Changes to the composition and function of the gut mononuclear phagocyte (MNP) compartment are associated with the development of intestinal inflammation. Much work has focused on the role of MNPs in gut-associated lymphoid tissue in maintaining homeostasis, however little is known regarding the roles of MNPs during colitis. We have investigated MNPs in the large intestinal lamina propria during the steady state and inflammation. One of our primary aims was to determine the contribution of MNP subsets to intestinal pathology. For our studies of inflammation, we focused mainly on the Helicobacter hepaticus infection + anti-IL-10R model, which induces inflammation of the colon and caecum (typhlocolitis). We defined the composition of the MNP compartment alongside intestinal pathology scores throughout Hh + anti-IL-10R typhlocolitis. Peak pathology, 2-3 weeks after induction of colitis, coincided with peak frequencies of CX₃CR1^int Ly6C^+ MNPs. Having observed the accumulation of CX₃CR1^int CD64^+ monocyte/macrophage MNPs in the inflamed lamina propria, we conducted comparative whole genome microarray analysis of these cells isolated from the large intestine three weeks after Hh + anti-IL-10R treatment. CX₃CR1^int CD64^+ MNPs selectively expressed a variety of pro- and anti-inflammatory genes, including a number of genes which individually can both promote and negatively regulate inflammation. IL-23 is essential for Hh + anti-IL-10R-induced intestinal pathology. We investigated the role of MNPs as a source of IL-23 which drives Hh + anti-IL-10R colitis. Unexpectedly, our results indicate that normally hyporesponsive CX₃CR1^hi macrophages may act as the initial source of IL-23, which induces development of colitis. Recruitment of Ly6C^+ MHCII^+ MNPs to the lamina propria was IL-23-dependent, and these cells also expressed IL-23, which may establish a positive feedback loop of immune cell recruitment, activation and IL-23 production. Finally, we also examined how MNPs might be recruited to the colonic lamina propria during inflammation. Our studies support the conclusion that CCR6 is not required for accumulation of monocyte-derived populations in the inflamed intestine. We cannot rule out a role for CCR2, however preliminary data from the Hh + anti-IL-10R colitis model suggest a potential role for CCR1 or its close relation CCRL2. Such pathways could represent new therapeutic targets in inflammatory bowel disease.

Theoretical foundation Crohn's disease is a chronical autoimmune disease categorized, together with ulcerative colitis, in the group of idiopatic intestinal inflammations. But in spite of this categorization, Crohn's disease may not be found only in the intestines but anywhere in the gastrointestinal tract. However, the intestinal localization is most frequent and is related with numerous manifestations like stomachake, diarrhoea, bloating, flatulence, belching, loss of weight, etc. The pathogenetic cause of those discomforts consists in disorder of autoimmunity, when the body starts producing antibodies against its own tissues. But the cause of start of that pathogenetic mechanism has not been clarified so far. Experts speak about influence of infections, food, psychosomatics, smoking, genetic perceptiveness, etc. The hope of the patients is pinned on the continuously improving treatment, culminating by biological preparations that have most influenced the health condition of those persons so far. But in spite of the modern therapy, all characteristics of the disease can have negative impact on the quality of life of the patients. Goal of the thesis The goal of this thesis consists in ascertaining the quality of life of Crohn's disease patients. Hypotheses H1: Crohn's disease patients have problems in physical area. H2: Crohn's disease patients have problems in psychic area. H3: Crohn's disease patients have problems in social area. Methodology The practical part of the thesis was implemented based on quantitative inquiry within the grant Project No. 120/2012/S ?Reflection of life quality in nursing?. Two standardized questionnaires were used for the inquiry: the WHOQOL-100 general questionnaire and the IBDQ specific questionnaire, distributed among Crohn's disease patients. Valid licence was bought for both questionnaires. The size of the research set was determined at 100 Crohn's disease patients, the Crohn's disease diagnosis being the only criterion for selection of the respondents. The distribution of the questionnaires among the respondents took place with the help of gastroenterological centres. Results All data obtained were statistically processed in the SASD (Statistical Analysis of Social Data) program. The results of the processing can be divided into three areas, by the three main hypotheses verified. The first area of results provided information on the problems confronted by Crohn's disease patients in physical area. Only one problem was confirmed here: the Crohn's disease patients feel fatigue. All the remaining problems under verification in this area were refused. The second area brought information on psychical problems of the patients. Similarly to the preceding case, only one problem troubling the Crohn's disease patients was found here: feeling of irritation. The occurrence of the remaining psychical problems under verification was not confirmed. The last area of results found out the problems of the patients in social area. The results were the most positive in this case, as none of the problems under verification in this area was confirmed. Based on all results stated above, the hypotheses were evaluated as follows: H1 Crohn's disease patients have problems in physical area - refused; H2 Crohn's disease patients have problems in psychic area - refused and H3 Crohn's disease patients have problems in social area - refused. Conclusion The thesis provides comprehensive view on the issue of quality of life of Crohn's disease patients. The results may be used particularly in the work of so called IBD nurses, endoscopic nurses, but also general nurses working with the patients. The thesis can be also used as study material or as foundation for further research.

The thesis titled Biological Therapy in Patients with Inflammatory Bowel Diseases deals with the needs of clients with Crohn's disease and ulcerative colitis prior and after biological therapy. The role of nurses in biological therapy centres, including the application of this therapy, was also investigated. Crohn's disease and ulcerative colitis are inflammatory bowel diseases. They are chronic inflammatory diseases of the gastrointestinal tract, which are accompanied by ample extraintestinal symptoms. This thesis also deals with biological therapy that involves the administration of highly effective substances of biological nature that inhibit specific sites of inflammatory reactions. This therapy is provided in centres of biological therapy and is used not only in gastroenterology but also in rheumatology and oncology. Teams of experts work in biological therapy centres; the task of these teams is to provide a comprehensive holistic health care. The thesis is divided into a theoretical part and an empirical part. The theoretical part focuses mainly on Crohn's disease, ulcerative colitis and biological therapy that helps patients suffering from these diseases. The methodological section employed qualitative research using in-depth semi-structured interviews with patients suffering from idiopathic inflammatory bowel diseases and with nurses who deal with these patients when applying biological therapy. Since head nurses from gastroenterology departments did not wish to record the interviews with a recorder, they were recorded in writing and transcribed subsequently. The questions dealt with the issues of biological therapy in connection with inflammatory bowel diseases. All the acquired data was processed with the Atlas.ti programme, which is designed for encoding, processing and interpretation of large amounts of textual and graphic qualitative data. Based on the research, an educational brochure for patients suffering from inflammatory bowel diseases was complied as well as educational materials for nurses starting work in biological therapy centres. Furthermore, the results can be used by nurses in practice and nursing students too.

Submitted by RODRIGO GALHARDI GASPARINI null (rggaspa@yahoo.com.br) on 2018-03-05T01:36:53Z No. of bitstreams: 1 Incidência e Prevalência de Doenças Inflamatórias Intestinais no Estado de Sâo Paulo - Brasil.pdf: 2020180 bytes, checksum: 64bba02d0cbc3e4d580ce7721fe858d7 (MD5) / Approved for entry into archive by Luciana Pizzani null (luciana@btu.unesp.br) on 2018-03-06T13:58:57Z (GMT) No. of bitstreams: 1 gasparini_rg_dr_bot.pdf: 2020180 bytes, checksum: 64bba02d0cbc3e4d580ce7721fe858d7 (MD5) / Made available in DSpace on 2018-03-06T13:58:57Z (GMT). No. of bitstreams: 1 gasparini_rg_dr_bot.pdf: 2020180 bytes, checksum: 64bba02d0cbc3e4d580ce7721fe858d7 (MD5) Previous issue date: 2018-02-23 / Introdução: As Doenças inflamatórias intestinais (DII), que tem como principais entidades a Retocolite Ulcerativa (RCU) e a Doença de Crohn (DC), tem altas taxas de incidência e prevalência em países desenvolvidos, especialmente da Europa e América do Norte, porém com aumento progressivo de sua frequência em todas os continentes. Este estudo visa estimar as taxas de incidência e prevalência das DII no Estado de São Paulo, Brasil, entre os anos de 2012 e 2015, e correlacionar os resultados com dados nacionais sobre estas doenças. Material e Método: Este é um estudo observacional analítico, do tipo descritivo e transversal. Foram incluídos dados epidemiológicos de 22.638 pacientes que iniciaram seu tratamento para Doença Inflamatória Intestinal através do programa de fornecimento gratuito de medicamentos do Estado de São Paulo, entre os anos de 2012 e 2015. As variáveis analisadas foram a data do início do tratamento, o diagnóstico clínico (DC ou RCU), a idade, gênero, cor/raça/etnia dos pacientes, assim como sua região de residência no Estado de São Paulo. As análises estatísticas incluíram média e desvio padrão para variáveis quantitativas. O nível de significância adotado foi de 1% Resultados: A taxa de incidência de DII no Estado de São Paulo foi, em média, de 13,31 casos novos / 100.000 habitantes / ano, enquanto a prevalência de DII no Estado de São Paulo foi de 52,5 casos / 100.000 habitantes. Os portadores de DC somavam 10.451 (46,16%), e os de RCU somavam 12.187 (53,83%), de 1 a 97 anos de idade, com média de 45,5 anos (DP = 16,7), sendo 9.124 (40,30%) do sexo masculino e 13.514 (59,70%) do sexo feminino. Conclusão: Este estudo demonstrou aumento das taxas de incidência e prevalência de Doenças Inflamatórias Intestinais no Estado de São Paulo. / Inflammatory bowel disease (IBD), which has as its main entities Ulcerative Colitis (UC) and Crohn's Disease (CD), have high rates of incidence and 11 prevalence in developed countries, especially in Europe and North America, but with increasing frequency in all continents. This study aims to verify the incidence and prevalence rates of IBD in São Paulo State, Brazil, between the years 2012 and 2015, and correlate with the national data on these diseases. Casuistic and Methods: This is an observational, descriptive and cross-sectional study. We included data from 22.638 patients who started their treatment for Inflammatory Bowel Disease through the Program of free medication supply of São Paulo State, between the years of 2012 and 2015. The variables analyzed were the date of beginning of treatment with drugs provided by the clinical diagnosis (CD or UC), the age, gender, color/race/ethnicity of the patients, as well as their region of residence in São Paulo State. Statistical analyses included mean and standard deviations for quantitative variables. The level of significance adopted was 1% Results: The incidence rate of IBD in the State of São Paulo was 13.31 new cases / 100.000 inhabitants per year, while the overall prevalence of IBD in the state of São Paulo was 52,5 cases/100.000 inhabitants. The patients with CD were 10,451 (46.16%), and those with UC were 12,187 (53.83%), from 1 to 97 years of age, with a mean of 45.5 years (SD = 16.7), of wich 9,124 (40.30%) were male and 13,514 (59.70%) were female. Conclusion: This study demonstrated an increase in the incidence and prevalence of Crohn's Disease and Ulcerative Colitis in the State of São Paulo.

Glicocorticoides e outras drogas imunossupressoras são comumente utilizados para o tratamento de condições inflamatórias, como as Doenças Inflamatórias Intestinais (DIIs). Apesar dos avanços na terapia medicamentosa, a remissão da doença ainda é difícil de ser mantida. Devido às suas propriedades imunomodulatórias, as Células-Tronco Mesenquimais (MSCs – Mesenchymal Stem Cells) têm emergido como reguladoras da resposta imune, e sua viabilidade e propriedades migratórias são essenciais para o sucesso da terapia celular. Entretanto, pouco se conhece sobre os efeitos das drogas convencionalmente utilizadas no tratamento das DIIs no comportamento das MSCs. Portanto, o objetivo deste estudo foi avaliar a viabilidade, a morfometria nuclear, a polaridade celular, a distribuição da actina-F e da FAK (Focal Adhesion Kinase), e o comportamento migratório das MSCs na presença das drogas Azatioprina (AZA) e Dexametasona (DEXA). As células foram isoladas de membranas coriônicas humanas e caracterizadas pela diferenciação em adipócitos e osteócitos, bem como pela expressão de um painel de marcadores de superfície. As MSCs foram previamente tratadas com AZA ou DEXA por 24h ou 7d nas concentrações de 1μM ou 10μM, respectivamente. Ambas as drogas não afetaram a viabilidade celular analisada por MTT (3-(4,5-dimethyltiazol-2-yl)-2,5- diphenyltetrazolium bromide) e morfometria nuclear. Entretanto, a análise do índice de polaridade resultou em uma morfologia mais alongada após o tratamento com AZA, enquanto células mais arredondadas foram observadas na presença de DEXA. Os filamentos de actina foram marcados por Rodamina-Faloidina e sua análise mostrou que a AZA preservou parcialmente a formação de lamelipódios e aumentou a presença de fibras de estresse ventrais, enquanto que a DEXA inibiu a formação de lamelipódios, evidenciou uma maior presença de fibras de estresse ventrais e diminuiu a estabilidade das protrusões de membrana, observadas em vídeo. Através da análise de microscopia de série temporal, foi observado que as células sob o efeito da AZA por 7d migraram por maiores distâncias e tiveram um aumento em sua velocidade de migração (24,35%; P < 0,05; n = 4), ao passo que a DEXA diminuiu a velocidade migratória em 24h e 7d (-28,69% e -25,37%, respectivamente; P < 0.05; n = 4) e diminuiu a distância alcançada pelas células. Em conclusão, nossos dados sugerem que as drogas AZA e DEXA podem afetar diferentemente a morfologia e o comportamento migratório das MSCs, possivelmente afetando o resultado da terapia celular. O protocolo de migração celular utilizado neste estudo foi estabelecido por nosso grupo de pesquisa, sendo que um artigo científico contendo todas as etapas do protocolo foi escrito para que outros laboratórios possam utilizá-lo de maneira simples e eficaz. / Glucocorticoids and other immunosuppressive drugs are commonly used to treat inflammatory disorders, such as Inflammatory Bowel Disease (IBD) and, despite few improvements, the remission of IBD is still difficult to maintain. Due to its immunomodulatory properties, Mesenchymal Stem Cells (MSCs) have emerged as regulators of immune response, and its viability and activation of migratory properties are essential for a successful cell therapy. However, little is known about the effects of immunosuppressant drugs used on IBD treatment on MSCs behavior. In this way, the aim of this study was to evaluate MSCs viability, nuclear morphometry, cell polarity, F-actin and FAK (Focal Adhesion Kinase) distribution and cell migration properties in the presence of the immunosuppressive drugs Azathioprine (AZA) or Dexamethasone (DEX). MSCs were isolated from human chorionic membranes and characterized through adipogenic and osteogenic differentiations, as well as a panel of surface markers. Cells were previously treated with AZA or DEX for 24 hrs or 7 days at 1μM and 10μM, respectively. Both drugs had no effects on cell viability analyzed through MTT (3-(4,5- dimethyltiazol-2-yl)-2,5-diphenyltetrazolium bromide) and nuclear morphometry. However, polarity index analysis showed that AZA treatment induced a more elongated cell shape while a greater presence of rounded cells was observed under DEX exposure. F-actin was stained by Rhodamine-Phalloidin and showed that AZA could partially preserve lamellipodia formation and increase the presence of ventral actin stress fibers, while DEX inhibited lamellipodia formation and increased the presence of ventral actin stress fibers while decreasing protrusion stability, observed in video. Through time-lapse microscopy, it was observed that after 7 days of treatment, AZA improved cell the spatial trajectory (ST) and increased migration speed (24.35%, P < 0.05, n = 4) while DEX impaired ST and migration speed after 24 hrs and 7 days treatment (- 28.69% and -25.37%, respectively; P < 0.05, n = 4). In conclusion our data suggests these immunosuppressive drugs can differently affect MSCs morphology and migration capacity, possibly impacting the success of cell therapy. The migration protocol used in this study was successfully established by our group, leading to the writing of a protocol paper to facilitate the usage of this technique by other laboratories in a simple and efficient manner.

A doença inflamatória intestinal (DII) e a esclerose sistêmica (ES) são doenças inflamatórias crônicas de difícil diagnóstico e tratamento. A etiologia da DII e da ES ainda não é completamente compreendida, mas sabe-se que fatores genéticos, imunológicos e ambientais estão envolvidos na sua patogênese. A DII possui dois principais subtipos clínicos: a doença de Crohn (DC) e a retocolite ulcerativa (RCU), caracterizados pela inflamação do intestino delgado e/ou cólon. Evidências sugerem que o aumento do estresse oxidativo desempenha um papel importante na fisiopatologia da DII. A ES é uma doença inflamatória autoimune rara, caracterizada pela fibrose progressiva da pele e de órgãos internos. A hipótese de que o aumento do dano oxidativo pode iniciar o dano vascular e desencadear os eventos patológicos observados na ES vem sendo investigada. Genes e enzimas envolvidos na metabolização (Fase I) e detoxificação (Fase II) de xenobióticos são utilizados como marcadores de susceptibilidade para o desenvolvimento de doenças que possuem fatores ambientais como fatores de risco. Em uma reação de Fase I, as enzimas do Citocromo P450 (CYP) inserem um átomo de oxigênio em um substrato deixando-o eletrofílico e reativo, criando um sítio para posterior conjugação pelas enzimas de Fase II. As enzimas Glutationa S-tranferases (GST) de Fase II catalisam a conjugação da glutationa com uma grande variedade de compostos eletrofílicos, detoxificando substâncias endógenas e exógenas. A atividade catalítica aumentada das enzimas CYP, bem como a falha na detoxificação de metabólitos pelas GST pode contribuir para o aumento do estresse oxidativo. O objetivo deste estudo foi investigar o papel de polimorfismos nos genes que codificam enzimas de metabolização (CYP1A*2C e CYP2E1*5B) e detoxificação (GSTT1 nulo, GSTM1 nulo e GSTP1 Ile105Val) na susceptibilidade a estas doenças. O grupo de pacientes com DII era constituído por 235 indivíduos e o grupo controle por 241 indivíduos, todos eurodescendentes. Na ES, 122 pacientes (99 eurodescendentes e 23 afrodescendentes) e 329 controles (241 eurodescendentes e 87 afrodescendentes) foram analisados. Os polimorfismos CYP foram genotipados por PCR-RFLP, enquanto que os polimorfismos em GSTT1 e GSTM1 foram genotipados por PCR multiplex e PCR-RFLP para GSTP1. As frequências alélicas e genotípicas foram comparadas entre pacientes e controles usando o teste de Qui-Quadrado. A respeito dos resultados das análises em DII, as frequências alélicas e genotípicas dos polimorfismos CYP1A1*2C, CYP2E1*5B e GSTP1 Ile105Val, bem como as frequências genotípicas do polimorfismo de presença/ausência de GSTM1, foram similares nos três grupos de pacientes (DII, DC e RCU) quando comparados ao grupo controle (P>0,05). Observouse uma frequência significativamente aumentada do genótipo nulo de GSTT1 no grupo de pacientes com DII quando comparado ao grupo controle [0,28 vs 0,18; χ² com Yates P=0,02; OR=1,71 (IC 95% 1,09 –2,71)]. Quando separamos o grupo de pacientes em DC ou RCU, esta frequência permaneceu significativamente aumentada somente no grupo de pacientes com RCU comparado ao grupo controle [0,29 vs 0,18; χ² com Yates P=0,035; OR=1,84 (IC 95% 1,03 –3,24)]. Com relação aos resultados das análises na ES, uma frequência significativamente aumentada do genótipo *1A/*1A (P=0,03; 0,74 vs. 0,61) e do alelo *1A (P=0,013; 0,86 vs 0,78; OR=0,57, IC 95% 0,36–0,90) do polimorfismo CYP1A1*2C foi observada entre os indivíduos controles eurodescendentes. Em contrapartida, a frequência do alelo *2C estava significativamente aumentada entre os pacientes de mesma etnia (P=0,013; 0,22 vs 0,14; OR=1,75, IC 95% 1,11–2,74). Com relação às frequências alélicas e genotípicas dos polimorfismos CYP2E1*5B e GSTP1 Ile105Val, e as frequências genotípicas do polimorfismo de presença/ausência de GSTM1, nenhuma diferença significativa foi observada quando os grupos de pacientes de ambas as etnias foram comparados aos grupos controle (P>0,05). Uma frequência significativamente aumentada do genótipo nulo de GSTT1 [0,29 vs 0,18; χ² com Yates P=0,035; OR=1,85 (IC 95% 1,03–3,29)], bem como uma alta frequência da dupla deleção de GSTT1/GSTM1 [0,19 vs 0,08; χ² com Yates P=0,007; OR=2,62 (IC 95% 1,25 –5,46)], foi observada no grupo de pacientes comparado aos controles (eurodescendentes). Estas associações não se repetiram entre indivíduos afrodescendentes. Concluindo, nossos resultados sugerem que o genótipo nulo de GSTT1 está associado à susceptibilidade a DII e pode influenciar na definição do curso da doença para a RCU. Além disso, o genótipo nulo de GSTT1 sozinho ou em combinação com o genótipo nulo de GSTM1 é um fator genético de susceptibilidade para a ES, enquanto que o genótipo *1A/*1A ou a presença do alelo *1A do polimorfismo CYP1A1*2C pode exercer um papel protetor contra o desenvolvimento da ES em indivíduos eurodescendentes. / Inflammatory bowel disease (IBD) and systemic sclerosis (SSc) are chronic inflammatory diseases of difficult diagnosis and treatment. The etiology of IBD and SSc is not completely understood but it is known that genetic, immunologic and environmental factors are involved in its pathogenesis. Crohn’s disease (CD) and ulcerative colitis (UC) are the two major subtypes of IBD, characterized by inflammation of the small intestine and/or colon. Evidences suggest that the increase of oxidative stress plays an important role in the pathophysiology of IBD. SSc is a rare autoimmune inflammatory disease of the connective tissue characterized by progressive fibrosis of the skin and internal organs. The hypothesis that the increase of oxidative stress can initiate vascular damage and triggers the pathological events in SSc has been investigated. Genes and enzymes involved in metabolism (Phase I) and detoxification (Phase II) of xenobiotics are used as markers of susceptibility to the development of diseases that have environmental factors as risk factors. In a Phase I reactions, the Cytochrome P450 (CYP) enzymes insert an oxygen atom in a substrate that making it more electrophilic and reactive, and creating a site for subsequent conjugation by Phase II enzymes. Phase II Glutathione S-transferases (GSTs) enzymes catalyze the conjugation of glutathione with a variety of electrophilic compounds, detoxifying endogenous and exogenous substances. A higher catalytic activity of CYP enzymes, as well as the failure in detoxifying of metabolites by GST enzymes may to contribute for the increase of oxidative stress. The aim of this study was investigated the role of polymorphisms in genes coding Phase I enzymes (CYP1A*2C and CYP2E1*5B) and Phase II (GSTT1 null, GSTM1 null and GSTP1 Ile105Val) in susceptibility to these diseases. IBD group was constituted by 235 patients and the control group by 241 individuals, all European-derived. In SSc group, 122 patients (99 European-derived and 23 African-derived) and 329 controls (241 European-derived and 87 African-derived) were analyzed. The CYP polymorphisms were genotyped by PCR-RFLP, whereas polymorphisms in GSTM1 and GSTT1 were genotyped by multiplex PCR and PCRRFLP for GSTP1. Allelic and genotypic frequencies were compared between patients and controls using the Chi-square test. Concerning IBD, allelic and genotypic frequencies of CYP1A1*2C, CYP2E1*5B and GSTP1 Ile105Val polymorphisms, as well as genotypic frequencies of GSTM1 presence/absence polymorphism were similar in all groups patients (IBD, CD, and UC) and controls (P>0.05). We observed a significantly increased frequency of GSTT1 null genotype in IBD group as compared to controls [0.28 vs. 0.18, χ ² with Yates P=0.02, OR=1.71 (95% CI 1.09 – 2.71)]. When patients were classified in CD or UC group, this frequency remained significantly increased only among UC patients [0.29 vs. 0.18, χ ² with Yates P=0,035, OR=1.84 (95% CI 1.03 – 3.24)] as compared to controls. Regarding results in SSc, a frequency significantly increased of *1A/*1A genotype (P=0.03; 0.74 vs. 0.61) and *1A allele (P=0.013; 0.86 vs 0.78; OR=0.57, 95% CI 0.36–0.90) from CYP1A1*2C polymorphism was observed among European-derived controls. On the other hand, the frequency of *2C allele was significantly increased among patients of same ethnic group (P=0.013; 0.22 vs 0.14; OR=1.75, 95% CI 1.11–2.74). The allelic and genotypic frequencies of CYP2E1*5B and GSTP1 Ile105Val polymorphisms, as well as genotypic frequencies of GSTM1 presence/absence polymorphism were similar between SSc patients and controls of both ethnic groups (P>0.05). We observed a significantly increased frequency of GSTT1 null genotype [0.29 vs. 0.18, χ ² with Yates P=0.035, OR=1.85 (95% CI 1.03–3.29)], as well as an increased frequency of GSTT1/GSTM1 double-null in SSc patients as compared to controls [0.19 vs. 0.08; χ ² with Yates P=0.007, OR=2.62 (95% CI 1.25 – 5.46)]. These associations were exclusive to European-derived individuals. In conclusion, our results suggest that the GSTT1 null genotype is associated with susceptibility to IBD and may influence in defining the course of the disease for RCU. Furthermore, the GSTT1 null genotype alone or combined with GSTM1 null genotype is a susceptibility genetic factor to SSc, while the *1A/*1A genotype or the presence of *1A allele from CYP1A1*2C polymorphism may plays a protector role in SSc development in Brazilian Europeanderived individuals.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-07-14T11:38:20Z No. of bitstreams: 1 lilianaandradechebli.pdf: 509558 bytes, checksum: 46eb6aa1950b8cf02f40073b054ed6c3 (MD5) / Approved for entry into archive by Diamantino Mayra (mayra.diamantino@ufjf.edu.br) on 2016-07-19T14:23:32Z (GMT) No. of bitstreams: 1 lilianaandradechebli.pdf: 509558 bytes, checksum: 46eb6aa1950b8cf02f40073b054ed6c3 (MD5) / Made available in DSpace on 2016-07-19T14:23:32Z (GMT). No. of bitstreams: 1 lilianaandradechebli.pdf: 509558 bytes, checksum: 46eb6aa1950b8cf02f40073b054ed6c3 (MD5) Previous issue date: 2011-10-17 / Colite ulcerativa é uma doença inflamatória intestinal idiopática da mucosa colônica caracterizada clinicamente por episódios intermitentes de exacerbações alternados com períodos de remissão. Os corticosteroides permanecem como uma das drogas mais efetivas no tratamento das exacerbações moderadas a graves da colite ulcerativa. Entretanto, eles não são adequados para terapia de manutenção devido à falta de eficácia na prevenção de recorrências. Além disso, seu uso associa-se frequentemente com vários efeitos adversos e, aproximadamente, 25% dos pacientes que respondem aos corticosteroides serão incapazes de tolerar sua retirada sem que apresentem recorrências sintomáticas. Consequentemente, ―dependência de esteróides‖ em pacientes com colite ulcerativa é um problema de grande relevância na prática e manutenção da remissão sem esteróides é meta importante a ser alcançada. Diversas modalidades terapêuticas podem ser empregadas em pacientes com colite ulcerativa córtico-dependente (CUCD). Tradicionalmente, a escolha é entre a cirurgia ou o escalonamento do tratamento clínico, que geralmente envolve o uso de imunossupressores. O tratamento com azatioprina (AZA) tem tido amplo uso neste cenário. Entretanto, estudos no longo prazo avaliando a eficácia da AZA na CUCD são inexistentes. Os objetivos deste estudo foram avaliar em pacientes com CUCD, a eficácia da AZA no longo prazo para manutenção da remissão clínica sem esteróides, bem como a segurança desta droga neste contexto. Neste estudo de coorte prospectivo observacional, pacientes adultos com CUCD foram recrutados para tratamento com AZA durante o período de 36 meses. AZA foi ajustada para a dose alvo de 2-3 mg/Kg/dia. A redução da dose de esteróides durante o estudo seguiu um esquema previamente padronizado. A avaliação primária de eficácia foi a taxa anual de pacientes que alcançaram resposta sustentada a AZA sem esteróides. Resposta sustentada foi definida como a retirada completa dos corticosteroides e manutenção da remissão clínica sem a necessidade de se reintroduzir esteróides durante pelo menos seis meses adicionais. As principais avaliações de eficácia secundária foram: dose cumulativa anual de esteróides, número anual de recorrências da colite após introdução da AZA e efeitos adversos. Em base intenção de tratar, a proporção de pacientes permanecendo em remissão sem esteróides em 12, 24, e 36 meses foi 0.55, 0.52, e 0.45, respectivamente. Significante diminuição na taxa de recidivas clínicas assim como no requerimento para esteróides foram observados durante três anos de tratamento com AZA comparado com o ano prévio (P=0.000 para ambos). Pacientes com e sem resposta sustentada foram similares de acordo com demografia, extensão da doença, dose de AZA, uso de esteróides e 5-ASA. Apenas a duração menor da doença (<36 meses) associou-se à remissão sem esteróides (P=0.02, OR 3.12 95% IC 1.89-7.64). AZA foi bem tolerada e o perfil risco-benefício favorável. Neste estudo, AZA mostrou eficácia sustentada para manutenção da remissão clínica sem esteróides e para poupar esteróides durante três anos de terapia em pacientes com CUCD. Pacientes com colite ulcerativa de início mais recente são aqueles que mais provavelmente alcançarão remissão sustentada sem esteróides no final de 12 meses enquanto em uso de AZA. Isto parece se manter por até 36 meses. / Ulcerative colitis (UC) is a lifelong, immune-mediated inflammatory condition of the colonic mucosa, which is characterized by a relapsing and remitting course. Corticosteroids remain one of the most effective therapies for inducing remission in patients with moderate-to-severe UC. Nonetheless, corticosteroids are not used in maintenance therapy, mainly because undesirable side effects outweigh the possible benefits. Furthermore, approximately 25% of the patients is unable to support its withdrawal without relapsing, suggesting that the need to start steroid therapy in UC is associated with a dismal long-term prognosis. Thus, corticosteroid dependence in patients with UC is a pivotal clinical problem and maintenance of steroid-free remission is an important current evolving treatment goal. Patients with steroid dependent UC are usually given a choice between colectomy or stepped-up medical treatment, which traditionally involves prescription of an immunosuppressive drug. Azathioprine (AZA) therapy has found widespread use for this setting in clinical practice. However, studies assessing the efficacy of azathioprine in steroid-dependent ulcerative colitis (SD-UC) are scarce. The purpose of this trial was to explore the efficacy and safety of AZA in maintaining long-term steroid-free remission in SD-UC patients and the factors associated to sustained response. In this observational cohort study 42 subjects with SD-UC were recruited for AZA therapy during a 3-year period. AZA was adjusted for a target dose of 2-3 mg/Kg/day. Steroid therapy was tapered off following a standardized regimen. The primary endpoint was the annual rate of steroid-free response to AZA. Secondary endpoints included clinical recurrence, yearly steroid dose, and safety of treatment. On an intention-to-treat basis, the proportion of patients remaining in steroid-free remission at 12, 24, and 36 months was 0.55, 0.52, and 0.45, respectively. A significant decrease in the flare-ups rate and in requirement for steroids were observed during 3 years on AZA compared with the previous year (P=0.000 for both). Patients with and without sustained response were comparable according to demographics, extent of disease, dose of AZA, steroids and 5-ASA use. Only disease duration <36 months was associated to off-steroids remission (P=0.02, OR 3.12 95% CI 1.89-7.64). The AZA benefit-risk profile was favorable. In this open-label observational trial AZA showed sustained efficacy for maintenance of clinical remission off steroids and steroid sparing through 3 years of therapy in SD-UC. Patients with earlier UC are those who most probably will have sustained steroid-free remission at the end of 12 months while on AZA. This appears to sustain until 36 months.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-10-04T13:18:43Z No. of bitstreams: 1 andreluistavarespinto.pdf: 5221976 bytes, checksum: aa9e110f12103765df1122351932b9b8 (MD5) / Approved for entry into archive by Diamantino Mayra (mayra.diamantino@ufjf.edu.br) on 2016-10-04T13:50:42Z (GMT) No. of bitstreams: 1 andreluistavarespinto.pdf: 5221976 bytes, checksum: aa9e110f12103765df1122351932b9b8 (MD5) / Made available in DSpace on 2016-10-04T13:50:42Z (GMT). No. of bitstreams: 1 andreluistavarespinto.pdf: 5221976 bytes, checksum: aa9e110f12103765df1122351932b9b8 (MD5) Previous issue date: 2010-03-30 / A doença de Crohn é uma afecção intestinal inflamatória crônica, multissistêmica e de caráter recorrente. Sua etiopatogênese permanece ainda desconhecida, mas considera-se haver um cenário fisiopatológico caracterizado, principalmente, pela inibição da imunidade inata com exacerbação da imunidade adaptativa, com atividade inflamatória mucosa intensificada. Por isso, os corticosteróides constituem a base fundamental do tratamento farmacológico na indução da remissão clínica na doença, graças às suas potentes ações como supressores do processo inflamatório. Entretanto, os proibitivos efeitos colaterais da corticoterapia prolongada associados à alta freqüência da cortico-dependencia na doença estimulou a busca de alternativas terapêuticas para manutenção da remissão no longo prazo. Nesse contexto, os imunossupressores, particularmente, os análogos da purina, azatioprina (AZA) ou 6mercaptopurina ocupam um papel central no tratamento de manutenção na doença, com efeitos “poupadores de esteróides”. A utilização desses agentes para manter a remissão clínica na doença é apoiada por evidências de estudos clínicos controlados e randomizados. No entanto, a maioria desses estudos não avaliou especificamente os doentes corticodependentes, não sendo claramente conhecida a ação dos análogos da purina nesse grupo de pacientes. Portanto, os objetivos do nosso estudo foram verificar a eficácia no longo prazo, da AZA em uma população exclusivamente portadora de doença de Crohn dependente de esteróides, assim como identificar os possíveis fatores preditivos associados à resposta clínica sustentada. Além disso foi verificada também a segurança dessa terapia, através da análise da incidência de eventos adversos. Para tanto, um total de 106 indivíduos adultos com doença de Crohn cortico-dependente foram prospectivamente incluídos para tratamento com AZA (2-3 mg/Kg/dia), durante o período de acompanhamento de até 10 anos. A proporção de doentes em remissão sustentada livre de esteróides ao final de 12, 24, 36, 48 e 60 meses foi de 0.61, 0.73, 0.72, 0,70 e 0.70 respectivamente. Depois disso, essa taxa anual foi sendo gradualmente reduzida, alcançando um nadir aos 108 meses de acompanhamento. O tempo médio de retirada completa dos esteróides foi de seis meses. Características demográficas, aquelas relacionadas à doença e a dose de AZA não se correlacionaram com remissão sustentada. Apenas a reduzida contagem leucocitária média durante o acompanhamento foi associada com a remissão livre de corticóides (P=0.01). Efeitos adversos graves relacionados à terapia com AZA foram incomuns. / The Crohn´s disease is a chronic, inflammatory, multisystem bowel disorder with a relapsing course. Her etiology remains unknown but probably there´s a scenario characterized by inibition of innate immunity and exacerbation of the adaptative immunity with exacerbated mucosal inflammatory activity. Then, the corticosteroids have been the mainstay of pharmacologic treatment for inducing clinical remission in the disease. However, the prohibitive side effects of prolonged corticosteroid therapy associated with high frequency of the corticosteroid- dependency in the disease taken to alternative treatments for long- term maintenance of clinical remission. The immunomodulators, especially, the purine analogs, azathioprine(AZA) or 6- mercaptopurine are the major option for this indication, with corticosteroid- sparing proprieties. The use of these agents is supported by randomized, controlled clinical studies. However, these trials have not evaluated the specific issue of the steroid dependence. Thus, our objectives in this study were to asses the efficacy and safety of AZA therapy in patients strictly with steroid-dependent Crohn`s disease and possibly, factors associated with sustained clinical remission. Therefore, 106 adults patients with steroiddependent Crohn`s disease were prospectively included for treatment with AZA (23mg/Kg/day) during the period of follow up as long as 10 years. The proportion of patients remaining in sustained steroid-free remission at 12, 24, 36, 48 and 60 months was 0.61, 0.73, 0.72, 0.70 and 0.70, respectively. Thereafter, the annual rate of weaning from steroids decreased gradually, reaching a nadir of 0.41 at 108 months. Median time to complete steroid withdrawal was 6 months. Demographics, disease-related data and the AZA dose did not correlate with sustained remission. Only the reduced mean leukocyte count during the follow up was associated with remission free steroids (P= 0.01). Serious adverse effects related to AZA therapy were uncommon.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2017-06-14T14:16:56Z No. of bitstreams: 1 lilianaandradechebli.pdf: 4797149 bytes, checksum: 48711245cd6bc4dca1d8093d1e776787 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-06-29T12:12:52Z (GMT) No. of bitstreams: 1 lilianaandradechebli.pdf: 4797149 bytes, checksum: 48711245cd6bc4dca1d8093d1e776787 (MD5) / Made available in DSpace on 2017-06-29T12:12:52Z (GMT). No. of bitstreams: 1 lilianaandradechebli.pdf: 4797149 bytes, checksum: 48711245cd6bc4dca1d8093d1e776787 (MD5) Previous issue date: 2009-08-06 / CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico / Colite ulcerativa é uma condição inflamatória imuno-mediada da mucosa colônica, caracterizada por curso intermitente e recorrente. Corticosteróides permanecem como uma das terapias mais efetivas para induzir remissão em pacientes com colite ulcerativa moderada a severa. Todavia, corticosteróides não são usados como terapia de manutenção, principalmente porque os efeitos colaterais indesejáveis superam seus possíveis benefícios. Além disso, em um ano, menos da metade dos pacientes com colite ulcerativa que requerem corticosteróides terão resposta sustentada, aproximadamente um terço dos pacientes necessitarão de colectomia e um quarto não tolerarão a retirada do mesmo sem que apresentem recidiva da doença. Assim, dependência de corticóides em paciente com colite ulcerativa é problema clínico fundamental e manutenção da remissão sem esteróides é uma importante meta terapêutica no presente. Em pacientes com colite ulcerativa córtico-dependente, usualmente é colocado a escolha entre colectomia ou escalonamento do tratamento clínico, o qual tradicionalmente envolve a prescrição de droga imunossupressora. A terapia com tiopurinas tem tido amplo uso neste cenário na prática clínica. Entretanto, estudos avaliando a eficácia da azatioprina (AZA) na colite ulcertiva córtico-dependente são escassos. Os objetivos deste estudo foram avaliar em pacientes com colite ulcerativa dependente de esteróides, a eficácia da AZA na manutenção da remissão clínica sem esteróides, bem como os possíveis fatores associados à resposta sustentada a esta droga. Neste estudo de coorte observacional, pacientes adultos com colite ulcerativa dependente de esteróides foram recrutados para tratamento com AZA durante o período de 12 meses. AZA foi ajustada para a dose alvo de 2-3 mg/Kg/dia. A redução da dose de esteróides durante o estudo seguiu um esquema previamente padronizado. A avaliação primária de eficácia foi a taxa anual de pacientes que alcançaram resposta sustentada a AZA sem esteróides. Avaliações secundárias incluíram o número anual de recorrências clínicas, dose mediana de esteróides utilizadas durante o ano e segurança do tratamento. O total de 42 pacientes foi incluído. Na análise intenção de tratar, a proporção de pacientes permanecendo em remissão sustentada sem esteróides no final de 12 meses foi de 0,55. Observou-se significante redução na taxa de recorrências clínicas, assim como no requerimento de esteróides durante 12 meses de tratamento com AZA quando comparado com o ano anterior ao uso desta droga. (P=0,000 para ambas as comparações). Apenas a duração da doença < 36 meses antes do início da AZA foi associada à remissão clínica sem esteróides (P=0,02, OR 3,12 95% IC 1,89-7,64). AZA foi bem tolerada e o seu perfil risco-beneficio favorável. AZA mostrou eficácia sustentada para a manutenção da remissão clínica sem esteróides, bem como efeito poupador de esteróides durante 12 meses de terapia em pacientes com colite ulcerativa dependente de esteróides. Os pacientes com colite ulcerativa de início mais precoce são aqueles que mais provavelmente alcançarão remissão sustentada sem esteróides durante o uso de AZA. / Ulcerative colitis (UC) is a lifelong, immune-mediated inflammatory condition of the colonic mucosa, which is characterized by a relapsing and remitting course. Corticosteroids remain one of the most effective therapies for inducing remission in patients with moderate-to-severe UC. Nonetheless, corticosteroids are not used in maintenance therapy, mainly because undesirable side effects outweigh the possible benefits. Furthermore, at one year, less than half of UC patients who require steroids have a sustained response, nearly one-third of patients require colectomy, and approximately a quarter is unable to support its withdrawal without relapsing. Thus, corticosteroid dependence in patients with UC is a pivotal clinical problem and maintenance of steroid-free remission is an important current evolving treatment goal. Patients with steroid dependent UC are usually given a choice between colectomy or stepped-up medical treatment, which traditionally involves prescription of an immunosuppressive drug. Thiopurine therapy has found widespread use for this setting in clinical practice. However, studies assessing the efficacy of azathioprine (AZA) in steroid-dependent ulcerative colitis (UC) are scarce. The purpose of this trial was to explore the efficacy of AZA in maintaining steroid-free remission in steroid-dependent UC patients as well as the factors associated to sustained response. In this observational cohort study adult subjects with steroid-dependent UC were recruited for AZA therapy during a 12 months period. AZA was adjusted for a target dose of 2-3 mg/Kg/day. Steroid therapy was tapered off following a standardized regimen. The primary endpoint was the rate of patients with sustained steroid-free response to AZA at the end of 12 months. Secondary endpoints included clinical recurrence, yearly steroid dose, and safety of treatment. A total of 42 patients were included. On an intention-to-treat basis, the proportion of patients remaining in sustained steroid-free remission at 12 months was 0.55. A significant decrease in the flare-ups rate as well as in requirement for steroids were observed during 12 months while on AZA compared with the previous year (P=0.000). Only disease duration of <36 months before the initiation of AZA was associated to off-steroids remission (P=0.02, OR 3.12 (95% CI 1.89-7.64)). AZA was well tolerated and its benefit-risk profile favorable. AZA showed sustained efficacy for maintenance of clinical remission off steroids and steroid sparing through 12 months of therapy in patients with steroid dependent UC. Patients with earlier UC are those who most probably will have sustained steroid-free remission while on AZA.

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