Histidine-rich glycoprotein (HRG) is a protein present in plasma at ~ 2 μM, but whose physiologic function is unclear. HRG is a multi-domain protein that contains a unique histidine-rich core that interacts with zinc and hydrogen ions to modulate ligand binding. Due to its modular structure and capacity to sense local changes in zinc and pH, HRG binds several ligands including complement proteins, phospholipids, DNA, fibrin(ogen), heparin, factor (F) XIIa and plasmin. Thus, it is hypothesized that HRG functions as an accessory or adapter protein that bridges different ligands together. Despite the array of ligands and potential involvement in immunity, angiogenesis, coagulation and fibrinolysis, no clear role for HRG has emerged. Congenital HRG deficiency in humans has been associated with a variable phenotype; some investigators report increased susceptibility to thrombosis while others do not. However, studies in HRG-deficient mice reveal that HRG attenuates coagulation. Coagulation is initiated via the intrinsic (or contact) and extrinsic (or tissue factor) pathways and culminates in the generation of thrombin. Thrombin catalyzes the conversion of fibrinogen into a fibrin meshwork that reinforces the platelet plug at sites of vascular injury. There are two circulating isoforms of fibrinogen that differ with respect to their γ-chains. Bulk fibrinogen is composed of a pair of γA-chains, and is designated γA/γA-fibrinogen, whereas a minor variant contains a γA-chain and a γʹ-chain, and is designated γA/γʹ-fibrinogen. The γʹ-chain contains an anionic 20-amino acid residue extension at its COOH-terminus, which provides an accessory binding site for thrombin. Thrombin possesses an anion binding pocket termed exosite II that flanks the active site and mediates its interaction with the γʹ-chain of fibrinogen. Exosite II is an evolutionary feature that is unique to thrombin, as this region is not observed on the prototypic serine protease trypsin or on other defibrinogenating enzymes from snake venom such as batroxobin. Although the physiologic function of the thrombin-γʹ-chain interaction is unclear, it is proposed that this interaction modulates thrombin’s activity when it is bound to fibrin clots. Consistent with this, we show that γA/γʹ-fibrin attenuates thrombin’s capacity to promote clot expansion compared with thrombin bound to γA/γA-fibrin clots, thereby demonstrating that γA/γʹ-fibrin attenuates thrombin’s activity. In the presence of physiologic concentrations of zinc, HRG binds the γʹ-chain of fibrino(gen) and competes with thrombin for binding, thereby suggesting that HRG is a unique modulator of thrombin activity on fibrin clots. Platelets store zinc and HRG in their α-granules and release both components when they undergo activation at sites of injury, which localizes HRG in the vicinity of fibrin-bound thrombin. Consistent with the role of HRG in modulating coagulation, we also show that HRG attenuates contact activation of coagulation, but has no impact on clotting initiated by the extrinsic pathway. The intrinsic pathway is initiated when FXII is activated by polyanions such as RNA and DNA, which are released into the blood after cellular activation, injury or death. FXIIa activates FXI, thereby propagating coagulation and leading to thrombin generation and fibrin formation. Recently, studies using rodent, rabbit and non-human primate models of thrombosis have shown that knock down of FXII or FXI with antisense oligonucleotides or blocking FXIIa or FXIa activity with inhibitors attenuates thrombosis, while having a minimal impact on hemostasis. With increasing evidence that the intrinsic pathway plays an important role in thrombosis, FXII and FXI have emerged as prominent targets for new anticoagulants. However, little is known about how the intrinsic pathway is regulated, so as to prevent uncontrolled clotting. HRG attenuates the intrinsic pathway by binding both FXIIa and the contact activators, RNA and DNA. By binding nucleic acids, HRG is localized to the site of contact activation, where it is poised to inhibit FXIIa. HRG binds to an allosteric region on FXIIa and attenuates its capacity to feedback activate FXII and to activate FXI, thereby inhibiting the initiating steps of contact activation. In addition, HRG attenuates the cofactor role of RNA and DNA in thrombin activation of FXI, which is an important feedback step. With the capacity to modulate multiple steps in the intrinsic pathway, HRG likely serves as a dynamic regulator of contact activation. We tested our hypothesis that HRG is a novel inhibitor of the intrinsic pathway in a murine model of FeCl3-induced arterial injury. HRG-deficient mice exhibit accelerated thrombosis compared with wild type controls, an effect that was abolished by repletion with human HRG. Therefore, these studies indicate that HRG deficiency induces a prothrombotic phenotype. Consistent with the role of HRG as a modulator of the intrinsic pathway, we show that thrombosis after the FeCl3-induced arterial injury is attenuated by administration of RNase, but not DNase, or by knock down of FXII, but not FVII. Therefore, these studies show that thrombosis in this model is induced by RNA and occurs in a FXII-dependent manner. Furthermore, blood loss after tail tip amputation is similar in HRG-deficient and wild type mice, demonstrating that HRG does not modulate hemostasis. Therefore, these studies suggest that HRG is a dynamic regulator of the intrinsic pathway, and acts as a molecular brake to limit procoagulant stimuli. The observations that HRG binds fibrin(ogen), FXIIa and nucleic acids and modulates the thrombin-γʹ-interaction and intrinsic pathway of coagulation, suggest that HRG is a key regulator of coagulation. HRG, the contact system and fibrin are also important in the innate immune response, demonstrating that the interaction of HRG with these factors may provide a unique link between coagulation and immunity. Since immune cells and the coagulation system contribute to both deep vein thrombosis and sepsis, further characterization of the role of HRG in these conditions will contribute to a better understanding of the pathophysiological role of HRG, and may identify novel therapeutic directions. / Thesis / Doctor of Philosophy (PhD)

Protein Kinase C delta (PKCδ) is expressed in platelets and activated downstream of protease-activated receptors (PAR)s and glycoprotein VI (GPVI) receptors. We evaluated the role of PKCδ in platelets using two approaches - pharmacological and molecular genetic approach. In human platelets pretreated with isoform selective antagonistic RACK peptide (δV1-1)TAT, and in the murine platelets lacking PKCδ, PAR4-mediated dense granule secretion was inhibited, whereas GPVI-mediated dense granule secretion was potentiated. These effects were statistically significant in the absence and presence of thromboxane A2 (TXA2). Furthermore, TXA2 generation was differentially regulated by PKCδ. However, PKCδ had a small effect on platelet P-selectin expression. Calcium- and PKC-dependent pathways independently activate fibrinogen receptor in platelets. When calcium pathways are blocked by dimethyl-BAPTA, AYPGKF-induced aggregation in PKCδ null mouse platelets and in human platelets pretreated with (δV1-1)TAT, was inhibited. In a FeCl3-induced injury in vivo thrombosis model, PKCδ-/- mice occluded similar to their wild-type littermates. Hence, we conclude that PKCδ differentially regulates platelet functional responses such as dense granule secretion and TXA2 generation downstream of PARs and GPVI receptors, but PKCδ deficiency does not affect the thrombus formation in vivo. We further investigated the mechanism of such differential regulation of dense granule release by PKCδ in platelets. SH2 domain-containing Inositol Phosphatase (SHIP)-1 is phosphorylated on Y1020, a marker for its activation, upon stimulation of human platelets with PAR agonists, SFLLRN and AYPGKF, or GPVI agonist, convulxin. GPVImediated SHIP-1 phosphorylation occurred rapidly at 15 sec whereas PAR-mediated phosphorylation was delayed, occurring at 1 min. Lyn and SHIP-1, but not SHIP-2 or Shc, preferentially associated with PKCδ upon stimulation of platelets with a GPVI agonists, but not with a PAR agonist. In PKCδ null murine platelets, convulxin-induced SHIP-1 phosphorylation was inhibited, suggesting that PKCδ regulates the phosphorylation of SHIP-1. Furthermore, in Lyn null murine platelets, GPVI-mediated phosphorylations on Y-1020 of SHIP-1, Y311 and Y155 of PKCδ were inhibited. In murine platelets lacking Lyn, or SHIP-1, GPVI-mediated dense granule secretions were potentiated, whereas PAR-mediated dense granule secretions were inhibited. Phosphorylated SHIP-1 associated with phosphorylated-Y155 PKCδ peptide. Therefore, we conclude that Lyn-mediated phosphorylations of PKCδ and SHIP-1 and their associations negatively regulate GPVI-mediated dense granule secretion in platelets. / Physiology

Platelets are crucial components of the hemostatic machinery of the body. When the endothelial continuity is disrupted due to injury or atherosclerotic plaque rupture, one of the earliest responses to arrest the bleeding is the adhesion of circulating platelets to the exposed subendothelial collagen matrix. Subsequent intracellular signaling mediated downstream of various receptor systems leads to alpha IIb beta 3 activation, thromboxane generation, ADP release, etc., culminating in platelet clot or thrombus formation. The protein kinase family of enzymes mediates a significant number of these intracellular signaling events that culminate in platelet activation. These enzymes can be broadly classified into two classes- tyrosine kinases and serine/threonine kinases. Syk (spleen tyrosine kinase) is an important non-receptor tyrosine kinase present in platelets and plays an important role downstream of GPVI-FcR gamma chain receptor complex activation. We studied the effects of curcumin (diferuloylmethane), which is the active ingredient found in the herbal remedy and food spice turmeric, on the GPVI-mediated platelet activation. We have found that it significantly inhibits the kinase activity of Syk without affecting its phosphorylation. Pre-incubating the platelets with curcumin for only a minute resulted in a concentration-dependent inhibition of aggregation and secretion, with approximately 75% inhibition observed at 50 mM curcumin. Additionally, the activation-dependent phosphorylation of tyrosines 753/759 on PLC gamma2 and phosphorylation of tyrosine 191 on the transmembrane scaffold protein LAT, were inhibited (p<0.05). However, the phosphorylation of the activation loop tyrosines 525/526 on Syk and of the tyrosine 145 on intracellular adaptor molecule SLP-76 were not significantly affected. Furthermore, the inhibitory action of curcumin on the catalytic activity of Syk was independent of any of its effects on the thromboxane generation because all our studies were performed using aspirin-treated platelets. PKC zeta is an atypical member of the PKC family of serine/threonine kinases. In this study, we have confirmed that it is expressed in human platelets and is constitutively phosphorylated at the activation loop threonine 410 as well as the turn motif threonine 560, which is an autophosphorylation site. Phosphorylation at these two residues has been shown to be important for its kinase activity. Furthermore, agonist-mediated platelet aggregation under stirring condition results in dephosphorylation of the Thr410 residue, which can be prevented by blocking integrin alpha IIb beta 3 by its antagonist SC-57101 (p<0.01). The dephosphorylation of Thr410 can also be prevented by okadaic acid, a Ser/Thr protein phosphatase inhibitor, at concentrations above 100 nM. However, in PP1c gamma null mice, we did not observe any effect on the dephosphorylation, suggesting that other isoforms of PP1 or other classes of the phosphatases could be responsible for this phenomenon, at least in these knockout mice. The basal phosphorylation of Thr560, however, remained unaffected by agonist stimulation, integrin activation, integrin blockade, okadaic acid treatment and in the PP1c gamma null mice. It can be speculated that PKC zeta may be constitutively active under basal resting conditions and acts as a negative regulator of platelet activation or functional responses. The Thr560 autophosphorylation signal alone may not be sufficient to sustain its full enzymatic activity. / Physiology

Background: Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction characterized by a lowered platelet count (50% from baseline) 4-10 days after heparin exposure. Autoantibodies specific for platelet factor 4 (PF4) bind PF4 and heparin complexes (PF4/H) and activate platelets through the FcgammaRIIA receptor. Severe cases of HIT can result in thrombotic complications including deep vein thrombosis, pulmonary embolism, and death. Pathogenic class-switched antibodies against PF4/H (IgG) are detectable in circulation as early as five days post-heparin exposure and peak at 14 days. The timeline and class of antibody found in HIT patients suggest that there must be pre-existing immunity against PF4/H. Thus, B cells producing anti-PF4/H antibodies must exist prior to heparin exposure. Cardiac surgery patients are disproportionately prone to anti-PF4/H seroconversion (up to 70%) and thus are utilized in this study as a model patient group. Research objective: The objective of this study is to determine whether the preoperative immune profile is associated with postoperative anti-PF4/H antibody production in a cohort of patients undergoing cardiac pulmonary bypass (CPB) surgery. Materials and methods: To characterize the preoperative immune profile, we used 1) a peripheral blood mononuclear cell (PBMC) enzyme linked immunospot (ELISPOT) assay to measure the prevalence of preoperative anti-PF4/H specific antibody secreting cells (ASC) and 2) a PF4/H-dependant enzyme immunoassay (EIA) to measure the anti-PF4/H antibodies produced by PBMCs in vitro. To characterize postoperative anti-PF4/H seroconversion in CPB patients, we used a PF4/H dependent EIA to measure in vivo levels of anti-PF4/H antibodies produced postoperatively. We also utilize a functional assay, 14C-serotonin release assay (SRA) to determine if seroconverting patients produced platelet activating antibody. Results: All patients were able to produce anti-PF4/H spots in the ELISPOT; however, this did not correlate with the titer of antibody production in vitro nor did it correlate with antibody production in the postoperative period. Instead, we found that pre-operative in vitro anti-PF4/H IgM production was associated with post-operative IgG anti-PF4/H seroconversion (Spearman’s r=0.39, P=0.018). We observed that 92.1% of CPB patients produced PF4/H antibody at postoperative week 3 with some combination of IgA, IgG, and IgM. Of the anti-PF4/H seropositive patients, 26% developed platelet activating antibody and were found seropositive when the SRA was supplemented with PF4 instead of heparin, while 15.7% were seropositive in the original SRA. It was noted that 4 of 10 patients that caused the most robust platelet activation were also seropositive for anti-PF4/H IgA antibody. Lastly, throughout this serosurveillance study, several patients that demonstrated unique immunological features are presented in this study as case studies. Specifically, we report the preoperative, surgical, clinical and postoperative characteristics for 3 patients of interest: 1) in a preoperative setting, a CPB patient’s PBMC were able to be activated and produce anti-PF4/H IgG antibody in vitro, 2) the second patient had platelet-activating antibodies in circulation prior to intraoperative heparin challenge and early post-surgery 3) the third patient who developed probable HIT. Conclusions: Based on our findings, we conclude that preoperative PF4/H ELISPOTs were unable to predict post-operative production of anti PF4/H antibodies. However, preoperative in vitro production of anti-PF4/H IgM may be associated with postoperative production of anti-PF4/IgG antibody and should be investigated further as this may help to elucidate the mechanisms for anti-PF4/H production related to HIT. / Thesis / Master of Science (MSc)

No description available.

La sévérité potentielle de la thrombose veineuse superficielle (TVS) des membres inférieurs a récemment été documentée par des études réalisées en soins secondaires et tertiaires. Son épidémiologie reste cependant inconnue en soins primaires. Le premier objectif de ce travail était de mesurer la prévalence de la TVS en soins primaires, ainsi que le taux d'évènements thromboemboliques concomitants au moment du diagnostic. Pour y répondre, un réseau de recherche collaborative entre médecins généralistes et médecins vasculaires de la région stéphanoise a été mis en place. Une étude transversale descriptive a été réalisée au sein de ce réseau pendant un an. La prévalence annuelle de la TVS a été mesurée à 0,64 pour mille habitants. Au moment du diagnostic, 24,6% des TVS étaient associées à une thrombose veineuse profonde symptomatique et 4,7% à une embolie pulmonaire symptomatique. Une seconde étude a recherché une variation saisonnière de la fréquence de la TVS en analysant les données individuelles de trois études aux designs différents ; l'étude STENOX, l'étude POST et l'étude STEPH. Une variation significative n'a été retrouvée que dans l'étude POST, et les peak-to-low ratios étaient inférieurs à 1,2 dans les trois études. Ainsi, si une variation existe, celle-ci parait être de faible envergure, sans conséquence sur la pratique et la recherche / The potential severity of superficial vein thrombosis (SVT) of the lower limbs has recently been shown by studies perfomed in secondary and tertiary care. The epidemiology of SVT remains unknown in primary care. The first objective of this study was to measure the prevalence of SVT in primary care, and the rate of concomitant thromboembolic events at diagnosis. A collaborative research network between general practitioners and vascular physicians from Saint-Etienne has been set up. A cross-sectional study has been conducted within this network during one year. The annual prevalence of SVT was measured to 0.64 per thousand inhabitants. At diagnosis, 24.6% of SVT were associated with symptomatic deep vein thrombosis and 4.7% with symptomatic pulmonary embolism. A second study was looking for a seasonal variation of SVT frequency by analyzing individual data from three studies with different designs; the STENOX study, the POST study and the STEPH study. A significant variation was found only in the POST study, and peak-to-low ratios were below 1.2 in the three studies. Thus, if other more powerful and exhaustive studies could find a seasonal variation, that variation would probably be of low magnitude and without clinical significance

Introdução: Pacientes submetidos à amputação de membro inferior por doença arterial obstrutiva periférica (DAOP) estão em risco para o desenvolvimento de trombose venosa profunda (TVP). Há poucos estudos na literatura sobre a incidência no pós-operatório precoce e quanto aos fatores de risco no desenvolvimento da TVP no membro amputado. Objetivo: A finalidade deste estudo é avaliar, de modo prospectivo, a incidência de trombose venosa profunda pós-operatória em até 35 dias, em pacientes submetidos à amputação de membro inferior por doença arterial obstrutiva periférica, sua relação com comorbidades e com óbito. Método: De setembro de 2004 a março de 2006, foram estudados 56 pacientes (29 homens; média de idade 67,25 anos) submetidos a 62 amputações (36 transtibiais e 26 transfemorais), utilizando-se eco-Doppler no pré-operatório e aproximadamente no 7º e 31° dia de pós-operatório. Resultado: Houve TVP em 16 (25,8%) membros amputados, sendo 10 casos em amputações transfemorais e 6 casos em transtibiais. A incidência cumulativa no período até 35 dias foi de 28% (Kaplan-Meier). Houve diferença significativa na incidência de TVP entre amputações transfemorais (37,5%) e transtibiais (21,2%), p = 0,04. Outro fator de risco para TVP foi idade igual ou superior a 70 anos (48,9 vs 16,8%, p=0,021). Houve 01 caso de embolia pulmonar sintomática não fatal em paciente com TVP já diagnosticada. Não houve relação entre outras comorbidades e TVP. A trombose venosa no membro amputado não influenciou na taxa de óbito que foi de 9,7%. Conclusões: A incidência de TVP no pós-operatório recente (até 35 dias) foi elevada principalmente em pacientes com idade igual e superior a 70 anos e nas amputações transfemorais. Os pacientes com DAOP submetidos a grandes amputações devem ser considerados de alto risco para TVP, mesmo após alta hospitalar. / Introduction: Patients undergoing amputation of the lower limb due to Peripheral Arterial Disease (PAD) are at risk for developing Deep Venous Thrombosis (DVT). There are few studies in the research literature on the incidence of DVT during the early postoperative period and the risk factors for the development of DVT in the amputation stump. Objective: The goal of this prospective study was to evaluate the incidence of deep venous thrombosis during the first 35 postoperative days in patients who had undergone amputation of the lower extremity due to PAD, and its relation to comorbidities and death. Method: From September 2004 to March 2006, fifty-six patients (29 men, mean age 67.25 years) underwent 62 amputations (36 below knee amputation BKA and 26 above knee amputation- AKA), and echo- Doppler scanning on preoperative, and approximately the seventh and 31st postoperative days. Results: DVT occurred in 16 (25.8%) of the amputated extremities, (10 AKA and 06 BKA). The cumulative incidence in the 35 day postoperative period was 28% (Kaplan-Meier). There was a significant difference in the incidence of DVT between AKA (37.5%) and BKA (21.2%), p = .04. Another DVT risk factor was age equal to or above 70 years (48.9 vs. 16.8%, p= .021). There was one case of symptomatic non-fatal pulmonary embolism in a patient already diagnosed with DVT. There was no relation between other comorbidities and DVT. Venous Thrombosis in the amputation stump did not influence the mortality rate which was 9.7%. Conclusions: The incidence of DVT in the early post-operative period (up to 35 days) was elevated mainly in patients 70 years of age or older and in AKA. Patients with PAD who have recently undergone major amputations should be considered at high risk for DVT, even after hospital discharge.

Introdução: Pacientes submetidos à amputação de membro inferior por doença arterial obstrutiva periférica (DAOP) estão em risco para o desenvolvimento de trombose venosa profunda (TVP). Há poucos estudos na literatura sobre a incidência no pós-operatório precoce e quanto aos fatores de risco no desenvolvimento da TVP no membro amputado. Objetivo: A finalidade deste estudo é avaliar, de modo prospectivo, a incidência de trombose venosa profunda pós-operatória em até 35 dias, em pacientes submetidos à amputação de membro inferior por doença arterial obstrutiva periférica, sua relação com comorbidades e com óbito. Método: De setembro de 2004 a março de 2006, foram estudados 56 pacientes (29 homens; média de idade 67,25 anos) submetidos a 62 amputações (36 transtibiais e 26 transfemorais), utilizando-se eco-Doppler no pré-operatório e aproximadamente no 7º e 31° dia de pós-operatório. Resultado: Houve TVP em 16 (25,8%) membros amputados, sendo 10 casos em amputações transfemorais e 6 casos em transtibiais. A incidência cumulativa no período até 35 dias foi de 28% (Kaplan-Meier). Houve diferença significativa na incidência de TVP entre amputações transfemorais (37,5%) e transtibiais (21,2%), p = 0,04. Outro fator de risco para TVP foi idade igual ou superior a 70 anos (48,9 vs 16,8%, p=0,021). Houve 01 caso de embolia pulmonar sintomática não fatal em paciente com TVP já diagnosticada. Não houve relação entre outras comorbidades e TVP. A trombose venosa no membro amputado não influenciou na taxa de óbito que foi de 9,7%. Conclusões: A incidência de TVP no pós-operatório recente (até 35 dias) foi elevada principalmente em pacientes com idade igual e superior a 70 anos e nas amputações transfemorais. Os pacientes com DAOP submetidos a grandes amputações devem ser considerados de alto risco para TVP, mesmo após alta hospitalar. / Introduction: Patients undergoing amputation of the lower limb due to Peripheral Arterial Disease (PAD) are at risk for developing Deep Venous Thrombosis (DVT). There are few studies in the research literature on the incidence of DVT during the early postoperative period and the risk factors for the development of DVT in the amputation stump. Objective: The goal of this prospective study was to evaluate the incidence of deep venous thrombosis during the first 35 postoperative days in patients who had undergone amputation of the lower extremity due to PAD, and its relation to comorbidities and death. Method: From September 2004 to March 2006, fifty-six patients (29 men, mean age 67.25 years) underwent 62 amputations (36 below knee amputation BKA and 26 above knee amputation- AKA), and echo- Doppler scanning on preoperative, and approximately the seventh and 31st postoperative days. Results: DVT occurred in 16 (25.8%) of the amputated extremities, (10 AKA and 06 BKA). The cumulative incidence in the 35 day postoperative period was 28% (Kaplan-Meier). There was a significant difference in the incidence of DVT between AKA (37.5%) and BKA (21.2%), p = .04. Another DVT risk factor was age equal to or above 70 years (48.9 vs. 16.8%, p= .021). There was one case of symptomatic non-fatal pulmonary embolism in a patient already diagnosed with DVT. There was no relation between other comorbidities and DVT. Venous Thrombosis in the amputation stump did not influence the mortality rate which was 9.7%. Conclusions: The incidence of DVT in the early post-operative period (up to 35 days) was elevated mainly in patients 70 years of age or older and in AKA. Patients with PAD who have recently undergone major amputations should be considered at high risk for DVT, even after hospital discharge.

Fundamento: Na descompensação da insuficiência cardíaca, pode ocorrer o baixo débito cardíaco, nessa situação o uso de inotrópico pode ser necessário. Se o acesso venoso for periférico, a infusão venosa prolongada de inotrópicos pode levar à flebite. Por outro lado, o acesso venoso central pode apresentar complicações. O Cateter Central de Inserção Periférica (PICC) pode ser uma opção nessa situação. O objetivo do presente estudo foi avaliar a incidência de flebite com o uso do PICC em comparação ao acesso venoso periférico. Métodos: em estudo clínico randomizado foram selecionados pacientes com insuficiência cardíaca congestiva avançada, em uso de inotrópico endovenoso; plaquetas >= 50.000/mm3 e fração de ejeção do ventrículo esquerdo (FEVE) < 0,45. Os pacientes foram randomizados para receberem o PICC ou manter o acesso venoso periférico. O desfecho principal foi à ocorrência de flebite. Os dados foram analisados pela regressão logística. Resultados: Foram incluídos 40 pacientes no Grupo PICC e 40 pacientes no grupo controle. A mediana da idade foi de 61,5 (IQR=16) anos, a FEVE foi de 24,0 (IQR= 10) % e a dose da dobutamina foi de 7,73 (IQR = 5,3) mcg/kg*min. No Grupo PICC a ocorrência de flebite foi de 2,5 % (1 paciente) enquanto no grupo controle foi de 95% (38 pacientes), com razão dos riscos (HR) de 0,1% (IC 95%: 0,0 a 1,6%, P < 0,001). Conclusões: O uso de PICC foi associado a redução da incidência de flebite durante a infusão endovenosa contínua de dobutamina em pacientes com baixo débito cardíaco durante internação por insuficiência cardíaca descompensada / Background: During decompensated heart failure, the use of intravenous inotropes can be necessary. With peripheral venous access, prolonged infusions can cause phlebitis. However, traditional central venous catheters have possible complications. Peripherally inserted central catheters (PICCs) may be an alternative to traditional catheters. Our objective was to compare the incidence of phlebitis between PICCs and catheters used to achieve peripheral venous access. Methods: In a randomized clinical trial, 40 patients were randomized to the PICC group and 40 patients were randomized to thecontrol group. The inclusion criteria were advanced heart failure, ejection fraction < 0.45, and platelets > 50,000/mm3. The patients were randomly assigned to receivea PICC or keep their peripheral venous access. The primary endpoint was the occurrence of phlebitis. Results: We included 40 patients in the PICC group and 40 patients in the control group. The median age was 61.5 (interquartile range [IQR]=16) years, the ejection fraction was 0.24 (IQR=0.10), and the dobutamine dose was 7.73 (IQR=5.3) mcg/kg*min. Phlebitis occurred in 1 patient (2.5%) in the PICC group and in 38 patients (95.0%) in the control group, with a hazard ratio of 0.1% (95% confidence interval [CI]: 0.0%-1.6%, P < 0.001). Conclusion: PICCs were associated with a lower incidence of phlebitis in patients hospitalized for decompensated heart failure with low cardiac output during intravenous dobutamine infusions

Santana, ANC. Estudo da trombose microvascular em biópsias pulmonares de pacientes com Granulomatose de Wegener. [tese]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2008. A granulomatose de Wegener (GW) é associada com eventos trombo-embólicos. Neste trabalho, quantificamos os trombos em artérias pulmonares de pequeno/médio calibre de pacientes com GW (n:24), comparando com um grupo Controle normal (n:16). O resultado mostrou que a área total das artérias no grupo GW foi similar a do grupo Controle. Já a área do trombo foi significativamente maior no grupo GW em relação ao Controle. Em contrapartida, a área livre do lúmen do vaso foi significativamente menor no grupo GW em comparação ao Controle. Concluindo, este estudo demonstra uma obstrução da microcirculação pulmonar na GW, sugerindo um papel da trombose in situ na fisiopatologia desta doença / Wegeners granulomatosis (GW) is associated with thromboembolic events. In this work, we quantified the thrombus in small/medium-sized pulmonary arteries of patients with GW (n:24) compared to normal controls (n:16). The results showed that the GW and control arteries were similar regarding total area. The thrombus area was significantly increased in GW compared to controls; in contrast, the free lumen area was significantly decreased in GW compared to controls. In summary, this study shows obstruction of microvascular bed in GW, suggesting a possible role of thrombosis in situ in pathophysiology of this vasculitis