Defensinas são peptídeos antimicrobianos produzidos na mucosa intestinal e fazem parte da imunidade inata, agindo sobre vários microrganismos luminais. Deficiência na expressão de defensinas tem sido relatada em doenças inflamatórias intestinais (DII), no entanto a contribuição de cada tipo de defensina, num cenário de polimorfismo genético, mantém alguma controversa. Βeta-defensinas humanas (HBDs) têm atividade antimicrobiana contra uma ampla variedade de fungos, bactérias e vírus e têm também, um papel na ligação entre a imunidade inata e adaptativa atuando como quimiotáticos. O gene DEFB1 (8p23), codificando a beta-defensina humana 1 (HBD-1), é expresso normalmente por células epiteliais de uma série de tecidos, mas sua expressão pode variar entre indivíduos e pode ser modificada durante processo inflamatório. Produção deficiente de defensinas parece contribuir para a patogênese de DII, e uma diminuição na expressão de HBD-1 tem sido relatada na mucosa de pacientes com doença de Crohn (DC) e retocolite ulcerativa (RCU). Nós avaliamos a possível associação de três polimorfismos do gene DEFB1 com a suscetibilidade a DII, RCU e DC, em 149 pacientes, 79 com DC e 70 com RCU; e 200 controles saudáveis do sul do Brasil. No nosso estudo não se observou diferença estatisticamente significativa entre a distribuição das frequências alélicas para DEFB1 SNPs -52G>A. -44C>G e -20G>A entre o total de pacientes com DII e controles. Porém, quando pacientes com DC foram estratificados de acordo com a localização anatômica, o alelo -20G>A foi mais frequente em pacientes com DC colônica do que em controles (65 % VS 44 %, p=0,048). De forma similar, o genótipo A/A foi mais frequente em pacientes com DC colônica do que em controles (36 % VS 16 %), mas neste caso, a diferença não foi estatisticamente significativa (p=0,07). Embora não se achou uma clara e forte associação entre os SNPs 5’-UTR DEFB1 e suscetibilidade/proteção à doença inflamatória intestinal, nossos resultados sugerem possível envolvimento do gene DEFB1 nestas enfermidades, especialmente com a localização colônica da doença de Crohn. Estudos com amostras maiores e populações diversas serão úteis para avaliar a tendência observada no nosso grupo. / Defensins are antimicrobial peptides produced by the intestinal mucosa and are part of the innate immune system, playing a protective role against various intestinal microorganisms. Deficiency in the expression of defensins has been reported in inflammatory bowel diseases (IBD), however there is some controversy over the contribution of each type of defensine, in a setting of great genetic polymorphism. Beta-defensins (HBDs) have an antimicrobial activity against a great variety of fungi, bacteria and viruses, and also have a role in connecting the innate and the adaptive immunity, acting as a chemostatic agent. Deficient production of defensins appears to contribute to the pathogenesis of IBD, and the lower expression of HBD-1 has been reported on the mucosa of Ulcerative colitis (UC) and Crohn’s disease (CD) patients. We evaluated a possible association of three polymorphisms of gene DEFB1 with susceptibility to develop IBD, UC and CD in 149 patients, 79 with CD and 70 with UC; and 200 healthy controls from the south of Brazil. The gene DEFB1 (8p23), which codifies human beta-defensin 1 (HBD-1), is constitutivelly expressed by epithelial cells of several tissues, but its expression may vary among different individuals and may be modified by inflammation. In our study we did not find a statistically significant difference between the distribution of the allelic frequencies for DEFB1 SNPs -52G>A, -44C.G and -20G>A between the total number of patients and controls. However, when patients were stratified according to the anatomic location, the allele -20G>A was more frequent in patients with colonic CD than in contros (65% VS 44%, p=0,048). Similarly, the genotype A/A was more frequent in patients with colonic CD than in controls (36% vs 16%), however, in this case, the difference wasn’t statistically significant (p=0,07). Although we did not find a clear and strong association between the 5’-UTR DEFB1 SNP and susceptibility to IBD, our results suggest a possible involvement of the DEFB1 gene and these diseases, particularlly colonic CD. Further studies with larger samples and diverse populations will be usefull to evaluate the trend observed by our group.

Orientador: Jose Geraldo P. Ferraz / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-06T17:03:45Z (GMT). No. of bitstreams: 1 Coppi_LucianeCristina_D.pdf: 5991264 bytes, checksum: bbcad7dd36b02092b27ac1c30b751988 (MD5) Previous issue date: 2004 / Resumo: Os eosinófilos estão envolvidos na patogênese de várias doenças inflamatórias crônicas? incluindo doenças inflamatórias intestinais (Dll)? como doença de Crohn (DC) e retocolite ulcerativa inespecífica (RCVI). No entanto? ainda é desconhecido como os eosinófilos contribuem para a patogênese das Dll. Portanto? o objetivo deste estudo foi avaliar a atividade dos eosinófilos isolados de sangue periférico de pacientes com Dll comparada aos voluntários sadios. Eosinófilos dos voluntários sadios (n=5)? com DC (n=5) e RCVI (n=5) foram purificados usando-se um gradiente de Percoll? seguido de separação imunomagnética. A atividade dos eosinófilos foi avaliada usando-se os ensaios de quimiotaxi~ adesão? liberação de peroxidase do eosinófilo (EPO)? citometria de fluxo? contagem histológica e análise morfométrica. A quimiotaxia dos eosinófilos induzida pelo N-formyl-metionyl-Ieucyl-fenilanina(fMLP) foi significativamente maior para as células isoladas de pacientes com DC e RCVI? quando comparada aos voluntários sadios.A adesão basal dos eosinófilos de pacientes com DC aumentou significativamente para fibronectina ou soro? quando comparada aos voluntários sadios e RCVI. A liberação basal e estimulada de EPO foi reduzida em células de pacientes com DC? quando comparada aos voluntários sadios. Entretanto? em células isoladas de pacientes com RCVI? a liberação de EPO basal foi significativamente maior quando comparada aos voluntários sadios. A expressão das moléculas de adesão macrophage-l antigen (Mac-l) e very late antigen 4 (VLA-4) não apresentou diferença em relação aos voluntários sadios. A contagem histológica dos eosinófilos em tecido intestinal e morfométrica dos grânulos destas células mostrar~ respectivamente? aumento significativo do número de eosinófilos e de seus grânulos em pacientes com DC e RCVI quando comparadas aos voluntários sadios. Nossos resultados sugerem que os eosinófilos periféricos estão pré-ativados em pacientes com Dll. A ativação dos eosinófilos periféricos? seguida da migração para o tecido intestinal deve contribuir para a patogênese das Dll / Abstract: Eosinophils are involved in the pathogenesis of several chronic inflammatory diseases, including inflammatory bowel disease (ffiD), as Crohn's disease (CD) and ulcerative colites (DC). However, how activation of intravascular eosinophils contributes to disease activity or ffiD pathogenesis is still unknown. The aim of this study was to investigate if eosinophils isolated ITomperipheral blood ITomffiD patients are activated compared to healthy volunteers. Eosinophils ITomhea1thyvolunteers (n=5), CD (n=5) and DC patients (n=5) were purified using a Percoll gradient followed by immunomagnetic cell separator. Eosinophil activity was investigated using chemotaxis, adhesion and mediator release assays (eosinophil peroxidase, EPO), flow cytometric, histologic counting and morphometric analysis. -formyl-metionyl-Ieucyl-fenilanina (fMLP) induced eosinophil chemotaxis was significandy augmented in cells isolated from CD and DC patients compared to hea1thyvolunteers. Eosinophil basal adhesion of CD significantlyincreased to fibronectin or serum if compared to DC or hea1thyvolunteers. Basal and stimulated EPO release was reduced in cells ITomCD patients compared to hea1thyvolunteers. However, basal EPO release was significantly enhanced in cells isolated from DC patients when compared to hea1thy volunteers. The expression of adhesion molecules macrophage-l antigen (Mac-l) and very late antigen 4 (VLA-4) isn't different in patients with DC and CD compared to hea1thyvolunteers. Histologic counting of eosinophils in intestinal tissue and morphometric analysis of granules of this cells showed, respectively, significant augmentation in the number of eosinophils and its granules in CD and DC patients compared to hea1thy volunteers. Our results suggest that peripheral eosinophils are preactivated in ffiD patients. Activation of peripheral eosinophils followed by migration to intestinal tissue probably contributes to ffiD pathogenesis / Doutorado / Ciencias Basicas / Doutor em Clínica Médica

Submitted by Renata Lopes (renatasil82@gmail.com) on 2017-06-19T14:20:56Z No. of bitstreams: 1 mariaterezabrandi.pdf: 1443789 bytes, checksum: 458ed97b54aff4733a442f3ecafbbe88 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-06-29T12:26:23Z (GMT) No. of bitstreams: 1 mariaterezabrandi.pdf: 1443789 bytes, checksum: 458ed97b54aff4733a442f3ecafbbe88 (MD5) / Made available in DSpace on 2017-06-29T12:26:23Z (GMT). No. of bitstreams: 1 mariaterezabrandi.pdf: 1443789 bytes, checksum: 458ed97b54aff4733a442f3ecafbbe88 (MD5) Previous issue date: 2007-10-31 / Embora fatores psicológicos tenham sido inicialmente postulados como determinantes na etiologia da doença de Crohn (DC), atualmente esta hipótese foi descartada, embora distúrbios de ansiedade e depressão possam exacerbar ou desencadear atividade da doença. Entretanto, a prevalência das síndromes de ansiedade e depressão nas DC, assim como seus possíveis fatores associados às mesmas estão pouco definidos. Objetivos: Avaliar em pacientes portadores de DC a prevalência de síndrome depressivo-ansiosa, bem como os possíveis fatores de risco. Material e Métodos: 110 pacientes (55 homens e 55 mulheres) com média de idade de 38,2 anos (variação 18 a 64 anos) com diagnóstico estabelecido de DC foram avaliados durante o período de Dezembro 2005 a Abril de 2007 para a presença de síndrome depressivo-ansiosa. Registrou-se dados sócio-demográficos relevantes, características clínicas relacionadas às DII, e os antecedentes pessoais. Na avaliação do fenótipo da DC usou-se a classificação de Viena, enquanto a atividade da DC foi avaliada pelo índice de atividade da doença de Crohn (IADC). Para a avaliação psicológica dos pacientes foram utilizados dois instrumentos de auto-avaliação: o Inventário de Depressão de Beck e a subescala de ansiedade da Escala Hospitalar de Ansiedade e Depressão. Os mesmos questionários foram aplicados em grupo controle de 110 pacientes (52 homens e 58 mulheres) com média de idade de 39,9 anos (variação 18 a 65 anos) atendidos em um ambulatório de gastroenterologia geral por doenças cronicas gastrointestinais (exceto DC). Para fins comparativos, os pacientes com DC foram divididos em grupos com e sem síndromes depressiva (SD) e/ou ansiosa (SA). Resultados: Os pacientes com DC e grupo controle foram similares com relação ao sexo, estado civil, idade, raça, emprego atual, e consumo de álcool. Entretanto, pacientes com DC foram mais freqüentemente tabagistas (p= 0.05) e tinham maior nível de escolaridade (p<0.02). Síndrome depressiva foi significantemente mais freqüente em pacientes com DC que no grupo controle (25,4% vs. 8,2%; p<0.003), enquanto a prevalência de SA (33,6% vs. 22,7%) e disforia (13,6% vs.6,4%) foram similares em ambos os grupos. Os pacientes com DC e SD comórbida foram significantemente mais prováveis de apresentarem doença ativa na inclusão quando comparado aqueles não depressivos (71,4% vs. 34,1%, respectivamente; p=0.04). Adicionalmente, o escore basal do IADC foi significantemente maior nestes (282 ± 113) do que naqueles sem SD (138 ± 50; p= 0.001). Nos 37 pacientes com DC e SA comorbida, houve nítida tendência do predomínio de mulheres. Em comparação aos pacientes sem SA, significantemente mais pacientes com SA tinham historia familiar de depressão (56,7% vs. 16,4%; p=0.002). Conclusão : Nossos resultados mostram que SD e/ou SA são distúrbios altamente prevalentes em pacientes com DC. A atividade da DC foi o principal fator associado com a coocorrência de SD, enquanto que historia familiar de depressão mostrou ser um fator significantemente associado a SA nestes pacientes. A alta prevalência de síndrome depressivas e/ou ansiosas encontradas em pacientes com DC, junto com a disponibilidade do tratamento efetivo para estas condições, indica que é oportuno recomendar rastreamento rotineiro para SD/SA como parte da melhora da qualidade do cuidado aos sujeitos com DC. / Although psychological factors have been initially postulated as the key in the etiology of Crohn's Disease (CD), nowadays this hypothesis has been discarded, even though anxiety and depression disorders, can exacerbate or trigger activity of the disease. However, the prevalence of anxiety and depression syndromes in CD, as well as its possible factors associated with them are poorly defined. Objective: To evaluate the prevalence of the anxious-depressive-syndrome, as well as the possible risk factors, in patients with CD. Materials and Methods: 110 patients (55 men and 55 women) with a mean age of 38.2 years (range 18 to 64 years) with established diagnosis of CD were evaluated during the period of December 2005 to April 2007 for the presence of anxiety-depressive syndrome. Socio-demographic relevant data, clinical characteristics related to inflammatory bowel disease, and personal background were recorded. To assess the CD phenotype we used the Vienna´s Classification, while the activity of the CD was evaluated by the Activity Index in Crohn's Disease (AICD). Two instruments of self-assessment were used for the psychological evaluation of patients: the Beck Depression Inventory, and the anxiety subscale of the Hospital Anxiety and Depression Scale. The same questionnaires were applied in the control group of 110 patients (52 men and 58 women) with mean age of 39.9 years (range 18 to 65 years) attended in a general gastroenterology clinic for gastrointestinal cronic diseases (except CD). For comparative purposes, patients with CD were divided into groups: with and without depressive (DS) and / or anxiety syndrome (AS). Results: Patients with CD and the control group were similar with respect to sex, marital status, age, race, current employment, and alcohol consumption. Meanwhile, CD patient were more often smokers (p = 0.05) and had higher level of education (p <0.02). Depressive syndrome was significantly more often in CD patients that in the control group (25.4% vs. 8.2%, p <0.003), although the AS prevalence (33.6% vs. 22.7 %), and dysphoria (13.6% vs.6, 4%) were similars in both groups. Patients with CD and DS comorbidity were significantly more likely to present active disease in the inclusion when compared with the non-depressive patients (71.4% vs. 34.1%, respectively, p = 0.04). Additionally, the baseline score of the AICD was significantly higher in these (282 ± 113) than those without DS (138 ± 50, p = 0.001). In 37 patients with CD and AS comorbidity, there were clear trend of the predominance of women. Significantly more patients with AS had a depression family history when compared to patients without AS (56.7% vs. 16.4%, p = 0.002). Conclusion: Our results show that DS and / or AS are highly prevalent disorders in patients with CD. The activity of the CD was the main factor associated with the co-occurrence of DS, while depression family history proved to be a significantly factor associated with AS in these patients. The high prevalence of DS and / or AS found in patients with CD, along with the availability of effective treatment for these conditions, indicates that it is appropriate to recommend routine screening for DS / AS as part of improving the quality of care for subjects with CD .

Submitted by Renata Lopes (renatasil82@gmail.com) on 2018-06-26T10:52:38Z No. of bitstreams: 0 / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2018-06-27T15:27:12Z (GMT) No. of bitstreams: 0 / Made available in DSpace on 2018-06-27T15:27:12Z (GMT). No. of bitstreams: 0 Previous issue date: 2018-05-25 / Introdução: A doença inflamatória intestinal (DII) é um grupo de doenças caracterizado por inflamação de natureza crônica e etiologia multifatorial, constituído principalmente pela doença de Crohn e pela retocolite ulcerativa. Tais doenças comprometem preferencialmente indivíduos jovens em fase produtiva, tem curso flutuante com fases de remissão e atividade, e frequentemente apresentam comportamento clínico agressivo, com impacto na qualidade de vida. O Clostridium difficile é um bastonete gram positivo, produtor de esporos, ubíquo na natureza e representa causa importante de diarreia associada ao uso de antimicrobianos, através da produção das toxinas A e B. A literatura tem relatado maior ocorrência da infecção por C. difficile (ICD) em pacientes com DII, o que aumenta o risco de recorrência da DII e pior evolução. Objetivo: Avaliar a prevalência, os aspectos epidemiológicos, os fatores associados e a evolução clínica da infecção por C. difficile em pacientes ambulatoriais com DII. Métodos: Neste estudo prospectivo longitudinal, realizado entre outubro de 2013 a julho de 2016, com 120 pacientes com DII (55% apresentando colite) e 40 controles não-DII foram avaliados para ICD, através de análise de amostras fecais para pesquisa de toxinas do C. difficile, através do teste de ELISA. Foi avaliado fatores de riscos associados a ICD. A regressão multivariada foi realizada para identificar preditores de ICD. Resultados: A proporção de pacientes com ICD foi significativamente maior em pacientes com DII em atividade que DII em remissão (28,8% vs. 5,6% vs. 0%, respectivamente, p = 0,001). Feminino (OR = 1,39, IC 95%, 1,13-17,18), idade mais jovem (OR = 0,77, IC 95%, 0,65-0,92), tratamento com esteróides (OR = 7,42, IC 95%, 5,17-40,20) e terapia com infliximabe (OR = 2,97, IC 95%, 1,99-24,63) foram independentemente associados com ICD. Houve aumento nas probabilidades de ter ICD em pacientes com prednisona. Conclusões: A ICD é uma condição altamente concorrente em pacientes com DII apresentando exacerbação de colite a nível ambulatorial. O sexo feminino, a idade mais jovem, a terapia com infliximabe e o uso de esteróides foram associados de forma independente à co-ocorrência de ICD. A maioria dos pacientes com ICD apresentaram doença leve a moderada e o tratamento com vancomicina foi muito efetivo, parecendo reduzir o risco de complicações graves relacionadas à ICD. / Introduction: Inflammatory bowel disease (IBD) comprises a group of diseases of multifactorial etiology, characterized by chronic and progressive inflammation of the gastrointestinal tract, consisting mainly of Crohn's disease and ulcerative colitis. Clostridium difficile is a gram-positive, spore-producing rod that is ubiquitous in nature and is an important cause of diarrhea associated with the use of antimicrobials and in immunocompromised patients. The literature has reported a higher occurrence of Clostridium difficile infection (CDI) in patients with IBD, leading to significant morbidity and mortality. Objective: To evaluate the prevalence, epidemiological aspects and clinical evolution of CDI in outpatients with recurrent IBD. Methods: In this prospective longitudinal study, conducted between October 2013 and July 2016, 120 patients with IBD (55% with colitis flare) and 40 non-IBD controls were evaluated for CDI by searching for toxins A and B in feces fresh by ELISA. All patients with CDI were treated with oral vancomycin and followed up for an additional six months. Multivariate regression was performed to identify predictors of CDI. Results: The proportion of patients with CDI was significantly higher in patients with active IBD than in those with IBD in remission or in non-IBD controls (28.8% vs. 5.6% vs. 0%, respectively, p = 0.001). Females (OR = 1.39, 95% CI, 1.13-17.18), younger age (OR = 0.77, 95% CI, 0.65-0.92), steroid treatment (OR = 7.42, 95% CI, 5.17-40.20) and infliximab therapy (OR = 2.97, 95% CI, 1.99-24.63) were independently associated with CDI. There was a dose-related increase in odds of having CDI in patients using prednisone. All patients treated with vancomycin responded to therapy, but 21% had recurrent CDI and 16% were hospitalized. Neither colectomy nor mortality was noticed.Conclusions: CDI is a highly concurrent condition in outpatients IBD with colitis flare. Females, younger age, infliximab therapy, and steroid use were independently associated with the cooccurrence of IBD. Most patients with CDI had mild to moderate disease and vancomycin treatment was very effective, seeming to reduce the risk of serious complications related to CDI.

Orientadores: Claudio Saddy Rodrigues Coy, Raquel Franco Leal / Tese (Doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T16:55:09Z (GMT). No. of bitstreams: 1 Maldaun_Daisy_D.pdf: 1445844 bytes, checksum: ff748e47d7a55e600aa2c0b5596a7b15 (MD5) Previous issue date: 2012 / Resumo: Denominam-se doenças inflamatórias intestinais (DII) afecções crônicas consideradas auto-imunes, que acometem principalmente o aparelho digestório sendo que duas são mais representativas: retocolite ulcerativa inespecífica (RCUI) e doença de Crohn (DC). Apresentam incidência progressiva, não apenas em nosso meio mas também em âmbito mundial. A importância das DII na gastroenterologia e na saúde publica, em particular se deve a: serem afecções crônicas, que atingem principalmente os jovens; terem crescente incidência com impacto na qualidade de vida e consequentemente nas relações sociais; abordagem complexa; e resposta terapêutica variável. A forma como os pacientes vivenciam a doença está associada a fatores de organização e interação familiar. Na investigação clínica, pacientes acometidos por DII podem vivenciar de forma singular, o seu processo de adoecer em função da estrutura e da dinâmica da família a qual pertencem. Assim, a investigação dos fatores emocionais e da influência da dinâmica familiar na evolução das DII e a constatação da existência de poucas pesquisas realizadas sobre esse tema, nos levaram à realização desse estudo. Objetivo: compreender a influência da dinâmica familiar do paciente com DII, seja ela afetiva ou conflitante na percepção da enfermidade, sob a visão do paciente e de seus genitores. Método;: como escolha foi utilizado o Método Clinico Qualitativo. Foram avaliadas as seguintes categorias: :a) conhecimento da DII; b) o sentido que a DII representa; c) o inter-relacionamento familiar e as modificações advindas da doença; d) a forma como convivem com a sintomatologia da doença; e) o momento da hospitalização. Quinze pacientes com idade entre 18 e 39 anos e seus respectivos genitores, provenientes do Ambulatório de Doença Inflamatória Intestinal "Prof. Dr. Juvenal Ricardo Navarro Góes" do Centro de Diagnóstico de Doenças do Aparelho Digestivo (GASTROCENTRO) da FCM-UNICAMP) sem distinção de raça, naturalidade, condição social, escolaridade, nível sócio-econômico e crença. A coleta de dados envolveu a aplicação, para os pacientes e respectivos genitores, de: Entrevista Inicial e Roteiro de entrevista semi-estruturada, (elaborada pelos pesquisadores desse estudo), para obtenção de informações clinicas e de estrutura familiar. Resultados: a família, como uma unidade dinâmica, é o mais importante suporte social e pode ser considerada como uma importante fonte de estress, que exerce uma significativa influência sobre a saúde e doença de seus membros Os achados, nas categorias selecionadas, mostraram que os pacientes com DII e seus respectivos genitores vivenciam a enfermidade, tanto na exacerbação quanto na remissão de sua sintomatologia, de forma única e singular, com conseqüências psicológicas, sociais e profissionais, de acordo com o convívio e a influência da dinâmica familiar a qual pertencem. Conclusão: A influência da dinâmica familiar, seja afetiva ou conflitante, é relevante em relação à convivência com os sintomas da doença e suas conseqüências, em virtude da dificuldade de ambos, pacientes e genitores, em administrar as características de suas personalidades / Abstract: Inflammatory Bowel Diseases (IBD) are chronic conditions, considered autoimmune, which affects specially the digestive system with two of them being more representative: ulcerative colitis (UC) and Crohn disease (CD). These are diseases with progressive incidence, not only in our local environment but also worldwide. The IBD importance in gastroenterology and public health care, is due to: being chronic conditions that affects mainly young people; they have growing incidence with impact on quality of life and consequently on social relations; complex approach and therapeutic response variable. The way patients experience the disease is associated to organizational factors and family interaction. In clinic investigation, patients affected by IBD experience, in a unique way, the process of becoming ill in function of the family structure and dynamics that they belong. Thus, the investigation of emotional factors, family dynamics influence in the IBD evolution and confirmation of a few available research made over this topic, have leaded us to accomplish this study. Objective; to understand the influence of family dynamics with IBD patients, either arising from affective or conflicting with the perception of the illness from the patient's and his/her parent's perspective/point of view. Method; Qualitative Clinic method was employed and the following categories were evaluated: (a) IBD knowledge, (b) the meaning of what IBD stands for, (c) family interrelationship and modifications originating from the illness (d) how they live with the disease's symptomatology and (e) hospitalization.: Fifteen patients, age varying between 18 and 39 and their respective parents, from the IBD outpatients unit "Prof. Dr. Juvenal Ricardo Navarro Góes" (GASTROCENTRO) of FCM-UNICAMP) without distinction of race, origin, education or social-economic level, education, were evaluated. The data were collected by the application of semi-structural interview (elaborated by the researches of this study) with the patients and their respective parents in order to obtain clinical and family structure information. Results; The family, as a dynamic unit, is the most important core of social support and can be considered as an important source of stress, exercising significant influence on the health and illness of its members. The findings of the selected categories have shown that patients with IBD and their respective genitors experienced the illness, both in grave condition or remission, in a unique manner with psychological, social and professional consequences, according to the relationship and family dynamics. Conclusion;: The influence of family dynamics, whether emotional or conflicting, it is relevant in relation to living with the symptoms of the disease and its consequences, due to the difficulty of both, patients and parents, to manage the characteristics of their personalities / Doutorado / Fisiopatologia Cirúrgica / Doutora em Ciências

Les maladies inflammatoires chroniques de l’intestin font partie des pathologies immunitaires. Leur pathogenèse est directement liée à une réponse immune exagérée dirigée contre des bactéries commensales normalement présentes dans l’intestin, chez des individus génétiquement prédisposés. Parmi les facteurs favorisants, on trouve l’amélioration du niveau d’hygiène ainsi qu’une diminution des infections parasitaires. Des études épidémiologiques ont suggéré une relation entre la prévalence des infections par les helminthes et l’incidence des maladies inflammatoires chroniques de l’intestin dans les pays en développement. Ces infections parasitaires induisant une réponse immune de type Th2, il est donc proposé qu’elles participent la régulation des maladies inflammatoires médiées par une réponse immune de type Th1, comme la maladie de Crohn.Notre équipe s’est intéressée à l’effet immuno-modulateur d’une protéine du Schistosome, la P28GST (Glutathion S-transferase) dont les propriétés immunogénétiques pro-Th2 ont été démontrées précédemment dans des modèles expérimentaux et chez l’homme. Au cours de notre travail, nous avons montré que l’immunisation avec la P28GST était capable de diminuer de manière façon significative la colite expérimentale dans deux modèles animaux. L’immunisation avec cette enzyme parasitaire, produite sous forme recombinante, a réduit les scores cliniques et histologiques obtenus après induction de colite expérimentale par injection de l’haptène TNBS chez des rats Sprague Dawley rats ainsi que chez des souris C57Bl/6. Cet effet est associé à une diminution des marqueurs de l’inflammation (Myéloperoxidase) et de lexpression de l’ARN messager codant pour des cytokines pro-inflammatoires (IL-1&#946;, IL-17 et TNF) dans le colon des animaux. Nous détectons une modulation de la réponse immune caractérisée par une diminution du profil Th1 mesuré par la présence d’ARN messager codant pour l’IFN&#947; vers un profil de type Th2, associé à une augmentation de l’ARN messager codant pour l’IL-4, l’IL-5 et l’IL-13. L’augmentation du rapport ARN messager Arg1/iNOS2 ainsi que la détection de cellules Arginase positives par immuno-histo chimie dans le colon des animaux immunisés suggèrent la présence de macrophages alternatifs (AAM), dont on connait le rôle anti-inflammatoire et l’association à une réponse de type Th2. Des résultats similaires ont été obtenus dans un autre modèle expérimental, chez la souris.Nous avons comparé l’effet de cette protéine du Schistosome avec l’effet de l’infection par des larves du parasite grâce à deux modèles d’infection : soit une infection au long cours (associé avec une réponse immune de type Th2), soit une infection récente (avec une réponse immune de type Th1). Nos résultats montrent que l’immunisation par une seule protéine de schistosome, la P28GST, réduit l’inflammation intestinale aussi bien que l’infection au long cours, tandis que les animaux récemment infectés n’étaient pas protégés de la colite. En conclusion, notre étude présente les premières évidences que l’immunisation avec une protéine recombinante de Schistosome pourrait réduire de manière préventive la colite expérimentale induite par l’injection d’une haptène dans deux modèles de rongeurs. Si les mécanismes d’action précis doivent encore être élucidés, nos travaux suggèrent que l’effet anti-inflammatoire de la P28 GST puisse avoir des applications dans la prévention de l’inflammation intestinale permettant d’envisager une utilisation chez l’homme, notamment dans la prévention des rechutes de la maladie de Crohn. / Inflammatory bowel diseases are considered part of immune-mediated inflammatory disorders. Their pathogenesis was linked to an inappropriate exaggerated immune response to commensal bacteria normally present in the bowel, in genetically predisposed individuals. Increase of the level of hygiene and decrease exposure to helminthic infections was suggested as predisposing factors to IBD. Epidemiologic data have given a clue on the relation of prevalence of helminthic infections and the incidence of inflammatory bowel diseases in developing countries. The Th2 polarized T cell response driven by helminthic infection has been linked to the attenuation of Th1 driven inflammatory responses, preventing some Th1 mediated autoimmune diseases in their host, including Crohn’s disease.Our work focused on the immuno-modulatory effect of a Schistosome protein – P28GST (a Glutathion S-transferase). Its immuno-genetique, pro-Th2, characters have been previously demonstrated in experimental models as well as clinical trials. We showed that immunization with P28GST was able to significantly reduce experimentally induced colitis in two animal models.Immunisation with this recombinant parasitic enzyme reduced clinical and histological scores of the TNBS induced colitis in both Sprague Dawley rats as well as in C57Bl/6 mice. This effect was associated with a decrease in the expression of inflammatory markers (Myeloperoxidase) as well as mRNA expression of pro-inflammatory cytokines (IL-1&#946;, IL-17 and TNF) in the colon of sacrificed animals. We detected a shift of the immune response characterized with decrease of Th1 immune response assessed by the mRNA expression of IFN&#947; towards a less pathological Th2 immune response assessed by the mRNA expression of IL-4, IL-5 and IL-13. An increase in the ratio of mRNA expression of Arg1/iNOS2, as well as the immuno-histochemical detection of Arginase positive cells in the colon of the sacrificed animals suggested the presence of alternatively activated macrophages (AAMs) characterized by their anti-inflammatory effect and their association with the Th2 immune response. Similar results have been obtained in another animal model, the C57Bl/6 mice.We have also compared the effect of a single recombinant Schistosome protein to two models of infection with living schistosome parasites, either with long standing infection (associated with a Th2-type response) or with a recent onset exposure (a Th1-type response). Our results showed that immunisation with a single Schistosome protein, the P28GST; give similar results to established infection in term of reduction of intestinal inflammation, whereas recently infected rats were not protected against colitis.In conclusion, this study provides the first evidence that immunization with a recombinant protein from the Schistosome helminth parasite prevents hapten-induced colitis in two models of rodents. Although further studies are needed to illustrate the exact mechanisms of action implicated in the immuno-modulatory effect, P28GST is a promising molecule exerting a potent anti-inflammatory role in the prevention of colitis. The potential effect of this helminthic enzyme is actually taken in consideration in the prevention of Crohn’s disease relapses in humans.

The last half-century has seen a dramatic and alarming rise in the incidence of autoimmune disease in industrialized nations too rapid to be accounted for by genetics alone. Among those, Inflammatory Bowel Disease (IBD) has risen from a western disease affecting industrialized populations to an emerging global threat affecting diverse populations around the world. IBD is a complex disease that combines genetic susceptibility and environmental exposure, but one aspect appears to be clear: the involvement of the gut microbiome. Current thought holds that IBD is an autoimmune attack on commensal microbiota, causing extensive collateral damage to the host intestinal tissues in the process. However, it has remained unclear in the field whether the changes observed in the IBD microbiome are causative in nature or whether the microbiome is responding to already-underway inflammatory processes within the host. This dissertation investigates one host factor in particular with regard to the microbiome and the development of inflammation: sodium-hydrogen exchange at the brush border, mediated by sodium hydrogen exchanger 3 (NHE3). NHE3 is inhibited during active IBD, but its loss in knockout animals is also enough to promote spontaneous colitis in a microbiome-dependent fashion. This dissertation investigates the specific contribution of the microbiome in NHE3 knockout animals to determine whether loss of NHE3 may be mediating the onset of colitis through pro-inflammatory changes in the microbiome. Our results suggest that the microbiome fostered in an NHE3-deficient environment may accelerate the onset and severity of experimental colitis, though likely in concert with additional host factors.

Ces dernières années, l'implication du microbiote intestinal dans la physiopathogénie des maladies inflammatoires chroniques de l'intestin (MICI) a été mise en évidence. Le but de nos travaux est de déterminer l'impact de la dysbiose sur l'écosystème intestinal au cours des MICI. Ces trois études nous ont permis de confirmer le rôle central de la dysbiose associée aux MICI : d'une part comme outil potentiellement prédictif de rechute, précédant une inflammation locale ou systémique, d'autre part comme acteur dans l'apparition d'un déséquilibre de l'écosystème intestinal. Ce déséquilibre est marqué par l'altération de l'activité enzymatique du microbiote modifiant le pool d'acides biliaires dans la lumière intestinale et pouvant affecter les effets anti-inflammatoires de certains acides biliaires sur les cellules épithéliales intestinales participant ainsi à une inflammation chronique au cours des MICI. Par ailleurs, cette dysbiose est possiblement entretenue par un déficit en défensine hBD1 et HD5, perpétuant une inflammation chronique intestinale.Ces résultats renforcent le rôle proéminent du microbiote dans l'évolution des MICI et suggèrent que la restauration de la normobiose au cours de la maladie devrait être un nouveau but dans la prise en charge de ces patients. / In recent years, the involvement of intestinal microbiota in the pathogenesis of inflammatory bowel disease (IBD) has been established. The aim of our study was to determine the impact of dysbiosis in intestinal ecosystem of IBD patients.These three studies allowed us to confirm the fundamental role of IBD-associated dysbiosis. First, IBD-associated dysbiosis has been identified as a potential predictive tool of relapse, before local or systemic inflammation. Second, IBD-associated dysbiosis has been involved as an actor in the emergence of an imbalance of intestinal ecosystem. This imbalance was characterised by an alteration of microbiota enzymatic activity leading to modifications in the luminal bile acid pool composition and may affect the anti-inflammatory effects of some bile acids on gut epithelial cells and could participate in the chronic inflammation loop of IBD. Moreover, a deficiency in the antimicrobial defense systems of defensins may be an explanation for the break of the antibacterial barrier function in inflammatory bowel diseases maintaining dysbiosis.These results reinforce the prominent role of the microbiota in the development of IBD and suggest that restoring normobiosis could be a new goal for optimal IBD management.

Magister Scientiae (Medical Bioscience) - MSc(MBS) / Background: A subtype of inflammatory bowel disease, Crohn’s disease is thought to represent a complex interaction between environmental factors, a defective immune system, the gastrointestinal microbiome and genetic susceptibility. Aim: The focus of this study was to investigate the association between environmental exposures during childhood and the subsequent development of Crohn’s disease, thus the two primary aims were to: 1) conduct a systematic review of the literature evaluating environmental risk factors during childhood, defined by studies either as, age intervals (e.g., 0-5, 6-10 and 11-18 years), or more 'broadly' as 0-18 years; and 2) investigate the association between childhood environmental exposures during three age intervals (0-5, 6-10 and 11-18 years), as well as frequency of childhood infections and the future development of Crohn's disease based on a score analysis, using a subset of previously collected data from a completed doctoral thesis involving a case control study design in study population, in the Western Cape, South Africa. The aim included a primary analysis of the latter dataset for childhood infections. Design: For the first aim of the study, a systematic search was conducted during March 2015 in electronic databases, such as EMBASE, EBSCOhost (Medline), Ovid, Scopus and World Cat, PubMed and Biomed Central, to identify epidemiological studies that examined the association between childhood environmental exposures and the subsequent development of Crohn's disease. Studies evaluating childhood exposure either by age intervals, or more broadly, from birth until 18 years were included. The environmental exposures evaluated in the review were; farm animal contact, place of upbringing, sibship size, household pets, primary water source and hot water availability. Of the 181 identified articles, 16 were included in the final systematic review. The second aim of the study involved a post hoc analysis of a subset of findings from the completed doctoral research by Abigail Basson with regard to the multiple logistic regression analysis evaluating environmental risk factor exposure during three age intervals; 0-5 years, 6-10 years and 11-18 years. In the present research, two different methodological approaches were undertaken. Briefly, exposure variables, of similar nature, were combined into subgroups and assigned weighting scores. The two 'subgroup models' were designated as: Group A and Group B. Based on these premises, a score analysis was performed, and the difference in scores, between case and control groups, was compared. In addition, multiple logistic regression models were conducted on a subset of original data from the aforementioned completed doctoral study to assess the association between the frequency of childhood infections between 0-20 years and risk of Crohn’s disease development. Following this, a score analysis was again performed. Results: Sixteen studies were included in the systematic review. Of the five studies that investigated the association between place of upbringing during the age interval 0-5 years and the subsequent development of Crohn's disease, three found no significant association; however of the three studies evaluating place of upbringing during the age intervals 6-10 and 11-18 years, only one study identified a significant association. Three studies investigated exposure to farm animals during the age interval 0-5 years, of which, two identified a significant association. Of the latter three studies, two investigated farm animal contact during the age intervals 6-10 and 11-18 years, but only one reported a significant association during these age intervals. Notably, this was the study which had failed to identify an association during the 0-5 year age interval. Both studies which broadly evaluated farm animal exposure during 'childhood' reported that not having contact with animals significantly increased the risk of developing Crohn's disease. Of the five studies that investigated exposure to pets during the age interval 0-5 years, only one identified a significant risk association, namely with exposure to cats. Of the three which investigated pet exposure during the age intervals 6-10 years and 11-18 years, one identified a significant association, for both age intervals. Five studies investigated pet exposure during 'childhood'; one found that having a pet significantly increased the risk of developing Crohn's disease, two reported that not having a pet significantly increased risk in developing Crohn's disease, whereas the remaining studies found no significant association. Only one study evaluated primary water source during the three age intervals; during the age interval 0-5 years and 11-18 years, having piped tap or bottled water was significantly associated with CD development. Of the four studies investigating primary water source during ‘childhood’, only one reported a significant association between primary water source and the development of Crohn's disease. The availability of hot water during the age interval 0-5 years was significantly associated with Crohn's disease development in one of the three relevant studies. Two studies investigated hot water availability during 6-10 and 11-18 years, however both failed to identify a significant association. When broadly evaluated, hot water availability during 'childhood' was significantly associated with Crohn's disease risk, in two of the three relevant studies. None of the studies which investigated sibship size and the risk of future Crohn's disease development during defined age intervals reported a significant association. Only two of the seven studies that evaluated sibship size during childhood reported a significant association. Results of the score analysis revealed a significant difference during all three age intervals between the case and control groups with Group A and Group B, with cases having significantly lower exposure scores (approximately 30% and 40% lower, respectively), when compared with that of controls. On multiple logistic regression analysis, subjects who never had tooth decay/cavity (OR = 1.78; 95% CI, 1.05-3.04), periodontitis (OR = 1.95; 95% CI, 1.10, 3.48), diarrhoea (OR = 2.71; 95% CI, 1.62-4.62), gastritis (OR = 2.13; 95% CI, 1.30-3.35), or mouth ulcers (OR = 2.02; 95% CI, 1.12-3.70), at least once per year or more, were at an increased risk for later development of Crohn's disease, when compared to those who were exposed to these infections at least once per year or more. There was a significant difference in exposure scores between the case and control groups (OR = 0.88; 95% CI, 0.82-0.94), thus indicating that cases had 12% less exposure to childhood infections from birth until the age of 20 years, when compared to the controls. Conclusion: The systematic review of the literature provides evidence in support of the hygiene hypothesis, in that delayed exposure to immunostimulatory microbes through the environmental exposures increases the risk for future CD development, in genetically susceptible individuals. In addition, the literature supports that the childhood environment plays an important role in the aetiology of Crohn's disease. However, the lack of consistent findings between studies, particularly those which have broadly defined ‘childhood’ implies that timing of exposure plays a crucial role in this ever evolving paradigm. Results from the score analysis provide insight into the 'compound' effects from multiple environmental exposures in the aetiology of Crohn's disease. While the present research was unable to provide any explanation for the underlying mechanism of disease pathogenesis, overall, the findings have important implications for future IBD-related studies as they demonstrate the importance of accounting for environment as a 'whole' when conducting epidemiological studies, as opposed to focusing on individual environmental factors, as well as that it is imperative to investigate environmental exposures within the context of defined age intervals.

Introduction: Inflammatory bowel disease (IBD), Crohn’s Disease and ulcerative colitis, are long term conditions which follow a relapsing and remitting pattern. The rising incidence of IBD in adults and children has implications for the lifelong burden of disease and the provision of specialist services. Patients are predominantly managed by secondary care and follow a traditional, scheduled follow-up cycle, which is unsustainable and unsatisfactory. Patients with IBD should have access to specialist care which is delivered according to their values and needs. However few studies have examined patients’ views of follow-up care. There is also concern in the UK that services for patients with long term conditions are not orgnised to promote independence with silo working in primary and secondary care.These may be brought together formally through the development of models of care. Utilization of current out-patient spaces to regularly review stable patients is inappropriate and is challenged by commissioners. The question remains as to what models of follow-up are we able to offer patients which are acceptable and what is the role of the general practitioner (GP) and primary care within this. The aim of this study was to develop an integrated, acceptable, model of follow-up care for patients with IBD.Methods The study follows the development phase of the MRC Framework for complex interventions. A best evidence synthesis was undertaken to identify the follow-up care models in IBD. A meta-synthesis of the health and social care needs of patients with IBD was conducted to explore the impact of living with IBD. Qualitative interviews with 24 IBD patients (18 patients had CD, and 6 UC, age range 27-72 years, disease duration range 2 – 40yr) and 20 GPs purposively selected from across NW England were carried out. Patients were asked about their experience, values and preference of follow-up care. The GPs were questioned about their current and potential role in IBD. Analysis was undertaken using Framework Analysis. The best evidence synthesis, meta-synthesis and interviews were synthesised by an expert panel, Consultant Gastroenterologist, patient, GP, IBD Nurse, to develop the model of follow-up care.Results There were similarities and commonalities between the patient and general practitioner interviews. Patients did not want to be seen when well, GPs wanted more involvement in care and there is scope for an IBD outreach nurse at the interface of primary/secondary care. Discharging quiescent patients into enhanced GP care, to ensure equitable treatment, was acceptable to all, as was the concept of ‘virtual’ clinics. Patients would initiate self referral within the ‘virtual’ arm whilst patients under GP care would be referred back into secondary care as a rapid referral < 7days and not using a new patient tariff. Complex IBD patients would remain under secondary care. A stratified model of follow-up care was developed.Conclusion This study provides an acceptable integrated model of follow-up for patients with IBD. It takes into account the growing incidence of IBD and UK policy to reduce inappropriate follow-up. It emphasises role of self management, the integration of primary and secondary care, placing the patient closer to home whilst allowing secondary care to concentrate on complex patient management.