Thesis (PhD (Med))--Stellenbosch University, 2011. / ENGLISH ABSTRACT: Background and Objective: The most common cause of severe proteinuria/nephrotic syndrome (NS) in children worldwide is minimal change disease (MCD). This is also the pattern observed in white and Indian children in South Africa (SA). By contrast, black and mixed race/coloured children of Southern Africa in the 1960s to 1990s were shown to have a different pattern of NS. One of the main differences was the frequency of hepatitis B virus (HBV) associated glomerulonephritis, usually membranous glomerulonephritis (MGN). The objective of this project was a clinicopathological study of this subgroup of nephrotic children to document the disease further and in particular to seek correlations between pathological and clinical features including prognosis. A central focus was to document the detailed ultrastructural examination of the renal biopsies of these children and to correlate the spectrum of pathological features with demographic, clinical, laboratory and prognostic features. The hypothesis was that the clinicopathological features of HBV MGN in children differed substantially from idiopathic MGN in general (children and adults) and also from HBV MGN in adults and that HBV MGN in children should be viewed as a distinct disease. Patients and methods: The childhood (12 years and younger) patient cohort was 309 children with severe proteinuria/nephrotic syndrome who presented at Tygerberg Hospital (TBH) over a 21 year period from 1974-1995, including 67 children from Namibia. The study group was 71 children with HBV MGN who were followed up to 2005. The comparative adult group was 45 adults with MGN of whom 12 had HBV MGN and 33 idiopathic MGN. (A comparison could not be made with idiopathic MGN in childhood as this centre only had 2 such patients during the study period.) Demographic, clinical, laboratory and renal pathology data were collected, compared and correlated. Results: HBV associated MGN was the most frequent cause of NS in the Namibian subgroup, 25/67 (37%) and the third most frequent, 71/309 (23%) in the childhood cohort as a whole. The MGN group was 86% (71/83) of the total HBV childhood nephrotic cohort, by far the dominant subgroup. The average age of the 71 children with HBV MGN was 6.0 years (range 2-12 years) at presentation and boys comprised 80% of the group. Hepatitis B envelope antigen (HBeAg) was identified in the serum of 87% of children tested. Laboratory features different from idiopathic MGN included more prominent haematuria, mildly raised serum transaminases and more frequently lowered serum C3 and C4 levels. Light microscopic examination of renal biopsies showed mesangial proliferation in all patients but with minimal glomerular sclerosis and interstitial disease. On ultrastructural examination mesangial and subendothelial deposits were common and prominent as was mesangial interposition. The MGN of HBV in children therefore frequently showed mesangiocapillary glomerulonephritis (MCGN) features in addition to the subepithelial deposits of MGN. The subgroup of 23 whose renal biopsies displayed severe mesangial interposition in addition to the subepithelial deposits of MGN were termed the mixed HBV MGN-mesangiocapillary GN group. Virus like bodies and tubuloreticular inclusion bodies were both found in more than 80% of biopsies of childhood HBV MGN. HBeAg was identified in the subepithelial deposits in the glomeruli. This was the first time this feature was demonstrated in Africa. The 46 South African children with HBV MGN showed a cumulative remission rate of 25% at 2 years and 52% at 4 years. Seven of the children (10%) of the total cohort developed chronic renal failure (CRF). Age of 6 years and above at presentation and severe mesangial deposits on biopsy correlated with fewer remissions and poorer outcome. In 3 patients the interval between the diagnosis of HBV MGN and the onset of CRF was more than 19 years with the longest being 23 years. The 358 cases of childhood HBV MGN from Southern Africa constitute 37% of the reported childhood patients. Comparative data A comparison was made between the 71 children with HBV MGN, 12 adults with HBV MGN and 33 adults with idiopathic MGN. The main differences were that both HBV MGN groups included only coloured and black patients and were more predominantly male while the idiopathic MGN group included all races. In the HBV patients, haematuria was more frequent and severe, liver enzymes were frequently raised and C3 more frequently reduced than in the idiopathic cohort. Both groups of adult MGN patients had normal C4 levels while the childhood HBV MGN group had reduced C4 levels. The immune complex pattern in both of the HBV MGN adult and childhood groups on biopsy was similar with more mesangial and subendothelial deposits as well as mesangial interposition than the idiopathic group. Despite this similarity between the two HBV groups, both adult groups showed more glomerular sclerosis and interstitial disease than the childhood group. The clinical outcome of the children’s cohort was better than the other 2 groups with remission (52%) more frequent at 4 years (p< 0.01) and better renal and patient survival. Including the 83 cases from this series, at least 1243 renal biopsy proven cases of HBV MGN have been reported in the English literature; children (80%) and adults (20%). The male gender predominance in both age groups for HBV MGN is similar (children 79%; adults 84%) and significantly greater than for idiopathic MGN. Conclusions: The findings confirm that HBV MGN in children is a distinct form of GN which broadens the classical morphologic description of MGN by often including a number of mesangiocapillary GN features. The subgroup of renal biopsies with the most severe mesangiocapillary GN features was classified as the mixed HBV MGNmesangiocapillary GN group. The MGN spectrum as a whole comprised 86% of the HBV positive childhood group. HBV MGN was the most frequent association with NS/severe proteinuria in the Namibian subgroup (37%) and the third largest group (19%) in the SA children. It showed a relatively high spontaneous remission rate but at least 10% of the children developed renal failure. Age of 6 years and above at presentation and severe mesangial deposits on biopsy correlated with fewer remissions and poorer outcome. Extended follow up (more than 15 years) was required to demonstrate renal failure in some patients in the poor outcome group. Urbanisation, associated with lower HBV carrier rates, and HBV vaccination (initiated routinely in 1995 in SA), have already lead to a sharply decreasing incidence of this disease in SA. HBV MGN has been a valuable and possibly unique model of human GN and MGN in particular in that the HBeAg has been identified in both the serum and glomeruli enabling confirmation of the aetiological role of HBeAg. / AFRIKAANSE OPSOMMING: Agtergrond en Doelwit: Die algemeenste oorsaak van erge proteïenurie/nefrotiese sindroom (NS) in kinders wêreldwyd is minimale veranderingsiekte. Hierdie patroon kom ook voor in blanke- en Indiër kinders in Suid-Afrika. In teenstelling hiermee is aangetoon dat swart en kleurling/gemengde ras kinders in Suider Afrika tussen die jare 1960s tot 1990s ’n ander patroon van nefrotiese sindroom gehad het. Een van die hoof verskille was die algemene voorkoms van hepatitis B virus (HBV) geassosieerde glomerulonefritis, gewoonlik membraneuse glomerulonefritis (MGN). Die doelwit van hierdie projek was ’n klinies-patologiese studie van hierdie subgroep van nefrotiese kinders ten einde die siekte verder te beskryf en veral om korrelasies te tref tussen patologiese en kliniese kenmerke insluitende prognose. Die gedetaileerde ultrastrukturele ondersoek van die kinders se nierbiopsies en die korrelasie van die spektrum patologiese kenmerke met demografiese, kliniese, laboratorium en prognostiese kenmerke was ‘n sentrale fokusarea. Die hipotese was dat die klinies-patologiese kenmerke van HBV MGN in kinders wesenlik van idiopatiese MGN in die algemeen verskil (in kinders en volwassenes) en ook van HBV MGN in volwassenes, en dat die beeld in kinders as ’n afsonderlike siekte beskou behoort te word. Pasiënte en metodes: Die kinder kohort (12 jaar en jonger) was 309 kinders met erge proteïenurie/nefrotiese sindroom wie in Tygerberg Hospitaal (TBH) behandel was oor ‘n 21 jarige periode vanaf 1974 tot 1995, insluitende 67 kinders van Namibië. Die studiegroep was 71 kinders met HBV MGN wie waar moontlik tot 2005 opgevolg was. Die vergelykende volwasse groep was 45 volwassenes met MGN van wie 12 HBV MGN gehad het en 33 idiopatiese MGN. (’n Vergelyking met idiopatiese MGN in kinders kon nie gedoen word nie omdat hierdie sentrum net twee sulke pasiënte tydens die studietyd behandel het.) Demografiese, kliniese, laboratorium en nierpatologie inligting is versamel, vergelyk en gekorreleer. Resultate: HBV geassosieerde MGN was die algemeenste oorsaak van NS in die Namibiese subgroep, 25/67 (37%) en die derde mees algemeen, 71/309 (23%) in die kinder kohort as geheel. Die MGN groep was 86% (71/83) van die totale HBV kinder nefrotiese kohort en verreweg die oorheersende subgroep. Die gemiddelde ouderdom van die 71 kinders met HBV MGN by presentering was 6.0 jaar (reikwydte 2-12 jaar) en seuns het 80% van die groep behels. Hepatitis B omhullingsantigeen (envelope antigen- HBeAg) is aangetoon in die serum van 87% van die kinders wie daarvoor getoets is. Laboratoriumkenmerke wat van idiopatiese MGN verskil het, het ingesluit meer prominente hematurie, gering verhoogde serum transaminases en meer dikwels verlaagde serum C3 en C4 vlakke. Ligmikroskopiese ondersoek van die nierbiopsies het mesangiale proliferasie in elke pasiënt getoon, maar met minimale glomerulêre sklerose en interstisiële siekte. Met ultrastrukturele ondersoek was mesangiale en subendoteliële neerslae asook mesangiale interposisie algemeen. Die MGN van HBV in kinders het dus dikwels kenmerke van mesangiokapillêre glomerulonefritis getoon bo en behalwe die subepiteliële neerslae van MGN. Die ondergroep van 23 van wie die nierbiopsies erge mesangiale interposisie aangetoon het asook die subepiteliale neerslae van MGN is die gemengde HBV MGN-mesangiokapillêre GN groep genoem. Virustipe liggaampies en tubuloretikulêre insluitingsliggaampies is in meer as 80% van die biopsies bevestig. HBeAg was in die subepiteliële neerslae identifiseer. Dit was die eerste keer dat hierdie kenmerk in Afrika identifiseer is. Die 46 Suid-Afrikaanse kinders het ’n kumulatiewe remissie koers van 25% teen 2 jaar en van 52% teen 4 jaar getoon. Sewe van die kinders (10%) van die hele kohort het kroniese nierversaking (KNV) ontwikkel. Ouderdom van 6 jaar en meer by presentasie en erge mesangiale neerslae in ‘n biopsie het met minder remissies en ’n swakker uitkoms gekorreleer. Drie pasiënte het meer as 19 jaar na aanvanklike voordoening ooglopende KNV ontwikkel, waarvan 23 jaar die langste interval was. Die 358 gevalle van kinderjare HBV MGN van Suidelike-Afrika maak 37% uit van die gerapporteerde kinder pasiënte. Vergelykende data ’n Vergelyking is getref tussen die 71 kinders met HBV MGN, 12 volwassenes met HBV MGN en 33 volwassenes met idiopatiese MGN. Die hoof verskille was dat beide HBV groepe net kleurling en swart pasiënte ingesluit het en meer oorwegend manlik was, terwyl die idiopatiese groep alle rasse ingesluit het. In die HBV pasiënte was hematurie meer algemeen en erg, lewer ensieme meer dikwels verhoog en C3 meer dikwels verlaag as in die idiopatiese kohort. Beide groepe van volwasse MGN pasiënte het normale C4 vlakke getoon terwyl die kindergroep met HBV MGN verlaagde C4 vlakke bewys het. Die immuunkompleks patroon in biopsies van die HBV MGN volwasse en kindergroepe was soortgelyk met meer mesangiale en subendoteliële neerslae asook meer mesangiale interposisie as in die idiopatiese groep. Ten spyte van hierdie ooreenkoms tussen die twee HBV groepe, het die twee volwasse groepe meer glomerulêre sklerose en interstisiële siekte as die kindergroep vertoon. Die kliniese uitkoms van die kinderkohort was beter as die ander twee groepe met remissie (52%) wat meer algemeen was teen 4 jaar (p< 0.01) en met beter nier- en pasïent oorlewing. Ingeslote die 83 gevalle van hierdie reeks, is ten minste 1243 nierbiopsie bewysde gevalle van HBV MGN in kinders (80%) en volwassenes (20%) in die Engelse literatuur gerapporteer. Die manlike oorheersing in beide ouderdomsgroepe van HBV MGN is soortgelyk (kinders 79%; volwassenes 84%) en betekenisvol meer as vir idiopatiese MGN. Gevolgtrekkings: Die bevindinge bevestig dat HBV MGN in kinders ’n afsonderlike vorm van GN is wat die klassieke beskrywing van MGN verbreed deur die algemene insluiting van ’n aantal mesangiokapillêre GN kenmerke. Die ondergroep van nier biopsies met erge mesangiokapillêre GN kenmerke is as die gemengde HBV MGNmesangiokapillêre GN groep geklassifiseer. Die MGN spektrum in geheel het 86% van die HBV positiewe kindergroep behels. HBV MGN was die mees algemene assosiasie met NS/erge proteïenurie in die Namibiese subgroep (37%) en die derde grootse groep (19%) onder die SA kinders. Die siekte het ’n relatiewe hoë spontane remissiekoers getoon, maar ten minste 10% van die kinders het nierversaking ontwikkel. Ouderdom van 6 jaar en meer by presentasie en erge mesangiale neerslae in ‘n nierbiopsie het met minder remissies en ’n slegter uitkoms gekorreleer. Uitgebreide opvolg (meer as 15 jaar) was nodig om nierversaking in sommige van die swak uitkomsgroep aan te toon. Verstedeliking is geassosieerd met laer HBV draersyfers en hierdie faktor saam met algemene HBV inenting in die kinderjare (wat in 1995 in SA begin was), het ’n skerp daling in die voorkoms van hierdie siekte in SA teweeg gebring. HBV MGN is ’n waardevolle en moontlik unieke model van menslike GN en MGN, veral omdat die HBeAg in beide die serum en glomeruli identifiseer kon word om die etiologiese rol van HBeAg te bevestig.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

Title Gait Analysis in Adolescents with Idiopathic Scoliosis: A Systematic Review. Aim The role of spine is vital as a gait stabilizer. Gait analysis may provide a more holistic view of how the body behaves to idiopathic scoliosis among adolescents. The aim of this thesis is to review the effectiveness and validity of gait analysis in examining AIS, and secondly to assess how the gait of AIS patients differ from adolescents without scoliosis. Method A systematic review of the topic was conducted. Information was gathered from six e-databases, and seventeen articles were selected, of which seven focusing solely on AIS subjects (i.e. non-comparative) and ten were focusing on AIS in relation to control subjects (i.e. comparative). Results Spatio-temporal (STP), kinematic, kinetic and EMG parameters show significant changes in AIS subjects during walking. But variations between results, lack of data for certain parameters and no significant relationship between gait parameters and scoliosis was also seen. Furthermore, AIS subjects differ in performance compared to non-scoliosis adolescents in at least one gait parameter across all studies. This includes abnormalities in muscle activity, less economical use of the body, poorer performance in kinematic parameters and differences in STP such as step...

Objective: Research on the role of acute post-surgical pain in children is extremely important in order to have a positive influence on pre-surgical preparation and post-surgical care and to prevent pain from becoming chronic, which can extend decades into adulthood. This project aims to identify predictors of acute post-surgical pain in adolescents with idiopathic scoliosis undergoing spinal fusion by utilizing sensory thresholds obtained through quantitative sensory testing (QST). Methods: Eligible candidates were Adolescent Idiopathic Scoliosis (AIS) patients ages 10-17 who have been recommended to receive elected spinal fusion surgery at Boston Children's Hospital (BCH). 9 successfully recruited and enrolled participants underwent a full series of QST tests on their palmar thenar eminence (non-surgical site), and their lower back (surgical site). Patients' Light Touch Detection Threshold (LTDT) and Pain Detection Threshold (PDT) scores were determined using Von Frey Hairs. Patients' Pressure-Pain Sensation Threshold (PPST) scores were determined using a pressure algometer. Patients' Warm/Cool and Hot/Cold Pain Detection Thresholds were detected using a calibrated thermode strapped to the skin. Following the full-series of QST tests, and after the patient was discharged from the hospital, a retrospective chart review was conducted to determine the patients': Age at Surgery, Gender, Number of Vertebrae Fused (Fusion Length), Length of Surgery, Pre-Operative Self-Identified Pain Level (NRS 0-10), Average Post-Operative Acute-Phase Self-Identified Pain Level (NRS 0-10), and daily Pain Medication Doses (Opiate Vs. Non-Opiate Vs. Total). Correlation calculations were done between each variable, including those determined through QST as well as retrospective chart review. For every QST test, each patient's individual score was compared to the cohort's median score, which helped determine whether the patient was either hyper- or hyposensitive for that particular test. For each QST test, these hyper- and hyposensitive groups were then compared to see if there were any significant differences in post-operative pain experienced. Results: Due to the low number of participants (N = 9), the results should be considered preliminary. Correlation studies demonstrate that pre-operative pain was significantly positively correlated with post-operative pain (r = 0.81, p <0.05), indicating that patients who are pre-operatively already in pain, will consequently experience the most pain post-operatively. Additionally, fusion length had a strong positive correlation to acute post-operative opiate pain medication administration (r = 0.71, P < 0.05), indicating that patients who had more vertebrae fused were given more opiates. Through the use of QST, we discovered that patients hypersensitive in the LTDT-Spine QST test experienced significantly less pain post-operatively (3.22 NRS 0-10) than that experienced by hyposensitive patients (5.52 NRS 0-10) from the same test. Identical results were discovered in patients determined hyper- and hyposensitive using the PPST-Spine test, respectively. Retrospective chart review data show that these hyposensitive patients were experiencing greater pain pre-operatively (0.75 NRS 0-10) than that experienced by the hypersensitive patients (0 NRS 0-10), which may have contributed to the hyposensitive cohort's greater post-operative pain. Although insignificant, patients hypersensitive in the Hot Pain - Spine QST test experienced greater post-operative pain (4.72 NRS 0-10) than that experienced by hyposensitive patients in the same test (4.06 NRS 0-10). Conclusions: The goal of this study was to determine a substantiated hypothesis to test in the future, using larger pediatric cohorts. Even though it initially appears that the hyposensitive patients, as determined by the LTDT-Spine and PPST-Spine QST tests, experienced greater post-operative pain, one must consider the fact that this hyposensitive group experienced a significantly greater amount of pre-operative pain. Not only has pre-operative pain been proven to have a strong correlation to post-operative pain in this study, it has also been proven in other larger studies as well. Other studies have identified a test similar to the Hot Pain - Spine QST test as a potential predictor of post-operative pain. The present study's results, although insignificant, share the same conclusion that hypersensitive patients determined through Hot Pain - Spine QST test experience greater post-operative pain. Therefore, the hypothesis to test in the future in pediatric cohorts should read: AIS patients with no pre-operative pain who demonstrate increased sensitivity to hot pain on their surgical site via thermal stimulation (QST) will experience greater post-operative pain in the acute-recovery phase.

INTRODUÇÃO: A urticária crônica é caracterizada pelo aparecimento de placas eritêmato-edematosas, pruriginosas, que perduram por mais de seis semanas. A etiologia é desconhecida na maioria dos pacientes sendo definida como idiopática (UCI). A desregulação imunológica na UCI pode ser devido a distúrbios na produção de citocinas e quimiocinas. OBJETIVOS: Avaliar o perfil citocinas e quimiocinas em pacientes submetidos ao teste de soro autólogo (ASST) avaliando os soros, a expressão de RNAm e a expressão intracelular de células mononucleares do sangue periférico (CMN) induzidas por estímulos policlonais. METODOLOGIA: Pacientes com UCI (n=37) foram selecionados do Ambulatório de Dermatologia do HC-FMUSP e submetidos ao ASST. O grupo controle foi constituído por indivíduos saudáveis (n=33). Os níveis séricos de citocinas e quimiocinas foram determinados por citometria de fluxo ou por ELISA e a expressão de RNAm de citocinas foi determinada por Real-Time PCR. RESULTADOS: Uma elevação dos níveis séricos de TNF-, IL-6, IL-1, IL-12p70 e IL-10 foi detectada nos pacientes com UCI comparados ao grupo controle, independente da resposta ao ASST. A secreção in vitro de citocinas por CMN estimuladas por fitohemaglutinina (PHA) mostrou aumento da produção de IL-2 nos pacientes com UCI e de IL-17A e IL-10 no grupo ASST positivo em relação ao grupo controle. A expressão de RNAm para IL-10 em CMN, foi diminuída no grupo ASST negativo comparado ao grupo controle. Além disto, um aumento da capacidade linfoproliferativa ao mitógeno Pokeweed foi observado nos pacientes ASST positivo em relação aos indivíduos controles. Os níveis séricos de CXCL8, CCL2, CXCL10 e CXCL9 foram encontrados elevados nos pacientes com UCI em relação aos controles. A secreção de quimiocinas in vitro, foi observado aumento dos níveis basais de CCL2 pelas CMN dos pacientes em relação aos controles, que se elevaram em resposta a enterotoxina A de Staphylococcus aureus (SEA). Já o estímulo com PHA promoveu aumento na produção de CXCL8 e CCL5 pelas CMN dos pacientes. A expressão intracelular de CXCL8 foi detectada principalmente nas células CD14+. A intensidade média de fluorescência (MFI) e a porcentagem da expressão de CXCL8 em CD14+ nos níveis basais e estimulados com SEA encontram-se diminuídos nos pacientes com UCI comparado ao grupo controle. A expressão intracelular de CCL2 em células CD14+ mostrou uma queda na porcentagem dos níveis basais somente nos pacientes ASST negativo em relação ao grupo controle. Além disto, em condições basais de cultura houve um aumento na porcentagem da expressão de CCR5 em células T CD8+ de pacientes com UCI, em função do aumento no grupo ASST positivo. CONCLUSÕES: Os resultados enfatizam o conceito de desequilíbrio imunológico na UCI, independente da resposta ao ASST, evidenciado pelo aumento na secreção de quimiocinas e citocinas pró-inflamatórias. Estes dados sugerem que na UCI, os linfócitos e monócitos estão ativados, os quais podem contribuir para a imunopatogênese da doença / INTRODUCTION: Chronic urticaria is skin disorder characterized by recurrent and transitory itchy weals occurring regularly for more than 6 weeks. The aetiology is not identified in most patients being considered as idiopathic (CIU). The immunological dysregulation in CIU could be due to a disturbed cytokines and chemokines production. OBJECTIVES: To evaluate the pattern of cytokine and chemokine in CIU patients who undergone autologous serum skin test (ASST), assessing sera, mRNA expression and intracellular expression of peripheral blood mononuclear cells (PBMC) through the secretion upon induced by policlonal stimuli. METHODS: CIU patients (n=37) were selected from the Dermatological Outpatient Clinic of the Hospital das Clínicas de São Paulo (HC-FMUSP) and submitted to the ASST. The control group consisted of healthy subjects (n=33). Cytokine and chemokine levels were assessed by flow cytometer and ELISA and mRNA expression was analyzed by Real-Time PCR. RESULTS: Elevated levels of TNF-, IL-6, IL-1, IL-12p70 and IL-10 were observed in sera from CIU patients compared to healthy control group. CIU patients also showed increased IL-2 production by PBMC stimulated with phytohemagglutinin (PHA). Moreover, it was observed higher IL-17A and IL-10 levels in the ASST+ group compared to control group. The IL-10 mRNA expression was diminished in the ASST- group compared to control group. Furthermore, an increased lymphoproliferative response to Pokeweed mitogen was observed in the ASST+ patients compared to healthy subjects. Seric levels of CXCL8, CCL2, CXCL10 and CXCL9 were higher in CIU patients. Regarding the in vitro chemokines secretion, it was detected higher basal levels of CCL2 in CIU patients, which was increased by Staphylococcus aureus enterotoxin A (SEA). Stimulation with PHA increased the CXCL8 and CCL5 production by CIU mononuclear cells. The main source of CXCL8 was the CD14+ cells. CIU CD14+ cells showed decreased mean fluorescence intensity and percentage of CXCL8 expression with and without SEA stimuli. The percentage of CD14+ producing CCL2 was lower in ASST- patients compared to healthy control subjects. Furthermore, in the absence of stimuli the percentage of CCR5-expressing CD8+ T cells was higher in CIU patients, mainly due to an increased expression by the ASST+ group. CONCLUSIONS: These results indicate an immunological dysregulation in CIU, without association to ASST response, which was evidenced by the increased production of pro-inflammatory cytokines and chemokines. The data suggest a higher activation of monocytes and lymphocytes in CIU, which may contribute to its immunopathogenesis

Made available in DSpace on 2016-03-22T17:27:39Z (GMT). No. of bitstreams: 1 Dissert Marcelo D.pdf: 460219 bytes, checksum: 7e6bdf276f771ccc2f3b623a56bfe198 (MD5) Previous issue date: 2006-09-15 / Introduction and aims: Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional alteration of the spine. Its etiology is unknown, and it starts at the beginning of puberty, and its progression is associated to the growth spurt. The movement angular analysis and the body posture would allow the physiotherapist to quantify and qualify the body posture/movement evaluation through static image, which is known as photogrammetry. This study was carried out to evaluate the validity and reliability of this instrument for the AIS detection in school exam. Subjects: fifth and eighth grade-students of elementary teaching at public and private schools from Pelotas. Methods: a cross-sectional study of school basis with digital image collection and radiographic exam in anteroposterior posture and profile. The sensitivity and the specificity of the photogrammetry were verified using three and two degrees of margin for the body surface inclination. Results: 314 students accomplished the computerized photogrammetry at the schools. Among them, 224 also accomplished the pattern radiological exam. The prevalence of adolescent idiopathic scoliosis found in this study was 4.5% (n=10), eight were girls and 2 were boys, with the average Cobb at 13.3º, average of 1.1 for vertebral rotation (Nash-Moe), dorsal kyphosis at 29.5º Cobb, iliolumbar angle at 3.6° and signs of Risser at 1.6. For three degrees, the sensitivity was 21.4% and the specificity was 90.7%. The sensitivity was 50% and the specificity was of 61.5% when two degrees were used. Based on these results, it was verified that the computerized photogrammetry cannot be accomplished as screening to detect scoliosis at schools / Introdução e Objetivos. A escoliose idiopática adolescente (EIA) é uma alteração tridimensional da coluna vertebral. Sua etiologia é desconhecida, e seu início ocorre no início da puberdade, tendo sua progressão associada ao estirão de crescimento. A análise angular de movimento e postura corporal através da imagem estática, conhecida como fotogrametria permitiria ao fisioterapeuta quantificar e qualificar sua avaliação da postura/movimento corporal. Este estudo foi realizado para avaliar a validade e confiabilidade deste instrumento na detecção da EIA no exame escolar. Sujeitos: Alunos de 5ª a 8ª série do ensino fundamental das redes pública e particular de Pelotas. Métodos. Estudo transversal de base escolar com coleta de imagem digital e exame radiográfico em postura antero-posterior e perfil. A sensibilidade e especificidade da fotogrametria foram verificadas utilizando três e dois graus de margem para desnivelamento da superfície corporal. Resultados. 314 alunos realizaram a fotogrametria computadorizada nas escolas. Destes, 224 também realizara o exame radiológico padrão. A prevalência de escoliose idiopática adolescente encontrada neste estudo foi de 4,5% (n=10), sendo oito meninas e dois meninos, com média de 13,3º Cobb, média de 1,1 para rotação vertebral (Nash-Moe), 29,5º Cobb para cifose dorsal, 3,6º para ângulo íleo-lombar e sinal de Risser em 1,6. Para três graus, a sensibilidade foi de 21,4% e a especificidade de 90,7%. Utilizando dois graus a sensibilidade foi de 50% e a especificidade de 61,2%. Com base nestes resultados, verificou-se que a fotogrametria computadorizada não pode ser realizada como screening para detecção de escoliose nas escolas

Introdução: A fibrose pulmonar idiopática (FPI) é uma grave doença pulmonar crônica com sintomas de dispneia progressiva, resultando na diminuição da capacidade de exercício, impactando negativamente na qualidade de vida relacionada à saúde (QVRS). A reabilitação pulmonar (RP) melhora a capacidade funcional (CF) com redução dos sintomas, porém na FPI avançada seus efeitos e magnitudes são pouco conhecidos. Objetivo: Avaliar o impacto da RP sobre a QVRS e a CF em pacientes portadores de FPI. Métodos: Estudo de coorte retrospectiva em que foram revisados dados de 56 prontuários de pacientes em lista de transplante de pulmão com diagnóstico de FPI de acordo com o consenso da American Toracic Society 2011, submetidos a 12 semanas (36 sessões) de RP ambulatorial entre o período de janeiro de 2008 a outubro de 2012. Foram avaliadas a CF e a QVRS através do teste de caminhada de seis minutos (TC6) e do questionário 36-item short-form survey, SF36, respectivamente, antes e imediatamente após a RP. Resultados: Vinte e sete pacientes foram incluídos no estudo, 16 (61%) gênero masculino com idade média de 53 ±13 anos. Dezoito pacientes (68%) tinham diagnóstico histológico por biópsia pulmonar com padrão de pneumonia intersticial usual (PIU), com tempo médio de diagnóstico de 3 ±1,7 anos. Quanto à classificação da dispneia pela escala modified Medical Research Council (mMRC) basal, 59% dos pacientes foram classificados entre 3-4. Houve aumento significativo na distância percorrida de 393 ±88 metros para 453 ±90 metros (p<0,001). As medianas de dispneia sofreram diminuição significativa (p=0,01) na escala do mMRC de 2 (IC95%: 1-4) para 1 (IC95%: 1-4) e de 5 (Mín/Máx:1-10) para 3 (Mín/Máx:0-10) no BORG de dispneia no final do TC6. Apesar de caminharem maiores distâncias, a fadiga em membros inferiores foi menor com uma mediana de 2 (Mín/Máx:0-10) para 1 (Mín/Máx:0-9) (p=0,02). Houve aumento em 5 dos 8 domínios, porém somente a capacidade funcional foi significativa de 26 (IC95%: 19-33) para 37 (IC95%: 27-48) (p<0,05); os demais domínios não tiveram significância estatística. Conclusão: Observaram-se nestes pacientes aumentos da CF, com diminuição dos sintomas dispneia e fadiga; o que não se refletiu em melhora clínica na QVRS em portadores de FPI em lista de transplante de pulmão após um programa de RP. / Introduction: Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease with severe symptoms of progressive dyspnea, resulting in decreased exercise capacity, negatively impacting the health-related quality of life (HRQL). Pulmonary rehabilitation (PR) improves functional capacity (FC) with reduction in symptoms, but in advanced IPF, its effects and magnitudes are unknown. Objective: To evaluate the impact of PR and in HRQL and in FC of patients with IPF. Methods: Coorte study with a retrospective review of data from 56 medical records of patients on lung transplant list diagnosed with IPF according to the American Toracic Society 2011 consensus, submitted to 12 weeks (36 sessions) of outpatient RP between January 2008 and October 2012. The FC and the HRQL were assessed through a six-minute walk test (6MWT) and the 36-item short-form survey (SF36) respectively before and immediately after PR. Results: Twenty-seven patients were included in the study, 16 (61%) male with a mean age of 53 ± 13 years. Eighteen patients (68%) had histologic diagnosis by lung biopsy compatible with usual interstitial pneumonia (UIP), with median time from diagnosis of 3 ± 1.7 years. Regarding the classification of the dyspnea in the modified Medical Research Council (mMRC) scale, 59% of patients were classified between 3-4. There was a significant increase in the distance covered from 393 ± 88 meters to 453 ± 90 meters (p <0.001). The baseline medians of dyspnea had a significant decrease (p = 0.01) in the mMRC scale from 2 (CI 95%: 1-4) to 1 (CI 95%: 1-4) and the median decreased from 5 (Min/Max: 1-10) to 3 (Min/Max :0-10) in the Borg dyspnea index at the end of the 6MWT. Although the patients walked greater distances, they had less fatigue in the legs, with a median decrease from 2 (Min/Max: 0-10) to 1 (Min/Max: 0-9) (p = 0.02). There was an increase in 5 of the 8 domains, but only the functional capacity was significant: from 26 (CI95%: 19-33) to 37 (CI95%: 27-48) (p <0.05), while the remaining areas were not statistically significant. Conclusion: We observed increases of FC in these patients, with decreased symptoms of dyspnea and fatigue; which were not reflected in clinical improvement in HRQL of patients with IPF on lung transplant list after a PR program.

Background Idiopathic pulmonary fibrosis (IPF) is one of a number of interstitial lung diseases (ILDs) that result in extensive and chronic pulmonary fibrosis. In IPF pathology, immunological dysfunction has been identified as a contributing factor to the ongoing fibrotic process, implicating cells and mechanisms of both the innate and humoral immune response. Due to the complex and diverse range of cells and mediators involved in IPF, the pathology is still poorly understood. Evidence of complement activation through the classical pathway in IPF lungs implies a role for IgG in the pathology. The active IgG in IPF may be autoreactive in nature, as IgG that target antigens of alveolar epithelial cells have been. Two autoantibodies in IPF, anti-periplakin IgG and anti-Hsp72 IgG, have been associated with poorer prognoses in IPF patients. The association of anti-Hsp72 IgG with IPF patient outcomes has not been validated and little work has been done to study the underlying mechanisms of autoantibodies in IPF pathogenesis. Hypothesis Anti-Hsp72 IgG is associated with poorer outcomes in IPF, and may induce alveolar macrophages to exhibit a pro-fibrotic phenotype. Aims The aims were to:  Optimise an ELISA for anti-Hsp72 IgG detection and determine any association of anti-Hsp72 IgG with IPF patient outcomes  Determine the location of anti-Hsp72 IgG producing cells and detect if Hsp72-IgG complexes are present in IPF patients’ lungs  Explore a potential underlying pro-fibrotic mechanism through which anti-Hps72 IgG modulates macrophage function. Results The presence of anti-Hsp72 IgG was determined in ILD patient and healthy control bronchoalveolar lavage fluid (BALf) and serum. A novel anti-Hsp72 IgG ELISA was developed and optimised and then compared against a commercial anti-Hsp72 IgGAM ELISA which became available during the PhD. Progression in IPF was defined by a decrease of ≥10% vital capacity (VC) over twelve months. Serum anti-Hsp72 IgG(AM) did not associate with changes in VC over 12 months. In contrast, BALf anti-Hsp72 IgG(AM) concentrations were elevated in IPF non-progressors. Patients with high BALf anti-Hsp72 IgGAM, had improved survival compared patient with low anti-Hsp72 IgGAM (adjusted HR 0.39, 95% CI 0.16-0.92; p=0.032) In contrast there was no association between anti-Hsp72 IgG and survival. Detection of anti-Hsp72 IgG subtypes in the serum and BALf of IPF patients revealed no significant difference in anti-Hsp72 IgG subtype detection levels between progressors and non-progressors. BALf anti-Hsp72 IgG1 levels were associated with a significantly lower rate of decline in VC over twelve months than patients with no detectable anti-Hsp72 IgG1. The presence of Hsp72-IgG complexes was confirmed by detection in purified IgG from IPF patient BALf. Immuno-histological detection of C4d deposition in the lungs of IPF patients coincided in areas of Hsp72 expression in alveolar epithelium. Summary These findings do not validate serum and-Hsp72 IgG as a biomarker for IPF. They support a role for anti-Hsp72 IgG in IPF, but associate with decreased rates of lung function decline and increased patient survival. Data also suggests that the decreased rate of decline may be related to specific anti-Hsp72 IgG subtype expression. The immune-histological data further suggests that anti-Hsp72 IgG may be targeting Hsp72 expressed by lung epithelium. Therefore these findings support a role for immunological dysfunction in IPF, but further work is required to determine the underlying mechanism.

Idiopathic pulmonary fibrosis (IPF) is an irreversible disease of unknown etiology that involves progressive scarring of the lung tissue, leading to respiratory failure and death.1 IPF is thought to develop from repetitive lung injury and aberrant wound healing that leads to the generation of fibrous tissue rather than restoration of normal tissue.2 It has been suggested in mice that vascular leak after lung injury contributes to the development of lung fibrosis.2,3 Gadofosveset is an intravascular enhancing, gadolinium-based contrast agent used with magnetic resonance imaging (MRI) to assess a variety of biological processes in vivo because it can reversibly bind to albumin.13-14 Gadofosveset has been used to assess endothelial permeability and function, as it diffuses through the vessel walls via leaky neovessels and damaged endothelium.15 Our research group has developed a new method to assess disease activity in IPF patients using gadofosveset-enhanced lung MRI. In unpublished work, we have demonstrated that this technique can be used to generate an albumin extravasation index (AEI), and we have found that this is significantly and diffusely increased in the lung of patients with idiopathic pulmonary fibrosis compared to healthy controls.16 The AEI is a measure of the change in signal intensity post-contrast minus pre-contrast in predefined regions of interest (ROIs) in the lung parenchyma divided by post- minus pre-contrast signal intensity in the ROI in the aorta. In this study, we compared the AEI in patients with IPF to healthy control (HC) subjects and evaluated the correlation between the AEI and high-resolution computed tomography (HRCT) and pulmonary function testing (PFT). We found that IPF subjects had increased AEI values compared with HC subjects. While not statistically significant, AEI was more strongly correlated with fibrosis (interstitial abnormalities) than ground-glass (alveolar abnormalities) on HRCT. Furthermore, there was a possible correlation between AEI and change in percent predicted forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), and diffusion capacity of carbon monoxide adjusted for hemoglobin (DLCO) [Hb]. Our results demonstrate that AEI calculations from gadofosveset-enhanced lung MRI are a surrogate measure of vascular leak and can potentially serve as an alternative method for predicting the clinical course and severity of IPF through its correlation with fibrosis on HRCT and pulmonary function.

Background: Juvenile idiopathic arthritis (JIA) refers to a group of auto-immune conditions involving joint inflammation that first appears before the age of 16. In the United States, about 294,000 children are affected. Although JIA can be widely attributed to genetic factors, the consensus is that environmental factors also play a role. Attempts to assess the role of environmental factors, though scarce, have focused on the role of infections, smoking exposure, and breastfeeding. Hygiene hypothesis, which suggests that adaptive immunological response improves with higher frequencies of pathogen exposure in early childhood, has been used to try to explain the risk of JIA. Common markers of microbe exposure in early life include sibling number, pet number, and maternal parity. Some prior studies conducted outside the U.S. suggests that increasing sibling number is protective against the risk of JIA. This study aimed to evaluate prior findings, using data from the U.S. Methods: The study used data from the 2017 Centers for Disease Control and Prevention National Survey for Child Health. The survey used a sample size of 21599 children to estimate the number of children in the U.S. Descriptive statistics was carried out, and logistic regression was used to determine the association between family number and the odds of developing JIA, while adjusting for sociodemographic variables. Family number was used as a proxy for sibling number. SAS v 9.4 was used for analysis. Results: Complete data on all the variables of interest were available for 17618 children, of which 67 had JIA. Although there was a marginal association between sibling number and JIA in the unadjusted model (OR [95% CI] 0.983-1.602) (P=0.068), in the adjusted model, there was no significant association between JIA and sibling number ([OR 95% CI] 0.8985-1.447) (P=0.29). There was a significant association between JIA and age, low birth weight, highest education level in the family, while sex had a marginal association. Conclusion: There was no association between family size and the development of JIA in this study. While some prior results have supported the observed significant effect of low birth weight, the disparity in results between this study and the Australian study could be due to the use of family number instead of sibling number. Further studies should assess the association of sibling number and developing JIA in the U.S.