos (p= 0,0207), enquanto que para o eixo tritan, o genótipo TTA/GCC esteve associado a uma piora de desempenho (p=0,014). Para os controles, não houve diferença entre os genótipos. Assim, os resultados mostraram uma piora na visão de cores de pacientes DM, associada ao haplótipo TTA/GCC / Diabetic Retinopathy (DR), a prevalent complication of diabetes, is the leading cause of blindness among those aged 20-74 years. Micro and macrovascular changes occur in Diabetes Mellitus (DM) with DR being the most common among these vascular complications, resulting in generalized retinal microgangiopathy. At different stages of the disease, localized edema, exudates and hemorrhages occur. Several pro-angiogenic factors have been suggested as possible mediators in the development of these microvascular changes. Among them is erythropoietin (EPO), a glycoprotein hormone whose expression is mediated by specific alleles of the EPO gene. Specific genetic profiles for three single nucleotide polymorphisms (SNPs) in the EPO gene (rs1617640, rs507392, rs551238) are associated with larger EPO concentrations in the vitreous humor of diabetic patients with RD. This association indicates a possible relationship between the identified genotypes (TTA) and the comorbidity´s development. This work aimed to investigate the association between genotypes considered at risk for the development of DR and functional changes in color vision among individuals diagnosed with DM. Thus, this study included a sample of 95 diabetic patients (49 women and 46 men, average age: 48.33 years; SD: 16.90), with a total of 31 DM type 1 and 64 type 2 and 114 controls (73 women and 41 men, average age: 38.38 years; SD: 12.81). Evaluation was performed using a psychophysical test (Cambridge Colour Test -CCT), to measure the discrimination threshold in three-color confusion axes in addition to genetic sequencing. In the protan axis of confusion color, performance among diabetics with the TTA/GCC genotype was significantly lower (p=0.048) than those in the control group. The results showed a poorer performance among those with the TTA / GCC genotype (p = 0.048), compared to controls. In deutan axis confusion, there was no difference among any of the genotypes (p = 0.0207), while for the tritan axis, the TTA / GCC genotype was associated with a poorer performance (p = 0.014). For the controls, there was no difference between genotypes. Thus, the results showed a worsening in color vision among DM patients associated with TTA / GCC haplotype

O objetivo geral deste estudo foi investigar o efeito do leite humano na redução de respostas biocomportamentais de dor em RNPTs submetidos ao exame de fundo de olho para diagnóstico precoce da retinopatia da prematuridade, em comparação com a sacarose 25%. Trata-se de ensaio clínico randomizado, realizado na unidade neonatal de um hospital universitário de Ribeirão Preto-SP, com 48 prematuros distribuídos randomicamente em dois grupos: leite humano e sacarose, administrados por via oral 2 minutos antes do procedimento doloroso. As variáveis dimensionadas foram mímica facial da escala de dor NFCS, choro, frequência cardíaca e cortisol salivar. A coleta de dados foi realizada em cinco períodos para a mímica facial e o NFCS: basal (05 minutos), olho direito e olho esquerdo, recuperação imediata (05 minutos após o procedimento) e recuperação tardia (05 minutos após a recuperação imediata); quatro períodos para a frequência cardíaca e o choro: basal (05 minutos), procedimento, recuperação imediata e tardia. O cortisol salivar foi coletado antes do início do exame de fundo de olho (basal), após 30 (cortisol resposta) e 60 (cortisol recuperação) minutos do término do exame. O projeto foi aprovado pelo Comitê de Ética em Pesquisa da instituição e foi registrado no Australian and New Zeland Clinical Trials. O Teste de Kolmogorov-Smirnov e o Teste t-student mostraram que os grupos são comparáveis. Para análise das variáveis de desfecho, utilizou-se a Análise de Variância com Medidas Repetidas (RM-ANOVA). Após testar a homogeneidade das variáveis (teste de Levene), foi avaliado o pressuposto da esfericidade das matrizes de variância (teste de Mauchly). Assumindo-se a esfericidade, adotaram-se a análise multivariada, com valor de épsilon < 0,75, e a estatística de Wilk´s Lambda. Para valores de épsilon > 0,75, adotaram-se a análise univariada e a estatística de Hunh-Feldt (HF) ou Greenhouse-Geisser. Para as variáveis categóricas, foi utilizado o teste Qui-quadrado ou Teste exato Fisher. O efeito do leite humano no alívio da dor, decorrente do exame de fundo de olho, não diferiu estatisticamente da sacarose 25%, ao avaliarmos a duração da presença de fronte saliente [Wilk\'s Lamba=0,918, F=0,960, p=0,241], do sulco nasolabial [Wilk\'s Lambda=0,883; F=1,43; p=0,241] e do choro [Wilk\'s Lambda=0,964; F=3,44; p=0,656], e o escore médio do NFCS adaptado ao considerarmos essas duas ações da mímica facial [Wilk\'s Lambda=0,924; F=0,884; p=0,481], a FC [Wilk\'s Lambda=0,977; F=3,44; p=0,792] e a concentração de cortisol salivar [Wilk\'s Lambda=0,978; F=2,45; p=0,612]. A comparação intrasujeitos mostrou diferença significativa nos períodos de coleta dos dados, com aumento nos escores do NFCS, na duração da fronte saliente e do sulco nasolabial, durante o exame do fundo de olho direito e esquerdo, como também no aumento do choro, durante o procedimento doloroso, em comparação com os períodos basal, recuperação inicial e tardia. A concentração do cortisol salivar aumentou significativamente aos 30 e 60 minutos após o procedimento, em comparação com os valores do cortisol basal; não houve diferença entre o cortisol resposta (30 minutos) e recuperação (60 minutos). A duração do sulco nasolabial, do choro e os escores do NFCS no basal não diferiram significativamente dos valores encontrados na recuperação inicial e tardia. Na FC, houve diferença no basal em relação à recuperação imediata, e na duração da fronte saliente houve diferença nas duas recuperações. Concluímos que o efeito do leite humano, na redução das respostas biocomportamentais de dor em prematuros submetidos ao exame de fundo de olho para diagnóstico da retinopatia da prematuridade, não é superior ao efeito obtido com a sacarose 25%, rejeitando-se a hipótese alternativa. / The general aim of this study was to investigate the effect of human milk on reducing biobehavioral pain responses in PN\'s undergoing the ocular fundus examination for the early diagnosis of retinopathy of prematurity, compared with 25% sucrose. This is a randomized clinical trial conducted in the neonatal unit of a university hospital of Ribeirão Preto-SP, with 48 premature newborns randomly distributed into two groups: human milk and sucrose, orally administered 2 minutes before the painful procedure. The variables investigated were the facial movements of the NFCS pain scale, crying, heart rate (HR) and salivary cortisol levels. Data collection was conducted in five periods for the facial movements and NFCS: baseline (05 minutes), right eye and left eye, immediate recovery (05 minutes after the procedure) and delayed recovery (05 minutes after immediate recovery); and in four periods for heart rate and crying: baseline (05 minutes), procedure, immediate and delayed recovery. Salivary cortisol was collected before the start of the fundus examination (baseline), and at 30 minutes (cortisol response) and 60 minutes (cortisol recovery) after the end of the examination. The project was approved by the Research Ethics Committee and was registered in the Australian and New Zealand Clinical Trials. The Kolmogorov-Smirnov test and Student\'s t-test showed that the groups were comparable. For the analysis of the outcome variables, the Analysis of Variance with Repeated Measures (RM-ANOVA) was used. After testing the homogeneity of the variables (Levene\'s test) the assumption of sphericity of the variance matrices was evaluated (Mauchly\'s test). Assuming sphericity, multivariate analysis was adopted, with a < 0.75 value of epsilon and Wilk\'s Lambda statistic. For values of epsilon > 0.75, univariate analysis and the Hunh-Feldt (HF) or Greenhouse-Geisser statistic were adopted. For the categorical variables, the chi-square test or Fisher exact test was used. The effect of human milk on pain relief, arising from the ocular fundus examination, did not differ statistically from 25% sucrose, when the duration of the presence of brow lowering [Wilk\'s Lambda=0.918; F=0.960; p=0.241], of deepening of the naso-labial furrow [Wilk\'s Lambda=0.883; F=1.43; p=0.241] and of crying [Wilk\'s Lambda=0.964; F=3.44; p=0.656] were evaluated, as well as the mean score of the NFCS adapted to consider these two facial movement actions [Wilk\'s Lambda=0.924; F=0.884; p=0.481], the HR [Wilk\'s Lambda=0.977; F=3.44; p=0.792] and the salivary cortisol concentration [Wilk\'s Lambda=0.978; F=2.45; p=0.612]. The intra-subject comparison showed a significant difference in the data collection periods, with an increase in the NFCS scores, in the duration of brow lowering and naso-labial furrow deepening, during the examination fundus of the right and left eyes, as well as increased crying during the painful procedure, compared with the baseline period, immediate and delayed recovery. The concentration of salivary cortisol increased significantly at 30 and 60 minutes after the procedure, compared with the baseline cortisol values; there was no difference between cortisol response (30 minutes) and recovery (60 minutes). The duration of naso-labial furrow deepening, of crying and the NFCS scores at the baseline did not differ significantly from the values found in the immediate and delayed recovery. In the HR, there was no difference between the baseline and the immediate recovery, and in the duration of brow lowering there was no difference in the two recoveries. We conclude that the effect of human milk, on the reduction of biobehavioral responses to pain in preterm infants undergoing the ocular fundus examination for the diagnosis of retinopathy of prematurity, is not greater than the effect obtained with 25% sucrose, rejecting the alternative hypothesis.

Retinal hypoxia is associated with many retinal diseases, such as diabetic retinopathy. Current retinal research suggests that retinal hypoxia appears prior to the onset of diabetic retinopathy. The preliminary association of retinal hypoxia to the early stages of diabetic retinopathy is stimulating the development of new technologies to measure the oxygen content of retinal tissue. Frequency domain phosphoresence lifetime imaging (PLI) is a promising technology that enables the mapping of the oxygen content across the entire retina in the form of two-dimensional images. The two-dimensional images generated from the PLI process are a spatial mapping of the retinal tissue's oxygen tension. Currently, the phosphorescent based oxygen tension PLI measurements contain contaminating auto-fluorescent signals in addition to the desired phosphorescent signals. These auto-fluorescent signals artificially inflate the oxygen tension readings due to the nature of fluorescent signals in phosphorescent imaging. Additionally, the maps generated through PLI appear to contain oxygen tension information from both the retinal vasculature and the choroidal vasculature. The choroidal vasculature is situated directly behind the retina and can have a different oxygen tension value than the retinal vasculature. This research enhanced the PLI system by mathematically eliminating the contaminating auto-fluorescent signals and investigated the methods aimed at separating the PO2s of the retinal and choroidal vasculature beds. In addition, the application of the enhanced PLI technology to the investigation of retinal oxygen changes in a rat model of type I diabetes yielded results that suggest a hyperoxic to hypoxic trend prior to the onset of diabetic retinopathy.

Dans les pays industrialisés, les pathologies oculaires à composante vasculaires, que ce soit la rétinopathie du prématuré (ROP), la rétinopathie du diabétique ou la dégénérescence lié à l’âge, représentent la première cause de cécité respectivement chez l’enfant, l’adulte et la personne âgée. Plusieurs études sur l’homme ou sur des modèles animaux ont souligné le rôle crucial joué des acides gras polyinsaturés (AGPI) au cours de ces rétinopathies et notamment l’action préventive des acides gras polyinsaturés oméga 3 (AGPI n-3) sur l’angiogenèse pathologique. Ces AGPI sont estérifiés dans les glycérophospholipides constituant les membranes cellulaires. On les retrouve également dans une classe particulière de glycérophospholipides, les plasmalogènes. La particularité des plasmalogènes réside dans leur liaison vinyl-éther en position sn-1 au lieu d’une liaison ester dans les autres glycérophospholipides. Les AGPI sont libérés des plasmalogènes par une phospholipase indépendante au calcium, la iPLA2, pour devenir des métabolites actifs. Les plasmalogènes via la libération des AGPI joueraient un rôle dans la mise en place et la maturation du réseau vasculaire rétinien et ce, notamment grâce à la bonne mise en place du réseau astrocytaire. Les astrocytes et les cellules de Müller sont les cellules macrogliales qui servent de soutien physique et métabolique à la rétine. De plus, les cellules de Müller participent au métabolisme des lipides. L’objectif de ce travail de thèse a été d’évaluer l’implication des plasmalogènes dans le métabolisme des cellules de Müller et des astrocytes mais aussi dans la communication entre ces cellules macrogliales. Nous avons également étudié le profil lipidique d’enfants prématurés pour mettre en évidence de potentielles altérations du métabolisme des plasmalogènes chez des nouveau-nés développant une rétinopathie à composante vasculaire, la rétinopathie du prématuré (ROP). Pour ce faire nous avons étudié les effets d’une diminution en plasmalogènes et/ou en iPLA2 sur des cellules de Müller en culture primaire après avoir préalablement vérifié l’expression de l’enzyme clef de la biosynthèse des plasmalogènes. Nous avons ensuite étudié les effets d’une diminution des teneurs en plasmalogènes sur la communication calcique entre les cellules de Müller et les astrocytes. Nos résultats ont montré que les cellules de Müller expriment l’enzyme-clé de synthèse des plasmalogènes et que ces cellules sont plus riches en plasmalogènes que la rétine entière. Les plasmalogènes seraient impliqués dans le contrôle de la migration des cellules de Müller par l’action de la voie ERK1/2 MAPK. Ces effets ne semblent pas passer par la libération des AGPI. De plus nos résultats suggèrent une dégradation de la communication entre les astrocytes et les cellules de Müller en cas de diminution des teneurs en plasmalogènes dans les cellules de Müller. Enfin chez l’homme nous avons mis en évidence une accumulation des AGPI n-6 au détriment des AGPI n-3 dans les érythrocytes des enfants développant une rétinopathie du prématuré et inversement dans le groupe d’enfants prématuré contrôle. L’ensemble de ces travaux confirme l’importance du métabolisme lipidique, et plus particulièrement celui des plasmalogènes, sur le fonctionnement de la rétine. / Retinal vascular disorders such as retinopathy of prematurity (ROP), diabetic retinopathy or age-related macular degeneration represent the first cause of vision loss at all ages in industrialized countries. Many epidemiological or animal studies have shown the involvement of polyunsaturated fatty acids (PUFA) in the regulation of vascular development and more specifically the beneficial properties of omega 3 PUFA (n-3 PUFA) against pathological vascularization. Those PUFA are esterified on glycerophospholipids (GP). GP are the primary constituents of the lipid bilayer of cell membranes. PUFA can be also esterified on a specific class of GP, called plasmalogens. Plasmalogens are characterized by the presence of a vinyl ether linkage at the sn-1 position of glycerol instead of an ester linkage as seen in other GP. PUFA are released from plasmalogens by a calcium-independent phospholipase (iPLA2). Free PUFA can be converted into biologically active metabolites. Plasmalogens may have an impact on the development and the maturation of retinal vascular network through the PUFA they release through the control of astrocyte template formation prior to vessel formation. Astrocytes and Müller cells are macroglials cells providing physical and metabolic supports to the retina. Müller cells are key actors of the retinal lipid metabolism. The aim of this work was to evaluate the involvement of plasmalogens in Müller cells and astrocytes metabolism as well as in the ability of these cells to communicate. On one hand, we have studied the effects of a decrease in plasmalogen biosynthesis and/or in iPLA2 activity on Müller cell physiology. Müller cells express a biosynthesis key enzyme of plasmalogen and reducing the biosynthesis of plasmalogens affects Müller cell ability to migrate through the ERK1/2 MAPK signalling. In a second series of studies, we studied the repercussions of such modifications on Müller cell physiology on their ability to communicate with retinal astrocytes through calcium signalling. Our results suggest that affecting plasmalogen metabolism in Müller cells alters the communication between astrocytes and Müller cells. Finally, and in order to investigate whether plasmalogen metabolism may be modified in a human disease displaying abnormal retinal vascular development, we performed a lipidomic study of circulating lipids in infants affected by retinopathy of prematurity. ROP was characterized by the accumulation of n-6 PUFA at the expense of n-3 PUFA, these changes being associated to plasmalogens. All these experiments confirm the importance of lipid metabolism, and especially plasmalogens, on the retina functioning.

Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2016-11-29T11:27:04Z No. of bitstreams: 1 Maurício Aguiar de Paula.pdf: 1738364 bytes, checksum: 310f918b6425fcb252dd0eefbda88d2c (MD5) / Made available in DSpace on 2016-11-29T11:27:04Z (GMT). No. of bitstreams: 1 Maurício Aguiar de Paula.pdf: 1738364 bytes, checksum: 310f918b6425fcb252dd0eefbda88d2c (MD5) Previous issue date: 2016-09-30 / Introduction: Diabetic retinopathy (DR), a frequent complication and one of the main preventable causes of blindness in Brazil and worldwide, it is asymptomatic in the early stages. The inappropriate metabolic and pressoric control is related to its onset and progression. Typically, diabetic patients seen in primary care of the Unified Health System (SUS) in Sorocaba and region are referred to the specialized service of ophthalmology (Ophthalmologic Hospital of Sorocaba - HOS) only when symptoms are already at an advanced stage of DR, which it requires ophthalmic intervention as laser or even surgery. For the accomplishment of these procedures is needed clinical setting that currently occurs in the primary care by generating counter-delay, low resolution and resulting social, economic and individual losses (even blindness). Objectives Create and offer multidisciplinary program of intensive clinical setting and diabetes education (DE) to patients with diabetic retinopathy (DR) treated at HOS; assess possible changes in the level of understanding and metabolic control of this population after attending the program; assess development in ophthalmologic table after the intervention referred to completion of the proposed procedures compared to similar people who did not undergo intervention; analyze the costs of treatment of DR forward the alternative of timely and intensive clinical setting, inserted in the specialized eye care process. Materials and Methods The program consisted of four individual medical care in consecutive weeks with support of groups of DE, with the aid of "Conversation Maps"™, in the first and third weeks. Therapeutic adjustments were based on clinical evaluation and structured blood glucose monitoring map analysis of seven measures of the three interleaved days preceding the next attendance. One group underwent clinical-educational intervention (n = 24) and another, control (n = 24) only assesseded the data obtained from medical records. Both had the same clinical characteristics. The intervention group was assessed before and after in terms of knowledge about DM, treatment adherence and attitudes in fighting the disease with appropriate questionnaires. It was compared the evolution of the ophthalmic conditions under the two groups on the achievement of specified procedures and costs involved in the activities of each clinical setting process: current (primary care) and proposed by the study. For economic analysis the activities of each clinical setting process were focused, defined its unit costs and compared alternatives through the cost-effective method. Results There were significant differences in the intervention group with improved of glycemic control, higher rate of accomplishment of scheduled procedures (96% vs. 48%; p = 0.00), lower performance time (1.2 month vs. 5 months) and better cost-effectiveness ratio. It proved to be a significant increase in knowledge about the disease, treatment adherence and improved attitude to the disease. Discussion Intensive clinical setting program with DE in support for patients with DR at an advanced stage offered in a specialized service as an alternative to currently practiced in primary care is more cost-effective, takes place in less time and can minimize personal losses, social and institutional arising from the development of DR related to inadequate clinical control / Introdução: A retinopatia diabética (RD), complicação frequente e uma das principais causas evitáveis de cegueira no Brasil e no mundo, é assintomática em estágios iniciais. O controle metabólico e pressórico inadequado está relacionado com sua instalação e progressão. Habitualmente, pacientes diabéticos atendidos na atenção primária em Sorocaba e região são encaminhados para o serviço especializado de oftalmologia (Hospital Oftalmológico de Sorocaba - HOS) apenas quando apresentam sintomas, já em estágio avançado da RD, o que exige intervenção oftalmológica, como o laser ou mesmo, cirurgia. Para a realização destes procedimentos há necessidade de ajuste clínico que, atualmente, ocorre na rede básica através de contrarreferência, gerando demora, baixa resolutividade e consequentes perdas sociais, econômicas e individuais (até cegueira). Objetivos Criar e oferecer programa multiprofissional de ajuste clínico intensivo e de educação em diabetes (ED) a pacientes com RD atendidos no HOS; avaliar possíveis mudanças no nível de entendimento e no controle metabólico desta população após a participação no programa; avaliar a evolução do quadro oftalmológico após a intervenção com relação a realização dos procedimentos propostos em comparação com população semelhante que não sofreu a intervenção; analisar os custos do tratamento da RD frente a alternativa de ajuste clínico oportuno e intensivo, inserido no processo de atendimento oftalmológico especializado. Material e Métodos O programa consistiu de quatro atendimentos médicos individuais em semanas consecutivas com suporte de ED, com auxílio de “Mapas de Conversação”™, na primeira e terceira semanas. Os ajustes terapêuticos basearam-se na avaliação clínica e análise da automonitorização glicêmica estruturada com sete medidas de três dias intercalados que antecediam o próximo atendimento. Um grupo sofreu intervenção clínico-educativa (n=24) e do outro, controle, (n=24) apenas avaliou-se os dados de prontuário. Ambos apresentavam as mesmas características clínicas. O grupo intervenção foi avaliado antes e após quanto ao conhecimento sobre DM, adesão ao tratamento e atitudes no enfrentamento da doença com questionários apropriados. Comparou-se a evolução do quadro oftalmológico nos dois grupos quanto à realização dos procedimentos indicados e custos envolvidos nas atividades de cada processo de ajuste clínico: o usual (da rede básica) e o proposto pelo estudo. Para a análise econômica foram mapeadas as atividades de cada processo de ajuste clínico, definidos seus custos unitários e comparadas as alternativas através do método de custoefetividade. Resultados Constatou-se diferença significante no grupo intervenção com melhora do controle glicêmico, maior taxa de realização de procedimentos agendados (96% vs 48%; p=0,00), menor tempo de realização (1,2 mês vs 5 meses) e melhor índice custo-efetividade. Comprovou-se incremento significante no conhecimento sobre a doença, adesão ao tratamento e na melhora da atitude frente à doença. Discussão Programa de ajuste clínico intensivo com suporte em ED para pacientes com RD em estágio avançado oferecido em serviço especializado como alternativa ao atualmente praticado na atenção primária tem melhor relação custo-efetividade, transcorre em menor tempo e pode minimizar as perdas pessoais, sociais e institucionais decorrentes da evolução da RD relacionada ao controle clínico inadequado

Submitted by Erika Demachki (erikademachki@gmail.com) on 2015-02-20T15:09:52Z No. of bitstreams: 2 Dissertação - Tatiana Vieira de Brito Marquez - 2010.pdf: 2722177 bytes, checksum: d3f571bcc9c3e44cf51b9d4539e6191d (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Erika Demachki (erikademachki@gmail.com) on 2015-02-20T15:10:12Z (GMT) No. of bitstreams: 2 Dissertação - Tatiana Vieira de Brito Marquez - 2010.pdf: 2722177 bytes, checksum: d3f571bcc9c3e44cf51b9d4539e6191d (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2015-02-20T15:10:12Z (GMT). No. of bitstreams: 2 Dissertação - Tatiana Vieira de Brito Marquez - 2010.pdf: 2722177 bytes, checksum: d3f571bcc9c3e44cf51b9d4539e6191d (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2010-07-06 / OBJECTIVES: To compare the response of bevacizumab and the response of the laser photocoagulation with indirect binocular ophthalmoscope (IBO) in infants with retinopathy of prematurity (ROP) stages II or III. METHODS: Data collection was performed in the neonatal intensive care unit of the Hospital Materno Infantil, from May to November 2009. Preterm infants with ROP stages II or III, with or without the plus disease were included. They were divided into two groups: on group I, an intra-vitreous injection of bevacizumab was performed and on group II, laser photocoagulation with IBO was performed. RESULTS: In group I, from the 20 eyes that underwent the application of bevacizumab, there was total regression of ROP with one application in 14 eyes, being 4 eyes with complete regression with two doses of bevacizumab, and 2 eyes with total regression after two applications of bevacizumab and one application of laser. On group II, from the 20 eyes treated with laser photocoagulation with IBO, there was total regression of ROP with laser therapy in 14 eyes and there was total regression with two laser sessions in 6 eyes. CONCLUSION: Bevacizumab is effective if compared to laser photocoagulation in ROP stages II and III. / OBJETIVOS: Comparar a resposta terapêutica do bevacizumabe intravítreo com à resposta da fotocoagulação a laser com oftalmoscópio binocular indireto, em prematuros portadores de retinopatia da prematuridade estágios II ou III. MÉTODOS: A coleta de dados foi realizada na UTI neonatal do Hospital Materno Infantil, no período de maio a novembro de 2009. Foram incluídos os prematuros com retinopatia da prematuridade graus II ou III, com ou sem doença plus. Estes foram divididos em dois grupos: no grupo I foi realizada a injeção intra-vitrea de bevacizumabe, no grupo II foi realizada a fotocoagulação a laser com oftalmoscópio binocular indireto. RESULTADOS: No grupo I, dos 20 olhos incluídos, houve regressão total da retinopatia da prematuridade com uma aplicação de bevacizumabe em 14 olhos, regressão total com duas aplicações em 4 olhos e regressão total após duas aplicações de bevacizumabe e uma aplicação de laser em 2 olhos. No grupo II, dos 20 olhos tratados com fotocoagulação a laser com oftalmoscópio binocular indireto, houve regressão total da retinopatia da prematuridade com uma sessão em 14 olhos e houve regressão total com duas sessões em 6 olhos. CONCLUSÃO: O bevacizumabe é tão eficiente quanto a fotocoagulação a laser na retinopatia da prematuridade nos estágios II e III.

Alterações macro e microvasculares ocorrem no Diabetes Mellitus (DM). A Retinopatia Diabética (RD) é uma complicação bem prevalente do DM e resulta de microangiopatia generalizada no tecido retiniano que, em diferentes estágios da doença, se observa como edema local, exsudatos, formação de neovasos e hemorragias, sendo a principal causa de cegueira na faixa etária de 20 a 74 anos. Alguns fatores angiogênicos são apontados como possíveis mediadores no desenvolvimento das alterações microvasculares no DM. Dentre eles, a Eritropoietina (EPO), hormônio glicoproteico, possui expressão mediada por alelos específicos do gene EPO. Determinados perfis genéticos para três SNPs-single nucleotide polymorphisms do gene EPO (rs1617640, rs507392, rs551238) encontram-se associados com maiores concentrações de EPO no humor vítreo de pacientes diabéticos com RD, o que pode ser indicativo da relação entre determinado genótipo de risco (TTA) e o desenvolvimento de tal comorbidade. O presente trabalho pretendeu investigar a associação entre o genótipo considerado de risco para o desenvolvimento de RD e alterações funcionais na visão de cores de pessoas com diagnóstico de DM. Tal estudo contou com uma amostra de 95 diabéticos (49 mulheres e 46 homens, média de idade: 48,33 anos; DP: 16,90), com um total de 31 DM tipo 1 e 64 tipo 2 e 114 controles (73 mulheres e 41 homens, média de idade: 38,38 anos; DP: 12,81). Foi realizada avaliação através de teste psicofísico (Cambridge Colour Test CCT), que visou medir o limiar de discriminação nos três eixos de confusão de cores e sequenciamento genético, a partir de amostras de sangue. Para os diabéticos, no eixo de confusão protan, os resultados mostraram uma piora de desempenho para o genótipo TTA/GCC (p= 0,048), com relação aos controles. No eixo de confusão deutan, não houve diferença para qualquer dos genótipos (p= 0,0207), enquanto que para o eixo tritan, o genótipo TTA/GCC esteve associado a uma piora de desempenho (p=0,014). Para os controles, não houve diferença entre os genótipos. Assim, os resultados mostraram uma piora na visão de cores de pacientes DM, associada ao haplótipo TTA/GCC / Diabetic Retinopathy (DR), a prevalent complication of diabetes, is the leading cause of blindness among those aged 20-74 years. Micro and macrovascular changes occur in Diabetes Mellitus (DM) with DR being the most common among these vascular complications, resulting in generalized retinal microgangiopathy. At different stages of the disease, localized edema, exudates and hemorrhages occur. Several pro-angiogenic factors have been suggested as possible mediators in the development of these microvascular changes. Among them is erythropoietin (EPO), a glycoprotein hormone whose expression is mediated by specific alleles of the EPO gene. Specific genetic profiles for three single nucleotide polymorphisms (SNPs) in the EPO gene (rs1617640, rs507392, rs551238) are associated with larger EPO concentrations in the vitreous humor of diabetic patients with RD. This association indicates a possible relationship between the identified genotypes (TTA) and the comorbidity´s development. This work aimed to investigate the association between genotypes considered at risk for the development of DR and functional changes in color vision among individuals diagnosed with DM. Thus, this study included a sample of 95 diabetic patients (49 women and 46 men, average age: 48.33 years; SD: 16.90), with a total of 31 DM type 1 and 64 type 2 and 114 controls (73 women and 41 men, average age: 38.38 years; SD: 12.81). Evaluation was performed using a psychophysical test (Cambridge Colour Test -CCT), to measure the discrimination threshold in three-color confusion axes in addition to genetic sequencing. In the protan axis of confusion color, performance among diabetics with the TTA/GCC genotype was significantly lower (p=0.048) than those in the control group. The results showed a poorer performance among those with the TTA / GCC genotype (p = 0.048), compared to controls. In deutan axis confusion, there was no difference among any of the genotypes (p = 0.0207), while for the tritan axis, the TTA / GCC genotype was associated with a poorer performance (p = 0.014). For the controls, there was no difference between genotypes. Thus, the results showed a worsening in color vision among DM patients associated with TTA / GCC haplotype

O objetivo geral deste estudo foi investigar o efeito do leite humano na redução de respostas biocomportamentais de dor em RNPTs submetidos ao exame de fundo de olho para diagnóstico precoce da retinopatia da prematuridade, em comparação com a sacarose 25%. Trata-se de ensaio clínico randomizado, realizado na unidade neonatal de um hospital universitário de Ribeirão Preto-SP, com 48 prematuros distribuídos randomicamente em dois grupos: leite humano e sacarose, administrados por via oral 2 minutos antes do procedimento doloroso. As variáveis dimensionadas foram mímica facial da escala de dor NFCS, choro, frequência cardíaca e cortisol salivar. A coleta de dados foi realizada em cinco períodos para a mímica facial e o NFCS: basal (05 minutos), olho direito e olho esquerdo, recuperação imediata (05 minutos após o procedimento) e recuperação tardia (05 minutos após a recuperação imediata); quatro períodos para a frequência cardíaca e o choro: basal (05 minutos), procedimento, recuperação imediata e tardia. O cortisol salivar foi coletado antes do início do exame de fundo de olho (basal), após 30 (cortisol resposta) e 60 (cortisol recuperação) minutos do término do exame. O projeto foi aprovado pelo Comitê de Ética em Pesquisa da instituição e foi registrado no Australian and New Zeland Clinical Trials. O Teste de Kolmogorov-Smirnov e o Teste t-student mostraram que os grupos são comparáveis. Para análise das variáveis de desfecho, utilizou-se a Análise de Variância com Medidas Repetidas (RM-ANOVA). Após testar a homogeneidade das variáveis (teste de Levene), foi avaliado o pressuposto da esfericidade das matrizes de variância (teste de Mauchly). Assumindo-se a esfericidade, adotaram-se a análise multivariada, com valor de épsilon < 0,75, e a estatística de Wilk´s Lambda. Para valores de épsilon > 0,75, adotaram-se a análise univariada e a estatística de Hunh-Feldt (HF) ou Greenhouse-Geisser. Para as variáveis categóricas, foi utilizado o teste Qui-quadrado ou Teste exato Fisher. O efeito do leite humano no alívio da dor, decorrente do exame de fundo de olho, não diferiu estatisticamente da sacarose 25%, ao avaliarmos a duração da presença de fronte saliente [Wilk\'s Lamba=0,918, F=0,960, p=0,241], do sulco nasolabial [Wilk\'s Lambda=0,883; F=1,43; p=0,241] e do choro [Wilk\'s Lambda=0,964; F=3,44; p=0,656], e o escore médio do NFCS adaptado ao considerarmos essas duas ações da mímica facial [Wilk\'s Lambda=0,924; F=0,884; p=0,481], a FC [Wilk\'s Lambda=0,977; F=3,44; p=0,792] e a concentração de cortisol salivar [Wilk\'s Lambda=0,978; F=2,45; p=0,612]. A comparação intrasujeitos mostrou diferença significativa nos períodos de coleta dos dados, com aumento nos escores do NFCS, na duração da fronte saliente e do sulco nasolabial, durante o exame do fundo de olho direito e esquerdo, como também no aumento do choro, durante o procedimento doloroso, em comparação com os períodos basal, recuperação inicial e tardia. A concentração do cortisol salivar aumentou significativamente aos 30 e 60 minutos após o procedimento, em comparação com os valores do cortisol basal; não houve diferença entre o cortisol resposta (30 minutos) e recuperação (60 minutos). A duração do sulco nasolabial, do choro e os escores do NFCS no basal não diferiram significativamente dos valores encontrados na recuperação inicial e tardia. Na FC, houve diferença no basal em relação à recuperação imediata, e na duração da fronte saliente houve diferença nas duas recuperações. Concluímos que o efeito do leite humano, na redução das respostas biocomportamentais de dor em prematuros submetidos ao exame de fundo de olho para diagnóstico da retinopatia da prematuridade, não é superior ao efeito obtido com a sacarose 25%, rejeitando-se a hipótese alternativa. / The general aim of this study was to investigate the effect of human milk on reducing biobehavioral pain responses in PN\'s undergoing the ocular fundus examination for the early diagnosis of retinopathy of prematurity, compared with 25% sucrose. This is a randomized clinical trial conducted in the neonatal unit of a university hospital of Ribeirão Preto-SP, with 48 premature newborns randomly distributed into two groups: human milk and sucrose, orally administered 2 minutes before the painful procedure. The variables investigated were the facial movements of the NFCS pain scale, crying, heart rate (HR) and salivary cortisol levels. Data collection was conducted in five periods for the facial movements and NFCS: baseline (05 minutes), right eye and left eye, immediate recovery (05 minutes after the procedure) and delayed recovery (05 minutes after immediate recovery); and in four periods for heart rate and crying: baseline (05 minutes), procedure, immediate and delayed recovery. Salivary cortisol was collected before the start of the fundus examination (baseline), and at 30 minutes (cortisol response) and 60 minutes (cortisol recovery) after the end of the examination. The project was approved by the Research Ethics Committee and was registered in the Australian and New Zealand Clinical Trials. The Kolmogorov-Smirnov test and Student\'s t-test showed that the groups were comparable. For the analysis of the outcome variables, the Analysis of Variance with Repeated Measures (RM-ANOVA) was used. After testing the homogeneity of the variables (Levene\'s test) the assumption of sphericity of the variance matrices was evaluated (Mauchly\'s test). Assuming sphericity, multivariate analysis was adopted, with a < 0.75 value of epsilon and Wilk\'s Lambda statistic. For values of epsilon > 0.75, univariate analysis and the Hunh-Feldt (HF) or Greenhouse-Geisser statistic were adopted. For the categorical variables, the chi-square test or Fisher exact test was used. The effect of human milk on pain relief, arising from the ocular fundus examination, did not differ statistically from 25% sucrose, when the duration of the presence of brow lowering [Wilk\'s Lambda=0.918; F=0.960; p=0.241], of deepening of the naso-labial furrow [Wilk\'s Lambda=0.883; F=1.43; p=0.241] and of crying [Wilk\'s Lambda=0.964; F=3.44; p=0.656] were evaluated, as well as the mean score of the NFCS adapted to consider these two facial movement actions [Wilk\'s Lambda=0.924; F=0.884; p=0.481], the HR [Wilk\'s Lambda=0.977; F=3.44; p=0.792] and the salivary cortisol concentration [Wilk\'s Lambda=0.978; F=2.45; p=0.612]. The intra-subject comparison showed a significant difference in the data collection periods, with an increase in the NFCS scores, in the duration of brow lowering and naso-labial furrow deepening, during the examination fundus of the right and left eyes, as well as increased crying during the painful procedure, compared with the baseline period, immediate and delayed recovery. The concentration of salivary cortisol increased significantly at 30 and 60 minutes after the procedure, compared with the baseline cortisol values; there was no difference between cortisol response (30 minutes) and recovery (60 minutes). The duration of naso-labial furrow deepening, of crying and the NFCS scores at the baseline did not differ significantly from the values found in the immediate and delayed recovery. In the HR, there was no difference between the baseline and the immediate recovery, and in the duration of brow lowering there was no difference in the two recoveries. We conclude that the effect of human milk, on the reduction of biobehavioral responses to pain in preterm infants undergoing the ocular fundus examination for the diagnosis of retinopathy of prematurity, is not greater than the effect obtained with 25% sucrose, rejecting the alternative hypothesis.

Made available in DSpace on 2016-04-27T13:10:27Z (GMT). No. of bitstreams: 1 Isabel Redondo de Campos.pdf: 3029986 bytes, checksum: 846f67976c76d8135c8f94c088696392 (MD5) Previous issue date: 2015-09-23 / Diabetic Retinopathy (DR) is one of the complications of Diabetes Mellitus (DM). It is the leading cause of adult blindness in working age in developed countries. The study aimed to analyze the profile of diabetic patients, treated at the retina ambulatory at Sorocaba´s Ophthalmology Hospital and to identify the knowledge of those patients on DM and DR. A questionnaire was developed and applied by the researcher to 46 patients (n=100%) from January to March 2015. The results showed that from the 46 subjects (all coming from Sorocaba or region, with DM confirmed by medical record data), 27 (58.7%) are male. The median age was 62.5 years (range: 41-79 years). Twenty-two patients (47.8%) were retired and 34 (73.9%) reported earning between one and three times the minimum wage. Most of the subjects said that they are overweight (n = 19; 41.3%) or obese (n = 13, 28.3%) and believed their diabetes control was regular. Regarding education, 41.3% attended between one to eight years of school and 10.9% reported to be illiterate. Regarding the type of DM, 23 (50%) did not know the type. The data records were incomplete in this classification. The most reported complication was DR, with the total of 23 (50%) patients, while 17 (36.9%) claimed to have no complication of DM. Only 21.8% could name ophthalmoscopy as indicated for ophthalmic evaluation. The most mentioned reason for seeking treatment was for partial loss of vision (50%). Only 35.0% of patients have participated in an education group in DM. The patients showed low levels of knowledge about their chronic disease as well as on the DR, on the examination required for early detection of this complication and on the measure needed to preserve eye health, even by those who reported prior participation in education groups in DM. It can be said that these programs, besides reaching a small proportion of patients, had poor results in the appropriation of knowledge about DM by this group. It was concluded that systematic education programs must be implemented in all health care levels, due to gaps in the patients previous knowledge to revert the appropriation of new knowledge and attitudes about the DM / A Retinopatia Diabética (RD) é uma das complicações do Diabetes Mellitus (DM). É a principal causa de cegueira dos adultos em idade ativa nos países desenvolvidos. O estudo teve como objetivos analisar o perfil de amostra de pacientes diabéticos, atendidos no ambulatório de retina do Hospital Oftalmológico de Sorocaba e identificar o conhecimento desses pacientes sobre DM e RD. Foi desenvolvido um questionário, aplicado pela pesquisadora a 46 pacientes atendidos de janeiro a março de 2015. Os resultados mostraram que dos 46 sujeitos (todos procedentes de Sorocaba ou região, com DM confirmado por dados do prontuário), 27 (58,7%) são homens. A mediana de idade foi de 62,5 anos (variação: 41 79 anos). Vinte e dois pacientes (47,8%) são aposentados e 34 (73,9%) declararam receber entre um e três salários mínimos. A maior parte referiu sobrepeso (n=19; 41,3%) ou obesidade (n=13, 28,3%) e apontam seu controle como regular. Em relação à escolaridade, 41,3% frequentou a escola entre um a oito anos e 10,9% referiram ser analfabetos. Sobre o tipo de DM, 23 (50%) não sabiam o tipo. Os dados de prontuários estavam incompletos nessa classificação. A complicação mais referida foi a RD, somando 23 (50%) pacientes, enquanto 17 (36,9%) alegaram não ter nenhuma complicação do DM. Somente 21,8% soube nomear o exame de fundoscopia como o indicado para avaliação oftalmológica. O motivo mais citado para procurar tratamento foi por perda parcial de visão (50%). Apenas 35,0% dos pacientes já participou em grupo de educação em DM. Os pacientes apresentaram baixos níveis de conhecimento sobre sua doença crônica, bem como quanto à RD, ao exame necessário para detecção precoce desta complicação e às medidas indicadas para preservação da saúde ocular, mesmo naqueles que referiram participação prévia em grupos de educação em DM. Pode-se dizer que estes programas, além de atingirem uma parcela pequena de pacientes, tiveram resultados pouco expressivos na apropriação do conhecimento sobre DM neste grupo. Concluiu-se então que deve-se implantar programas de educação sistemáticos em todos os níveis de atenção à saúde, voltados às lacunas do conhecimento prévio dos pacientes para se reverterem na apropriação de novos conhecimentos e atitudes sobre o DM

<p>In a prospective population-based study in Stockholm County, 1998-2000, the incidence of retinopathy of prematurity (ROP) was investigated and was found to be 36% in prematurely-born infants with a birth weight of ≤ 1500 grams. Compared to a study performed ten years ago, the overall incidence was unchanged, but was reduced in “mature” infants and increased in immature ones. The incidence of ROP was 25% in infants with a gestational age of ≤ 32 weeks at birth. The main risk factors for ROP were the gestational age at birth, followed by the birth weight. Current guidelines for ROP screening in Sweden were modified.</p><p>A 10-year follow-up study of the ophthalmological findings in prematurely-born children, previously included in a prospective population-based incidence study of ROP, was performed. The children were compared with full-term ones. </p><p>Prematurely-born children ran a four times higher risk of refractive errors than full-term ones. The cryotreated children had the highest risk, but those without ROP also had more refractive errors than the full-terms. Within the group of prematurely-born children, the cryotreated ones had the highest prevalence of myopia, astigmatism and anisometropia, but no difference was found regarding hypermetropia.</p><p>The visual acuity of prematurely-born children was poorer than that of the full-terms. The cryotreated children and those with neurological complications had the most marked reduction, but the children without ROP and neurological findings also had a poorer visual outcome than the full-terms. The prevalence of visual impairment was 1.8% among the prematurely-born children, and was due to ROP in half the cases and cerebral lesions in the others. </p><p>The cryotreated children had constricted peripheral visual fields compared to the untreated prematurely-born and full-term children. The central visual fields tended to be reduced in the prematurely-born children compared to the full-terms, but no difference was observed within the preterm group.</p>