Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-07-07T18:04:16Z No. of bitstreams: 1 monicacalilborgesferreira.pdf: 2981549 bytes, checksum: 3acac42eeb4cf1c5133b9c3cd804459e (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-07-08T13:22:50Z (GMT) No. of bitstreams: 1 monicacalilborgesferreira.pdf: 2981549 bytes, checksum: 3acac42eeb4cf1c5133b9c3cd804459e (MD5) / Made available in DSpace on 2016-07-08T13:22:50Z (GMT). No. of bitstreams: 1 monicacalilborgesferreira.pdf: 2981549 bytes, checksum: 3acac42eeb4cf1c5133b9c3cd804459e (MD5) Previous issue date: 2012-03-28 / As hemoglobinopatias constituem o distúrbio genético de maior frequência nos seres humanos, sendo a doença falciforme (DF), com destaque para a anemia falciforme, a de maior impacto clínico, social e epidemiológico. Devido às características raciais do Brasil essas desordens genéticas passaram a representar um grave problema de saúde pública. Minas Gerais por meio da Fundação Centro de Hematologia e Hemoterapia (Hemominas) é pioneira na implantação de uma política de atenção aos portadores de DF, sendo que, desde 1998 a doença foi incluída na triagem neonatal (TN), enquanto que no Programa Nacional tal vinculação só ocorreu a partir de 2001. No Brasil, dos seus 27 estados apenas 18 realizam a TN para a DF. A implantação de uma triagem precoce para hemoglobinopatias não garante por si só o sucesso do Programa, pois é necessário acompanhar constantemente a rede de atenção a DF, visando avaliar e promover melhorias desde a atenção básica à saúde, com o “teste do pezinho”, até o tratamento em serviços de maior complexidade. Trata-se de um estudo quantitativo que se propôs a avaliar o espaço cronológico entre as etapas da TN, assim como a frequência e caracterização socioeconômica dos casos de portadores de DF matriculados no Hemocentro Regional de Juiz de Fora (HRJF) - Hemominas, durante o período de 1998 a 2007. No período proposto, foram triados em Minas Gerais 2.549.097 recém-nascidos, sendo que, 210.696 nascidos nas 34 cidades que referenciam o HRJF como centro de tratamento da DF. As cidades que melhor representam a incidência estadual de DF são Juiz de Fora e Ubá. Das crianças estudadas com DF não houve diferença significativa entre os gêneros. Em relação ao perfil hematológico dos acompanhados pelo HRJF (n=109) a HbSS esteve presente em 42,2% pacientes, a HbFC em 27,5%, a HbFS em 23,8% e a HbS/B-talassemia em 6,4%, sendo o percentual de meninos HbSS de 48,2% para 35,8% meninas HbSS. A maioria das famílias relatou viver com renda familiar menor que um salário mínimo por mês (37%). Em relação a fonte de renda foi identificado que o pai trabalha com carteira assinada em 44,9% e as mães em apenas 18,3%. Em 7,33% das famílias o pai está desempregado e as mães em 32,1%, fato que reforça a vulnerabilidade social das crianças portadoras de DF. Outro aspecto importante é a presença da DF em mais de um filho na mesma família, constatando a presença de 56% dos irmãos com a doença, sendo que deste, em 41% o diagnóstico é de anemia falciforme. Quanto ao traço falciforme, 36,7% possuem ao menos mais um filho com traço falciforme e 6,4% desconhece a presença do traço entre os irmãos da criança entrevistada, o que demonstra a necessidade de orientação aos pais quanto ao planejamento familiar. O espaço cronológico entre a coleta de sangue e o cadastro no HRJF foi de 17 dias, período este considerado ideal. Como produto geral da pesquisa, obteve-se um maior conhecimento dos programas integrais de atenção à DF implementados pelo HRJF propiciando uma compreensão mais ampla da situação da DF no nosso Estado na tentativa de favorecer num futuro bem próximo o planejamento de políticas públicas e outras ações que possam contribuir para reduzir a morbimortalidade e melhorar a qualidade de vida do doente falciforme. Além disso, como o Programa Nacional de TN está em alguns estados brasileiros em fase inicial de implantação, em muito contribuiria para esta iniciativa uma ampla divulgação dos estudos, para que medidas de prevenção e controle sejam melhor implementadas. / Hemoglobinopathies are the most frequent genetic disease in humans, and sickle cell disease (SCD), especially for sickle cell anemia, the most clinical impact, social and epidemiological. Due to the racial characteristics of Brazil these genetic disorders now represent a serious public health problem. Minas Gerais through the Foundation Center of Hematology (Hemominas) is pioneer in implementing a policy of care for patients with SCD, and since 1998 the disease was included in newborn screening (NS), while in this National Program Binding occurred only after 2001. In Brazil, the 27 states only 18 do the NS to perform the SCD. The implementation of an early screening for hemoglobinopathies is not in itself guarantee the success of the program, it is necessary to constantly monitor the care net SCD, to evaluate and promote improvement since the primary health care, with the "Guthrie test" to the treatment services of greater complexity. This is a quantitative study aimed to evaluate the space between the chronological stages of NS, as well as the frequency and socioeconomic characteristics of the cases of patients with SCD enrolled in Regional Blood Center of Juiz de Fora (RBCJF) - Hemominas during the period 1998 to 2007. The proposed period, were screened in Minas Gerais 2,549,097 newborns, and that 210,696 newborns in 34 cities that reference the RBCJF as a center for treatment of SCD. The cities that best represent the incidence of SCD are state Juiz de Fora and Uba. From these children with SCD did not differ between genders. Regarding the hematological profile of RBCJF accompanied by (n = 109) to HbSS was present in 42.2% patients, HBFCs by 27.5% to 23.8% and HbFS HbS / B thalassemia in 6.4 %, the percentage of boys HbSS 48.2% to 35.8% HbSS girls. Most families reported living with family income less than one minimum wage per month (37%). Regarding the source of income was identified as the father works with a formal contract in 44.9% and mothers in only 18.3%. In 7.33% of families the father is unemployed and mothers in 32.1%, a fact that reinforces the social vulnerability of children with SCD. Another important aspect is the presence of SCD in more than one child in the family, noting the presence of 56% of the siblings with the disease, and this, in 41% the diagnosis is sickle cell anemia. As for the sickle cell trait, 36.7% have at least one child with sickle cell trait and 6.4% were unaware of the presence of the trait among the siblings of children interviewed, which demonstrates the need for guidance to parents about family planning. The space between the chronological collection of blood and register for RCBJF was 17 days, a period considered ideal. As a product of the research, we obtained a greater knowledge of comprehensive attention to SCD RCBJF implemented by providing a broader understanding of the situation in our state of the SCD in trying to promote in the near future planning policies and other actions that may help reduce morbidity and improve quality of life of sickle cell patients. Moreover, as the National Program for NS is in some Brazilian states in the initial deployment, greatly contribute to this initiative a wide dissemination of studies, so that prevention and control measures are best implemented.

Submitted by Geandra Rodrigues (geandrar@gmail.com) on 2018-06-29T14:15:54Z No. of bitstreams: 1 thaisanettosouzavalentefrossard.pdf: 4978395 bytes, checksum: ac5dc0c8f717447878ea3a336969d945 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2018-07-03T14:14:30Z (GMT) No. of bitstreams: 1 thaisanettosouzavalentefrossard.pdf: 4978395 bytes, checksum: ac5dc0c8f717447878ea3a336969d945 (MD5) / Made available in DSpace on 2018-07-03T14:14:30Z (GMT). No. of bitstreams: 1 thaisanettosouzavalentefrossard.pdf: 4978395 bytes, checksum: ac5dc0c8f717447878ea3a336969d945 (MD5) Previous issue date: 2018-04-09 / Hipocolesterolemia e hipertrigliceridemia são documentadas na Doença Falciforme (DF) há muitos anos, mas as causas e os efeitos na fisiopatologia ainda precisam ser esclarecidos. Além disto, relatos sobre marcadores genéticos relacionados ao metabolismo lipídico que explicam a variação dos níveis de lipídios e suas associações com os subfenótipos de hemólise e vaso-oclusão e com a variabilidade clínica da DF não foram publicados até o momento. O objetivo geral do estudo foi investigar se havia dislipidemia e se polimorfismos de um único nucleotídeo (SNPs) em genes ligados às variações lipídicas e inflamatórias estariam associados a alterações nas variáveis hematológicas, bioquímicas e clínicas, em crianças e adolescentes com as duas formas mais frequentes da DF, anemia falciforme (HbSS) e hemoglobinopatia SC (HbSC). A população consistiu de 155 indivíduos nascidos entre 2001 e 2010, com média de idade de 12,54 anos, sendo 55,5% do sexo masculino, acompanhados nos Hemocentros Regionais de Governador Valadares e de Uberaba da Fundação Hemominas. Um grupo conrole constituído de 40 crianças sem DF com média de idade de 12,98 anos também foi incluído para comparações com dados lipídicos. Foram realizadas coletas de dados em registros médicos, exames bioquímicos, genotipagens dos SNPs de ANGPTL4, APOA5, ZNF259 e TNFA, pesquisa de alfa-talassemia e avaliação do uso de hidroxiuréia (HU). Verificaram-se associações entre as variáveis investigadas e, destas, com a ocorrência de eventos clínicos da DF. Para estes fins foram aplicados testes qui-quadrado, Mann-Withiney, Teste T de Students, ANOVA, Kruskal-Wallis e realizadas correlações com o teste de Spearman. A significância estatística foi estabelecida em P < 0,05. Dentre os achados, foram encontrados piores índices de marcadores de hemólise e inflamação nos indivíduos HbSS em relação aos HbSC. A hipocolesterolemia (HDL < 40 mg/dL) foi encontrada em 64,52% da população com DF, havendo diferença significativa entre os indivíduos e os controles, sem diferença entre HbSS e HbSC. Indivíduos com DF que possuíam a HDL superior a 40 mg/dL apresentaram maiores níveis de APOA1 e menores de colesterol total e triglicerídios. A hipertrigliceridemia (TG > 100 mg/dL até os 10 anos e > 130 mg/dL acima de 10 anos) presente em apenas 8,51% dos pacientes DF não mostrou diferença significativa entre os grupos HbSS e HbSC e foi associada com níveis elevados da enzima LDH. Nos indivíduos HbSS os baixos níveis de HDL estavam em maior proporção se comparados ao grupo HbSC. O uso de HU no grupo HbSS não interferiu nos níveis de lipídios. A variante rara do gene ANGPTL4 rs116843064 (G>A), no modelo de dominância, foi associada com redução de leucócitos globais e monócitos e aumento de apolipoproteína A1 e colesterol total nos indivíduos com DF. O polimorfismo de ZNF259 rs964184 (c.724C>G) foi associado ao aumento dos marcadores de hemólise/inflamação (leucócitos globais, reticulócitos e bilirrubinas total e direta) e apresentou efeito dose dependente nos níveis de bilirrubina direta. A variante de menor frequência (-308A) de TNFA rs1800629 foi associada com aumento de 73% dos níveis de bilirrubina direta. A co-herança de alfa-talassemia presente nos dois grupos HbSS e HbSC, reduziu VCM e HCM, mas não influenciou os níveis de HbF, reticulócitos, bilirrubina ou o perfil lipídico. Em conclusão, a hipocolesterolemia foi caracterizada por baixos níveis de HDL em ambos os grupos de indivíduos HbSS e HbSC e o uso terapêutico da hidroxiuréia ou a co-existência de alelos de deleção dos genes HBA parecem não influenciar este quadro dislipidêmico. Entre os polimofismos estudados o de ZNF259 rs964184 foi o único associado a níveis de lipídios nos indivíduos com DF. Nosso estudo é o primeiro a mostrar que a variantes de menor frequência de ZNF259 rs964184 e TNFA rs1800629 estão associadas a hiperbilirrubinemia em pacientes com DF. / Hypocholesterolemia and hypertriglyceridemia have been documented in sickle cell disease (SCD) for many years, but the causes and effects on pathophysiology still need to be clarified. In addition, reports on genetic markers related to lipid metabolism that explain the variation of lipid levels and their associations with subtypes of hemolysis and vaso-occlusion and clinical variability of SCD have not been published to date. The overall objective of the study was to investigate whether dyslipidemia and single nucleotide polymorphisms (SNPs) in genes linked to lipid and inflammatory changes would be associated with changes in hematological, biochemical and clinical variables in children and adolescents with the two most frequent forms of SCD, sickle cell anemia (HbSS) and hemoglobinopathy SC (HbSC). The population consisted of 155 individuals born between 2001 and 2010, with a mean age of 12.54 years, being 55.5% male, followed in the Regional Hemocenters of Governador Valadares and Uberaba of the Hemominas Foundation. A conrole group consisting of 40 children without SCD with a mean age of 12.98 years was also included for comparison with lipid data. Data collection on medical records, biochemical tests, genotyping of ANGPTL4, APOA5, ZNF259 and TNFASNPs, alpha-thalassemia screening and assessment of hydroxyurea (HU) use were performed. There were associations between the variables investigated and, of these, with the occurrence of clinical events of the SCD. For these purposes chi-square, Mann-Withiney, Student's T-Test, ANOVA, Kruskal-Wallis and correlations with the Spearman test were applied. Statistical significance was set at P <0.05. Among the findings, we found worse markers of hemolysis and inflammation in HbSS individuals in relation to HbSC. Hypocholesterolemia (HDL <40 mg / dL) was found in 64.52% of the SCD population, with a significant difference between individuals and controls, with no difference between HbSS and HbSC. Individuals with SCD that had HDL greater than 40 mg / dL had higher levels of APOA1 and lower total cholesterol and triglycerides. Hypertriglyceridemia (TG> 100 mg / dL up to 10 years and> 130 mg / dL over 10 years) present in only 8.51% of SCD patients showed no significant difference between the HbSS and HbSC groups and was associated with high levels of the LDH enzyme. In the HbSS subjects the low HDL levels were in a higher proportion when compared to the HbSC group. The use of HU in the HbSS group did not interfere with lipid levels. The rare variant of the ANGPTL4 gene rs116843064 (G> A) in the dominance model was associated with reduction of global leukocytes and monocytes and increase of apolipoprotein A1 and total cholesterol in subjects with DF. The polymorphism of ZNF259 rs964184 (c.724C> G) was associated with increased markers of hemolysis/ inflammation (total leukocytes, reticulocytes and total and direct bilirubin) and had a dose-dependent effect on direct bilirubin levels. The lower frequency variant (-308A) of TNFA rs1800629 was associated with a 73% increase in direct bilirubin levels. Alpha-thalassemia co-inheritance in both HbSS and HbSC groups reduced MCV andMCH, but did not influence HbF, reticulocyte, bilirubin or lipid profile levels.In conclusion, hypocholesterolemia was characterized by low levels of HDL in both groups of HbSS and HbSC and the therapeutic use of hydroxyurea or the coexistence of deletion alleles of HBA genes does not appear to influence this dyslipidemic condition. Among the polymorphisms studied, that of ZNF259 rs964184 was the only one associated with lipid levels in SCD. Our study is the first to show that the lower frequency variants of ZNF259 rs964184 and TNFA rs1800629 are associated with hyperbilirubinemia in SCD.

Orientador: Erich Vinicius de Paula / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-25T23:01:14Z (GMT). No. of bitstreams: 1 Souza_GleiceReginade_M.pdf: 1983428 bytes, checksum: 435b8d4ea1f6b2d6d8254be7fd9c00b2 (MD5) Previous issue date: 2014 / Resumo: Há cerca de 50 anos sabe-se que pacientes com anemia falciforme (AF) apresentam maiores concentrações plasmáticas de heme livre. Recentemente, foi demonstrado que o heme é capaz de ativar a resposta imune inata, desencadeando resposta dependente de receptores "Toll-like", envolvendo a expressão de vários genes pró-inflamatórios. Em consonância com estes achados, o papel pró-inflamatório do heme foi confirmado em diferentes modelos experimentais de AF, colocando este metabólito como potencial desencadeante da oclusão microvascular e síndrome torácica aguda. Tromboses micro e macro vasculares são características da AF, e o papel do heme na patogenia destes eventos foi recentemente sugerido pela demonstração de sua capacidade de induzir a expressão de fator tecidual (FT) em células endoteliais e monócitos. No entanto, a relevância funcional da expressão deste achado ainda não foi demonstrada através de marcadores clinicamente relevantes da coagulação. Métodos: A expressão do FT induzida pelo heme foi avaliada em células mononucleares de sangue periférico (PBMC) através de dois ensaios globais da hemostasia: tromboelastometria (TEM) e teste de geração de trombina (TGT). Sangue de voluntários saudáveis foram coletados por uma veia antecubital com mínima estase em tubos de citrato de sódio (1:10) ou heparina. A TEM foi realizada em amostras de sangue total (n=10) incubadas com 30 ?M do heme (Sigma¿Aldrich) durante 4 horas a 37°C, em um equipamento ROTEM (Pentapharm). A coagulação foi ativada pela adição de CaCl2. Como controle, amostras dos mesmos indivíduos foram incubadas concomitantemente com o veículo (n=10). O TGT foi realizado em amostras de plasma duplamente centrifugadas, separadas a partir de sangue total estimulado com heme ou veículo sob as mesmas condições (n=16). A TGT foi realizada utilizando flurímetro Fluoroskan Ascent® (Thermolab). A coagulação foi ativada com FT (5pM) e fosfolipídios ( Reagente PPP, Thrombinoscope). A expressão de FT foi avaliada por qRT-PCR. PBMC e neutrófilos foram separados por centrifugação de gradiente de densidade (Ficoll) e então incubados com 30 uM de heme (n=6) ou salina (n=6) por 24hs. Teste estatístico não-paramétrico foi utilizado em todas as análises. Resultados: a incubação do sangue total com 30 uM de heme resultou numa potente indução de expressão de FT quando comparado com o veículo em PBMC (AU) (0,03±0,06 vs 1,18±0,60; P=0,03). Não foi possível detectar a expressão de FT em neutrófilos. A ativação da coagulação induzida pelo heme pode ser demonstrada através da TEM. O Heme diminuiu significativamente o tempo de coagulação (seg) (562,1±88,2 vs 387±84.3; P=0,002) e a MaxV-t (tempo para a velocidade máxima) (651,4±119,2 vs 451,1±87,4; P=0,002), que são dois indicadores de um estado de hipercoagulabilidade. Uma tendência para a diminuição do tempo de formação do coágulo também pode ser observada (P=0.07). Nenhuma diferença pode ser observada na área sob a curva da TEM. Um perfil de hipercoagulabilidade, também foi observado no TGT. Mudanças estatisticamente significativas, compatíveis com a ativação da coagulação foram observadas em parâmetros como: pico de trombina (aumentado), tempo para atingir a trombina (diminuição), índice de velocidade (aumento), período de latência (diminuição) e StarTail (diminuição) (todos<0,05). Nenhuma mudança estatisticamente significativa pode ser observada no parâmetro de pontencial endógeno de trombina. Discussão e Conclusão: A TEM e o TGT são dois testes globais em hemostasia, amplamente utilizados para avaliação de estados de hipo e hipercoagulabilidade. Ambos os métodos tem sido utilizados em pacientes com AF, que apresentam estado de hipercoagulabilidade similar ao encontrado em nosso trabalho, caracterizada por um início mais rápido da ativação da coagulação. Nossos resultados demonstram pela primeira vez que o heme, em concentrações semelhantes às observadas em pacientes com AF, é capaz de estimular não só a expressão do TF em PBMC, mas também de alterar o equilíbrio da coagulação para um estado de hipercoagulabilidade. Estes resultados fornecem um suporte adicional à hipótese de que o heme é um mediador chave na trombose micro e macro vascular na AF e, possivelmente, em outras doenças hemolíticas. Nosso estudo também avaliou de forma preliminar, o efeito do heme sobre a fosforilação do resíduo S879 da proteína p120-catenina, como um marcador indireto da quebra de barreira endotelial. Os resultados, ainda preliminares, sugerem que pode haver um efeito do heme sobre a integridade de barreira endotelial, fato que será investigado em estudos futuros / Abstract: It has been known for more than 50 years that patients with sickle cell disease (SCD) present higher plasma concentrations of heme. More recently, it was shown that heme is capable to activate innate immune response, and to trigger a toll-like receptor-dependent response that involves the expression of several pro-inflammatory genes. Accordingly, the role of heme as critical inflammatory mediator in SCD has been confirmed in different experimental models, suggesting that heme can be a trigger for microvascular occlusion and acute chest syndrome (ACS). The association between innate immune response and coagulation activation dates back to 450 million years in evolution, so that activation of the former is frequently accompanied by activation of the latter. Micro and macrovascular thrombosis are a hallmark of SCD, and the role of heme in the pathogenesis of these events has been recently suggested by demonstrations of heme-induced expression of tissue factor (TF) by endothelial cells and monocytes. However, the functional relevance of heme-induced TF expression on clinically-relevant coagulation markers has not been demonstrated. Methods: herein we evaluated heme-induced TF expression in peripheral blood mononuclear cells (PBMC), and used two different global assays of hemostasis, namely thromboelastometry (TEM) and Thrombin Generation Test (TGT) to evaluate the effect of heme on coagulation activation. Blood from healthy volunteers was drawn from an antecubital vein with minimal stasis in 0.106 sodium citrate tubes (1:10) or heparin. TEM was performed in whole-blood samples (n=10) incubated with 30 µM heme (Sigma-Aldrich) for four hours at 37oC, in a ROTEM equipment (Pentapharm). Coagulation was activated with the addition of CaCl2. Samples from same individuals incubated with vehicle were assayed concomitantly as controls (n=10). TGT was performed in double centrifuged plasma samples, separated from whole blood stimulated with heme or vehicle under the same conditions (n=16). TGT was performed using a Fluoroskan Ascent Flourimeter (Thermolab). Coagulation was activated with TF (5pM) and phospholipids (PPP reagent, Thrombinoscope). Expression of TF was evaluated by qRT-PCR. Heparin-anticoagulated blood was incubated with 30 µM heme (n=6) or vehicle (n=6) for 24 hours. PBMC and neutrophils were then separated by density gradient centrifugation (Ficoll). Non-parametric statistics were used in all analysis. Results: incubation of whole blood with heme 30 µM resulted in a potent induction of TF expression in PBMC compared to vehicle (AU)(0.03±0.06 vs 1.18±0.60; P=0.03). No TF expression could be detected in neutrophils. Heme-induced coagulation activation could be demonstrated by TEM. Heme significantly decreased the coagulation time (sec) (562.1±88.2 to 387±84.3; P=0.002) and the MaxV-t (time to maximum velocity) (651.4±119.2 to 451.1±87.4 ; P=0.002), which are two indicators of shift towards a hypercoagulable profile. A trend towards a lower clot formation time was also observed (P=0.07). No difference could be observed in the area under the TEM curve. A hypercoagulable profile was also observed in TGT in samples incubated with heme. Statistically significant changes compatible with a shift towards coagulation activation were observed in parameters such as peak thrombin (increased), time to peak thrombin (decreased), velocity index (increased), lagtime (decreased) and StarTail (decreased) (all P<0.05). No statistically significant change could be observed in the endogenous thrombin potential parameter (p=0.10). Discussion and conclusions: TEM and TGT are global hemostasis assays, widely used for evaluation of hypo- and hypercoagulable states. Both methods have been used in patients with SCD, who present hypercoagulable profiles similar to those obtained in our study, and characterized by faster onset and offset of coagulation activation. We demonstrate for the first time that heme, in concentrations similar to those observed in patients with SCD and other hemolytic disorders, is capable to not only stimulate the expression of TF by PBMC, but also to shift the coagulation balance towards a hypercoagulable state, similar to that observed in patients with SCD. These results provide additional support to the hypothesis that heme is a key mediator micro- and macrovascular thrombosis in SCD and possibly, in other hemolytic disorders. Our study also evaluated in a preliminary form the effect of heme on the phosphorylation of the residue S879 from p120-catenin, as a surrogate marker of endothelial barrier breakdown induced by heme. Though preliminary, our results suggest that heme might also affect endothelial barrier integrity. Additional studies are underway to evaluate this hypothesis / Mestrado / Clinica Medica / Mestra em Clínica Médica

Orientadores: Nicola Amanda Conran Zorzetto, Fernando Ferreira Costa / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-18T19:38:48Z (GMT). No. of bitstreams: 1 Almeida_CamilaBononide_D.pdf: 2554249 bytes, checksum: c6b3764fee73b2d53da308d36c53522b (MD5) Previous issue date: 2011 / Resumo: Anemia falciforme (AF) é um distúrbio na síntese de hemoglobina causada por uma mutação pontual que leva a produção de uma hemoglobina anormal, HbS. Em locais com baixa concentração de O2, a HbS se polimeriza resultando em uma série de alterações que podem culminar em processos vaso-oclusivos, a principal causa de dor e mortalidade entre os pacientes falciformes. A AF é uma doença inflamatória crônica caracterizada por níveis de citocinas alterados, além de um elevado número de leucócitos e lesões nas células endoteliais. Os leucócitos apresentam um papel importante na AF uma vez que, seu recrutamento pode levar a um bloqueio do fluxo sanguíneo da microvasculatura, já que são células grandes, pouco deformáveis e que aderem facilmente ao endotélio ativado, além de interagirem com eritrócitos circulantes. As estratégias terapêuticas utilizadas e desenvolvidas para o tratamento da doença baseiam-se em 3 pontos principais: 1) diminuir a concentração intracelular de HbS como, por exemplo, aumento da HbF; 2) reduzir processos inflamatórios e o estresse oxidativo; 3) inibir a adesão celular e consequentemente, reduzir a vaso-oclusão (VO). A Hidroxiuréia (HU) é um agente quimioterápico que vem sendo utilizada com sucesso no tratamento da AF. Essa droga é capaz de elevar a HbF e também de reduzir o número de células brancas. Entretanto, além dos efeitos adversos provocados por ela, nem todos os pacientes respondem à terapia. Assim, faz-se necessária uma melhor compreensão da fisiopatologia da AF, incluindo o papel dos leucócitos e os mecanismos envolvidos no processo de VO, para o desenvolvimento de terapias alternativas. Neste estudo, tivemos como objetivos principais 1) verificar a ação de fatores presentes no soro de pacientes com AF quanto à modulação do número de neutrófilos e à geração de estresse oxidativo; 2) melhor compreensão do papel dos neutrófilos na iniciação e propagação de processos inflamatórios e consequentemente a participação dessas células no processo de VO. Dados indicaram que fatores presentes no soro de pacientes com AF são capazes de alterar a apoptose de neutrófilos e também iniciar a geração de espécies reativas de oxigênio (ROS), possivelmente pela ativação da enzima NADPH presente nestas células. Adicionalmente, resultados obtidos com um modelo de camundongo transgênico falciforme indicaram que a ativação da via dependente de GMPc pode ser uma abordagem interessante para a inibição da adesão de neutrófilos à parede vascular sob condições inflamatórias. Além disso, os dados mostram que o uso de drogas que amplificam os efeitos da HU poderiam ser úteis na prevenção da VO / Abstract: Sickle Cell Disease (SCD) is a disorder of hemoglobin synthesis, caused by a point mutation, and resulting in the production of abnormal sickle hemoglobin, HbS. The consequence of low oxygen levels is HbS polymerization, which is responsible for the vaso-occlusive phenomenon that is the hallmark of the disease. SCD is a chronic inflammatory disease characterized by alterations in cytokine levels and an increase in leukocytes number and endothelial cell injury. Leukocytes play an important role in SCD since their recruitment to the microvasculature, consequent adhesion to the vessel wall, and interactions with other cells may interrupt the blood flow and culminate in vaso-occlusion. Therapeutic strategies for SCD treatment are based on three points: 1) reduction of intracellular HbS concentration, for example, by increasing the erythrocytic HbF concentration; 2) reduction of inflammatory processes and oxidative stress; 3) inhibition of cellular adhesion and, as a consequence, a reduction in vaso-occlusion. HU is a chemotherapeutic drug used for SCD treatment. This drug is able to increase HbF concentrations and reduce white blood cells counts, although it has some adverse effects and some patients do not respond to this therapy. Thus, it is necessary to fully understand the mechanisms that contribute to the vaso-occlusive process, including the role of the leukocytes in this phenomenon. The goals of this study are: 1) To check the influence of factors present in SCD serum on mechanisms that may affect the neutrophil count and oxidative stress generation; 2) understand the role of neutrophils in the initiation and propagation of vascular inflammation and vaso-occlusion. Date indicate that factors present in the SCD serum are able to alter neutrophil apoptosis and induce reactive oxygen species (ROS) generation, possibly by the activation of the NADPH enzyme expressed in these cells. Additionally, results obtained from a SCD inflammatory mouse model indicate that an activation of the cGMP - dependent pathway can inhibit neutrophil adhesion to the vascular endothelium cells after inflammatory induction and that drugs that amplify the effects of HU may represent a potential new therapy for SCD treatment / Doutorado / Biologia Estrutural, Celular, Molecular e do Desenvolvimento / Doutor em Fisiopatologia Medica

Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2015-11-05T13:03:56Z No. of bitstreams: 1 Elvira Maria Martins Siqueira de Carvalho.pdf: 2164262 bytes, checksum: 2459194ee7d5695bfffe1d9155f55399 (MD5) / Made available in DSpace on 2015-11-05T13:03:56Z (GMT). No. of bitstreams: 1 Elvira Maria Martins Siqueira de Carvalho.pdf: 2164262 bytes, checksum: 2459194ee7d5695bfffe1d9155f55399 (MD5) Previous issue date: 2014 / Mestrado Acadêmico em Ciências do Cuidado em Saúde / Trata-se de pesquisa qualitativa, descritiva, do tipo Estudo de Caso, sobre a pessoa com doença falciforme em unidade de emergência que teve como objetivos: analisar os limites e possibilidades da equipe de enfermagem no cuidado a pessoa com doença falciforme na unidade de emergência, identificar as necessidades de cuidado da pessoa com doença falciforme na unidade de emergência e descrever como a equipe de enfermagem cuida da pessoa com doença falciforme na unidade de emergência. O estudo foi desenvolvido em um Hospital Público Estadual, de alta complexidade, localizado no Município do Rio de Janeiro, especializado em hematologia, referência no atendimento a pessoas com doença hematológica. Participaram do estudo 32 pessoas, sendo 20 clientes com DF internados no setor de emergência e 12 membros da equipe de enfermagem que atuam no referido setor. A produção de dados foi desenvolvida no período de abril a setembro de 2014, mediante as técnicas de observação simples e entrevista semiestruturada. Após análise de conteúdo dos dados emergiram as seguintes categorias temáticas: A Pessoa com Doença Falciforme em unidade de emergência e O Cuidado de Enfermagem a pessoa com doença falciforme. A vivência das pessoas com Doença Falciforme está, geralmente, associada a sofrimento e ocorrência de múltiplas internações na emergência, principalmente devido à dor, agravo clínico mais comum da doença, que leva seus portadores a procurar atendimento para alívio dessa manifestação e suporte as demais intercorrências relacionadas ao desenvolvimento da doença. O cuidado a pessoa com DF, portanto, envolve para além do tratamento, considerar os fatores sociais, históricos e culturais que permeiam a experiência relacionada à doença falciforme e estão imbricados nos modos de agir dos próprios clientes e também dos profissionais nas instituições de saúde. Para cuidar dessas pessoas os membros da equipe de enfermagem precisam estar preparados para identificar e avaliar suas necessidades, visando o bem estar e autonomia das mesmas, mediante uma escuta atenta e sensível as suas demandas físicas, psicológicas e sociais para o planejamento e implementação de cuidados efetivos que propiciem melhora do quadro clinico, conforto e segurança durante a permanência no ambiente da emergência, o qual requer infraestrutura de recursos humanos e materiais adequados. Assim, considerando que a pessoa com Doença Falciforme necessita de cuidados contínuos de saúde, é fundamental estabelecer estratégias de participação ativa da mesma no autocuidado e tratamento, mediante ações educativas que possibilitem a promoção e manutenção da saúde com organização de programas de suporte com atividades em grupo sob coordenação da enfermeira, elemento facilitador no processo de conscientização da pessoa acerca da tomada de decisão quanto às ações de autocuidado para preservação da saúde e autonomia na realização das atividades de vida diária e melhoria da qualidade de vida / This is a qualitative, descriptive research, the type Case Study on the person with sickle cell disease in emergency unit that aimed to: analyze the limits and possibilities of the nursing staff caring person with sickle cell disease in the emergency department identify the care needs of people with sickle cell disease in the emergency department and describe how the nursing staff takes care of the person with sickle cell disease in the emergency department. The study was developed in a State Public Hospital, highly complex, located in the city of Rio de Janeiro, specializing in hematology, reference in caring for people with hematologic disease. The study included 32 people, including 20 customers with DF admitted to the emergency department and 12 members of the nursing staff who work in that sector. The production data was developed from April to September 2014, by the simple observation techniques and semi-structured interview. After data content analysis emerged the following thematic categories: The person with sickle cell disease in the emergency department and the nursing care the person with sickle cell disease. The experience of people with sickle cell disease is usually associated with pain and occurrence of multiple hospitalizations in emergency, mainly due to the pain, the most common clinical aggravation of the disease, which causes patients to suffer seek treatment for relief from this event and support the other complications related to the development of the disease. The care the person with PD, therefore, involves in addition to treatment, consider the social, historical and cultural factors that permeate the experience related to the disease and are intertwined in ways of acting of their own customers and professionals alike in health institutions. To take care of these people members of the nursing team must be prepared to identify and assess their needs, for the well being and autonomy of the same by a careful and sensitive listening to their physical, psychological and social demands for the planning and implementation of care that provide effective clinical improvement, comfort and safety while in the emergency room, which requires infrastructure human resources and materials. Considering that the person with sickle cell disease need for continuing health care, it is essential to establish active participation of the same strategies in self-care and treatment through educational activities that enable the promotion and maintenance of health programs supported organization with activities in group coordinated by nurse facilitator in the person's awareness about process of decision making regarding self-care actions to preserve the health and autonomy in activities of daily living and improved quality of life

La drépanocytose résulte d’une mutation du gène β-globine entrainant la synthèse d’une hémoglobine anormale, l’HBS, qui polymérise en condition désoxygénée. Le globule rouge deviendra plus rigide et plus fragile, donnant lieu a deux conséquences majeures : l’hémolyse accrue et l’occlusion vasculaire.Récemment, un nouvel acteur moléculaire, l’adénosine, a été identifie. Ce nucléoside présente des effets bénéfiques sur les atteintes pulmonaires en inhibant l’activation des cellules « tueur naturel t inductibles », mais aussi délétères en favorisant la polymérisation de l’HBS et la survenue du priapisme, une des complications drépanocytaires.Les travaux menés ont pour objectifs d’étudier les effets délétères potentiels de l’adénosine, à travers l’étude de l’implication des enzymes de la voie métabolique de l’adénosine dans l’hémolyse ainsi que dans la survenue du priapisme chez des patients drépanocytaires. Pour ce faire, une cohorte composée d’adultes et d’enfants SS a été étudiée. Les résultats obtenus ont permis de préciser le rôle du métabolisme de l’adénosine dans les mécanismes physiopathologiques de la drépanocytose. Nos résultats n’ont pas permis de mettre en évidence de différence d’expression (ARN, protéine) des enzymes du métabolisme de l’adénosine entre les patients présentant des antécédents priapiques et ceux indemnes de cette complication. Néanmoins, nos recherches ont permis d’identifier l’adénylate cyclasse 6 comme gène modulateur de l’hémolyse et d’apporter de nouveaux éléments en accord avec la classification du priapisme comme appartenant au sous-phénotype hyperhémolytique à travers notamment l’étude des caractéristiques hemorhéologiques. / Sickle-cell disease is caused by a mutation in the β-globin gene leading to an abnormal hemoglobin, hbs. This change allows polymerization of HBS when deoxygenated. Erythrocytes become more rigid and fragile, leading to the two major manifestations of the disease: hemolysis and vaso-occlusion.Recently, adenosine has been identified as a new molecular actor of this disease. This nucleoside may have beneficial effects by preventing inkt cells activation and pulmonary inflammation. But it may also exhibit deleterious effects by activing a signalling pathway leading to erythrocyte sickling and the occurrence of priapism, a sickle cell disease complication.The purpose of our work, based on the potential deleterious effects induced by adenosine was to precise the involvement of adenosine metabolic pathway enzymes in hemolysis and the occurrence of priapism. Two cohorts of children and adult ss patients and men ss have been studied respectively.Our results had clarified the role of metabolism of adenosine in the pathophysiological mechanisms of sickle cell disease. Our results did not allow detecting evidence of differential expression (rna, protein levels) of adenosine metabolism enzymes between ss adult patients exhibiting priapic events and those who had never experienced this complication. Nevertheless, our work has led to the identification of adenylate cyclase as modifier gene of hemolysis and has bring new elements on the priapism classification to the hyper hemolytic sub-phenotype with the description of the hemorheological features associated with this complication.

La famille est une ressource potentielle pour les personnes malades, mais la fratrie est moins souvent étudiée que les parents. Il est important de comprendre ce que vivent les frères et sœurs d’un enfant atteint d’une maladie létale comme la drépanocytose, maladie génétique se manifestant par des crises de douleur et par l’anémie chronique. S’inscrivant dans une approche compréhensive, cette thèse a exploré, via l’entretien et le dessin de la famille, le vécu de 4 frères et 10 sœurs d’enfants atteints de drépanocytose rencontrés au Cameroun dans 9 familles différentes. L’analyse des entretiens et celle des dessins mettent montrent que les enfants donnent sens à la maladie en s'appuyant sur des représentations traditionnelles et occidentales. Ils ressentent des sentiments d’impuissance, de culpabilité, de honte et vivent le malade comme étrange durant les crises. Ils disent avoir peur d’être atteints à leur tour et désirent/craignent la mort de l’enfant malade. Chacun se sent seul, la fratrie n’est pas une ressource et parler de la maladie est problématique. L’enfant malade est vécu comme une victime passive, pas comme un frère. Cette thèse montre les spécificités du vécu de ces enfants et souligne comme d’autres travaux sur la fratrie la nécessité de proposer un accompagnement aux frères et sœurs et à l’enfant malade pour qu’il puisse être/devenir un enfant parmi les autres. / The family is a potential social resource for sick people. However, under such circumstances, siblings are less often considered and even studied than parents. It is important to understand how siblings of a child with a chronic condition such as sickle cell disease cope with the situation. This genetic disease is characterized with pain and chronic anemia, generally unpredictable. This dissertation explored the experiences of 4 brothers and 10 sisters of children with sickle cell disease met in 9 different families in Cameroon through the clinical interview and the family drawing. The analysis of interviews and the analysis of family drawings highlight the children give meaning to the disease by relying on traditional and Western representations. They have feelings of helplessness, guilt, shame and experience the sick as strange during crises. They are afraid of being contaminated as well while having ambivalent feelings whereby they wish for the sick sibling’s death while at the same time exhibiting fear of the same. They feel lonely, siblings are not a resource and talking about the disease is a challenge. The sick child is perceived as a passive victim, not like a brother. This dissertation shows the specificities of the experiences of these siblings and emphasizes the need to offer a listening ear among them and the sick child so that he/she can be/become a child among others.

Sickle cell trait (SCT) is a very prevalent disorder in the United States, especially among African Americans or people of African descent. However, even with the prevalence of the disorder, there are no standardized guidelines for providing patients with information about SCT and the implications of the disorder at physicals and well-check visits. The purpose of this evidence-based project was to increase awareness for African American patients 18-44 years old in the practice setting about SCT and to provide options for testing and genetic counseling. Kotter's contemporary change theory was used as a guide to implement the new practice approach. A quasi-experimental, single-group, pretest-posttest-only design was used to explore the relationship between providing consistent SCT education and the impact on the rate of SCT screening and genetic counseling. A total of 71 patients participated in the program. The analysis showed a significant (p < 0.001) mean difference of 18.16 points from the preintervention SCT and genetics test mean, which indicated that the intervention was successful in raising SCT and genetics knowledge scores among the target population. The results demonstrated that the implementation of SCT education in the practice setting can enhance social implications related to SCT awareness and opportunities for SCT testing and genetic counseling. The implementation of SCT clinical guidelines can help to increase awareness about SCT and improve the overall population health and reduce the financial burden affiliated with care of those with sickle cell disease and SCT complications.

Nigeria has high rates of sickle cell disease (SCD), which is attributed to the lack of awareness of the disease among the reproductive age in the country. The purpose of this cross-sectional study was to explore the role of religious leaders in contributing to awareness and prevention of SCD in Nigeria. Religious leaders' knowledge, attitude, and prevention and awareness practices of SCD, and how they translated to the prevention of SCD through improved counseling of premarital couples, were explored. A stratified random sampling was employed in selecting a sample of 150 religious leaders from different religious affiliations. Data were collected through a survey of sampled religious leaders in Nigeria by use of semi-structured questionnaires. Correlation analysis was used to determine the relationship among the variables under study. According to study findings, the level of knowledge towards SCD among the religious leaders was high. Additionally, there was no significant relationship between the religious leaders' knowledge of SCD and their efforts in increasing testing and genetic counseling among their congregation members. The level of awareness among the religious leaders did not contribute to the prevention of SCD in the country. The implications for positive social change from this research include religious leaders' commitment to emphasizing genotype testing during regular premarital counseling sessions and including religious leaders in health promotion activities, especially SCD prevention.

Oral health may serve as an indicator of overall systemic health, with each disease or condition manifesting differently in the oral cavity. Sickle cell disease (SCD) is a genetic disorder in which sickled red blood cells cause blood vessel occlusion and potentially bleeding in specific sites (e.g., gastrointestinal and intracranial bleeding). With SCD being one of the most common hereditary diseases in the world, it is essential to understand the disease and improve awareness to better treat this population. While studies have been done to evaluate the oral health of persons with SCD, few have explored the occurrence of gingival bleeding and their experience with dental care. Due to this gap in the literature, the present study investigates the potential relationship between SCD, gingival bleeding, and certain other oral manifestations. Adults with and without SCD responded to an online questionnaire regarding oral health and dental care. The data was collected and analyzed during the 2022 spring semester. The data collected from Qualtrics was downloaded into JASP for statistical analysis. While there was a greater prevalence of gingival bleeding and caries in those with SCD, analysis of the sample showed no significant association between the oral manifestations and SCD. A deeper subgroup analysis suggested that those with SCD and no employment may be at higher risk for dental caries, orofacial pain, and gingival bleeding. Further investigation is necessary to determine the direct effect of the disease. The findings may justify further studies to include clinical evaluations by oral health care providers and larger quantity of participants. A better understanding of the relationship between SCD and oral health may lead to oral hygiene improvement strategies geared explicitly toward persons with SCD.