INTRODUÇÃO E OBJETIVO: Recidiva da hepatite C crônica com progressão acelerada, embora imprevisível, da fibrose é responsável por piora no prognóstico após o transplante de fígado (Tx). Biópsia hepática protocolar é considerada o padrão ouro para estadiamento da fibrose na recidiva da hepatite C pós-Tx. Para superar as limitações da biópsia, principalmente custo e complicações, marcadores simples e não invasivos de fibrose hepática têm sido propostos para pacientes imunocompetentes, porém com escassos estudos disponíveis no contexto pós-Tx. O objetivo desse estudo é avaliar o desempenho diagnóstico dos marcadores não-invasivos para estadiar fibrose hepática em pacientes pós-Tx. MÉTODOS: Pacientes consecutivos receptores de Tx com recidiva da hepatite C (n=45) que foram submetidos a 118 biópsias hepáticas foram incluídos. Variáveis laboratoriais dentro de trinta dias de cada biópsia foram consideradas. Índice da razão AST-plaqueta (APRI), razão AST/ALT, Escore discriminativo de Bonacini (EDB), Escore de Pohl e índice idade-plaqueta foram calculados para cada biópsia. Fibrose significante foi definida como estágio METAVIR 2. RESULTADO: A área sob a curva ROC (receiver operating characteristic) do Escore discriminativo de Bonacini para predizer fibrose significante foi 0,68, superior aos outros testes avaliados. Utilizando-se o melhor ponto de corte, um valor de Escore discriminativo de Bonacini 8 foi 42% sensível e 95% específico, com razão de verossimilhança positiva e negativa de 7,98 e 0,62, respectivamente. Análise multivariada identificou razão AST/ALT como preditor independente de fibrose significante (OR=4.2; CI 95%=1.5-11.4; p-valor=0.005, ponto de corte 0,89). Análise adicional considerando apenas uma biópsia por paciente confirmou o desempenho superior do Escore discriminativo de Bonacini em relaçãoaos outros testes avaliados, com uma área sob a curva de 0,76. CONCLUSÃO: Escore discriminativo de Bonacini foi o marcador laboratorial não invasivo com melhor desempenho diagnóstico para predizer fibrose hepática significante em pacientes com recidiva de hepatite C crônica pós-Tx / BACKGROUND AND AIM: Recurrent hepatitis C with accelerated, although unpredictable, fibrosis progression accounts for a poor prognosis after liver transplantation (LT). Per protocol liver biopsy is considered the gold standard for fibrosis staging in recurrent hepatitis C after LT to overcome the limitations of liver biopsy, mainly cost and complications, simple non-invasive liver fibrosis tests have been proposed for immunocompetent patients, butfew data are available in the post-transplant setting. The aim of this study was to evaluate diagnostic performance of noninvasive tests to stage liver fibrosis in LT setting. METHOD: Consecutive LT patients with recurrent hepatitis C (n=45) who have undergone 118 liver biopsy were included. Laboratory variables at the time of biopsies were recorded. AST to platelet ratio index (APRI), AST/ALT ratio, Bonacini discriminant score (BDS), Pohl score and age-platelet index were calculated at the time of biopsies. Significant fibrosis was defined as METAVIR stage 2. RESULT: The area under the receiver operating characteristic (ROC) curve (AUC) of Bonacini discriminant score for predicting significant fibrosis was 0,68, better than the other non-invasive liver fibrosis tests. Using the best cutoff value, Bonacini discriminant score value 8 was 42% sensitive and 95% specific, with positive and negative likelihood ratio of 7,98 and 0,62, respectively. Multivariate analysis identified AST/ALT ratio as an independent predictor of significant fibrosis (OR=4.2; CI 95%=1.5-11.4; p-value=0.005, cutoff point 0,89). Additional analysis considering only one biopsy per patient confirmed the superior performance of Bonacini discriminant score compared to the other non-invasive liver fibrosis tests, with an AUC of 0,76. CONCLUSION: Bonacini discriminant score was the non-invasive liver fibrosis test with the best performance for significant liver transplant patients with recurrent hepatitis C

Introdução: A cirrose hepática é uma patologia crônica grave e irreversível. Ela causa debilidades variadas que afetam de forma significativa a qualidade de vida (QV), além de provocar constante vulnerabilidade emocional. O transplante é a única terapêutica capaz de reverter o estado de saúde do paciente em estágio terminal e de promover o retorno a uma vida potencialmente saudável. As taxas de sobrevida são satisfatórias e os benefícios deste tipo de cirurgia sobre a QV são demonstradas em alguns estudos. No entanto, não é raro encontrar ressalvas quanto aos ganhos em saúde mental após o transplante de fígado. Mensurar os efeitos desse tratamento sobre a vida do paciente tem sido um importante indicador para decisões e intervenções no campo da medicina, mas também para outras especialidades, entre elas, a psicologia da saúde. Objetivo: Avaliar a QV de pacientes em lista de espera e após seis meses de realizado o transplante hepático, identificar os fatores de maior influência sobre a QV e analisar a percepção do impacto do adoecimento e do transplante na vida dos doentes. Método: Participaram da pesquisa 42 pacientes que estavam em acompanhamento ambulatorial pelo Serviço de Transplante de Órgãos Abdominais do HC-FMUSP. O estudo teve um desenho prospectivo longitudinal, exploratório e descritivo, com abordagem metodológica mista (quantitativa e qualitativa). Foram aplicados dois questionários de QV (SF-36 e LDQOL), uma escala sobre autopercepção de saúde (EQ VAS) e uma entrevista em profundidade. Os dados quantitativos foram avaliados de acordo com as normas propostas por cada instrumento e submetidos à análise estatística (teste de Mann-Whitney). Para a realização da análise multivariada, foi aplicada a técnica de análise fatorial. A amostra da análise qualitativa foi composta por 10 pacientes e definida por critério de saturação. As entrevistas foram gravadas, transcritas, decompostas em categorias e submetidas à análise temática, conforme o método de análise de conteúdo proposto por Bardin. Resultados: A amostra total foi composta por 27 (64,3%) homens e 15 (35,7%) mulheres, com idade entre 21 e 70 anos. O perfil clínico dos pacientes abrangeu diferentes categorias diagnósticas, sendo a hepatite pelo vírus C a mais frequente (36,73%). Complicações graves associadas à hepatopatia apareceram em 90,47% dos casos. Os resultados obtidos por meio dos instrumentos SF-36 e LDQOL e da escala EQ VAS registraram expressiva melhora da QV após o transplante hepático, na maior parte dos domínios avaliados. Apenas os domínios \'limitações por aspectos emocionais\' (p= 0,083), do SF-36, e \'interação social\' (p= 0,087), do LDQOL, não atingiram significância estatística. A análise fatorial permitiu identificar as dimensões que mais interferiram sobre a percepção da QV, e a entrevista em profundidade possibilitou discutir, de forma mais ampla, as limitações impostas pela condição crônica da doença hepática, bem como as transformações trazidas pelo transplante. Conclusão: A melhora da qualidade de vida após o transplante foi confirmada por todos os instrumentos utilizados. Entretanto, verificou-se ressalvas quanto a melhora da qualidade da saúde psíquica do paciente transplantado, não ocorrida na mesma proporção que a expressiva reconquista do bem-estar físico / Background: Liver cirrhosis is a serious and irreversible chronic disease. It causes varied weaknesses that significantly affect quality of life (QOL), as well as causing constant emotional vulnerability. Transplantation is the only therapy capable of reversing the patient\'s state of health in the terminal stage and of promoting a return to a potentially healthy life. Survival rates are satisfactory and the benefits of this type of surgery on QOL are demonstrated in some studies. However, it is not uncommon to find caveats regarding gains in mental health after liver transplantation. Measuring the effects of this treatment on the patient\'s life has been an important indicator for decisions and interventions in the field of medicine, but also for other specialties, among them, health psychology. Aims: To assess the QOL of patients on the waiting list and after six months of liver transplantation, to identify the factors that have a greater influence on QoL and to analyze the perception of the impact of illness and transplantation on patients\' lives. Method: A total of 42 patients who underwent ambulatory follow-up by the Abdominal Organ Transplantation Service of HC-FMUSP participated in the study. The study has a prospective longitudinal, exploratory and descriptive design, with a mixed methodological approach (quantitative and qualitative). Two QOL questionnaires (SF-36 e LDQOL) were applied, one scale of self-perceived health (EQ VAS) and one in-depth interview. The quantitative data were evaluated according to the norms proposed by each instrument and submitted to statistical analysis (Mann-Whitney test). For the multivariate analysis the factorial analysis technique was applied. The sample of the qualitative analysis was composed by 10 patients and defined by saturation criterion. The interviews were recorded, transcribed, broken down into categories and submitted to thematic analysis, according to the method of content analysis proposed by Bardin. Results: The total sample consisted of 27 (64.3%) men and 15 (35.7%) women, aged between 21 and 70 years. The clinical profile of patients covered different diagnostic categories, being hepatitis C virus the most frequent (36.73%). Severe complications associated with hepatopathy appeared in 90.47% of the cases. The results obtained using the SF-36 and LDQOL instruments and the EQ VAS scale showed a significant improvement in QOL after liver transplantation in most of the evaluated domains. Only the domains \'limitations by emotional aspects\' (p = 0.083), SF-36, and \'social interaction\' (p = 0.087), LDQOL, did not reach statistical significance. Factor analysis allowed us to identify the dimensions that most interfered with the perception of QoL, and the in-depth interview made it possible to discuss, in a broader way, the limitations imposed by the chronic condition of the liver disease, as well as the transformations brought about by the transplant. Conclusions: The improvement in the quality of life after transplantation was confirmed by all the instruments used. However, there were reservations regarding the improvement in the quality of the psychic health of the transplanted patient, not occurring in the same proportion as the expressive reconquest of physical well-being

OBJETIVOS: Analisar a expressão de EGFR, proteínas da via de sinalização ou relacionadas aos seus efeitos em carcinoma hepatocelular (CHC) primários, metastáticos e em tecido hepático não tumoral em autópsias. Correlacionar os achados a dados clínico-patológicos e marcadores de classes moleculares. Avaliar a heterogeneidade de expressão em CHC metastáticos e fatores de disseminação extra-hepática. MÉTODOS: Oitenta autópsias de pacientes com CHC ao exame foram incluídas em estudo retrospectivo transversal. Foram analisados sexo, idade, raça, etilismo, infecção por vírus da hepatite B (VHB) e C (VHC), infecção pelo HIV, tratamento prévio, causas básica e imediata de óbito, peso do fígado, cirrose, número e tamanho dos nódulos, padrão macroscópico, grau histológico, variantes histológicas, padrão arquitetural, invasão de grandes veias e metástases extra-hepáticas. Imuno-histoquímica foi realizada em micromatrizes teciduais para pesquisa de EGFR, pEGFR(Tyr 1173), HER2, ERK1/2, MAPKAPK-2, pMAPK, Ag Ki67, caspase 3, citoqueratina 19 (CK19), mTOR, ciclina D1, Met, vimentina, p53 e beta-catenina. A expressão de EGFR foi avaliada em intensidade (0-3+) e distribuição (0-100%) em um sistema de escores de 0 a 300. Hiperexpressão foi definida para escores >= 200. Amostras de fígado normal foram incluídas como controles. Amostras de CHC primário foram pareadas às suas metástases e consideradas concordantes quando na mesma categoria de expressão. No tecido não tumoral foram semi-quantificadas a reação ductular expressando CK19 e a densidade da população de células estromais perissinusoidais pela vimentina. Estatística foi realizada através dos testes do qui-quadrado ou exato de Fisher ao nível de significância de 0,05. Para as correlações de escores e variáveis categóricas foi utilizado o coeficiente de Spearman. RESULTADOS: Foram incluídos 62 casos do sexo masculino e 18 do sexo feminino (58,1 ± 10,9 anos). Infecção pelo VHC foi a principal causa em 49% (39/80), seguida por etilismo em 30% (24/80) e infecção por VHB em 19% (15/80). Cirrose foi identificada em 90% (72/80) dos casos. Os tumores mostraram-se avançados em 95% (76/80). Invasão de grandes veias foi detectada em 19% (15/80) e metástases extra-hepáticas em 38% (30/80). MAPKAPK2, pEGFR (Tyr1173) e HER2 tiveram expressão fraca ou ausente. A expressão de EGFR foi mais frequente no fígado não neoplásico (26/26) (P < 0,05) - e nos controles normais (8/8) do que nas amostras tumorais primárias (60/75) e nas metástases (12/17). Nenhuma amostra dos controles apresentou hiperexpressão de EGFR, a qual foi mais frequente na cirrose (65% - 17/26) do que nos tumores avançados (36% - 26/72) (P < 0,05). EGFR hiperexpresso foi mais frequente nos tumores de grau 1/2 (P < 0,01) e nos casos com menos de quatro nódulos hepáticos (P = 0,014). A expressão de EGFR correlacionou-se à expressão de caspase 3 (P < 0,01). A expressão das quinases ERK1 e ERK2 foi correlacionada à proliferação celular pelo Ag Ki67 (P < 0,01), porém não ao escore de expressão de EGFR. CK19, p53 e beta-catenina nuclear foram correlacionaram-se às lesões de maior grau e a maiores taxas de proliferação celular (P<0,01). Met, EGFR e caspase 3 foram correlacionados a lesões mais diferenciadas. Vimentina teve forte correlação com CK19 (P < 0,01). A concordância de expressão entre tumores hepáticos e respectivas metástases variou de 50 a 85%. Para o EGFR foi de 61%. A expressão endotelial 2-3+ de pMAPK foi mais frequente nas metástases (P = 0,09). A disseminação extra-hepática foi mais frequente nos casos com baixa densidade de células perissinusoidais positivas para vimentina (P = 0,054) e nos casos sem reação ductular no tecido não neoplásico (P = 0,095). CONCLUSÕES: O EGFR tem papel relevante nas etapas iniciais e intermediárias do CHC, sendo sua expressão reduzida nas formas avançadas. Diferentes classes de CHC podem estar associadas a ativação da via do EGFR. A presente análise imuno-histoquímica ampla parece validar pelo menos dois grupos de CHC que nesta série de autópsias parecem ter sido separados pelo grau histológico. Confirma-se a hiperexpressão das quinases como evento importante na progressão tumoral, porém não necessariamente associada à hiperexpressão de EGFR. A heterogeneidade de expressão entre o CHC primário e suas metástases variou de 15 a 45% / OBJECTIVES: To analyze the expression of EGFR and proteins related to its signaling pathway or to its effects in hepatocellular carcinoma (HCC), metastases and surrounding liver tissue in a series of autopsies. To correlate expression patterns to clinicopathological data and other markers of molecular classification. To assess the heterogeneity of expression in metastatic HCC and factors related to extrahepatic spread. METHODS: Eighty autopsies of patients with HCC were included in a cross-sectional retrospective study. We analyzed gender, age, race, alcohol intake, infection with hepatitis B (HBV) and C virus (HCV), HIV infection, prior treatment, basic and immediate causes of death, the weight of the liver, cirrhosis, number and size of nodules, gross pattern, histological grade, histological variants, architectural pattern, invasion of large veins and extrahepatic metastases. Immunohistochemistry was performed on tissue microarrays to survey EGFR, pEGFR(Tyr 1173), HER2, ERK1/2, MAPKAPK-2, pMAPK, Ag Ki67, caspase 3, cytokeratin 19 (CK19), mTOR, cyclin D1, Met, vimentin, p53 and beta-catenin. EGFR expression was evaluated in intensity (0-3+) and distribution of membrane staining (0-100%) in a 0 - 300 score. Overexpression was defined for scores >= 200. Normal liver samples were included as controls. Intra-hepatic HCC samples were matched to their respective metastases and expression was considered concordant when they were assigned to the same category. Ductular reaction expressing CK19 and the density of perisinusoidal vimentin positive stromal cells were semi-quantified in non-tumor tissue. Statistics was performed using the chi- square or Fisher exact test at a significance level of 0.05. For the correlations of scores and categorical data we used the Spearman coefficient. RESULTS: Sixty-two males and eighteen females were included (age 58.1 ± 10.9). HCV was the major cause in 49% (39/80), followed by alcoholism in 30% (24/80) and HBV infection in 19% (15/80). Cirrhosis was identified in 90% (72/80) and advanced tumors in 95% (76/80). Large vein invasion was detected in 19% (15/80) and extra-hepatic metastases in 38% (30/80). MAPKAPK2, pEGFR (Tyr1173) and HER2 expression were weak or absent. The EGFR expression was more frequent in non-tumoral liver (26/26) (P <.05) and in normal controls (8/8) than in primary HCC tumor samples (60/75) and in metastatic HCC (12/17). No samples taken from the controls showed overexpression of EGFR, which was more common in cirrhotic tissue (65% - 17/26) than in advanced tumors (36% - 26/72) (P <0.05). EGFR overexpression was more frequent in grade 1/2 tumors (P <0.01) and in cases with less than four hepatic nodules (P = 0.014). EGFR expression was correlated to the expression of caspase 3 (P <0.01). The expression of the kinases ERK1 and ERK2 was correlated to Ag Ki67 cell proliferation index (P <0.01), but not to the EGFR expression score. CK19, p53 and nuclear beta- catenin were correlated to high grade lesions and to higher rates of cell proliferation (P <0.01). Met, EGFR and caspase 3 were correlated with more differentiated lesions. Vimentin was strongly correlated with CK19 (P <0.01). The concordance of expression between liver tumors and their metastases ranged from 50 to 85% (61% for EGFR). The 2-3+ expression of pMAPK in tumor endothelial cells was more common in metastases (P = 0.09). Extrahepatic dissemination was more frequent in cases with low density of vimentin positive perisinusoidal cells (P = 0.054) and in cases with no detectable ductular reaction in non-neoplastic tissue (P = 0.095). CONCLUSIONS: EGFR plays an important role in the early and intermediate stages of HCC progression, with lower expression in advanced tumors. Different classes of HCC may be associated with activation of EGFR. The present comprehensive immunohistochemical approach seems to validate at least two molecular classes of HCC, and histological grade seems to be able to discriminate these groups. We herein confirmed overexpression of kinases as a key event in tumor progression, but not necessarily associated with overexpression of EGFR. The heterogeneity of expression between primary HCC and its metastases ranged from 15 to 45%

Syfte: Att testa den patientenkät som används i utvärdering av en leversjuksköterskemottagning på patienter med dekompenserad levercirros för att undersöka upplevelsen av att besvara frågorna samt frågornas relevans till patientens situation. Metod: Pilotstudiens metod var mixad. Resultat: Spridningen av deltagarnas upplevelse av oro/obehag av enkäten var stor (VAS 6-100 millimeter). Vid få sjukdomssymtom väcktes oro om framtida sjukdomsutveckling men vid längre tids sjukdom kändes samtliga symtom igen, tankar om tidigare beteende uppstod vid alkoholsorsakad sjukdom. En mindre spridning (VAS 66-92 millimeter) sågs gällande hur viktiga/väsentliga frågorna upplevdes. Frågor om bemötande ansågs viktiga och påverkade upplevelsen av rätten till vård. Kompletterande frågor om individuellt anpassad information samt upplevelsen av delaktighet vid information efterfrågades. Deltagarna visade hög uppskattning (VAS 73-95 millimeter) till att sjukdomen/situation uppmärksammades genom enkäten. Besöken till sjuksköterskan skiljde sig från läkarbesök. Sjuksköterskan fokuserade på egenvård och mer tid fanns för information. För en informant innebar försöksverksamheten ökade antal sjukhusbesök, samordning innebar för- och nackdelar. Vid symtom på fatigue och nedsatt koncentrationsförmåga upplevdes enkäten lång, tvådelad enkät efterfrågades. Vid lindrig sjukdom upplevdes enkäten inte ansträngande. Språket var enkelt att förstå och innehållet upplevdes relevant. De öppna frågeställningarna tillförde inte något för de tre informanterna. / Purpose: To test the patient questionnaire used in the evaluation of an intervention with nurse-led clinic for patients with decompensated liver cirrhosis to examine the experience of answering the questions as well as their relevance to the patient's situation. Method: The pilot study was conducted with a mixed method. Results: The variation of the participants' experience of anxiety/discomfort of the questionnaire was large (VAS 6-100 millimeters). Individuals with few disease symptoms had concerns about future development of the disease, in the case of long disease experience all the symptoms was familiar. Following alcohol induced disease thoughts of past behavior occurred. A smaller variation (VAS 66-92 millimeters) was seen regarding the experience of how important/essential the questions felt. Questions about treatment were considered important and affected the perception of care. Questions about individualized information was requested as well as the experience of participation in the exchange of information. The participants showed a high appreciation (VAS 73-95 millimeters) that the disease/situation was highlighted by the survey. The visits to the nurse differed from appointments to physicians. The nurse focused on self-care and more time was available for information. For one informant the intervention increased the total number of hospital visits, coordination meant advantages and disadvantages. Symptoms of fatigue and impaired concentration made the questionnaire experienced as too long, a two-parted questionnaire was requested, the size was not strain in mild disease. The language was easy to understand and the content perceived relevant. The open issues brought nothing for the three informants.

Κατά τη διάρκεια της τελευταίας δεκαετίας παρατηρείται ένα προοδευτικώς αυξανόμενο ενδιαφέρον για την διερεύνηση της ύπαρξης ή μη συσχέτισης, ανάμεσα στην γενετική ποικιλομορφία της περιοχής του πυρηνικού υποκινητή (Core Promoter, CP, 1700-1849), της προπυρηνικής περιοχής (Precore, PC, 1814-1901) και της περιοχής του κυρίως πυρηνικού αντιγόνου (Core, 1901-2450) του ιού της Ηπατίτιδας Β, τόσο σε νουκλεοτιδικό όσο και σε πρωτεϊνικό επίπεδο, και στην κλινική εικόνα της Οξείας ή Χρόνιας Ηπατίτιδας Β, την πιθανότητα εξέλιξης και το ρυθμό εξέλιξης της χρόνιας HBV λοίμωξης σε Χρόνια Ενεργό Ηπατίτιδα, Κίρρωση του Ήπατος και Ηπατοκυτταρικό Καρκίνωμα (ΗΚΚ). Στόχοι Έρευνας: Λαμβάνοντας υπόψη όλες τις προηγουμένως δημοσιευθείσες εργασίες και δεδομένης της ολοένα και αυξανόμενης σημασίας που αποκτά η γενετική ποικιλομορφία της περιοχής του πυρηνικού αντιγόνου στην εξέλιξη της χρόνιας HBV λοίμωξης, προχωρήσαμε σε ανάλυση της γονιδιακής αλληλουχίας των περιοχών του κυρίως πυρηνικού υποκινητή , και της προπυρηνικής περιοχής καθώς και σε ανάλυση της γονιδιακής και πρωτεϊνικής αλληλουχίας του πυρηνικού αντιγόνου σε στελέχη του ιού που απομονώθηκαν από 23 Χρόνιους Ασυμπτωματικούς Φορείς (ΧΑΦ) του ιού HBV, χρησιμοποιώντας ως μάρτυρες (controls) στελέχη του ιού που απομονώθηκαν από 4 ασθενείς με Χρόνια Ενεργό Ηπατίτιδα Β (ΧΕΗΒ) προ της ενάρξεως οποιασδήποτε θεραπευτικής αγωγής και κλωνοποιήθηκαν. Οι στόχοι της παρούσας έρευνας συνοψίζονται ως εξής: α) Να καταγράψουμε το σύνολο των μεταλλάξεων στις υπό μελέτη περιοχές και το σύνολο των αμινοξικών αντικαταστάσεων στο πυρηνικό αντιγόνο χωρίς να εστιάσουμε μόνο σε 3-4 μεταλλάξεις οι οποίες αποτέλεσαν μεμονωμένο αντικείμενο μελέτης στην συντριπτική πλειονότητα των έως τώρα δημοσιευμένων ερευνών, β) Να εξακριβώσουμε την συχνότητα εμφάνισης κάθε μετάλλαξης και πως αυτή διαφοροποιείται ανάλογα με την κλινική κατάσταση και το ορολογικό προφίλ των ασθενών, τον γονότυπο, και τον υπότυπο του ιού, γ) να προτείνουμε ένα ακριβές προφίλ μεταλλάξεων και αμινοξικών αντικαταστάσεων που χαρακτηρίζει τους ΧΑΦ και να δείξουμε πως αυτό διαφοροποιείται στους ασθενείς με ΧΕΗΒ, δ) Να ερευνήσουμε την ποσοτική αλλά και ποιοτική επίπτωση των διαπιστούμενων, στην κωδικοποιούσα το πυρηνικό αντιγόνο αλληλουχία, νουκλεοτιδικών αλλαγών επί της αμινοξικής αλληλουχίας του πυρηνικού αντιγόνου, και πως αυτή επηρεάζει την σύσταση των αντιστοίχων επί του πυρηνικού αντιγόνου αντιγονικών επίτοπων, ε) Να προτείνουμε νέες τεχνικές απομόνωσης ιικού DNA και πολυμερισμού τμημάτων του ιικού γονιδιώματος σε ασθενείς με πολύ χαμηλά επίπεδα ιαιμίας, όπως οι ΧΑΦ, στ) Να επιβεβαιώσουμε ή να αντικρούσουμε τα δεδομένα της διεθνούς βιβλιογραφίας, που αφορούν στην συχνότητα εμφάνισης μεταλλάξεων και την εντόπιση τους στις υπό μελέτη περιοχές, την διαφοροποίηση αυτών μεταξύ διαφορετικών κατηγοριών ασθενών, διαφορετικών γονότυπων και διαφορετικών υπότυπων του αυτού γονότυπου του ιού. / Infection with HBV may lead to a wide spectrum of liver disease that ranges, in acute infection from mild self-limited to fulminant hepatitis, and in persistent infection from an ASC state to severe chronic hepatitis, cirrhosis and HCC. Several host factors are important in determining outcome, including age at infection, immune competence and MHC haplotype. Viral factors may also play an important role. Over the past decade, there has been considerable interest in whether certain genetic variants of HBV are associated with increased pathogenicity, such as the development of acute liver failure and progression of persistent infections to Chronic Active Hepatitis B, Liver Cirrhosis and Hepatocellular Carcinoma. Aims We proceeded to the sequencing of the entire CP, PC and Core regions of the HBV genome and the analysis of the Molecular variation in them in HBV isolates derived from 23 ASCs and 4 patients with CHB. 17 ASCs were Greeks (genotype D [ayw3]) and 6 were Chinese (Genotype C [ayr]) while all CHB patients were Greeks (though 3 of Genotype D ayw3 and 1 of Genotype D ayr). Our ultimate aims were the identification of all nucleotide and amino acid substitutions within the aforementioned regions and Core protein, respectively, and the demonstration of the differential presentation, distribution and frequency patterns of these substitutions and their respective combinations, in terms of clinical, virological and immunological characteristics of the patients.

Darbo tikslas buvo nustatyti vartų venos hipertenzijos (VVH) neinvazinių parametrų ir kepenų venų spaudimų gradiento ryšį, įvertinti medikamentinio gydymo efektyvumą mažinant VVH sergantiems kepenų ciroze. Darbo uždaviniai - Nustatyti neinvazinių VVH požymių ryšį su kepenų venų spaudimų gradiento pakitimais (KVSG) ir įvertinti parametrus, rodančius kliniškai reikšmingą KVSG padidėjimą (≥12 mm Hg). - .Nustatyti veiksnius, susijusius su kraujavimu iš varikozinių stemplės venų. - Įvertinti ir palyginti karvedilolio ir nebivololio efektyvumą mažinant vartų venos hipertenziją kepenų ciroze sergantiems pacientams. Išvados 1.Didesnį KVSG parodo B, C klasės kepenų funkcijos nepakankamumas (pagal CTP), didelio laipsnio varikozinės stemplės venos (F2 ir F3) bei praeityje buvęs varikozinis kraujavimas. 2.Kliniškai reikšmingą KVSG padidėjimą (≥12 mm Hg) parodo protrombino indeksas, albumino kiekis serume, didesnis balų skaičius vertinant kepenų funkcijos nepakankamumą pagal CTP bei MELD sistemas. 3.Ultragarsu randamas sumažėjęs viršutinės pasaito arterijos pulsatiliškumo indeksas, monofazinė kepenų venų kraujotaka bei rekanalizuota bambinė vena parodo kliniškai reikšmingą KVSG padidėjimą. 4.Sergant kepenų ciroze, kraujavimas iš varikozinių stemplės venų yra susijęs su didelio (F2-F3) laipsnio išsiplėtusiomis stemplės venomis, KVSG ≥18 mm Hg, didesniu blužnies skersmeniu, lėtesniu maksimaliu kraujotakos greičiu kepenų venose. 5.Tiek karvedilolis, tiek nebivololis efektyviai sumažino... [toliau žr. visą tekstą] / The aim of the study was to evaluate the relationship of baseline HVPG and noninvasive parameters of portal hypertension and to assess the efficacy of pharmacological therapy in cirrhotic patients. The objectives of the study 1.To evaluate the relationship of baseline HVPG with clinical, laboratory, endoscopy and ultrasound parameters of portal hypertension. 2.To establish the noninvasive parameters of portal hypertension predicting clinically significant HVPG (>12 mm Hg). 3.To identify the factors predicting the variceal bleeding, which is one of the most serious complications of portal hypertension. 4.To assess and compare the effect of two β-blockers, carvedilol and nebivolol, on HVPG in cirrhotic patients. Conclusions 1.Child’s B, C classes (CTP scoring system) liver cirrhosis, F2, F3 oesophageal varices and history of variceal bleeding are closely related with significant increase of hepatic venous pressure gradient. 2.INR, serum albumin, higher score according to the CTP scoring and MELD systems indicate clinically significant portal hypertension. 3.Decreased superior mesenteric artery pulsatility index, monophasic blood flow in the hepatic veins and patent paraumbilical vein at colour Doppler imaging ultrasound reflects clinically significant portal hypertension. 4.Large (F2-F3) oesophageal varices, hepatic venous pressure gradient of ≥18 mm Hg, larger spleen diameter and low maximal hepatic flow velocity are related with variceal bleeding in cirrhotic patients. 5... [to full text]

Cirrhosis is a leading cause of death in the United States and has severe and costly complications. Because of the clinical significance of cirrhosis, it is important that noninvasive methods be developed to detect cirrhosis early and to monitor its progression with advancing liver disease. Previous studies on portal venous hemodynamics have been performed mainly with ultrasound with mixed results. Magnetic Resonance Imaging offers several advantages over ultrasound including acquisition of both high quality anatomical and hemodynamic information. Phase-Contrast MR was used to gather velocity data for the portal venous system. Methods were developed to perform registration, segmentation and isolation of the portal vein geometries and velocity data. Computational Fluid Dynamics was also employed to further investigate the flow within the portal vein. Velocity data for the portal vein, superior mesenteric vein, splenic vein and the right or left portal vein was acquired in varying numbers for both data sets. Even with the limited number of subjects a few parameters were significant. Patients with cirrhosis had a significantly increased portal vein area and a significantly decreased average velocity per liver volume and velocity variance. Patients with cirrhosis had a significantly increased splenic vein area and average flow rate per liver volume. While these results are preliminary due to small sample size, they are promising and require further investigation and more subjects including varying stages of disease.

Submitted by LETICIA DE CAMPOS FRANZONI null (leticiafranzoni@hotmail.com) on 2017-04-05T01:59:34Z No. of bitstreams: 1 Tese Doutorado Versao Final 13 jan 2017 - Franzoni.pdf: 1564703 bytes, checksum: 96d71fb57b63c2b888283c1b53168fd1 (MD5) / Approved for entry into archive by Luiz Galeffi (luizgaleffi@gmail.com) on 2017-04-12T17:18:02Z (GMT) No. of bitstreams: 1 franzoni_lc_dr_bot.pdf: 1564703 bytes, checksum: 96d71fb57b63c2b888283c1b53168fd1 (MD5) / Made available in DSpace on 2017-04-12T17:18:02Z (GMT). No. of bitstreams: 1 franzoni_lc_dr_bot.pdf: 1564703 bytes, checksum: 96d71fb57b63c2b888283c1b53168fd1 (MD5) Previous issue date: 2017-02-17 / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / Introdução: Os aminoácidos de cadeia ramificada (BCAA) são parte do tratamento da encefalopatia hepática (HE) e aumentam a perfusão cerebral. Como são compostos por três aminoácidos diferentes, as proporções de cada um variam nos ensaios clínicos, tornando difícil esclarecer qual substância está mais envolvida na perfusão cerebral e em outros parâmetros significativos. O objetivo deste estudo foi comparar os efeitos clínicos e de perfusão cerebral obtidos pela suplementação de leucina versus isoleucina para tratamento da HE. Métodos: Cinqüenta pacientes ambulatoriais com cirrose e HE foram randomizados para receber suplementos orais contendo 30 g de leucina ou isoleucina diariamente, por um ano. As avaliações clínicas e a avaliação nutricional foram realizadas bimestralmente. A Tomografia Computadorizada cerebral por emissão de fóton único (SPECT) e a cintilografia cerebral dinâmica foram realizadas pré-tratamento e em 1, 8 e 12 meses de suplementação. Vinte e sete indivíduos concluíram o estudo (16 com isoleucina e 11 com leucina). Resultados: O aumento da perfusão cerebral foi observado apenas no grupo isoleucina. O aumento foi documentado aos 8 meses de tratamento tanto pelo SPECT como pela cintilografia cerebral (p <0,001 e p = 0,05, respectivamente) e pelo SPECT no 12º mês (p <0,05). Foi associado a uma melhora significativa de HE em 8 e 12 meses neste grupo (p = 0,008 e 0,004, respectivamente), o que foi menos claro no grupo leucina (p = 0,313 e 0,055, respectivamente). Conclusões: A suplementação de isoleucina permitiu alcançar um melhor impacto nas manifestações de HE e na perfusão cerebral de pacientes com cirrose. Os resultados sugerem que pacientes com HE devem receber mais isoleucina do que leucina. / Introduction: Branched chain amino acids (BCAA) are part of hepatic encephalopathy (HE) treatment and lead to brain perfusion increasing. As they are composed by three different amino acids, the proportions of each one vary in the clinical trials, making difficult to clarify which substance is more involved in brain perfusion and other significant endpoints. The aim of this study was to compare clinical and brain perfusion effects obtained by supplementation of leucine versus isoleucine for HE treatment. Methods: Fifty outpatients with cirrhosis and HE were randomized to receive oral supplements containing 30 g of leucine or isoleucine on a daily basis for one year. Clinical evaluations and nutritional assessment were performed bimonthly. Brain Single Photon Emission Computed Tomography (SPECT) and dynamic brain scintigraphy were performed pretreatment and at 1, 8 and 12 months of supplementation. Twenty-seven subjects concluded the study (16 taking isoleucine and 11 taking leucine). Results: Increasing in brain perfusion was observed only in the isoleucine group. The increase was documented at 8 months of treatment by both SPECT and brain scintigraphy (p<0.001 and p= 0.05, respectively) and by SPECT at the 12th month (p <0.05). It was associated with a significant HE improvement at 8 and 12 months in this group (p=0.008 and 0.004, respectively), which was less clear in the leucine group (p=0.313 and 0.055, respectively). Conclusions: Isoleucine supplementation allowed achieving a better impact on HE manifestations and brain perfusion of patients with cirrhosis. The results suggest that patients with HE should receive more isoleucine than leucine. / FAPESP: 2013/11761-2

A cirrose hepática é uma doença crônica e irreversível com modificações histológicas caracterizadas por nódulos de regeneração e desarranjo de hepatócitos, com aumento difuso de tecido conjuntivo e perda de função. As células-tronco têm sido amplamente estudadas para o tratamento de injúrias hepáticas. Fibrose e cirrose foram induzidas em ratos Wistar, através da aplicação de tioacetamida (TAA) intraperitoneal a 200 mg/kg por 8 ou 14 semanas, seguido de terapia celular com aplicação intravenosa única de 1x106 células-tronco de membrana amniótica de ratas. Amostras de sangue foram coletadas para análises bioquímicas, e tecido hepático para histologia e imunohistoquímica. A histopatologia para colorações de hematoxilina-eosina para graduação e estadiamento da lesão hepática foi realizada, com observação de alterações celulares; picrosírius para quantificação do colágeno parenquimal; ácido periódico-Schiff para mucopolissacarídeos neutros e glicogênio; e alcian blue para mucopolissacarídeos ácidos. Imunohistoquímica foi realizada para marcação de PCNA, colágenos tipo 1 e 3, e &alpha;-SMA. O cultivo celular apresentou ótimo crescimento, sendo transduzido com GFP e negativo para micoplasma. Os animais induzidos experimentalmente mostraram baixo ganho de peso durante o experimento, com notável recuperação nas duas primeiras semanas após término da indução. A mortalidade experimental foi de 10 %. A indução da fibrose e cirrose hepática obtiveram sucesso no período de 8 e 14 semanas, respectivamente Análises macroscópicas mostraram melhor aspecto de fígados cirróticos após terapia celular. Não houve diferenças estatísticas após a terapia celular para as análises bioquímicas, graduação, estadiamento, alterações celulares, proliferação de ductos, mucopolissacarídeos ácidos e neutros e imunohistoquímicas para colágeno 1 e 3, PCNA e &alpha;- SMA. Houve, porém, uma tendência a melhora na graduação e estadiamento da fibrose e cirrose com redução da atividade necroinflamatória; redução na proliferação de ductos; menor deposição de mucopolissacarídeos ácidos e neutros; diminuição das alterações celulares com indicativos de menor grau de lesão tecidual e maior grau de regeneração; diminuição da expressão de &alpha;-SMA e colágenos 1 e 3; e aumento do PCNA. O colágeno intralobular teve diminuição após terapia celular em fígados fibróticos. Em animais induzidos a cirrose, houve diminuição de ambos colágenos interlobular e intralobular. Conclui-se que houve uma tendência de melhora dos animais após tratamento com células-tronco da membrana amniótica de ratas, o que nos encoraja a aplicação de protocolos de terapia celular. Apesar dos resultados promissores, um maior número de animais precisa ser testado para que se tenham mais dados, que possam dar subsídios para o uso destas células na prática clínica para o tratamento da cirrose hepática / Liver cirrhosis is a chronic and irreversible disease with histological changes characterized by regenerative nodules and disarray of hepatocytes with diffuse increase in connective tissue and loss of function. Stem cells have been extensively studied for the treatment of liver injury. Fibrosis and cirrhosis was induced in Wistar rats by application of thioacetamide (TAA) intraperitoneally at 200 mg/kg for 8 or 14 weeks, followed by cell therapy with a single intravenous administration of 1x106 stem cells from amniotic membrane of rats. Blood samples were collected for biochemical analyzes, and liver tissue for histology and immunohistochemistry. Histopathology by hematoxylin-eosin for grading and staging of hepatic injury with observation of cellular changes was performed; picrosirius for quantification of parenchymal collagen; periodic acid-Schiff for neutral mucopolysaccharides and glycogen; and alcian blue for acid mucopolysaccharides. Immunohistochemistry was performed for PCNA, type 1 and 3 collagens, and &alpha;-SMA. Cell culture showed optimal growth, being transduced with GFP and negative for mycoplasma. Animals induced to liver disease showed low weight gain during the experiment, with remarkable recovery in the first two weeks after completion of induction. Experimental mortality was 10%. Induction of fibrosis and cirrhosis was successful after the period of 8 and 14 weeks, respectively. Macroscopic analysis showed improvement in the aspect of cirrhotic livers after cell therapy. There were no statistical differences after cell therapy for biochemical analyzes, grading, staging, cellular changes, proliferation of ducts, acidic and neutral mucopolysaccharides and immunohistochemistry for collagen 1 and 3, PCNA and &alpha;-SMA. There was, however, a tendency on improvement in grading and staging of fibrosis and cirrhosis with reduced necroinflammatory activity; reduction in the proliferation of ducts; lower deposition of acidic and neutral mucopolysaccharides; decrease in cellular changes indicating a lower degree of tissue damage and a greater degree of regeneration; decreasing on the expression of &alpha;-SMA and type 1 and 3 collagens; and increased PCNA. Intralobular collagen decreased after cell therapy in fibrotic livers. In cirrhotic animals, there was a decrease of both interlobular and intralobular collagen. We conclude that was a trend to improvement of animals after treatment with stem cells derived from amniotic membrane of rats, which encourages the application of cell therapy protocols. Despite the promising results, a larger number of animals must be tested, so we can have more data to make allowances for the use of these cells in clinical practice for the treatment of liver cirrhosis

A cirrose hepática é um processo irreversível caracterizado pelo desequilíbrio entre a deposição e a degradação de componentes da matriz extracelular (MEC), acarretando disfunção hepatocelular e aumento da resistência ao fluxo sanguíneo, resultando em insuficiência hepática e na hipertensão portal. A cirrose em cães, muitas vezes é identificada nos estágios finais, já que o estágio inicial é assintomático. Em humanos, no estágio final da cirrose, o transplante é o único tratamento. Desta forma, a busca por tratamentos alternativos torna-se imprescindível. A administração de fatores hepatotróficos (FH) tem sido estudada como uma alternativa de tratamento. Este estudo objetivou avaliar os efeitos dos FHs na cirrose hepática murina induzida pela tioacetamida (TAA), imediatamente após o tratamento, e 60 dias pós o seu término. 75 ratas Wistar foram subdivididas em quatro grupos; FH (n=15) e o seu grupo controle (CT, n=30), e FH+60d (n=15) e seu controle (CT, n=15); todos os animais foram induzidos à cirrose hepática pela administração TAA (200mg/Kg), ip, 3 vezes/semana, por 14 semanas. Após a indução, dois grupos receberam a solução de FHs por 12 dias. Um foi eutanasiado imediatamente após o tratamento e o outro, 60 dias após o seu término. Foram realizadas análises bioquímica sérica e histopatológica; a quantificação do colágeno; avaliação da proliferação celular e da ativação das células estreladas. Ainda, foram avaliadas a expressão gênica de proteínas envolvidas na fibrogênese, como, colágeno tipo 1, TGF-1, TIMP-1, MMP-2, MMP-13 e PLAU. Os resultados obtidos imediatamente após o tratamento mostraram que os FHs melhoraram as funções hepáticas, reduziram a deposição de colágeno e a ativação das células estreladas; alterando os mecanismos moleculares envolvidos na fibrogênese pela redução da expressão do colágeno tipo 1, aumento de TIMP-1, MMP-13 e PLAU. A maioria destes efeitos se manteve após o término do tratamento. Os resultados indicam que os FHs auxiliam no restabelecimento das funções e arquitetura hepáticas, atuando sobre os mecanismos de deposição e degradação da MEC, e que o tratamento com os FHs têm ação prolongada, não desaparecendo imediatamente após o tratamento. / Hepatic cirrhosis is an irreversible process characterized by an imbalance between deposition and degradation of extracellular matrix components (ECM). This disease leads to hepatocellular dysfunction and increased resistance to blood flow resulting in liver failure and portal hypertension. The cirrhosis, in dogs, is often identified in the final stages whereas the early stage is asymptomatic. In humans, in the final stage of the cirrhosis, transplantation is the only treatment. Thus, the search for alternative treatments becomes essential. The administration of hepatotrophic factors (HF) has been studied as a treatment alternative. This study evaluated the effects of HFs in murine liver cirrhosis induced by thioacetamide (TAA) immediately after treatment, and 60 days after it ends. 75 female Wistar rats were distributed into four groups: HF (n=15) and control group (n=30), and HF+60d (n=15) and control group (n=15). Hepatic cirrhosis was induced in all animals by TAA administration (200 mg/kg), ip, 3 times a week for 14 weeks. After induction, two groups received the HFs solution for 12 days. One group was euthanized immediately after treatment and another group was euthanized 60 days after treatment. The following analyzes were performed: serum biochemistry, histopathologic, collagen quantification, cell proliferation, and stellate cells activation. In addition, the gene expression of proteins involved in fibrogenesis such as type 1 collagen, TGF-1, TIMP-1, MMP-2, MMP-13, and PLAU was evaluated. The results found immediately after treatment showed that HFs improved liver function, and reduced collagen deposition and stellate cells activation. Alterations of the molecular mechanisms involved in fibrogenesis were observed by reducing the expression of collagen type 1 and increased expression of TIMP-1, MMP-13 and PLAU. Most of these effects remained after the treatment. The results indicate that the HFs assist in restoration of liver function and architecture, acting on the mechanisms of deposition and degradation of ECM. Furthermore, the treatment with HFs showed prolonged action, remaining during the post-treatment.