Introduction: Coronary artery disease (CAD) has been associated with depressive symptoms and deficits in cognitive performance, both of which have been associated with poorer medical prognoses and poorer psychosocial outcomes. Physical activity can improve cognitive and depressive symptoms, and, for those with CAD, improve medical prognoses. It was hypothesized that depressive symptoms and poorer cognitive performance would be associated with poorer cardiopulmonary fitness in patients with CAD, and that these sequelae would be associated prospectively with noncompletion of cardiac rehabilitation (CR). The benefits of physical activity are thought to result, in part, from decreased inflammatory activity and increased adaptive neural plasticity, to which the ratio of kynurenine to tryptophan (K/T) and brain derived neurotrophic factor (BDNF), respectively, in peripheral blood may pertain. Methods and Results: In a cohort study of patients entering CR, depressive symptoms (Center for Epidemiological Studies Depression scale; CES-D scores) were associated with cardiopulmonary fitness (peak volume of oxygen uptake; VO2Peak) during an exercise stress test (B=-.404, p=.001, n=366). The VO2Peak was also associated with performance across multiple cognitive domains, but most strongly with performance on tests involving executive function, attention and psychomotor processing speed (β=.322, p=.002 for composite score, n=81) in a cohort of patients entering CR. In prospective cohort studies, Major Depressive Disorder (adjusted hazard ratio [HR] 2.5, 95% confidence interval [CI] 1.3–4.7, n=195) and poorer performance on a verbal memory test (HR 0.86, 95% CI 0.77-0.96, p=.009, n=131) predicted non-completion of CR. In patients undertaking CR, higher serum K/T ratios were associated with CES-D scores (β=.322, p=.002, n=95) and with VO2Peak (β=-.391, p<.001, n=95), and in a cohort of patients entering CR (n=88), serum concentrations of BDNF were associated with psychomotor processing speed (F1,87=9.620, p=.003), overall cognitive status (Mini Mental Status Exam) scores (F1,87=15.406, p<.0005) and VO2Peak (β=.305, p=.013). Conclusions: Depressive symptoms and poorer cognitive performance are clinically important in patients with CAD entering CR and they are both associated with poorer cardiopulmonary fitness. Poorer cardiopulmonary fitness was also associated with higher K/T ratios and with lower BDNF concentrations in serum, which predicted depressive symptoms and poorer cognitive performance, respectively.

Introduction: Coronary artery disease (CAD) has been associated with depressive symptoms and deficits in cognitive performance, both of which have been associated with poorer medical prognoses and poorer psychosocial outcomes. Physical activity can improve cognitive and depressive symptoms, and, for those with CAD, improve medical prognoses. It was hypothesized that depressive symptoms and poorer cognitive performance would be associated with poorer cardiopulmonary fitness in patients with CAD, and that these sequelae would be associated prospectively with noncompletion of cardiac rehabilitation (CR). The benefits of physical activity are thought to result, in part, from decreased inflammatory activity and increased adaptive neural plasticity, to which the ratio of kynurenine to tryptophan (K/T) and brain derived neurotrophic factor (BDNF), respectively, in peripheral blood may pertain. Methods and Results: In a cohort study of patients entering CR, depressive symptoms (Center for Epidemiological Studies Depression scale; CES-D scores) were associated with cardiopulmonary fitness (peak volume of oxygen uptake; VO2Peak) during an exercise stress test (B=-.404, p=.001, n=366). The VO2Peak was also associated with performance across multiple cognitive domains, but most strongly with performance on tests involving executive function, attention and psychomotor processing speed (β=.322, p=.002 for composite score, n=81) in a cohort of patients entering CR. In prospective cohort studies, Major Depressive Disorder (adjusted hazard ratio [HR] 2.5, 95% confidence interval [CI] 1.3–4.7, n=195) and poorer performance on a verbal memory test (HR 0.86, 95% CI 0.77-0.96, p=.009, n=131) predicted non-completion of CR. In patients undertaking CR, higher serum K/T ratios were associated with CES-D scores (β=.322, p=.002, n=95) and with VO2Peak (β=-.391, p<.001, n=95), and in a cohort of patients entering CR (n=88), serum concentrations of BDNF were associated with psychomotor processing speed (F1,87=9.620, p=.003), overall cognitive status (Mini Mental Status Exam) scores (F1,87=15.406, p<.0005) and VO2Peak (β=.305, p=.013). Conclusions: Depressive symptoms and poorer cognitive performance are clinically important in patients with CAD entering CR and they are both associated with poorer cardiopulmonary fitness. Poorer cardiopulmonary fitness was also associated with higher K/T ratios and with lower BDNF concentrations in serum, which predicted depressive symptoms and poorer cognitive performance, respectively.

Neste estudo avaliamos o papel do metabolismo do triptofano (Trp) na homeostasia, na vaginose bacteriana e nas lesões cervicais associadas ao HPV. A importância do metabolismo do Trp se deve a sua ação na proliferação de microrganismos e de células do sistema imune. O consumo de triptofano tem sido identificado como uma forma de controlar o crescimento bacteriano limitando a infecção. Por outro lado, a oxidação de Trp produz quinurenina (QUIN), que tem papel chave na tolerância imunológica. A formação de QUIN se dá através das enzimas indoleamina 2,3-dioxigenase (IDO) e triptofano 2,3- dioxigenase (TDO). A mais estudada delas no âmbito das infecções/ imuno escape é a enzima IDO. Mais recentemente, tem-se dado ênfase ao papel da TDO no câncer. Nesta dissertação, o interesse foi avaliar a expressão da IDO no epitélio cervicovaginal de mulheres com vaginose bacteriana e de IDO e TDO em amostras cervicais de mulheres com diferentes graus de lesão cervical associada ao HPV. Foram incluídas 165 mulheres atendidas no CAISM/UNICAMP, as quais foram divididas em dois grupos: grupo caso composto por mulheres com lesão de baixo ou alto grau e carcinoma invasor (n=42) e grupo controle composto por mulheres com citologia oncológica normal, independente de apresentar infecção genital (n=123). IDO foi avaliada por imunocitoquímica em citologia em base líquida e IDO e TDO em biópsias cervicais. Mulheres com vaginose bacteriana apresentaram expressão aumentada de IDO em células escamosas em comparação às mulheres sem vaginose bacteriana (OR=7.41; IC 95%= 2.50 a 21.4; p <0.0001). No epitélio vaginal normal com ou sem infecção por HPV houve uma expressão leve de IDO em células escamosas. Na presença de lesões ou carcinoma, houve um aumento no número de células escamosas displásicas e de leucócitos IDO-positivos; aumento de IDO também pôde ser observada em culturas de pele organotípicas transduzidas com as oncoproteínas E6/ E7 do HPV16. Nas lesões cervicais, assim como visto para a IDO, a TDO esteve expressa em leucócitos, especialmente os infiltrados na região estromal e na parede dos vasos sanguíneos. A expressão basal de IDO no epitélio cervical normal e sua regulação positiva na infecção por HPV e lesões associadas sugerem a participação do metabolismo do Trp nos mecanismos imunossupressores envolvidos na doença. Embora o papel do IDO já tenha sido abordada anteriormente, até onde sabemos esta é a primeira evidência da expressão de TDO no epitélio vaginal, na neoplasia intraepitelial cervical e carcinoma de células escamosas. Ainda, em leucócitos, especialmente aqueles com morfologia típica de polimorfonucleares, parecem ser importantes fontes de IDO na cérvix uterina. / In this study we evaluated the role of tryptophan (Trp) metabolism in cervix homeostasis, bacterial vaginosis and HPV-associated lesions. The importance of Trp metabolism is due to its action on microorganisms and immune cells. Tryptophan consumption has been identified as a way to controlling bacterial growth limiting infection. On the other hand, the oxidation of Trp produces kynurenine (Kyn) which plays a key role in immunological tolerance. The formation of Kyn occurs through the enzymes indoleamine 2,3-dioxygenase (IDO) and tryptophan 2,3-dioxygenase (TDO). IDO is the most studied of them within the context of infections / immune escape. More recently, TDO has also been considered in studies of cancer progression. In this thesis, we were interested in cervicovaginal epithelium IDO expression in women with bacterial vaginosis and of IDO and TDO in cervical samples of women with different degrees of cervical lesion associated with HPV. A total of 165 women attended at CAISM/UNICAMP were divided into two groups: a case group composed of women with low or high grade lesions and invasive carcinoma (n = 42) and a control group composed of women with normal cytology, independent to present genital infection (n =123). IDO was evaluated by immunocytochemistry in liquid-based cytology and IDO and TDO in cervical biopsies. Women with bacterial vaginosis had increased IDO expression in squamous cells compared to women without bacterial vaginosis (OR = 7.41, 95% CI = 2.50- 21.74; p<0.0001). In normal vaginal epithelium with or without HPV infection there was a mild IDO expression in squamous cells. In the presence of cervical intraepithelial lesions or squamous cell carcinoma, there was an increase in the number of IDO-positive dysplastic squamous cells and leukocytes; increase in IDO can also be observed in organotypic skin cultures transduced with HPV-16 E6/E7 oncoproteins. In cervical lesions, as observed for IDO, TDO was expressed in leukocytes, especially infiltrates in the stromal region and in the wall of blood vessels. The basal expression of IDO in the normal cervical epithelium and its positive regulation in HPV infection and associated lesions suggests the participation of Trp metabolism in the immunosuppressive mechanisms involved in the disease. Although some previous data have already considered the role of IDO, as far as we know this is the first evidence of the participation of TDO in the vaginal epithelium, cervical intraepithelial neoplasia and squamous cell carcinoma. In addition, in leukocytes, especially those with a typical polymorphonuclear morphology, appear to be important sources of IDO in the uterine cervix.