Fluid strategies and outcomes in patients with acute respiratory distress syndrome, systemic inflammatory response syndrome and sepsis: a protocol for a systematic review and meta-analysis

Background
Fluid administration to critically ill patients remains the subject of considerable controversy. While intravenous fluid given for resuscitation may be life-saving, a positive fluid balance over time is associated with worse outcomes in critical illness. The aim of this systematic review is to summarise the existing evidence regarding the relationship between fluid administration or balance and clinically important patient outcomes in critical illness.

Methods
We will search Medline, EMBASE, the Cochrane Central Register of Controlled Trials from 1980 to the present and key conference proceedings from 2009 to the present. We will include studies of critically ill adults and children with acute respiratory distress syndrome (ARDS), sepsis and systemic inflammatory response syndrome (SIRS). We will include randomised controlled trials comparing two or more fluid regimens of different volumes of fluid and observational studies reporting the relationship between volume of fluid administered or fluid balance and outcomes including mortality, lengths of intensive care unit and hospital stay and organ dysfunction. Two independent reviewers will assess articles for eligibility, data extraction and quality appraisal. We will conduct a narrative and/or meta-analysis as appropriate.

Discussion
While fluid management has been extensively studied and discussed in the critical care literature, no systematic review has attempted to summarise the evidence for post-resuscitation fluid strategies in critical illness. Results of the proposed systematic review will inform practice and the design of future clinical trials.

Systematic review registration
PROSPERO CRD42013005608. (http://​www.​crd.​york.​ac.​uk/​PROSPERO/​)

Ansiedade social e assertividade na adolescência

O presente trabalho pretende caracterizar a associação entre ansiedade social e assertividade na adolescência, bem como desenvolver um modelo compreensivo e de intervenção teórica e empiricamente fundamentado acerca desta problemática. A ansiedade social é definida por medo intenso em situações sociais, associado a crenças negativas predisponentes e comportamentos de segurança ou evitamento subsequentes de situações sociais. A assertividade consiste numa resposta comportamental de auto-expressão empática, fundamentada em crenças positivas e activação emocional reduzida. Assim, estes dois conceitos parecem estar em dissonância, uma vez que, por definição, a ansiedade social surge associada a défice de comportamentos sociais adequados e a assertividade a diminuída activação ansiosa em eventos sociais. Por outro lado, ansiedade social e défice assertivo poderão fundamentar-se em mecanismos psicológicos semelhantes. Para verificar estas duas premissas, o presente trabalho utilizou uma amostra de 679 adolescentes do ensino secundário público de ambos os sexos. Para avaliar a ansiedade social nas três dimensões do funcionamento psicológico foram utilizadas a Escala de Crenças e Pensamentos Sociais e a Escala de Ansiedade e Evitamento de Situações Sociais para Adolescentes. No caso da assertividade, foram utilizados o Questionário de Esquema Interpessoal Assertivo e Escala de Comportamento Interpessoal. A análise de dados permite verificar a existência de uma associação recíproca negativa entre ansiedade social e assertividade, em todos os níveis considerados. Igualmente, os resultados obtidos indicam que esta associação poderá ser fundamentada na existência de baixas crenças sociais positivas que activam pensamentos sociais negativos e subsequentemente ansiedade e desconforto em situações sociais e reduzida frequência de comportamento assertivo. Esta conclusão fundamentou uma intervenção integrada para a promoção da gestão de ansiedade social e da prática de competências assertivas. Esta intervenção foi construída, implementada e avaliada em dois ensaios clínicos junto a 6 adolescentes. Os resultados de significância clínica indicam que o programa tem eficácia terapêutica, ainda que este estudo preliminar não exclua a necessidade de uma avaliação mais aprofundada do benefício associado a esta intervenção. Estes trabalhos assumem, assim, implicações educativas e terapêuticas, ao permitir explicitar e clarificar a associação entre ansiedade social e assertividade, e ao contribuir para o desenvolvimento e avaliação de formas de intervenção adequadas junto ao adolescente social tímido ou inibido. A compreensão e intervenção preventiva para a promoção do ajustamento psicossocial do adolescente emergem como uma realidade possível, pertinente e acessível a todos os agentes educativos.

Ruthenium(II)-trithiacyclononane complexes as potential antitumourals

Os únicos complexos metálicos presentemente utilizados em quimioterapia compreendem exclusivamente compostos de platina, com as desvantagens de apresentarem um leque de acção restrito e de provocarem sérios efeitos secundários. Na constante procura por novos fármacos antineoplásicos metálicos, os complexos de ruténio têm sido apresentados como uma alternativa adequada e existem já dois complexos de Ru(III) em ensaios clínicos. Estes são descritos como pró-fármacos, postulando-se que o seu mecanismo de acção envolva redução in vivo para originar complexos de Ru(II) activos. Assim, o actual desenvolvimento de fármacos antitumorais baseados em ruténio passará por criar novos complexos de Ru(II). O trabalho aqui descrito enquadra-se neste objectivo, tendo sido sintetizados complexos de ruténio(II)-tritiaciclononano com ligandos biologicamente activos, e avaliada a sua actividade antitumoral in vitro. Os ligandos utilizados compreendem um hidroxifenilpirazole, aminoácidos e derivados, flavonóides e quinonas. No primeiro capítulo do trabalho são apresentados os actuais desafios no desenvolvimento de complexos metálicos para quimioterapia e é ilustrada a importância dos complexos de Ru(II) aqui descritos no panorama actual de investigação. No capítulo dois, é apresentada uma descrição pormenorizada dos procedimentos experimentais, materiais e equipamentos utilizados na síntese, caracterização e ensaios biológicos. O capítulo três é dividido em duas sub-secções, a primeira analisando os resultados das sínteses e a caracterização estrutural dos complexos, e a segunda apresentando os resultados da sua actividade antiproliferativa. Foram obtidos onze novos complexos de ruténio(II)-tritiaciclononano, com rendimentos razoáveis. São apresentadas propostas das suas estruturas moleculares, sendo que estas mostram uma variedade interessante de modos de coordenação de acordo com os diferentes ligandos, ou seja, N, N,O, O,O e O. A actividade antiproliferativa dos complexos e dos respectivos ligandos foi avaliada em quatro linhas celulares tumorais, representativas de três tipos de cancro: osso (MG-63), próstata (PC-3) e mama (MCF-7 e MDA-MB-231). Quatro dos novos complexos demonstraram uma actividade antiproliferativa promissora, ou seja, aqueles que apresentam um hidroxifenilpirazole, a 3,7-dihidroxiflavona, a plumbagina ou a juglona na sua esfera de coordenação. Entre estes resultados, destacam-se os valores de IC50 para a linha celular MDA-MB-231 por se apresentarem inferiores ao apresentado pelo complexo de Ru(II)-tritiaciclononano mais activo descrito na literatura.

Diopside-fluorapatite-wollastonite based bioactive glasses and glass-ceramics

Bioactive glasses and glass–ceramics are a class of biomaterials which elicit special response on their surface when in contact with biological fluids, leading to strong bonding to living tissue. This particular trait along with good sintering ability and high mechanical strength make them ideal materials for scaffold fabrication. The work presented in this thesis is directed towards understanding the composition-structure-property relationships in potentially bioactive glasses designed in CaOMgOP2O5SiO2F system, in some cases with added Na2O. The main emphasis has been on unearthing the influence of glass composition on molecular structure, sintering ability and bioactivity of phosphosilicate glasses. The parent glass compositions have been designed in the primary crystallization field of the pseudo-ternary system of diopside (CaO•MgO•2SiO2) – fluorapatite (9CaO•3P2O5•CaF2) – wollastonite (CaO•SiO2), followed by studying the impact of compositional variations on the structure-property relationships and sintering ability of these glasses. All the glasses investigated in this work have been synthesized via melt-quenching route and have been characterized for their molecular structure, sintering ability, chemical degradation and bioactivity using wide array of experimental tools and techniques. It has been shown that in all investigated glass compositions the silicate network was mainly dominated by Q2 units while phosphate in all the glasses was found to be coordinated in orthophosphate environment. The glass compositions designed in alkali-free region of diopside – fluorapatite system demonstrated excellent sintering ability and good bioactivity in order to qualify them as potential materials for scaffold fabrication while alkali-rich bioactive glasses not only hinder the densification during sintering but also induce cytotoxicity in vitro, thus, are not ideal candidates for in vitro tissue engineering. One of our bioglass compositions with low sodium content has been tested successfully both in vivo and in preliminary clinical trials. But this work needs to be continued and deepened. The dispersing of fine glass particles in aqueous media or in other suitable solvents, and the study of the most important factors that affect the rheology of the suspensions are essential steps to enable the manufacture of porous structures with tailor-made hierarchical pores by advanced processing techniques such as Robocasting.

Lipidomic analysis of mesenchymal cells candidates for cell therapy

Mesenchymal stromal cells are adult stem cells found mostly in the bone marrow. They have immunosuppressive properties and they have been successfully applied as biological therapy in several clinical trials regarding autoimmune diseases. Despite the great number of clinical trials, MSCs’ action is not fully understand and there are no identified markers that correlate themselves with the immunomodulatory power. A lipidomic approach can solve some of these problems once lipids are one of the major cells’ components. Therefore, in this study cells’ lipidome was analysed and its deviations were evaluated according to the medium of culture and to the presence of pro-inflammatory stimuli, mimicking physiological conditions in which these cells are used. This was the first study ever made that aimed to analyse the differences in the phospholipid profile between mesenchymal stromal cells non-stimulated and stimulated with proinflammatory stimulus. This analysis was conducted in both cells cultured in medium supplemented with animal serum and in cells cultured in a synthetic medium. In cells cultured in the standard medium the levels of phosphatidylcholine (PC) species with shorter fatty acids (FAs) acyl chains decreased under pro-inflammatory stimuli. The level of PC(40:6) also decreased, which may be correlated with enhanced levels of lysoPC (LPC)(18:0) - an anti-inflammatory LPC - observed in cells subjected to TNF-α and IFN-γ. Simultaneously, the relative amounts of PC(36:1) and PC(38:4) increased. TNF-α and IFN- γ also enhanced the levels of phosphatidylethanolamine PE(40:6) and decreased the levels of PE(38:6). Higher expression of phosphatidylserine PS(36:1) and sphingomyelin SM(34:0) along with a decrease in PS(38:6) levels were observed. However, in cells cultured in a synthetic medium, TNF-α and IFN-γ only enhanced the levels of PS(36:1). These results indicate that lipid metabolism and signaling is modulated during mesenchymal stromal cells action.

Antimicrobial resistance and synergy in herbal medicine

Antimicrobial resistance (AMR) is a serious and growing threat to human health. The development of new antibiotics is limited and slow. The tradition of synergy in herbal medicine is being used as a source of research ideas. A literature review of antimicrobial research and plant synergy published in a five year period was carried out using online databases. The in vitro findings were that most of the research reported synergy both within plants and between plants and antibiotics. Whole plant extracts and combinations of compounds were shown to be more effective antimicrobials than isolated constituents. The discussion highlights that the in vitro herbal research findings are difficult to apply to practice and aren’t progressing to clinical trials. Collaborative, innovative, inter-disciplinary clinical research is recommended.

Characterization of TRIB2 following PI3K inhibition

Dissertação de mestrado, Oncobiologia,(Mecanismos Moleculares do Cancro), Departamento de Ciências Biomédicas e Medicina, Universidade do Algarve, 2015

Évaluation prospective de l’état nutritionnel et risque de complications post-opératoires de la cystectomie radicale

La cystectomie radicale est le traitement de référence pour les cancers de la vessie infiltrant le muscle. Cette chirurgie entraine un taux élevé de complications et diminue la qualité de vie des patients à court et à long terme. Une revue de la littérature a d’abord été effectuée afin d’identifier les facteurs de l’état nutritionnel associés au risque de complications et de mortalité après la cystectomie radicale. L’hypoalbuminémie a été identifiée comme un prédicteur potentiel de la mortalité post-opératoire. Une étude de cohorte a ensuite été menée afin d’identifier des facteurs de l’état nutritionnel associés au risque de développer des complications après cette chirurgie. Un indice de masse corporelle élevé, une baisse de l’appétit, une perte de poids, une hypo-albuminémie et une hypo-préalbuminémie avant l’opération sont les facteurs qui ont été associés au développement de complications post-opératoires. Des analyses et des études supplémentaires doivent être menées dans l’optique développer des interventions qui pourraient diminuer le risque de complications après la cystectomie radicale.

Using genomics for drug discovery in medulloblastoma

Tese de doutoramento, Medicina (Neurocirurgia), Universidade de Lisboa, Faculdade de Medicina, 2014

Constructing a 7-day Ahead Forecast Model for Grass Pollen at North London, United Kingdom

A number of media outlets now issue medium-range (~7 day) weather forecasts on a regular basis. It is therefore logical that aerobiologists should attempt to produce medium-range forecasts for allergenic pollen that cover the same time period as the weather forecasts. The objective of this study is to construct a medium-range (< 7 day) forecast model for grass pollen at north London. The forecast models were produced using regression analysis based on grass pollen and meteorological data from 1990-1999 and tested on data from 2000 and 2002. The modelling process was improved by dividing the grass pollen season into three periods; the pre-peak, peak and post peak periods of grass pollen release. The forecast consisted of five regression models. Two simple linear regression models predicting the start and end date of the peak period, and three multiple regression models forecasting daily average grass pollen counts in the pre-peak, peak and post-peak periods. Overall the forecast models achieved 62% accuracy in 2000 and 47% in 2002, reflecting the fact that the 2002 grass pollen season was of a higher magnitude than any of the other seasons included in the analysis. This study has the potential to make a notable contribution to the field of aerobiology. Winter averages of the North Atlantic Oscillation were used to predict certain characteristics of the grass pollen season, which presents an important advance in aerobiological work. The ability to predict allergenic pollen counts for a period between five and seven days will benefit allergy sufferers. Furthermore, medium-range forecasts for allergenic pollen will be of assistance to the medical profession, including allergists planning treatment and physicians scheduling clinical trials.

Towards the therapeutic use of regulatory T cells for the treatment of human autoimmune diseases

Tese de doutoramento, Medicina (Imunologia Clínica), Universidade de Lisboa, Faculdade de Medicina, 2016

Telaprevir or boceprevir based therapy for chronic hepatitis C infection: Development of resistance-associated variants in treatment failure

The use of triple-therapy, pegylated-interferon, ribavirin and either of the first generation hepatitis C virus (HCV) protease inhibitors telaprevir or boceprevir, is the new standard of care for treating genotype 1 chronic HCV. Clinical trials have shown response rates of around 70–80%, but there is limited data from the use of this combination outside this setting. Through an expanded access programme, we treated 59 patients, treatment naïve and experienced, with triple therapy. Baseline factors predicting treatment response or failure during triple therapy phase were identified in 58 patients. Thirty seven (63.8%) of 58 patients had undetectable HCV RNA 12 weeks after the end of treatment. Genotype 1a (p = 0.053), null-response to previous treatment (p = 0.034), the rate of viral load decline after 12 weeks of previous interferon-based treatment (p = 0.033) were all associated with triple-therapy failure. The most common cause of on-treatment failure for telaprevir-based regimens was the development of resistance-associated variants (RAVs) at amino acids 36 and/or 155 of HCV protease (p = 0.027) whereas in boceprevir-based regimens mutations at amino acid 54 were significant (p = 0.015). SVR12 rates approaching 64% were achieved using triple therapy outside the clinical trial setting, in a patient cohort that included cirrhotics.

Comparação dos Perfis Lipídicos de Plasma de uma População da Região Norte

Os ácidos gordos desempenham um papel fisiológico importante como componentes indispensáveis na estrutura celular, bem como fontes de energia. Nas últimas décadas, tem havido um aumento notável do interesse público nos ácidos gordos polinsaturados ómegas 3 e 6 e no seu impacto sobre a saúde humana, especialmente em doenças metabólicas e cardiovasculares. Estes ácidos gordos específicos podem prevenir e/ou tratar várias patologias metabólicas, atuando nomeadamente como compostos anti-inflamatórios. A menopausa é um fator de risco para doença cardiovascular, a diminuição de estrogénio, que ocorre neste estado fisiológico, provoca disfunção endotelial e stresse oxidativo. Consequentemente há uma redução dos níveis de ácidos gordos polinsaturados ómegas 3, o que contribui para o aparecimento de aterosclerose e doença cardiovascular. Neste contexto, o objetivo deste estudo foi avaliar e caracterizar o perfil lipídico de ácidos gordos de uma amostra de mulheres pós-menopausa e com este, estudar as associações entre o perfil lipídico determinado e parâmetros metabólicos de risco (parâmetros clínicos e bioquímicos). Inicialmente, os ácidos gordos foram extraídos da matriz plasmática através da derivatização destes e a sua composição percentual no plasma foi determinada com recurso a cromatografia gasosa com deteção de ionização de chama. De seguida, através do software IBM SPSS Statistics 21, foram estabelecidas associações entre os parâmetros clínicos e bioquímicos e o perfil lipídico determinado. A população em estudo foi divida em dois grupos consoante o período de entrada na menopausa (há menos de 7 anos e há 7 anos ou mais). Não há conhecimento de estudos semelhantes ao apresentado, que relacionem todo o perfil de ácidos gordos com parâmetros metabólicos de risco considerando o estado menopausal. Os resultados obtidos mostram que o perfil lipídico influencia vários marcadores metabólicos / endócrinos com relevância clínica que devem ser explorados em futuros ensaios clínicos. Para as mulheres na menopausa há menos de 7 anos foram estabelecidas as seguintes relações: i) entre os ácidos gordos saturados e insaturados cis e os níveis de ALP; ii) entre os ácidos gordos mono e polinsaturados cis e os níveis de GGT, IL10 e estradiol; iii) entre os ácidos gordos polinsaturados trans e o IMC e os níveis de IL6; iv) entre os ómegas 3 e os níveis de IL10 e ácido úrico; v) entre os ómegas 6 e os níveis de estradiol, ALP e GGT; vi) entre os ómegas 9 e os níveis de estradiol e GGT; vi) entre os ácidos gordos de curta cadeia e os níveis de colesterol total, LDL, triglicerídeos e IL10; vii) entre os ácidos gordos saturados de cadeia longa e o ΣÁcido láurico, mirístico, palmítico e esteárico e os níveis de triglicerídeos, ALP e GGT; viii) os níveis de IL10 podem ser simultaneamente associados com os ácidos gordos de curta cadeia e os ómegas 3. Para as mulheres na menopausa há 7 anos ou mais foram estabelecidas relações: i) entre os ómegas 3 e o IMC e os níveis de triglicerídeos; ii) entre os ácidos gordos monoinsaturados cis e os ómegas 9 com os níveis de ALT. Relações independentes do estado menopausal também foram estabelecidas, nomeadamente: i) entre os ácidos gordos polinsaturados cis e ómegas 6 e os níveis de ALT, triglicerídeos e AST; ii) entre os níveis de ácidos gordos monoinsaturados cis e ómegas 9 e os níveis de AST e triglicerídeos. O perfil lipídico de ácidos gordos pode ser considerado um biomarcador para a condição de saúde da mulher na menopausa.

Economic Evaluation of Ticagrelor for Secondary Prevention Following Acute Coronary Syndromes

INTRODUCTION AND OBJECTIVES: To estimate the cost-effectiveness and cost-utility of ticagrelor in the treatment of patients with acute coronary syndromes (unstable angina or myocardial infarction with or without ST-segment elevation), including patients treated medically and those undergoing percutaneous coronary intervention or coronary artery bypass grafting. METHODS: A short-term decision tree and a long-term Markov model were used to simulate the evolution of patients' life-cycles. Clinical effectiveness data were collected from the PLATO trial and resource use data were obtained from the Hospital de Santa Marta database, disease-related group legislation and the literature. RESULTS: Ticagrelor provides increases of 0.1276 life years and 0.1106 quality-adjusted life years (QALYs) per patient. From a societal perspective these clinical gains entail an increase in expenditure of €610. Thus the incremental cost per life year saved is €4780 and the incremental cost per QALY is €5517. CONCLUSIONS: The simulation results show that ticagrelor reduces events compared to clopidogrel. The costs of ticagrelor are partially offset by lower costs arising from events prevented. The use of ticagrelor in clinical practice is therefore cost-effective compared to generic clopidogrel.

Bioprocess design of canine adenovirus vectors for gene therapy applications

The potential of human adenovirus vectors as vehicles for gene transfer with clinical applications in vaccination, cancer treatment and in many monogenic and acquired diseases has been demonstrated in several studies and clinical trials. However, the clinical use of these vectors can be limited by pre-existing humoral and cellular anti-capsid immunity. One way to circumvent this bottleneck while keeping the advantages of using adenovirus vectors is using non-human viruses such as Canine Adenovirus type 2 (CAV-2). Moreover, CAV-2 vectors present attractive features to develop potential treatment of neurodegenerative and ocular disorders. While the interest in CAV-2 vectors increases, scalable and robust production processes are required to meet the need for preclinical and possibly clinical uses.(...)