Avaliamos a influência do transplante renal (Tx) e de \"polimorfismos de nucleotídeos isolados\" (SNPs), na região promotora do gen codificador da proteína C reativa, sob os níveis de PCR, em 50 pacientes com doença renal crônica em terapia dialítica. Os níveis de PCR foram avaliados no período pré-Tx, no primeiro e segundo anos pós-Tx. Inicialmente, os pacientes foram divididos em três grupos de acordo com os percentis (25, 50 e 75) dos níveis de PCR no período pré-Tx. Em seguida, avaliamos os genótipos para 2 SNPs, um bi-alélico na posição -409 (G->A) e um tri-alélico (C->T->A) na posição -390. Na análise geral os níveis de PCR decresceram significativamente no primeiro ano pós-Tx e tiveram uma elevação, não significativa, no segundo ano após o transplante. Após a divisão por percentis, observamos que nos pacientes cujos níveis de PCR se situavam dentro da normalidade (percentis 25 e 50), este marcador se manteve estável ao longo do estudo, enquanto houve uma significativa e progressiva redução dos níveis de PCR, pós-Tx, nos pacientes do percentil 75 (p=0,002). Todos os pacientes apresentaram o genótipo -409GG, quando avaliados para o SNP nesta posição. Quando avaliados para a posição -390, não foram encontrados pacientes com o alelo \"A\", havendo 15 pacientes com o genótipo \"CC\", 11 \"TT\" e 24 \"CT\". A média geral dos níveis de PCR diferiu significativamente entre os indivíduos de diferentes genótipos (p=0,019). A presença do alelo \"T\" associou-se a níveis mais elevados de PCR no pré-transplante (p=0,007) e no primeiro ano pós (p=0,001), fato não observado no segundo ano (p=0,146). Concluímos que o Tx reduz os níveis de PCR em pacientes com PCR previamente elevada. SNPs na posição -390 da região promotora do gen codificador da PCR influenciam os níveis basais desta proteína, de tal forma que o alelo \"C\" se associa com os menores níveis de PCR e o alelo \"T\" com os maiores. Em nossos pacientes, esta influência deixou de ser observada no segundo ano pós-Tx. / We evaluated the influence of kidney transplantation (Tx), as well as single nucleotide polymorphisms (SNPs) in the \"C\" reactive protein (CRP) gene promoter region on CRP levels in 50 patients with chronic kidney disease under dialysis. CPR levels were evaluated at pre-Tx, as well as during the first and second years post-Tx. Initially, patients were divided into tree groups according to pre-Tx CRP percentiles (25, 50 and 75). At the same time, we evaluated the genotypes for 2 SNPs, a bi-allelic (G->A) at the -409 position and a tri-allelic (C->T->A) at the -390 position. In general analysis, CRP levels was significantly reduced in the first year and increased, not significantly, in the second year post Tx. Upon dividing the groups, the patients with CRP levels under the normal range (25th and 50th percentiles) presented stable, whereas there was a progressive and significant reduction in the post Tx CRP levels in patients in the 75th percentile (p=0.002). All patients presented the -409GG genotype. When evaluated for the -390 position, the \"A\" allele was not found and there were 15 \"CC\" pts, 11 \"TT\" and 24 \"CT\". CRP general means were different among patients with different genotypes (p=0.019). Also, allele \"T\" presence was associated with higher CRP levels in the pre-Tx (p=0.007) and first year post (p=0.001), but not at the second year post-Tx (p=0.146). We concluded that Tx reduces CRP levels in patients with previously high CRP. SNPs at the -390 position of the CRP gene promoter region influence CRP´s basal levels in such a way that the \"C\" allele correlates with the lowest and the \"T\" with the highest. We did not observe this influence in our patients at the second year post-Tx.

A doença cardiovascular aterosclerótica é a principal causa de morte no hemisfério ocidental, portanto também no Brasil. A detecção não invasiva da aterosclerose é fundamental para prevenção. Objetivos: Correlacionar os fatores de risco (escore de Framingham), o perfil lipídico, a PCR-us, a espessura da íntima-média da carótida, a função endotelial, o índice tornozelo-braquial e o escore de cálcio pela tomografia computadorizada, com a extensão da doença coronariana determinada pelo índice de Friesinger, na cinecoronariografia. Casuística e métodos: Foram estudados 100 pacientes de ambos os sexos, com idade de 55,1±10,7 sendo 55% homens e 45% mulheres. Não foram incluídos pacientes com síndrome coronariana aguda, insuficiência renal dialítica, doença do colágeno e câncer. Todos se submeteram a avaliação clínica, laboratorial (glicemia, perfil lipídico e PCR-us), função endotelial da artéria braquial e ultrasonografia da artéria carótida por ultra-som de alta resolução, índice tornozelo-braquial e tomografia computadorizada coronária para determinação do escore de cálcio. Foram calculados o colesterol não HDL-c e a relação TG/HDL-c. Todos os pacientes foram submetidos à cinecoronariografia por indicação do médico assistente. Foram considerados normais pacientes sem lesão obstrutiva na cinecoronariografia. Resultados: Pela análise univariada, escore de cálcio (529,5 ± 930,9) um HDL-c (45,9±15,5), relação TG/HDL (5,5±9,2) e IMT (0,77±0,22) mostraram correlação significativa com o índice de Friesinger. Já por análise multivariada somente o escore de cálcio, relação TG/HDL-c aumentada e HDL-c baixo correlacionaram-se significativamente com a extensão da DAC. A PCR-s (3,4±3,5), LDL-c (122,8±51,5) e DMF (4,8±5,7) não se correlacionaram com o índice de Friensinger. Conclusão: Assim, é possível ter uma idéia aproximada da presença/extensão da DAC usando métodos não invasivos, especialmente escore de cálcio, relação TG/HDL-c e HDL-c baixo. / Background: Atherosclerotic cardiovascular disease is the leading cause of death in the western hemisphere including Brazil. Non-invasive detection of atherosclerosis is critical to prevention. Objectives: We correlated the risk factors (score of Framingham), lipid profile, PCR-us, carotid intima-media thickness, endothelial function, ankle-brachial index and calcium score by computed tomography with the extent of coronary disease determined by the Friesinger index, by coronary angiography. Methods: We studied 100 patients of both sexes, aged from 55.1 ± 10.7, 55% men and 45% women. Patients with acute coronary syndrome, renal dialitic, collagen disease and cancer were not included. All were submitted to clinical evaluation, laboratory (blood glucose, lipid profile and hs-CRP), endothelial function of brachial artery and ultra-sonography of carotid artery by high-resolution ultra-sound, ankle-brachial index and computed tomography for coronary determination of calcium score. We calculated the cholesterol not HDL-c and TG/HDL-c ratio. All patients were submitted to coronary angiography for indication by attending physician. We considered normal patients without obstructive lesion in coronary angiography. Results: By univariate analysis, calcium score, HDL-c, TG/HDL ratio and IMT showed significant correlation with Friesinger index. However, multivariate analysis only calcium score, increased TG/HDL-c and low HDL-c correlated significantly with the extension of the CAD. The hs-CRP, LDL-c and FMD, did not correlate Friensinger index. Conclusion: Thus, it is possible to have an approximate idea of the presence/extension of CAD by non-invasive methods, especially calcium score, TG/HDL-C ratio and HDL-c.

Pesquisas recentes têm demonstrado que a periodontite pode modificar a concentração sanguínea de uma série de tipos celulares e substâncias bioquímicas, que são considerados fatores de risco para doenças cardiovasculares. Este trabalho tem como objetivo avaliar a associação entre a periodontite crônica e marcadores de risco para doença cardiovascular. No Estudo I foram examinados 100 pacientes aparentemente saudáveis sistemicamente, sendo 66 portadores de periodontite crônica e 34 pacientes controle, sem doença periodontal. Exames periodontais e exames sanguíneos foram realizados, e obtidas as espessuras das camadas íntima-média (IMT) da artéria carótida. No Estudo II, 66 pacientes participantes do Estudo I, diagnosticados com periodontite crônica, foram aleatoriamente submetidos a tratamento periodontal imediato (Grupo Teste, n=33) ou tratamento periodontal retardado (Grupo Controle, n=33). Os dados colhidos no Estudo I foram registrados como pré-tratamento (T0). Novos exames clínicos periodontais e laboratoriais foram realizados no período de 2 meses (T2) e 6 meses (T6) após os exames iniciais (Grupo Controle) ou conclusão do tratamento periodontal (Grupo Teste). Os dados colhidos foram analisados através de testes estatísticos. Os resultados mostraram que pacientes com periodontite crônica quando comparados ao grupo controle, apresentaram valores médios significativamente mais elevados na contagem total de hemácias (p<0,001), hemoglobina (p<0,001), hematócrito (p<0,001), contagem de plaquetas (p=0,019), velocidade de hemossedimentação (p<0,001), proteína C-reativa (p<0,001). Os níveis de HDL-colesterol foram significativamente mais baixos nos pacientes com periodontite crônica quando comparados ao grupo controle (p<0,001). As camadas íntima-média da parede da artéria carótida esquerda foram significativamente mais espessas nos pacientes com periodontite crônica quando comparados ao grupo controle (p=0,049). Os indíviduos com periodontite crônica também apresentaram 3,26 vezes mais chances de possuir Síndrome Metabólica do que aqueles indivíduos que não possuem doença peridontal (IC 95%: 1,8-5,9). No Estudo II, quando comparados os valores médios dos dados hematológicos após tratamento, no grupo teste, foi possível observar melhora estatisticamente significativa, entre T0/T2, dos valores de VHS e triglicerídeos (p=0,002; p=0,004; respectivamente). Redução nos valores médios da contagem total de leucócitos, VHS, CRP, transaminase glutâmico pirúvica, colesterol total e triglicerídeos, entre T0/T6, foi verificada no grupo teste pós-tratamento (p=0,028; p<0,001; p<0,001; p=0,010; p<0,001; p=0,015, respectivamente). Os resultados indicaram que a periodontite crônica severa está associada com níveis elevados de marcadores da inflamação e trombogênese, além de alterações no perfil lipídico em indivíduos sistemicamente saudáveis, podendo atuar como possível fator de risco para as doenças cardiovasculares. O tratamento periodontal não-cirúrgico mostrou-se eficaz na redução dos níveis dos marcadores sistêmicos da inflamação e na melhora do perfil lipídico em indivíduos com doença periodontal severa, consequentemente, reduzindo o risco de doenças cardiovasculares. / Recent studies have shown that periodontitis seems to modify the blood concentration of a range of cell types and biochemical substances, which are considered risk factors for cardiovascular disease. This study aims to evaluate the association between periodontitis and risk markers for cardiovascular disease. In the Study I, 100 patients apparently healthy were examined, being 66 patients diagnosed with severe chronic periodontitis and 34 control patients without periodontal disease. Periodontal examinations and blood samples were performed. The carotid intima-media thickness (IMT) were obtained. In the Study II, 66 patients participating in the Study I, diagnosed with chronic periodontitis, were randomly submitted to immediate periodontal treatment (test group, n=33) or delayed periodontal treatment (control group, n=33). The data collected in Study I were recorded as pre-treatment (T0). Further periodontal and laboratory examinations were performed in the period of 2 months (T2) and 6 months (T6) after the initial examination (control group) or completion of periodontal treatment (Test Group). The data collected were analyzed using statistical tests. The results demonstrated that patients with chronic periodontitis when compared with the control group showed significantly higher values in the total count of red blood cells (p<0.001), hemoglobin (p<0.001), hematocrit (p<0.001), platelet count (p=0.019), erythrocyte sedimentation rate (ESR, p<0.001), C-reactive protein (CRP, p<0.001). The levels of HDL-cholesterol were significantly lower in patients with chronic periodontitis when compared with the control group (p<0.001). The layers of the intima-media wall of the left carotid artery was significantly thicker in patients with chronic periodontitis when compared with the control group (p=0.049). Individuals with chronic periodontitis also had 3.26 times more likely to have metabolic syndrome than individuals who do not have peridontal disease (CI 95%: 1.8-5.9). In Study II, compared the mean values of hematological data after treatment in the test group, it was possible to observe statistically significant improvement from T0/T2, in the values of ESR and triglycerides (p=0.002, p=0.004, respectively). Reduction in the average values of total leukocyte count, ESR, CRP, glutamic pyruvic transaminase, total cholesterol and triglycerides, between T0/T6 was observed in the test group after treatment (p=0.028, p<0.001 p<0.001, p=0.010 p<0.001, p=0.015, respectively). The results indicated that, in the population studied and with the methodology used, the severe chronic periodontitis is associated with high levels of markers of inflammation and trombogenesis, and changes in lipid profile in systemically healthy individuals, can act as a possible risk factor for cardiovascular diseases. The non-surgical periodontal treatment was effective in reducing the levels of markers of systemic inflammation and improves the lipid profile in subjects with severe periodontal disease, thus reducing the risk of cardiovascular disease.

Durante a transição menopausal e a pós-menopausa cerca de 75% das mulheres apresentam sintomas de hipoestrogenismo, tais como fogachos. O emprego de terapia hormonal (TH) para alívio dos sintomas da menopausa está bem estabelecido, mas seus efeitos cardiovasculares (CV) permanecem controversos. Dados de estudos recentes indicam a presença de duas populações distintas quanto aos efeitos CV da TH. Essa diferenciação estaria relacionada principalmente com a idade e o tempo de pós-menopausa. Evidências sugerem também que a presença de fatores de risco cardiovascular antes do início do TH, ou de uma associação de fatores de risco, podem ser determinantes dos efeitos CV do TH. Dose de medicação, via de administração e o tipo de progestogênio utilizado em associação com estrogênio para TH também vem sendo estudados como possíveis fatores relacionados ao impacto CV do TH. O presente trabalho é composto por: 1) Ensaio clínico randomizado, comparando os efeitos da via oral baixa dose e via não oral sobre variáveis relacionadas com risco CV em uma população de mulheres saudáveis na pósmenopausa recente; 2) Ensaio clínico randomizado, onde foram avaliados os efeitos da adição de progesterona natural micronizada ao estrogênio não oral durante TH em mulheres na pós-menopausa recente; e 3) Revisão sistemática e meta-análise, onde foram sistematicamente buscados todos os artigos com TH baixa dose que avaliassem os efeitos desta terapia sobre variáveis relacionadas com risco cardiovascular: peso, índice de massa corporal, pressão arterial, proteína C reativa e lipídios. Desenvolvemos ensaio clínico randomizado, cross-over, com objetivo de avaliar os efeitos de dois tipos de tratamento hormonal na menopausa: oral baixa dose, estradiol 1 mg e drospirenona 2 mg diário e não oral, estradiol 17 β gel 1.5 mg (ou nasal 300 mcg) diário e progesterona micronizada vaginal, 200 mg, 14 dias por mês, sobre peptídeo natriurético atrial, variáveis relacionadas com inflamação e função endotelial, perfil antropométrico e metabólico em mulheres na pós-menopausa recente e sem doença clínica evidente. 101 mulheres na pós-menopausa foram alocadas aleatoriamente para iniciar o TH por um dos dois grupos de tratamento: via oral baixa dose (n=50) ou via não oral (n=51). Todas as pacientes utilizaram ambos os TH de forma seqüencial. Após o primeiro período de 2 a 3 meses de TH a paciente passava para o segundo tratamento, sem período de washout. A avaliação laboratorial foi realizada antes e após cada um dos tratamentos. A amostra do estudo foi composta por mulheres com média etária de 51 ± 3 anos e tempo de amenorréia de 22 ± 10 meses. Oitenta e seis pacientes concluíram o estudo. Peso e índice de massa corporal não se modificaram, enquanto que a circunferência da cintura reduziu de forma similar em ambos os grupos de tratamento. Colesterol total e LDL-C reduziram após ambos os TH, e triglicerídeos reduziram somente após a TH não oral. Insulina e glicemia de jejum não se modificaram. Não foram observadas modificações nos níveis de fibrinogênio, fator von Willebrand (FvW) e proteína C reativa (PCR) após TH oral. Após TH não oral, observou-se redução significativa de fibrinogênio e FvW. Níveis de PCR não se modificaram. Houve redução do número de pacientes no maior tertil de PCR (alto risco CV) após TH não oral. Essas pacientes passaram a integrar os grupos de risco intermediário e baixo. Níveis de peptídeo natriurético atrial (PNA) mantiveram-se inalterados após os ambos os TH. Não houve modificações significativas na pressão arterial e esta não se correlacionou com valores de PNA. Realizamos análise adicional do TH não oral, quanto às diferenças entre a via nasal e a percutânea e quanto aos efeitos da adição de progesterona natural micronizada ao estrogênio. Não houve diferenças significativas para todas as variáveis estudadas entre a via nasal e a via percutânea. A adição de progesterona natural micronizada não modificou os efeitos metabólicos e CV do estrogênio não oral. Foi realizada busca sistemática de todos os artigos que incluíssem como TH estrogênio baixa dose e avaliassem os efeitos deste tratamento sobre as variáveis de interesse: peso, índice de massa corporal, pressão arterial, proteína C reativa e lipídeos. Foram consultadas as bases MEDLINE, Cochrane CENTRAL, EMBASE. Foram revisadas todas as referências dos artigos de interesse e revisões e metaanálises no assunto, em busca de artigos relevantes. Após exclusão dos artigos em duplicata, 8610 artigos foram revisados. Destes, 28 artigos foram selecionados para meta-análise. Desta análise foi possível concluir que pacientes em uso de TH baixa dose apresentaram em média menor peso corporal, colesterol total e LDL-C do que não usuárias. A TH baixa dose não apresentou efeitos deletérios sobre demais variáveis estudadas. Em conclusão, ambos os TH apresentaram efeitos neutros ou benéficos sobre variáveis relacionadas com risco CV em uma população de mulheres na pósmenopausa recente e sem evidência de doença CV. A adição de progesterona natural micronizada não modificou os efeitos do estrogênio não oral. Os resultados da metaanálise sobre TH baixa dose e variáveis relacionadas com risco CV também permitem concluir que a TH baixa dose não exerceu efeitos deletérios sobre lipídeos e pressão arterial, e foi observado um possível efeito benéfico deste tratamento sobre o peso corporal. / During the menopausal transition and postmenopause about 75% of women have symptoms of hypoestrogenism symptoms such as hot flushes. The use of hormone therapy (HT) for relief of menopausal symptoms is well established, but its cardiovascular effects (CV) remain controversial. Data from more recent studies suggest the presence of two distinct populations regarding the cardiovascular effects of HT. This differentiation is related mainly to age and time after menopause. Evidence also suggests that the presence of cardiovascular risk factors before the onset of HT, or a combination of risk factors may be determinants of CV effects of HT. Medication dose, route of administration and type of progestin used in combination with estrogen for HT has also been studied as possible factors related to the CV impact of HT. This work consists of: 1) Randomized clinical trial, comparing the effects of low dose oral and non-oral route of variables related to CV risk in a population of healthy women in early postmenopausal; 2) A randomized clinical trial, which we assessed the effects of the addition of natural micronized progesterone to non-oral estrogen for HT in women in early postmenopausal; and 3) systematic review and meta-analysis, which were systematically searched all items with low-dose HT to assess the effects of this therapy on variables related to cardiovascular risk: weight, body mass index, blood pressure, C-reactive protein and lipids. A cross-over, randomized clinical trial was designed in order to evaluate the effects of two types of HT: low dose oral treatment, estradiol oral 1 mg and drospirenone 2 mg, by day and non-oral treatment, estradiol 1.5 mg 17 β gel by percutaneous route (or nasal route 300 mcg) by day and vaginal micronized progesterone, 200 mg/d, 14 days by month on atrial natriuretic peptide, variables associated with inflammation and endothelial function, anthropometric and metabolic variables on early and healthy postmenopausal women. One hundred one women were randomly allocated to start with one of the treatments: low dose oral treatment (n=50) or non-oral treatment (n=51). At the end the first three months period, the patients were crossed over without washout for an additional three months. Laboratory evaluated were carried before and after oral and non-oral HT. The sample of the study included postmenopausal women with a mean age of 51 years and duration of amenorrhea of 22±10 months. Eighty-six patients completed the study. Weight and body mass index remained unchanged, while the waist circumference decreased similarly in both treatment groups. Total cholesterol and LDL-cholesterol reduced after both the HT and triglycerides reduced only after nonoral HT. Insulin and fasting glucose did not change. No changes were observed in the levels of fibrinogen, von Willebrand factor (vWF) and C-reactive protein (CRP) after oral HT. After non-oral HT, there was a significant reduction of fibrinogen and vWF. CRP levels did not change. There was a reduction in the number of patients in the highest tertile of CRP (high CV risk) after non-oral HT. These patients have joined the groups of intermediate and low risk. Levels of atrial natriuretic peptide, ANP, were unchanged after both HT. There were no significant changes on blood pressure and did not correlate with values of ANP. We performed additional analysis of nonoral HT, for the differences between nasal and percutaneous and about the effects of addition of natural micronized progesterone to estrogen. There were no significant differences for all the variables studied between the nasal and percutaneously. The addition of micronized natural progesterone did not modify the metabolic and CV effects of non-oral estrogen. Systematic search of all articles that include as TH low dose estrogen and evaluate the effects of this treatment on the variables of interest was taken: weight, body mass index, blood pressure, C-reactive protein and lipids. The MEDLINE, Cochrane CENTRAL, EMBASE databases were consulted. All references of interest and reviews and meta-analyzes on the subject, in search of relevant articles were reviewed. After removing duplicate articles, 8610 articles were reviewed. Of these, 28 articles were selected for meta-analysis. From this analysis it was concluded that patients using low-dose TH had on average lower body weight, total cholesterol and LDL-C than non-users. The TH low dose showed no deleterious effects on other variables. In conclusion, low-dose oral and non-oral treatments had neutral or beneficial effects on variables related to CV risk in a population of women in early post menopausal and without evidence of CV disease. The addition of micronized natural progesterone did not modify the effects of non-oral estrogen. The results of the metaanalysis of low dose and TH variables related CV risk also showed that the TH low dose did not exert deleterious effects on lipids and blood pressure, and a possible beneficial effect of this treatment on body weight was observed.

O Brasil, que conta hoje com 7% de idosos, será a sexta maior população de idosos do Planeta em 2020. A doença cardiovascular aumenta significativamente com a idade e evidências indicam a importância do endotélio e da hipercolesterolemia na aterosclerose. Contudo, não está bem estabelecido, que o tratamento da dislipidemia em idosos melhora a função vasomotora. Objetivos: Analisar a resposta vasomotora e parâmetros metabólicos em idosos com hipercolesterolemia ao tratamento com estatina. Delineamento: Ensaio Clínico Randomizado Duplo Cego. Casuística e Métodos: 72 idosos com idade 65 anos [75 ± 7,7 (65 a 92)], 64% mulheres, excluídos diabéticos, hipertensos graves, obesos, corticoterapia, reposição hormonal, doença em estágio terminal; todos realizaram avaliação clínica, laboratorial (glicose, lípides, TGO, TGP, CPK, Proteina C reativa ultra-sensível (PCR)) e função vasomotora por ultra-sonografia de alta resolução da artéria braquial, com equipamento ATL HDI 5000 e transdutor multifreqüencial de 7 a 10 MHz, segundo Diretrizes. Utilizou-se hiperemia reativa para resposta vasomotora dependente do endotélio (DMF) e nitrato sub-lingual para a independente do endotélio (DNT). Destes, 47 pacientes apresentaram LDL 130 mg/dL e foram randomicamente designados para grupo placebo (GP) e grupo tratamento (GT); todos realizaram avaliação antes e depois da intervenção (placebo ou atorvastatina 20mg oral por 30 dias). Para a análise estatística, utilizaram-se testes paramétricos e não-paramétricos, valores de p 0,05 foram considerados estatisticamente significantes. Resultados: Os grupos foram semelhantes em suas características basais; a DMF não apresentou diferença estatisticamente significante entre o GP e GT após intervenção [6,2 ± 6,2 (-4,8 23,7) e mediana = 6,4 vs. 5,0±5,6 (-5,1 18,9) e mediana= 3,5 p = 0,551], o mesmo ocorrendo para a DNT [7,1 ± 4,7 (-1,3 21,2) e mediana = 6,8 vs. 8,6±5,0 (1,4 21,6) e mediana = 6,8 p = 0,373). A análise estratificada sugere potencial modificador de efeito das co-variáveis estratificadas sexos, estratos etários (<80 e 80 anos) e níveis de LDL (< 160mg/dL e 160mg/dL) em relação à associação atorvastatina e função vasomotora. A PCR diminuiu 64% no grupo estatina (mediana no GP = 0,3 mg/dL vs. GT = 0,1 mg/dL p = 0,014). A redução do colesterol total foi de 27%, LDL = 41%, VLDL = 20% e triglicérides = 34%; o HDL elevou 12% no GT. A maior elevação enzimática não ultrapassou 3 vezes o limite e não ocorreram mialgias. Conclusões: Apesar da diminuição dos lípides, não houve modificações significativas da função vasomotora, o que sugere alterações intrínsecas do vaso associado ao envelhecimento. Os níveis de PCR reduziram significativamente, sugerindo um provável efeito antiinflamatório / The Brazil, where old people make up 7% of the population, will have the sixth greatest population of elderly people in the world. Cardiovascular disease increases significantly as a person grows older and evidences show the importance of the endothelium and hypercholesterolemia in arteriosclerosis. However, it has not been established yet if treating dyslipidemia in the elderly will improve this function. Objectives: To evaluate vasomotor response in elders suffering from hypercholesterolemia to the treatment with statin and to evaluate their lipids, c-Reactive Protein (CRP). Design: Double-blind randomized clinical trial. Methods: Seventy-two elderly people aged >65 years old [75 ± 7.7 (65 to 92)], 65% of women, excluding those suffering from diabetes, serious hypertension, obesity, steroid use, hormone replacement, end-stage disease; all of them underwent clinical evaluation, laboratorial evaluation (glucose, lipids, liver enzymes, CPK, high sensitivity CRP (CRP). Vasomotor response was evaluated by means of ATL HDI 5000 high resolution ultrasound scan of the brachial artery and multifrequency transduction of 7 to 10 MHz. Reactive hyperemia was used for endothelium-dependent flow response (DMF) and sublingual nitrate for the endothelium-independent dilation (DNT). Out of those patients, 47 presented LDL 130 mg/dl and were ramdonly divided into placebo (n = 23) and treatment group (n = 24); all of them had underwent evaluation before and after intervention (placebo or atorvastatin 20 mg, orally, during 30 days); for statistic analysis parametric and non-parametric tests were used and p 0.05 values were considered statistically significant. Results: The groups were similar in their basal characteristics; DMF did not present any statistically significant difference between placebo and treatment group after intervention [6.2 ± 6.2 (-4,8 - 23.7) and median = 6.4 vs. 5.0 ± 5.6 (-5.1 - 18.9) and median = 3.5 p = 0.551], the same occurred to DNT [7.1 ± 4,7 (-1.3 - 21.2) and median = 6.8 vs. 8.6 ± 5.0 (1.4 - 21.6) and median = 6.8 p = 0.373). Stratified analysis suggests effect modifying factor of the gender, age strata (< 80 and 80 years of age) and LDL (< 160 mg/dL e 160 mg/dL). CRP diminished 64% in the treatment group (median in the placebo group = 0.3 mg/dL vs. treatment group = 0.1 mg/dL p = 0.014). The reduction of total cholesterol was 27%, LDL = 41%, VLDL = 20% and triglycerides = 34%; HDL raised 12% in the treatmente group in relation to the placebo group. The highest enzymatic elevation did not surpass 3 times the limit and there were no myalgia. Conclusions: In spite of a significant decrease in lipids, there were no significant changes in vasomotion response with statin therapy, suggesting intrinsic alterations of the vessel associated with ageing. However, CRP reduction suggested an anti-inflammatory effect

The yeasts Pichia pastoris and Kluyveromyces lactis were used to express several recombinant human proteins for further biochemical characterization. Two substitution variants of recombinant human enteropeptidase light chain (rhEPL) were engineered to modify the extended substrate specificity of this serine protease. Both were secreted as active enzymes in excess of 1.7 mg/L in P. pastoris fermentation broth. The substitution variant rhEPL R96Q showed significantly reduced specificities for the preferred substrate sequences DDDDK and DDDDR; however, the rhEPL Y174R variant displayed improved specificities for these substrate sequences relative to all other reported variants of this enzyme. The neutrophil serine proteases human cathepsin G (hCatG) and human neutrophil elastase (HNE) were expressed in P. pastoris and HNE was also expressed in K. lactis. The recombinant variants rhCatG and rHNE, with intact C-terminal extensions, were expressed as fusion proteins with the soluble heme-binding domain of cytochrome B5 (CytB5) and an N-terminal hexahistidine (6xHis) tag for purification. The CytB5 domain was linked to the native N-termini of active rhCatG and rHNE by the EPLcleavable substrate sequence DDDDK~I, where ~ is the sessile bond. These fusion proteins were directed for secretion. The yeast P. pastoris expressed up to 3.5 mg/L of EPL-activable rHNE in fermentation broth; however, only 200 μg/L of rhCatG could be produced by this method. Recombinant expression in K. lactis never surpassed 100 μg/L of activable rHNE. The CytB5 fusion domain was present in the heme-bound form, conferring a red color and 410 nm absorbance peak to solutions containing the fusion proteins. This absorbance pattern was most readily visible during the purification of CytB5-rHNE from P. pastoris. Human C-reactive protein (hCRP) and the substitution variant CRP E42Q were expressed in recombinant form and secreted by P. pastoris. Both products were found to bind phosphocholine (PCh) in the same manner as native hCRP. Difficulties encountered during purification revealed that wild type recombinant CRP (rCRP) was produced at 2 different molecular masses. The P. pastoris recombinant expression system yielded better results than K. lactis. Bioreactor-scale fermentation in a 5 L vessel facilitated expression and characterization of these recombinant proteins.

Human C-reactive protein (CRP) is the prototypic acute phase protein whose serum concentration increases rapidly during inflammation. CRP is also associated with atherosclerosis; it is deposited at lesion sites where it may interact with modified lipoproteins. There are 2 major questions regarding CRP: 1. How is the serum concentration of CRP regulated? 2. What are the functions of CRP in atherosclerosis? Our first aim was to determine the role of the constitutively expressed transcription factor Oct-1 in regulating CRP gene expression. We found that Oct-1 overexpression inhibited (IL-6+IL-1β)- induced CRP gene expression; maximal inhibition required the binding of Oct-1 to an octamer motif at (-59 to -66) on the CRP promoter. Oct-1 overexpression inhibited both (IL-6+IL-1β)- induced and C/EBPβ-induced CRP gene expression even when the Oct-1 site was deleted. These findings suggest that Oct-1 is a repressor of CRP gene expression that acts via binding to its cognate site on the CRP promoter as well as through indirect interactions with other promoterbound transcription factors. Our second aim was to investigate the interaction of CRP with oxidized low density lipoprotein (ox-LDL). Acidic pH, a hallmark of atherosclerotic lesions, reversibly alters CRP structure and exposes a hidden binding site that enables CRP to bind ox-LDL. Using site-directed mutagenesis we constructed a CRP mutant (E42Q) that showed significant binding to ox-LDL at physiological pH. E42Q CRP required a less acidic pH for maximal binding and bound ox-LDL more efficiently than wild type CRP at any pH. We then examined if reactive oxygen species also induced CRP – ox-LDL interaction. H2O2-treated CRP bound ox-LDL at physiological pH. Like acidic pH, H2O2-treatment induced only a local structural change exposing the ox-LDL binding site. E42Q and H2O2-modified CRP are tools to study the function of CRP in animal models of atherosclerosis, which may not have an inflammatory environment sufficient to modify CRP and induce binding to atherogenic ox-LDL. We conclude that Oct-1 is one of the critical regulators of CRP gene expression, and that CRP can be modified in vitro to convert it into an atherogenic LDL-binding molecule.

<p>This thesis deals with problem solving of general practitioners (GPs), which is explored with different methods and from different perspectives. The general aim was to explore and describe rules of thumb and to analyse the management of respiratory and urinary tract infections (RTI and UTI) in general practice in Sweden. The results are based upon focus group interviews concerning rules of thumb and a prospective diagnosis-prescription study concerning the management of patients allocated a diagnosis of RTI or UTI. In addition unpublished data are given from structured telephone interviews concerning specific rules of thumb in acute sinusitis and prevailing cough.</p><p>GPs were able to verbalize their rules of thumb, which could be called tacit knowledge. A specific set of rules of thumb was used for rapid assessment when emergency and psychosocial problems were identified. Somatic problems seemed to be the expected, normal state. In the further consultation the rules of thumb seemed to be used in an act of balance between the individual and the general perspective. There was considerable variation between the rules of thumb of different GPs for patients with acute sinusitis and prevailing cough. In their rules of thumb the GPs seemed to integrate their medical knowledge and practical experience of the consultation. A high number of near-patient antigen tests to probe Streptococcus pyogenes (Strep A tests) and C-reactive protein (CRP) tests were performed in patients, where testing was not recommended. There was only a slight decrease in antibiotic prescribing in patients allocated a diagnosis of RTI examined with CRP in comparison with patients not tested. In general, the GPs in Sweden adhered to current guidelines for antibiotic prescribing. Phenoxymethylpenicillin (PcV) was the preferred antibiotic for most patients allocated a diagnosis of respiratory tract infection.</p><p>In conclusion, the use of rules of thumb might explain why current practices prevail in spite of educational efforts. One way to change practice could be to identify and evaluate rules of thumb used by GPs and disseminate well adapted rules. The use of diagnostic tests in patients with infectious illnesses in general practice needs critical appraisal before introduction as well as continuing surveillance. The use of rules of thumb by GPs might be one explanation for variation in practice and irrational prescribing of antibiotics in patients with infectious conditions.</p> / On the day of the public defence the status of the articles IV and V was: Accepted.

This thesis deals with problem solving of general practitioners (GPs), which is explored with different methods and from different perspectives. The general aim was to explore and describe rules of thumb and to analyse the management of respiratory and urinary tract infections (RTI and UTI) in general practice in Sweden. The results are based upon focus group interviews concerning rules of thumb and a prospective diagnosis-prescription study concerning the management of patients allocated a diagnosis of RTI or UTI. In addition unpublished data are given from structured telephone interviews concerning specific rules of thumb in acute sinusitis and prevailing cough. GPs were able to verbalize their rules of thumb, which could be called tacit knowledge. A specific set of rules of thumb was used for rapid assessment when emergency and psychosocial problems were identified. Somatic problems seemed to be the expected, normal state. In the further consultation the rules of thumb seemed to be used in an act of balance between the individual and the general perspective. There was considerable variation between the rules of thumb of different GPs for patients with acute sinusitis and prevailing cough. In their rules of thumb the GPs seemed to integrate their medical knowledge and practical experience of the consultation. A high number of near-patient antigen tests to probe Streptococcus pyogenes (Strep A tests) and C-reactive protein (CRP) tests were performed in patients, where testing was not recommended. There was only a slight decrease in antibiotic prescribing in patients allocated a diagnosis of RTI examined with CRP in comparison with patients not tested. In general, the GPs in Sweden adhered to current guidelines for antibiotic prescribing. Phenoxymethylpenicillin (PcV) was the preferred antibiotic for most patients allocated a diagnosis of respiratory tract infection. In conclusion, the use of rules of thumb might explain why current practices prevail in spite of educational efforts. One way to change practice could be to identify and evaluate rules of thumb used by GPs and disseminate well adapted rules. The use of diagnostic tests in patients with infectious illnesses in general practice needs critical appraisal before introduction as well as continuing surveillance. The use of rules of thumb by GPs might be one explanation for variation in practice and irrational prescribing of antibiotics in patients with infectious conditions. / On the day of the public defence the status of the articles IV and V was: Accepted.

Background Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system. It usually strikes during young adulthood, and 2.5 million individuals are estimated to have the disease worldwide. The causes of MS are not known, but several factors have been shown to be associated with the risk of the disease, including certain genes, vitamin D, smoking and Epstein- Barr virus infection. Little is known about how/if these factors interact. Methods Study I: The risk of MS by month of birth was investigated using MS cases from the Swedish MS registry and using general population controls. Studies II–V: We identified MS cases who had donated blood prior to disease onset, and MS cases whose mothers had donated blood during pregnancy, by cross-linking a database of MS cases, and a database of mothers of MS cases, to two local biobank cohorts. One of them consisted of blood samples collected during early pregnancy, and one with samples collected during health controls. Levels of 25(OH)D (25-hydroxyvitamin D), RBP (retinol binding protein, a surrogate marker for vitamin A), CRP (C- reactive protein), cotinine (a nicotine metabolite) and anti Epstein-Barr virus nuclear antigen-1 (EBNA-1) antibodies were measured in cases and matched controls. The risk of MS by categories of these exposures was estimated in bi- and multivariable matched logistic regression models. Results Subjects born in spring had a higher risk of MS, but no influence of early gestational levels of the measured risk factors on the risk of MS in the offspring was observed. In prospective samples from MS cases and controls, 25(OH)D levels ≥75 nmol/l, intermediate RBP levels, and elevated CRP levels in young were associated with a decreased risk of MS. Elevated cotinine levels (suggestive of smoking) and high antibody reactivity against EBNA-1 were associated with an increased risk of MS. All factors but RBP were more clearly associated with MS in young subjects. Conclusion All factors analyzed in prospectively collected samples were associated with the risk of MS, and taken together, the data indicate that the key etiopathological events that lead to MS occur before the age of 20–30. Study II provides support for trials exploring the primary preventive potential of oral vitamin D supplementation.