Predição precoce de risco de Pré-eclâmpsia na doença hipertensiva e diabetes na gravidez: Papel de fatores angiogénicos

RESUMO: A pré-eclâmpsia tem elevada morbi-mortalidade materna e perinatal. A sua etiologia multi-fatorial tem sido objeto de investigação, não sendo ainda totalmente conhecida. Não se conhece também a razão da diferente suscetibilidade individual e das diferentes expressões da doença. A hipertensão crónica e a diabetes são fatores de risco reconhecidos, e o adiamento da maternidade contribui para que estas duas patologias sejam atualmente mais prevalentes entre as mulheres grávidas. Uma vez que o seu quadro fisiopatológico precede em meses o quadro clínico, tem-se investigado a possibilidade de serem encontrados marcadores precoces e indicadores de risco. Em Portugal, os estudos relativos à hipertensão na gravidez são escassos, bem como a investigação sobre fatores de risco e marcadores para a mesma. No sentido de avaliar possíveis marcadores de risco para o desenvolvimento de préeclâmpsia ou complicações hipertensivas foi colhida, para esta dissertação, uma amostra de 1215 mulheres que frequentaram a consulta de Hipertensão ou de Diabetes na gravidez de um centro terciário, entre 2004 e 2013. Optou-se pela realização de três estudos independentes, abrangendo os dois primeiros um leque temporal de 9 e de 2 anos respetivamente. O primeiro, centrado na hipertensão, pesquisou, em 521 mulheres com hipertensão na presente ou em anterior gravidez, fatores de risco capazes de influenciar a progressão para pré-eclâmpsia. O segundo, direcionado para a diabetes gestacional, considerou uma amostra de 334 grávidas, parte das quais tinha também hipertensão crónica e procurou identificar fatores que contribuíram para o aparecimento de complicações hipertensivas. O terceiro estudo, realizado em 2012 e 2013, em três coortes de grávidas com hipertensão crónica, com diabetes gestacional, e sem estas patologias - procurou avaliar no 1º trimestre o comportamento de dois marcadores placentares obtidos no 1º trimestre - proteína plasmática A associada à gravidez (PAPP-A) e o fator de crescimento placentar (PlGF) - e o seu papel, quer como bio-marcadores isolados, quer em associação aos fatores de risco encontrados nos anteriores estudos, na construção de um modelo preditivo de préeclâmpsia. No primeiro estudo, a nuliparidade, a hipertensão gestacional, a fluxometria das artérias uterinas com IP superiores ao P95 entre as 20-22 semanas e a existência de restrição de crescimento fetal, foram os fatores que contribuíram para a construção de um modelo preditivo de pré-eclâmpsia. No segundo estudo, a coexistência de diabetes e hipertensão crónica agravou o prognóstico, associando-se as complicações hipertensivas à multiparidade, obesidade, idade materna e etnia negra. No terceiro estudo verificou-se uma redução da PlGf e da PAPP-A no 1º trimestre nas duas primeiras coortes, comparativamente à coorte sem patologia; na análise separada de cada coorte, quando se verificaram complicações hipertensivas ou pré-eclâmpsia, as concentrações de PlGf e PAPP-A também foram inferiores. Contudo, na elaboração de um modelo preditivo de pré-eclâmpsia, em conjunto com marcadores encontrados, apenas a PlGf pode ser integrada no modelo preditivo, o que se verificou na coorte com hipertensão crónica. Os marcadores bioquímicos em estudo tiveram valores inferiores nas coortes com patologia hipertensiva, demonstrando uma deficiente produção destas proteínas placentares nestas situações, podendo ser importante a sua pesquisa. Contudo, neste estudo, apenas na coorte de hipertensão crónica a PlGf teve participação como fator de risco, na construção de um modelo preditivo de pré-eclâmpsia.--------------------------------------------------------------------------------------------------ABSTRACT: Preeclampsia is associated with a great maternal and perinatal morbimortality. Its multifactorial etiology has been under investigation and is still insufficiently understood. The reason why there are differences in individual susceptibility and differences in expressions of the disease is still unknown. Chronic hypertension and diabetes are known risk factors for preeclampsia and maternity delay contributes to the great prevalence of these pathologies among pregnant women. As the physiopathological signs antedate by months the clinical course of the disease, early risk factors and biological markers are object of clinical research. In Portugal, scarce clinical studies were devoted to hypertension in pregnancy and to risk factors and markers of this pathology. This dissertation inquires 1215 pregnant women who were treated for hypertension or diabetes in a tertiary care center between 2004 and 2013, in order to find risk markers for hypertensive complications or preeclampsia. We conducted three independent studies for this purpose. In the first one we investigated which risk factors could influence the progression to preeclampsia in 521 pregnant women with present or past history of hypertension. The second one was conducted to find what factors were associated to hypertensive complications, with a sample of 334 pregnant women with gestational diabetes, some also with chronic hypertension, addressing the identification of the factors contributing to hypertensive complications. The third study was conducted between 2012 and 2013 with three cohorts of pregnant women, with chronic hypertension, gestational diabetes, and in the third one, pregnant women had a low risk pregnancy. The objective of the study was to evaluate the behavior of two placental markers – PAPP-A and PlGf – obtained in the first trimester, and the role of these markers as isolated biomarkers or in association with other risk factors, in order to define a predictive model of early preeclampsia. In the first study, nuliparity, gestational hypertension, uterine arteries doppler with PI above P95 between 20-22 weeks of gestation and the presence of fetal growth restriction were the markers involved in a predictive model for preeclampsia. In the second study the cohort with the coexistence of diabetes and hypertension had registered worse result and hypertensive complications were associated to multiparity, obesity, maternal age and black ethnicity. In the third study there was a reduction of the PlGf and a PAPP-A concentration for the first trimester in the two first cohorts comparatively to the low risk cohort; the separate analysis of each cohort showed that plGf and PAPP-A concentrations were reduced when hypertensive complications appeared. However, when trying to find a preeclampsia predictive model, only plGf gave significant results for being considered in the model and this was only possible in the chronic hypertension cohort. The biochemical markers investigated in this study were reduced in the cohorts when high blood pressure complications occurred, showing a defective production of these placenta proteins, and suggesting that they should be investigated as first trimester biomarkers. Nevertheless, for this research, in the cohort of chronic hypertension only PlGf had a significant result, when multivariate analysis of all the risk factors was considered for the construction of a preeclampsia predictive model.

Atendimento no Ambulatório de Nutrição Renal da Faculdade de Nutrição da Universidade Federal Fluminense e Hospital Universitário Antônio Pedro : efeitos de um programa de treino de força intradialítica em pacientes renais crónicos

Relatório de estágio de mestrado, Nutrição Clínica, Universidade de Lisboa, Faculdade de Medicina, 2015

Extracellular matrix components in peripheral nerve repair: how to affect neural cellular response and nerve regeneration?

Peripheral nerve injury is a serious problem affecting significantly patients' life. Autografts are the "gold standard" used to repair the injury gap, however, only 50% of patients fully recover from the trauma. Artificial conduits are a valid alternative to repairing peripheral nerve. They aim at confining the nerve environment throughout the regeneration process, and providing guidance to axon outgrowth. Biocompatible materials have been carefully designed to reduce inflammation and scar tissue formation, but modifications of the inner lumen are still required in order to optimise the scaffolds. Biomicking the native neural tissue with extracellular matrix fillers or coatings showed great promises in repairing longer gaps and extending cell survival. In addition, extracellular matrix molecules provide a platform to further bind growth factors that can be released in the system over time. Alternatively, conduit fillers can be used for cell transplantation at the injury site, reducing the lag time required for endogenous Schwann cells to proliferate and take part in the regeneration process. This review provides an overview on the importance of extracellular matrix molecules in peripheral nerve repair.

Structural analysis of Turtle mountain (Alberta) using digital elevation model: Toward a progressive failure

In 1903, the eastern slope of Turtle Mountain (Alberta) was affected by a 30 M m3-rockslide named Frank Slide that resulted in more than 70 casualties. Assuming that the main discontinuity sets, including bedding, control part of the slope morphology, the structural features of Turtle Mountain were investigated using a digital elevation model (DEM). Using new landscape analysis techniques, we have identified three main joint and fault sets. These results are in agreement with those sets identified through field observations. Landscape analysis techniques, using a DEM, confirm and refine the most recent geology model of the Frank Slide. The rockslide was initiated along bedding and a fault at the base of the slope and propagated up slope by a regressive process following a surface composed of pre-existing discontinuities. The DEM analysis also permits the identification of important geological structures along the 1903 slide scar. Based on the so called Sloping Local Base Level (SLBL) an estimation was made of the present unstable volumes in the main scar delimited by the cracks, and around the south area of the scar (South Peak). The SLBL is a method permitting a geometric interpretation of the failure surface based on a DEM. Finally we propose a failure mechanism permitting the progressive failure of the rock mass that considers gentle dipping wedges (30°). The prisms or wedges defined by two discontinuity sets permit the creation of a failure surface by progressive failure. Such structures are more commonly observed in recent rockslides. This method is efficient and is recommended as a preliminary analysis prior to field investigation.

Ventricular arrhythmia in coronary artery disease: limits of a risk stratification strategy based on the ejection fraction alone and impact of infarct localization.

AIMS: Estimates of the left ventricular ejection fraction (LVEF) in patients with life-threatening ventricular arrhythmias related to coronary artery disease (CAD) have rarely been reported despite it has become the basis for determining patient's eligibility for prophylactic defibrillator. We aimed to determine the extent and distribution of reduced LVEF in patients with sustained ventricular tachycardia or ventricular fibrillation. METHODS AND RESULTS: 252 patients admitted for ventricular arrhythmia related to CAD were included: 149 had acute myocardial infarction (MI) (Group I, 59%), 54 had significant chronic obstructive CAD suggestive of an ischaemic arrhythmic trigger (Group II, 21%) and 49 patients had an old MI without residual ischaemia (Group III, 19%). 34% of the patients with scar-related arrhythmias had an LVEF > or =40%. Based on pre-event LVEF evaluation, it can be estimated that less than one quarter of the whole study population had a known chronic MI with severely reduced LVEF. In Group III, the proportion of inferior MI was significantly higher than anterior MI (81 vs. 19%; absolute difference, -62; 95% confidence interval, -45 to -79; P < or = 0.0001), though median LVEF was higher in inferior MI (0.37 +/- 10 vs. 0.29 +/- 10; P = 0.0499). CONCLUSION: Patients included in defibrillator trials represent only a minority of the patients at risk of sudden cardiac death. By applying the current risk stratification strategy based on LVEF, more than one third of the patients with old MI would not have qualified for a prophylactic defibrillator. Our study also suggests that inferior scars may be more prone to ventricular arrhythmia compared to anterior scars.

Diseña tu plan de mercadeo: Documento descargar

Bogotá Emprende

Diseña tu plan de mercadeo: Documento de preguntas y respuestas

Bogotá Emprende

Ajuste: Diseña tu plan de mercadeo: Documento de preguntas y respuestas: Consejos prácticos

Bogotá Emprende

Balance económico y social de la región Bogotá-Cundinamarca 2010 - 2011

Gestión del conocimiento

Informe del sector externo de Bogotá - Cundinamarca en el 2007 y en el primer semestre del 2008

Gestión del conocimiento

Estrategias para la armonización fiscal de Bogotá con los municipios de la zona metropolitana

Gobernanza

Guía Práctica de las Entidades sin Ánimo de Lucro y del Sector Solidario

Las Entidades sin Ánimo de Lucro (ESAL) surgen como desarrollo del derecho fundamental de asociación contenido en los artículos 38 y 39 de la Constitución política, en donde el Estado garantiza la libertad de las personas para reunirse y desarrollar actividades comunes desprovistas del ánimo de lucro. Para ello, el ordenamiento jurídico colombiano exige que dichas entidades nazcan a la vida jurídica como el resultado de la expresión de voluntad para asociarse y la creación de reglas de participación democrática de quienes se asocian.

Structural analysis of interior layered deposits in north and south Coprates Chasma, Mars

Interior layered deposits within an embayment in the northern as well as near the southern wall of Coprates Chasma in the Valles Marineris, Mars are studied using HRSC, CTX, HiRISE and CRISM data. In the northern embayment, layered deposits outcrop in three separate locations (a western deposit, a central deposit and an eastern deposit). The central layered deposit in the north has a stratigraphic thickness of 2 km. The western layered deposit abuts against the chasma wall appearing to have a relatively un-eroded depositional surface. The eastern deposit is near a landslide scar which appears to have exposed basement layering showing downward displacement. This northern embayment is suggested to have been an ancestral basin. The triangular edged deposit near the southern wall of Coprates Chasma has an elongated mound protruding from the central edge and is suggested to be the outer limits of a fault block which is back rotated 6° south. The rotation may be the result of the Valles Marineris opening.

L’implication du Stromal Cell-derived Factor-1 alpha dans le remodelage cardiaque une semaine après un infarctus du myocarde

L’injection de cellules souches provenant de la moelle osseuse est reconnue pour améliorer la fonction ventriculaire ainsi que le remodelage cicatriciel après un infarctus du myocarde (IM). Le Stromal Cell-derived factor-1 alpha (SDF-1 alpha), une chimiokine induite par l’ischémie cardiaque, représente une grande importance en raison de son rôle dans le recrutement de cellules inflammatoires et de cellules souches de la moelle osseuse vers les sites endommagés. Quoique les recherches sur le rôle de la chimiokine SDF-1 alpha dans le remodelage ventriculaire se multiplient, son implication dans la phase aiguë du remodelage reste inexplorée. Le but de la présente étude est de déterminer l’effet du SDF-1 alpha sur la taille de la cicatrice, l’hypertrophie cardiaque ainsi que la fonction ventriculaire chez des rats et des souris une semaine après un IM. La stratégie utilisée implique l’administration de l’AMD3100 (1 mg/kg, 24 heures après l’IM, pendant 6 jours), l’antagoniste sélectif du récepteur du SDF-1 alpha, le CXCR4. Ce récepteur est couplé à une protéine G alpha i et induit la migration et la prolifération cellulaire. Chez les rats du groupe IM, l’expression de la chimiokine a été détectée surtout dans les cellules musculaires lisses et les cellules endothéliales des vaisseaux cicatriciels. Le profil d’expression de la chimiokine dans le cœur infarci indique un gradient de concentration vers la cicatrice. Une semaine après l’IM, le traitement avec l’AMD3100 a diminué la taille de la cicatrice, résultant en une amélioration de la fonction ventriculaire et une diminution de l’élévation de l’expression de l’ARNm de l’ANP dans le ventricule gauche non infarci (VGNI). Chez les souris, le traitement avec l’AMD3100 a engendré les mêmes effets, soit une diminution de la taille de la cicatrice ainsi qu’une amélioration de la fonction ventriculaire. La réduction de la taille de la région infarcie chez les souris traitées avec l’AMD3100 est associée avec une atténuation de l’infiltration des neutrophiles dans la région ischémique. Ces résultats suggèrent que le blocage pharmacologique de l’axe SDF-1 alpha/CXCR4 lors de la phase aiguë du remodelage ventriculaire après un IM diminue la taille de la cicatrice et améliore la fonction ventriculaire, en partie, par la diminution de la réaction inflammatoire.

Étude du rôle des gènes TGF-β1 et HSP-70 lors du processus de régénération du membre chez l’axolotl

Les urodèles amphibiens, dont fait partie l’axolotl (Ambystoma mexicanum), ont la capacité de régénérer leurs organes et membres suite à une amputation, tout au long de leur vie. La patte est l’organe dont le processus de régénération est le mieux caractérisé et ce dernier est divisé en deux phases principales. La première est la phase de préparation et commence immédiatement suite à l’amputation. Elle renferme des étapes essentielles au processus de régénération comme la guérison de la plaie et la formation d’une coiffe apicale ectodermique. Par la suite, les fibroblastes du derme et certaines cellules musculaires vont revenir à un état pluripotent via un processus appelé dédifférenciation cellulaire. Une fois dédifférenciées, ces cellules migrent et s’accumulent sous la coiffe apicale pour former le blastème. Lors de la phase de redéveloppement, les cellules du blastème se divisent puis se redifférencient pour régénérer la partie amputée. Fait intéressant, la régénération d’un membre ou la guérison d’une plaie chez l’axolotl ne mène jamais à la formation d’une cicatrice. Afin d’en apprendre plus sur le contrôle moléculaire de la régénération, les gènes Heat-shock protein-70 (Hsp-70) et Transforming growth factor-β1 (Tgf-β1) ont été sélectionnés. Ces gènes jouent un rôle important dans la réponse au stress et lors de la guérison des plaies chez les mammifères. HSP-70 est une chaperonne moléculaire qui est produite pour maintenir l’intégrité des protéines cellulaires lorsqu’un stress se présente. TGF-β1 est une cytokine produite suite à une blessure qui active la réponse inflammatoire et qui stimule la fermeture de la plaie chez les amniotes. Les résultats présentés dans cette thèse démontrent que Hsp-70 est exprimé et régulé lors du développement et de la régénération du membre chez l’axolotl. D’autre part, nos expériences ont mené à l’isolation de la séquence codante pour Tgf-β1 chez l’axolotl. Nos résultats montrent que Tgf-β1 est exprimé spécifiquement lors de la phase de préparation dans le membre en régénération. De plus, le blocage de la voie des Tgf-β avec l’inhibiteur pharmacologique SB-431542, lors de la régénération, mène à l’inhibition du processus. Ceci démontre que la signalisation via la voie des Tgf-β est essentielle à la régénération du membre chez l’axolotl.