Thesis--Utrecht. / Summary in French. Includes bibliographical references (p. 311-326) and index.

Proefschrift Universiteit van Amsterdam. / Met lit. opg., reg. - Met samenvatting in het Duits.

Proefschrift--Universiteit van Amsterdam, 2001. / Bibliogr. p. 254-268. Index. Résumé en anglais.

Proefschrift Universiteit van Amsterdam. / Met lit. opg. - Reg. - Met een samenvatting in het Engels.

Texte abrégé et remanié de: Thèse--Lettres--Paris IV, 1973. / Thèse soutenue sous le titre : "Gérard de Saint-Jean et la peinture dans les Pays-Bas du Nord au XVm siècle" Bibliogr. p. 247-257. Index.

Thesis--Utrecht. / With a French summary. Includes bibliographical references (p. 311-336) and index.

Submitted by Ana Maria Fiscina Sampaio (fiscina@bahia.fiocruz.br) on 2013-10-15T19:41:49Z No. of bitstreams: 1 Erivelton 1 Oliveira Souza Caracterizaçao dos perfis...2012.pdf: 2501634 bytes, checksum: c5ec35828b8fce881d7f6a1ae0ff2b45 (MD5) / Made available in DSpace on 2013-10-15T19:41:49Z (GMT). No. of bitstreams: 1 Erivelton 1 Oliveira Souza Caracterizaçao dos perfis...2012.pdf: 2501634 bytes, checksum: c5ec35828b8fce881d7f6a1ae0ff2b45 (MD5) Previous issue date: 2012 / Fundação Oswaldo Cruz. Centro de Pesquisas Gonçalo Moniz. Salvador, BA, Brasil / A resistência aos fármacos utilizados no tratamento da tuberculose (TB) é um importante desafio no combate à doença. A rifampicina e a isoniazida são dois fármacos de primeira linha essenciais para a cura da doença, a qual tem como agente o M. tuberculosis. Pacientes com TB cujos isolados de M. tuberculosis apresentem resistência in vitro simultânea a estes dois fármacos desenvolvem a TB multirresistente (TBMR). A resistência do M. tuberculosis está relacionada com mutações em genes importantes para a sobrevivência do bacilo. O tratamento da TBMR é mais longo e utiliza fármacos anti-TB de segunda linha, os quais são de maior toxicidade, predispondo os pacientes à não adesão aos esquemas de tratamento. O paciente com TBMR, quando não devidamente tratado, pode selecionar cepas resistentes aos fármacos anti-TB de segunda linha, proporcionando o surgimento da TB extensivamente resistente (TBXDR). Por sua vez, estas cepas podem ser transmitidas em comunidades, constituindo um grave problema de saúde pública. Segundo a Organização Mundial de Saúde, a TBXDR tem sido documentada em alguns países, mas no Brasil estes dados são escassos. A caracterização genética de cepas de M. tuberculosis envolvidas com os casos TBMR/TBXDR pode facilitar a identificação de vias de transmissão. OBJETIVO: Pesquisar casos de TBXDR na Bahia e caracterizar perfis genéticos de isolados de M. tuberculosis de pacientes com TB multirresistente, associando o perfil genético encontrado com as características sócio-demográficas e clínicas dos pacientes envolvidos. MATERIAIS E MÉTODOS: Isolados de M. tuberculosis obtidos de pacientes com diagnóstico de TBMR entre 2008-2011 residentes no Estado da Bahia (Brasil) foram submetidos ao teste de sensibilidade utilizando fármacos anti-TB de primeira e segunda linha e genotipados pela técnica do Número Variável de Repetições em Tandem de Unidades Repetitivas Inter-espaçadas Micobacterianas (MIRU-VNTR) para obtenção de perfis genéticos que foram associados com perfis da base de dados internacional MIRU-VNTRplus. Isolados com perfis genéticos não associáveis a linhagens com o uso desta técnica foram adicionalmente genotipados por Spoligotyping e ambas as informações foram consideradas para assimilação de linhagens utilizando esta mesma base de dados. Informações clínico-epidemiológicas foram obtidas do banco de dados “Sistema TBMR” do Ministério da Saúde. RESULTADOS: Foram analisados 392 isolados. Destes, 35% foram excluídos por ausência de crescimento ou contaminação e 12% constituíam amostras em duplicata, resultando em 206 pacientes com TBMR no estudo. Comprovou-se a ocorrência da TBXDR em 7% (14/206) dos pacientes; destes, dois não possuíam registro anterior para qualquer tratamento anti-TB. Os pacientes estudados foram provenientes de 45 municípios do Estado. A capital, Salvador, concentrou 71% dos casos TBMR e 76% dos TBXDR. Dos casos TBXDR, 36% (5/14) apresentaram isolados resistentes a todos os fármacos testados. Observou-se associação de resistência combinada entre estreptomicina e etambutol (8/14, 57%) e o perfil TBXDR (RP 4,0; IC95% 1,2-13,8; P=0,01). Dos casos TBXDR, 71% (10/14) desenvolveram uma ou mais comorbidades (P=0,04), sendo o transtorno mental uma comorbidade significativa neste grupo (21%; 3/14; P=0,04). Encontrou-se 56 perfis genéticos, 38 únicos e 18 agrupados em clusters (contendo de 2 a 11 isolados). Quase a totalidade (92%) dos casos TBXDR esteve agrupada em clusters, diferindo dos casos não-TBXDR (P=0,049). Os perfis genéticos estiveram principalmente associados a seis famílias: LAM (70%), Cameroon (16%), Haarlem (10%) e as famílias X, S, Uganda I, que combinadas perfizeram 4%. Os casos TBXDR foram representados pelas famílias LAM (45%, ST’s 376, ST42, ST20), Cameroon (36%, ST61 único) e Haarlem (18%, ST50). CONCLUSÕES: A Bahia apresentou casos de TBXDR e as famílias de M.tuberculosis envolvidas com estes casos foram LAM, Cameroon e Haarlem. A genotipagem auxiliou na descoberta de casos epidemiologicamente relacionados. / Resistance to drugs used in tuberculosis (TB) chemotherapy is a major challenge to fighting this disease caused by M. tuberculosis. Rifampin and isoniazid are two main first-line drugs to achieve TB cure. TB patients whose M. tuberculosis isolates exhibit resistance simultaneously to these two drugs develop multidrug-resistant TB (MDR-TB). M. tuberculosis resistance is related to mutations in genes important for bacillus survival. MDR-TB treatment is longer and uses more toxic second-line anti-TB drugs, predisposing patients to non-adherence to treatment regimens. Patients with MDR-TB, when not properly treated, can select strains resistant to second-line anti-TB drugs leading to the emergence of extensively drug-resistant TB (XDR-TB). These strains can be transmitted in communities, constituting a serious public health problem. According to the World Health Organization, XDR-TB has been documented in some countries, but in Brazil these data are scarce. The genetic characterization of M. tuberculosis strains involved in MDR/XDR-TB cases could facilitate the identification of transmission chains. AIMS: To investigate cases of XDR-TB in Bahia and to characterize the genetic profiles of the isolates of M. tuberculosis from patients with multidrug-resistant TB, associating the genetic profiles observed with the socio-demographic and clinical characteristics of patients involved. MATERIALS AND METHODS: M. tuberculosis isolates obtained from patients diagnosed with MDR-TB between 2008-2011 resident in the State of Bahia (Brazil) were tested for sensitivity against first and second-line anti-TB drugs and genotyped by the Variable Number of Tandem Repeats in Repetitive Unit Inter- Mycobacterial spaced (MIRU-VNTR) technique to obtain the genetic profiles that were associated with profiles in the international database MIRU-VNTRplus. Isolates whose genetic profiles have not matched any lineage with the use of this technique were further genotyped by Spoligotyping and information from both methods were considered to test for the possible matching with lineages from the same database. Clinical and epidemiological data were obtained from the database "Sistema TBMR" of the Ministry Health. RESULTS: We analyzed 392 isolates. Of these, 35% were excluded due to absence of growth or contamination and 12% corresponded to duplicate samples, resulting in 206 patients with MDR-TB in the study. XDR-TB was found in 7% (14/206) of the patients, two of which had no previous record of any anti-TB treatment. The patients studied were from 45 cities of the State. The capital, Salvador, concentrated 71% of all MDR-TB and 76% of the XDR-TB cases. Among XDR-TB cases, 36% (5/14) had isolates resistant to all drugs tested here. Combined resistance to streptomycin and ethambutol (8/14, 57%) was associated with the XDR-TB profile (OR 4.0, 95% CI 1.2 to 13.8, P = 0.01). 71 %(10/14) of XDR-TB cases developed one or more comorbidities (P= 0.04), mental disorder being a significant comorbidity in this group (21%, 3/14, P=0.04). Genotyping yielded 56 profiles, 38 unique and 18 in clusters (containing 2 to 11 isolates). Almost all (92%) XDR-TB cases were clustered, differing from non-XDR-TB cases (P=0.049). The genetic profiles were mainly associated with six families: LAM (70%), Cameroon (16%), Haarlem (10%), and the families X, S, Uganda I, which altogether amounted to 4%. The XDR-TB cases were represented by LAM (45% ST's 376, ST42, ST20), Cameroon (36%, single ST61) and Haarlem (18% ST50). CONCLUSIONS AND STUDY CONTRIBUTIONS: Bahia presented cases of XDR-TB and the families involved with these cases were LAM, Haarlem and Cameroon. Genotyping helped in epidemiologically linked case finding.

The Night Nativity by Geertgen tot Sint Jans depicts the birth of Christ in a manner that emphasizes the role of the Virgin as mother and Christ as the enlightener of the world. In this paper, I will argue that the Night Nativity was directed primarily toward meeting the devotional needs and interests of the nuns of the Convent of Our Lady of the Visitation near Haarlem. This convent is of particular interest because it is associated with the Windesheim Congregation of the Modern Devotion, which was a religious movement that privileged certain forms of lay spirituality. In particular, the adherents of the Modern Devotion seemed to have preferred various forms of affective devotion often associated with “women’s spirituality.” Geertgen’s image, I believe, appealed to the women in the convent because it focuses on the role of the Virgin and, in doing so, activated well-known tropes of female spirituality.