A importância da doença arterial coronariana (DAC) na sociedade \"moderna\" é atestada pelo grande número de pessoas afetadas por ela. Os dados da Organização Mundial de Saúde estimam que a doença isquêmica do coração será a segunda principal causa de morte em todo o mundo até 2030. Além disso, com o advento das ferramentas de predição de riscos e estudos de associação genômica ampla (GWAS, do inglês Genome-Wide Association Studies), vários estudos tem demonstrado o uso de escores genéticos de risco para predizer DAC, porém estes escores apresentam apenas uma discreta melhora em nossa capacidade de avaliação. O presente estudo desenvolveu um escore genético de risco (GRS, do inglês Genetic risk score) para DAC, utilizando polimorfismos previamente associados a DAC e/ou a fenótipos relacionados à doença. Mil, trezentos e quarenta e nove indivíduos, provenientes do Estudo Longitudinal da Saúde do Adulto (ELSA-BRASIL), foram genotipados para nosso estudo. Usando polimorfismos de nucleotídeo único (SNP, do inglês Single Nucleotide Polymorphisms) obtidos a partir da base de dados online de GWAS avaliamos a associação de cada polimorfismo escolhido com os fatores de risco para doença cardiovascular. Os indivíduos foram submetidos à determinação do escore de cálcio (EC) coronário e um EC > 100 foi usado como desfecho. Modelos Zero-inflacionados foram utilizados para a construção do escore de risco genético (GRS). Escore de risco de Framingham para DAC em 10 anos (FRS, do inglês Framingham Risk Score) foi calculado de acordo com o descrito por Wilson e D\'Agostino. Nosso GRS foi composto de 47 variantes genéticas, ajustado por sexo e idade, associadas com DAC ou outros fenótipos da doença coronária ou fatores de risco. O GRS mostrou precisão significativamente melhor do que o Escore de Risco de Framingham para predizer o risco de CHD (AUC, 0,90; IC 95%: 0,88-0,93; P < 0,01). Também foram criados outros dois escores: o primeiro, um modelo com apenas a idade e sexo; o segundo, apenas utilizando a informação genética. Comparamos o modelo Idade+Sexo com o GRS e FRS por meio de curva ROC e avaliamos o desempenho dos modelos em comparação com FRS. Análises do NRI e IDI foram realizadas para avaliar a reclassificação do GRS e do modelo Idade+Sexo em relação ao FRS, que é o atualmente utilizado para a estratificação de indivíduos da população geral. O escore apenas com os SNPs foi utilizado para comparar sua adição a um modelo com fatores de risco. Por fim, analisamos a associação entre o GRS, fatores de risco e CAC usando modelos lineares generalizados. Em suma, criamos um GRS composto por 47 SNPs associado com doença coronariana ou fatores de risco cardiovascular que apresentou bons resultados na predição de risco para DAC. O GRS melhorou a reclassificação de risco para doença arterial coronariana, e melhorou significativamente a discriminação entre os indivíduos afetados e não afetados / Importance of coronary artery disease (CAD) in \"modern\" society is attested by the large increase of people affected by it. Data from the World Health Organization estimated that ischemic heart disease is the second leading cause of death worldwide by 2030. Futhermore, with the advent of predictive risk tools and genome-wide association studies, several studies have demonstrated the use of genetic risk scores (GRS) for predicting CAD, but these scores shows a slight improvement in the assessment. This study built a genetic risk score for CAD, using polymorphisms previously associated with CAD and phenotypes related to disease. One thousand, Three hundred forty-nine individuals, from the Brazilian Longitudinal Study of Adults Health (in Portuguese, Estudo Longitudinal da Saúde do Adulto-BRASIL), were genotyped for our study. Using single nucleotide polymorphisms (SNPs) obtained from the online database of GWAS evaluated the association of each polymorphism chosen with risk factors for cardiovascular disease. Individuals underwent determination of calcium artery coronary score (CACS) and CAC > 100 was used as the end-point. Zero inflated models were used for the construction of GRS. Framingham Risk Score (FRS) for CHD in 10 years was calculated as described by Wilson and D\'Agostino. In addition, our GRS consists of 47 genetic variants, adjusted for sex and age, associated with CHD or other phenotypes of coronary heart disease or risk factors. GRS showed significantly better accuracy than the Framingham Risk Score to predict the risk of CAD (AUC, 0.90; 95% CI: 0.88 0.93; P < 0.01). Also other two scores were created: first, a model with only age and sex; second, only the genetic information. We compare the Age+Sex model with the GRS and FRS through ROC curve and evaluate the performance of models compared with FRS. NRI and IDI analysis were performed to evaluate the reclassification of GRS and Age + Sex model in relation to the FRS model. The score only the SNPs was used to compare their addition to a model with risk factors. Finally, we analyzed the association between the GRS, risk factors and CAC using generalized linear models. In short, we create a GRS composed of 47 SNPs associated with coronary heart disease or cardiovascular risk factors that showed good results in risk prediction for CAD. GRS improved reclassification of risk for coronary artery disease, and significantly improves the discrimination between affected and unaffected individuals

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.

Sepsis is the most frequent cause of mortality in most intensive care units. Cardiovascular dysfunction is a major complication associated with sepsis, with high mortality rates up to 70%. Currently, there is no effective treatment approach for sepsis. The integrity of the endothelium is fundamental for the homeostasis of the cardiovascular system. Sepsis induces endothelial cell injury which is the key factor for multiple organ failure. The increased expression of adhesion molecules and chemokines in endothelial cell promotes leukocytes infiltration into the tissue. The loss of tight junction proteins and increased permeability of the endothelial cells will provoke tissue hypoxia and subsequent organ failure. Therefore, preservation of endothelial function is a critical approach for improving sepsis-induced outcome. Here, we showed that endothelial specific protein HSPA12B plays a critical role in the preservation of cardiovascular function in polymicrobial sepsis. HSPA12B is the newest member of HSP70 family which predominantly expresses in endothelial cells. We observed that HSPA12B deficiency (HSPA12B-/-) exaggerated polymicrobial sepsis-induced endothelial dysfunction, leading to worse cardiac dysfunction. HSPA12B-/- significantly increases the expression of adhesion molecules, decreases tight junction protein levels and enhances vascular permeability. HSPA12B-/- alsomarkedly promotes the infiltration of inflammatory cells into the myocardium and inflammatory cytokine production. We investigated the cardioprotective mechanisms of HSPA12B in sepsis induced cardiovascular dysfunction. Exosomes play a critical role in intercellular communication. Exosome is a natural vehicle of microRNAs. We found that exosomes isolated from HSPA12B-/- septic mice induced more expression of adhesion molecules in endothelial cells and inflammation in macrophages. Interestingly, the levels of miR-126 in serum exosomes isolated from HSPA12B-/- septic mice were significantly lowers than in WT septic mice. Importantly, delivery of miR-126 carried exosomes significantly improved cardiac function, suppressed the expression of adhesion molecules, reduced immune cell infiltration in the myocardium, and improved vascular permeability in HSPA12B-/- septic mice. The data suggests that HSPA12B is essential for endothelial function in sepsis and that miR-126 containing exosomes plays a critical role in cardiovascular-protective mechanisms of endothelial HSPA12B in polymicrobial sepsis.

Hydroxytyrosol, 3,4-dihydroxyphenolethanol, a naturally occurring polyphenol most common in olive tree (Olea europaea), is one of the most effective member of the polyphenols family, because of its remarkable antioxidant activity, its ability to inhibit oxidation of low density lipids (LDL), and its protection against DNA oxidative damage. Hydroxytyrosol, which is widely used in cosmetics and food supplements industries, can be purchased as an olive oil extract that contains low concentration of hydroxytyrosol besides other polyphenols. The price and low natural abundance of hydroxytyrosol make alternative synthetic sources very attractive. In this research, a novel method for the synthesis of pure hydroxytyrosol from a commercially inexpensive precursor catechol was developed; this can satisfy the increasing market demand and provide a more economical alternative source for this valuable polyphenol.

L’hypercholestérolémie familiale à transmission autosomique dominante (ADH), caractérisée par une élévation des taux plasmatiques en cholestérol total et LDL-C, est due à des altérations de 4 gènes : LDLR, APOB, PCSK9 et APOE. L’objectif principal de cette thèse est d’identifier de nouveaux gènes impliqués dans l’ADH. L’identification de nouveaux gènes sera suivie de l’étude des mécanismes physiopathologiques liés à leurs mutations. Un deuxième objectif est de calculer le score génétique (GRS) chez tous les individus appartenant à 5 familles où une mutation FH a déjà été identifiée afin de déterminer si une forme polygénique expliquerait les cas de phénocopies observés. Parallèlement, nous avons mené une étude dans la population libanaise caractérisée par une fréquence élevée de dyslipidémie et qui représente un outil d’étude remarquable au plan génétique du fait de l’existence d’une forte homogénéité du fond génétique.Ce projet de recherche a permis de révéler un gène candidat pouvant être impliqué dans l’ADH : LRP6. De plus il a permis de remettre en question le rôle du récepteur LRP6 jusqu’à présent considéré comme un protagoniste important dans l’internalisation des LDL. Des études supplémentaires sont encore nécessaires afin de confirmer ou non l’implication de ce gène dans l’ADH et de déterminer son rôle exact dans le métabolisme du cholestérol. Concernant le score polygénique, nous avons montré que le GRS ne peut pas être considéré comme un outil de diagnostic pour différencier les sujets avec une hypercholestérolémie monogénique de ceux avec une hypercholestérolémie polygénique et ne peut pas être utilisé pour expliquer les cas de phénocopies / Atherosclerosis and its cardiovascular complications are the leading causes of morbidity and mortality in industrialized countries. Hypercholesterolemia is one of the major cardiovascular risk factors and it affects one in 20 subjects in the general population. Autosomal dominant hypercholesterolemia (ADH), characterized by elevated plasma total cholesterol and LDL-C levels, is due to alterations in 4 genes: LDLR, APOB, PCSK9 and APOE. The fundamental work of Brown and Goldstein revealed the important role of the mutations in the LDLR gene in ADH and contributed to the development of a major class of cholesterol-lowering drugs: statins. Similarly, the discovery by Abifadel et al. in 2003 of the first hypercholesterolemic mutations of PCSK9 was the starting point of an adventure which resulted, 12 years later, in the development of a new class of cholesterol-lowering drugs: anti-PCSK9 antibodies. The main objective of this thesis is to discover new genes, major genetic factors and modifiers involved in ADH. The identification of new genes will be followed by the study of the pathophysiological mechanisms linked to their mutations. A second objective of this work is to calculate the genetic risk score (GRS) in all individuals belonging to 5 families where a mutation responsible of the hypercholesterolemic phenotype has been already identified in order to determine whether a polygenic form would explain the phenocopies observed in these families. In parallel to these two projects, we conducted a study in the Lebanese population which is characterized by a high incidence of dyslipidemia. In this population, it is interesting to conduct genetic studies because of the existence of a limited number of sub-populations that constitute "genetic isolates" with a high homogeneity of their genetic background, making it easier to study many hereditary diseases such as familial hypercholesterolemia. The results obtained in this project revealed a candidate gene that could be involved in ADH: LRP6. Moreover, it allowed us to question about the exact role of the LRP6 receptor until now considered as an important protagonist in the internalization of LDL particles. Further studies are still needed to confirm whether or not this gene is involved in ADH and to determine its exact role in cholesterol metabolism. Concerning the genetic score, we have shown that the GRS does not seem to be a reliable diagnostic tool to identify polygenic hypercholesterolemia at the individual level. The 6-SNP score did not give us a clear answer and thus we cannot use the GRS to identify phenocopies within ADH families

Cardiovascular complications associated with elevated levels of glucose in the blood (Hyperglycemia, HG) is a growing health concern. HG is known to be associated with a variety of cardiovascular morbidities including higher incidence of electrical disturbances. Although effects of chronic HG have been widely investigated, electrophysiological effects of acute hyperglycemia are relatively less known. Further, hyperglycemic effects on adrenergic response is not widely investigated. We used excised ventricular tissues from mice to record trans-membrane potentials during a variety of pacing protocols to investigate cellular/tissue level electrophysiological effects of acute hyperglycemia and adrenergic stimulation (1µM Isoproterenol, a β-adrenergic agonist). A custom program was used to compute action potential durations (APD), maximal rates of depolarization (dv/dtmax), and action potential amplitudes (APA) from the recorded trans-membrane potentials. From these computed measures, electrical restitution and alternans threshold were quantified. Restitution was quantified using the Standard Protocol (SP; basic cycle length BCL= 200ms), Dynamic Protocol (DP; 200-40ms or until blockade) and a novel diastolic interval (DI) control protocol with Sinusoidal Changes in DI. Results from 6 mice show that acute hyperglycemia causes prolongation of the APD. Effects of adrenergic stimulation during acute hyperglycemia were partially blunted compared with non-hyperglycemic state, i.e. hyperglycemia minimized the decrease in APD that was produced by adrenergic stimulation. Similar, but less consistent (across animals) effects were seen in other electrophysiological parameters such as alternans threshold. These results show that acute hyperglycemia may itself alter cellular level electrophysiology of myocytes and importantly, modify adrenergic response. These results suggest that in addition to long term re-modeling that occurs in diabetes, acute changes in glucose levels also affect electrical function and further may contribute to systemically observed changes in diabetes by blunting adrenergic response. Therefore, further investigation into the electrophysiological effects of acute changes in glucose levels are warranted.

Interleukin-18 (IL-18) is a pro-inflammatory cytokine known to be involved in maintaining metabolic homeostasis; however, also capable of inducing cardiac dysfunction. Additionally, IL-18, has been shown to bind to a novel receptor, the Na-Cl Co-transporter (NCC). We hypothesized that NCC mediates IL-18 metabolic and cardiac signaling in mice. Using male C57BL/6J mice, we compared the metabolic and cardiac function changes after at least 8 weeks of high-saturated fat high sugar diet (Western Diet) in NCC knockout (NCCKO), IL-18 knockout (IL-18KO), and wild-type mice. We show that NCCKO mice have significantly increased body weight gain from baseline, no difference in fasting blood glucose, and attenuated cardiac diastolic dysfunction after WD compared to wild-type mice. Collectively, the metabolic and cardiac phenotypes of NCCKO mice resembled that of the IL-18KO mice, indicating that NCC may mediate IL-18 signaling in a mouse model of diet-induced obesity and cardiac dysfunction.

5-HT2B receptor agonism causes cardiac valvulopathy, a condition characterized by thickening of the heart valves and as a result, regurgitation of blood within the heart. The anti-obesity drug fenfluramine, which was originally prescribed as an anorectic, was withdrawn from the market due to causing cardiac valvulopathy. Fenfluramine, after metabolism by N-dealkylation, produces the metabolite norfenfluramine, which acts as a more potent valvulopathogen. The same was seen with MDMA (ecstasy), a popular drug of abuse, which is metabolized by N-dealkylation to produce MDA, a more potent valvulopathogen. Glennon and co-workers. studied a series of 2,5-dimethoxy-4- substituted phenylisopropylamines (DOX type) hallucinogens and determined their affinities at the three types of 5-HT2 receptors. A high correlation was found between the affinities of these molecules at 5-HT2A and 5-HT2B receptors. Therefore, these hallucinogens have a high possibility of causing valvulopathy, which gives rise to a new class of valvulopathogens. Since certain hallucinogens have the common phenylisopropylamine structural scaffold as that of MDA and norfenfluramine, we conducted 3D-QSAR studies to identify the common structural features of these molecules that are responsible for their high affinities. We were unable to obtain a suitable CoMFA and CoMSIA model for 5-HT2B receptors, but we were able to obtain an internally and externally validated model for 5-HT2A receptor affinities which indicated the hydrophobicity of the substituent at the 4- position was essential for high affinity. Following up with this evidence, we conducted a correlation analysis for the hydrophobicity (π-value) of the 4-position substituent and found a positive correlation between the π-value and the affinity of the molecules. The same results were not observed for the volume of the substituents. We docked the molecules into the 5-HT2B receptor and successfully generated models of the putative interactions made by the DOX molecules and the receptor. In order to compare their binding modes with respect to known valvulopathogens, we also generated models for norfenfluramine and MDA. Our docking results revealed that DOX molecules bind in a more or less similar manner to valvulopathogens MDA and norfenfluramine. Ours is the first in silico model developed for the potent valvulopathogen MDA and the hallucinogenic DOX series of molecules.

Uncontrolled growth of vascular stem cells as a result of endothelial-mesenchymal transition is considered to cause hyper-proliferative vascular remodeling in severe pulmonary arterial hypertension (PAH) patients. Hyperplastic intimal growth is one of the causes of closure of the lumen of pulmonary arterioles. This abnormal vessel remodeling leads to the progressive increase in pressure of the pulmonary arterioles causing severe PAH; and debilitating harm to patients resulting in mortality from right heart failure. Environmental factors, including polychlorinated biphenyls (PCBs), are considered to be involved in hyper-proliferative vascular remodeling because genetic makeup can only explain about 10% of severe PAH cases. PCB involvement in lung toxicity has received attention because (i) they have been reported to accumulate in the lung; (ii) PCBs produce pathological vascular remodeling in the experimental model; high levels of PCBs are found in human lung tissue; and (iii) epidemiological studies show the association between lung toxicity and PCBs; and prevalence of hypertension and elevated concentrations of particularly PCB153. Recent studies identify PCB153 as one of the largest contributors for total PCB body burden in humans. Our previous studies demonstrated PCB153 mediated vascular endothelial dysfunction and activated the inhibitor of differentiation protein 3 (ID3). ID3 is an important determinant of mitogen and reactive oxygen species-induced G1→S phase cell cycle progression. Although phosphorylation of ID3 increases cell growth by antagonizing the transcription of cell cycle inhibitors, still there is a critical gap in understanding the molecular mechanism(s) of pulmonary proliferative vascular remodeling associated with PCB exposure in humans and the role of the transcription regulator ID3. Our overall objective was to investigate ID3 mediated transcriptional reprogramming as a driver of PCB153-induced pathological proliferative vascular remodeling. Stable ectopic expression of ID3 in lung endothelial cells contributed to endothelial-mesenchymal transition (EndMT), cell proliferation, and cell migration. Using an endothelial spheroid assay, an established method to measure aberrant hyper-proliferation of endothelial cells in PAH patients, we show that stable ectopic expression of ID3 increased the number and size of vascular spheres. ID3 overexpressing cells exposed to environmentally relevant concentrations of PCB153 showed a two-fold increase in cell proliferation as determined by MTT, SRB, and BrdU assays. ID3 overexpressing cells showed the loss of VE-cadherin and gain of MMP9 and vimentin, which are markers of EndMT. PCB153 also increased phosphorylation of ID3 in lung endothelial cells. To determine the molecular mechanism by which ID3 contributes to hyper-proliferative endothelial cells, we investigated ID3 transcriptional reprogramming using ChIP-Seq and RNA-Seq technology. We show here for the first time that ID3 is part of a more general mechanism of transcriptional regulation. Our ChIP-Seq data show that ID3 binds to a subset of approximately 1200 target genes. Comprehensive motif analysis of ChIP-Seq data using the MEME Suite software toolkit revealed that ID3 bound to the GAGAGAGAGA motif sequence on genomic DNA. We also show a significant preference of ID3 binding to motifs associated with transcription factors IRF1, BC11A, IRF4, PRDM1, FOXJ3, SMAD4, ZBTB6, GATA1, and STAT2. Using an integrative approach of ChIP-Seq and RNA-Seq data, we identified 19 genes whose promoter region was bound by ID3 and RNA was differentially expressed in ID3 overexpressing cells. In summary, our data demonstrated that PCB153 and/or ID3 induces proliferation of lung endothelial cells via transcriptional reprogramming. Discoveries from these findings will lay the necessary groundbreaking work for testing the efficacy of ID3 antagonists for the prevention and treatment of pathological vascular remodeling as well as provide a new paradigm by which PCBs may contribute to lung vascular toxicity.

Orientador: Roberto Carlos Burini / Resumo: Fetuina-A é uma glicoproteína multifuncional, sintetizada pelo fígado como proteína de fase aguda. Atua na inibição da cascata da insulina, e estimula a síntese de citocinas pró-inflamatórias. Assim, sugere-se que a fetuina-A esteja envolvida na patogênese da doença gordurosa hepática não-alcoólica (DGHNA), constituindo-se em um dos seus indicadores. O presente estudo tem como objetivo investigar as concentrações de fetuina-A na DGHNA e sua associação com distúrbios metabólicos, bem como, com o risco de fibrose hepática, e doença cardiovascular (DCV), mediante marcadores bioquímicos. Para tanto, foi realizado estudo transversal com mulheres ingressantes em programa para mudança do estilo de vida. Foram avaliadas 148 mulheres com idade entre 35 a 78 anos, as quais foram submetidas às avaliações clínicas, sócio-demográfica, antropométrica, de consumo alimentar e análises bioquímicas. O nível de significância considerado foi p<0,05. Verificou-se DGHNA, pelo Índice de Gordura Hepática (IGH≥60), em 55,4% das mulheres. Fetuina-A sérica correlacionou-se positivamente com Índice de Massa Corporal, circunferência abdominal, IGH e proteína C-reativa ultra-sensível (PCR-us). A proporção de mulheres com resistência insulínica (RI) pelo modelo homeostático de resistência à insulina (HOMA-IR) foi maior dentre os valores maiores (Tercil 3) de fetuina-A, comparativamente, aos menores valores (Tercil 1). Resultado análogo foi encontrado para a PCR-us, mas não para proteína ligadora de lipopol... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Fetuin-A is a multifunctional glycoprotein, synthesized by the liver as a acute phase protein. It acts in insulin cascade inhibition, and stimulates pro-inflammatory cytokines. It is postulated that fetuin-A is involved in non-alcoholic fatty liver disease (NAFLD) pathogenesis, as one of its indicators. The present study aims to investigate fetuin-A concentration in NAFLD and its association with metabolic disturbers, as well as with hepatic fibrosis risk, and cardiovascular disease (CVD), through biochemical markers. For that, a cross-sectional study was carried out with women entering a lifestyle modification program. We evaluate 148 women, with age that range from 35 to 78 years old that were submitted to clinical, sociodemographic, anthropometric, food consumption and biochemical evaluation. The statistical significance considered was p<0,05. We verified that NAFLD, measured by Fatty Liver Index (FLI ≥60), was found in 55.4% of women. Serum fetuin-A was positively correlated with Body Mass Index, waist circumference, FLI and high-sensitivity C-reactive protein (hs-CRP). The proportion of women with insulin resistance (IR) by insulin resistance homeostatic model assessment (HOMA-IR), was higher among the higher values (Tercil 3) of fetuin-A, compared to the lowest values (Tercil 1). Analog results were found to hs-CRP, but not to lipopolysaccharide-binding protein (LBP), albuminemia and hepatic fibrosis. After adjustments, HOMA-IR and hs-CRP altered, constitute independent... (Complete abstract click electronic access below) / Mestre