SUSTANCIAS CONSOLIDADAS PARA BIOESTIMULADORES DE COLÁGENO: FORMA DE ACCIÓN, INDICACIÓN E INTERCURRENCIA- REVISIÓN DE LA LITERATURA

Os bioestimuladores de colágeno são uma ótima opção no tratamento para o rejuvenescimento facial, visto sua capacidade de estimular a formação de um novo colágeno através de processo inflamatório local. O PLLA não possui um efeito imediato, já a CaHA assim que injetado provoca uma correção imediata, tendo a dissipação do seu gel carreador de forma mais lenta que no PLLA, mas ambos tem seu efeito alcançado de forma progressiva e gradual. Há uma grande diferença entre os produtos com relação à longevidade dos efeitos. A hidroxiapatita de cálcio, e o ácido poli-L-láctico são considerados biodegradáveis e semi permanentes, tendo a CaHA o menor tempo de duração quando comparada ao PLLA , em média de 12 a 18 meses, podendo chegar até 24 meses. Já o ácido poli-L-láctico apresenta efeitos mais duráveis, de até 4 anos sem necessidade de retoques. As complicações sistêmicas são mais raras, porém existe a possibilidade de nódulos não inflamatórios, pápulas, granulomas, celulite e necrose.  Os bioestimuladores de colágeno são uma ótima opção no tratamento para o rejuvenescimento facial, visto sua capacidade de estimular a formação de um novo colágeno através de processo inflamatório local. O PLLA não possui um efeito imediato, já a CaHA assim que injetado provoca uma correção imediata, tendo a dissipação do seu gel carreador de forma mais lenta que no PLLA, mas ambos tem seu efeito alcançado de forma progressiva e gradual. Há uma grande diferença entre os produtos com relação à longevidade dos efeitos. A hidroxiapatita de cálcio, e o ácido poli-L-láctico são considerados biodegradáveis e semi permanentes, tendo a CaHA o menor tempo de duração quando comparada ao PLLA , em média de 12 a 18 meses, podendo chegar até 24 meses. Já o ácido poli-L-láctico apresenta efeitos mais duráveis, de até 4 anos sem necessidade de retoques. As complicações sistêmicas são mais raras, porém existe a possibilidade de nódulos não inflamatórios, pápulas, granulomas, celulite e necrose.  Collagen biostimulators are a great option in the treatment for facial rejuvenation, given their ability to stimulate the formation of new collagen through local inflammatory process. PLLA does not have an immediate effect, since CaHA as soon as injected causes an immediate correction, having the dissipation of its carrier gel more slowly than in PLLA, but both have their effect achieved progressively and gradually. There is a big difference between the products with respect to the longevity of the effects. Calcium hydroxyapatite and poly-L-lactic acid are considered biodegradable and semi-permanent, with CaHA having the shortest duration when compared to PLLA, on average from 12 to 18 months, and can reach up to 24 months. Poly-L-lactic acid has more durable effects, up to 4 years without the need for retouching. Systemic complications are rarer, but there is the possibility of non-inflammatory nodules, papules, granulomas, cellulitis and necrosis.  Los bioestimuladores de colágeno son una gran opción en el tratamiento para el rejuvenecimiento facial, dada su capacidad para estimular la formación de nuevo colágeno a través del proceso inflamatorio local. El PLLA no tiene un efecto inmediato, ya que el CaHA tan pronto como se inyecta provoca una corrección inmediata, teniendo la disipación de su gel portador más lentamente que en el PLLA, pero ambos tienen su efecto logrado progresiva y gradualmente. Hay una gran diferencia entre los productos con respecto a la longevidad de los efectos. La hidroxiapatita de calcio y el ácido poli-L-láctico se consideran biodegradables y semipermanentes, con CaHA que tiene la duración más corta en comparación con PLLA, en promedio de 12 a 18 meses, y puede alcanzar hasta 24 meses. El ácido poli-L-láctico tiene efectos más duraderos, hasta 4 años sin necesidad de retoques. Las complicaciones sistémicas son más raras, pero existe la posibilidad de nódulos no inflamatorios, pápulas, granulomas, celulitis y necrosis. 

Plasma kinetics of an LDL-like non-protein nanoemulsion and transfer of lipids to high-density Lipoprotein (HDL) in patients with rheumatoid arthritis

Artrite reumatóide é uma doença auto-imune que apresenta acentuado quadro inflamatório e proliferação celular o que, provavelmente, determina a alta prevalência de doenças cardiovasculares quando comparados a população mundial. A mortalidade e a morbidade conseqüentes das doenças cardiovasculares estão 2 vezes aumentadas em pacientes com artrite reumatóide e um dos principais fatores de risco relacionados ao desenvolvimento da aterosclerose é a dislipidemia. Esse importante fator de risco vem sendo associado à artrite reumatóide e as concentrações plasmáticas de lípides são constantemente avaliadas, já que se encontra bem estabelecido a relação entre dislipidemia e alta incidência de doença cardiovascular. No entanto, o verdadeiro impacto das alterações lipídicas na artrite reumatóide não é bem conhecido, já que os resultados de perfil lipídico são contraditórios. Alterações nas concentrações plasmáticas de lípides não necessariamente acompanham distúrbios no metabolismo das lipoproteínas plasmáticas. O objetivo do presente estudo foi avaliar aspectos do metabolismo da LDL e da HDL, em pacientes com artrite reumatóide. Nesse sentido, foi avaliada a cinética plasmática de uma nanoemulsão lipídica artificial com comportamento metabólico semelhante ao da LDL em 30 pacientes com artrite reumatóide divididos em 2 grupos de acordo com a atividade da doença, alta atividade (n=14) e remissão (n=16) e 30 indivíduos controle. A nanoemulsão marcada com éster de colesterol 14EC (EC-14C) e colesterol livre 3H (CL-3H) foi injetada endovenosamente após 12 horas de jejum. As amostras de sangue foram coletadas em tempos pré-determinados (5 min, 1, 2, 4, 6, 8 e 24 horas) após a injeção, para determinação das curvas de decaimento plasmático e da taxa fracional de remoção (TFR) dos lípides marcados, por análise compartimental. As TFR-EC-14C e TFR-CL-3H foram maiores no grupo AR quando comparado ao grupo controle (49%, p<0,05 e 44%, p<0,05, respectivamente), não havendo diferença entre os subgrupos de artrite reumatóide. No grupo artrite reumatóide e em seus subgrupos, as concentrações de HDL-C e apo E foram maiores quando comparados ao grupo controle (33%, p<0,0001 e 20%, p<0,01, respectivamente), enquanto os níveis de apo B foram menores na artrite reumatóide quando comparados ao grupo controle (16%, p<0,05). A transferência de colesterol esterificado radioativo da nanoemulsão para a HDL foi menor na artrite reumatóide, comparando-se com o grupo controle. A transferência dos outros lípides foi similar nos dois grupos. A HDL dos pacientes com artrite reumatóide foi menor do que a dos controles. Esses resultados podem contribuir com a melhor compreensão de possíveis mecanismos relacionados a uma maior incidência de doenças cardiovasculares em pacientes com artrite reumatóideMortality and morbidity, as a consequence of cardiovascular diseases, is twice as high in patients with rheumatoid arthritis than in the general worldwide population. This autoimmune disease has predominant inflammatory and cell proliferation background probably explains the high prevalence of cardiovascular disease. Dyslipidemias are important risk factors for cardiovascular disease. This study investigated the link between RA and plasma lipids as a predisposition to this high cardiovascular disease incidence. However, the impact of lipids on cardiovascular risk in rheumatoid arthritis is unclear. So much so, that lipid profiles in patients with rheumatoid arthritis in published studies is contradictory. The events of intravascular lipoprotein metabolism do not necessarily produce altered levels of plasma lipids. In an attempt to unravel novel dysfunctional mechanisms that could trigger pro-atherogenic processes beyond the concentration of the plasma lipids, plasma clearance of a lipidic nanoemulsion that resembles the LDL metabolic behavior were investigated in rheumatoid arthritis patients and compared to control subjects without the disease. 30 patients with rheumatoid arthritis divided into 2 groups according to disease activity, high activity (n=14) and remission (n=16), and 30 controls were studied. A nanoemulsion labeled with 14C-cholesteryl esther (14C-CE) and 3H-free cholesterol (3H-FC) were endovenously injected after which blood samples were collected at pre-determined periods (5 min, 1, 2, 4, 6, 8 and 24 hours), in order to determine the radioactivity of the plasma decay curves and calculate the fractional clearance rate (FCR) of the labeled lipids for compartmental analysis. In the rheumatoid arthritis group and subgroups the HDL-C and apo E concentration were higher when compared to control group (33%, p<0,0001 e 20%, p<0,01, respectively) while apo B concentration was lower (16%, p<0,05). The 14-CE-FCR and 3H-FC-FCR were greater in rheumatoid arthritis group and subgroups when compared to controls (49%, p<0,05 e 44%, p<0,05, respectively). There were no differences between the rheumatoid arthritis subgroups. Therefore, rheumatoid arthritis accelerates the LDL plasma removal, as indicated by a higher 14-CE-FCR and 3H-FC-FCR. The transfer of other lipids was also similar in both groups. The HDL of the rheumatoid arthritis patients was lower than that of the control group. These results could clarify possible mechanisms that can be related to a higher cardiovascular incidence in patients with rheumatoid arthriti

Núcleos de Ensino da Unesp: artigos 2007

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p&lt;0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p&lt;0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status

Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

© 2017 British Journal of Anaesthesia Background: The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods: Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results: We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P\u3c0.01], but no difference in complication rates [OR 1.02 (0.88–1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62–0.92); P\u3c0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61–0.88); P\u3c0.01; I2=89%). Conclusions: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine

Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

This was an investigator initiated study funded by Nestle Health Sciences through an unrestricted research grant, and by a National Institute for Health Research (UK) Professorship held by RP. The study was sponsored by Queen Mary University of London