Orientador: Maria de Lourdes Ribeiro de Souza da Cunha / Coorientador: Carlos Magno Castleo Branco Fortaleza / Banca: Carlos Roberto Veiga Kiffer / Banca: Elizabeth Losshchagin Pizzolitto / Resumo: Estudos recentes apontam para elevação da incidência e da gravidade das infecções por Staphylococcus aureus. Esse fato é agravado pela ampla disseminação de isolados de Staphylococcus aureus resistentes à meticilina (MRSA) nos hospitais, além de sua recente introdução na comunidade. A colonização nasal de indivíduos assintomáticos é o principal fator responsável pela persistência e disseminação de S. aureus nas populações humanas. Assim sendo, inquéritos de carreamento nasal são importantes para estimar a "carga" (burden) de S. aureus como um todo e de MRSA na comunidade. Além disso, a compreensão da relação bactéria-hospedeiro e dos fatores de virulência envolvidos se faz necessária para o combate às infecções que colocam em risco a vida da população em geral. O presente trabalho teve como objetivo investigar a distribuição de clones de Staphylococcus aureus e MRSA na população da área urbana de Botucatu, SP, identificando a prevalência dos determinantes de virulência junto aos fatores de risco associados em isolados obtidos da nasofaringe de indivíduos hígidos do município. Um total de 223 amostras de S. aureus isoladas de secreções nasais foi submetido a testes de susceptibilidade antimicrobiana à oxacilina e cefoxitina através da técnica de discodifusão. O método de E-test foi empregado para determinar a Concentração Inibitória Miníma (CIM) em amostras resistentes. Em seguida, foram realizadas reações de PCR para a detecção dos genes mecA, genes codificadores de fatores de virulência das enterotoxinas (sea, seb e sec) e toxina associada à síndrome do choque tóxico (tst); toxinas esfoliativas A e B (eta, etb), leucocidina de Panton-Valentine (lukS-PV e lukF-PV), hemolisinas alfa e delta (hla e hld); e biofilme (icaA e icaD). A tipagem molecular para a determinação dos clusters foi realizada pela técnica de PFGE. Para avaliar os fatores ... / Abstract: Recent findings show an increase on the incidence and severity of Staphylococcus aureus infection. This fact is worsened by the wide dissemination of the methicillin-resistant S. aureus (MRSA) isolates in hospitals and its recent introduction in the community settings. The nasal colonization in asymptomatic individuals remains the main factor responsible for the persistence and dissemination of S. aureus in the human population. Thereby, nasal carriage surveys are an important tool in order to estimate the total S. aureus burden and the MRSA in the community. Besides, understanding the bacterial-host relationship and the virulence factors involved is necessary in order to manage the infections that jeopardize the population's health. The present study aims at investigating the clonal distribution of S. aureus and MRSA strains in an urban population area in Botucatu, SP, identifying both the prevalence of the virulence determinants together to the associated risk factors in samples obtained from the nasopharynx of healthy individuals from Botucatu. A total of 223 S. aureus samples isolated from nasal secretions were submitted to the antimicrobial susceptibility tests through the disk-difusion method with oxacillin and cefoxitin disks. The E-test method with oxacillin was applied in order to obtain the Minimum Inhibitory Concentration (MIC) among oxacillin disk resistant samples. Afterwards, PCR (Polimerase Chain Reaction) was carried out for the detection of the mecA gene and of the following virulence genes: enterotoxins (sea, seb and sec), toxic shock syndrome toxin (tst), exfoliative toxin A and B (eta, etb), Panton-Valentine Leukocidin (lukS-PV and lukF-PV), alphaand delta-hemolysins (hla and hld), and biofilms (icaA and icaD). The PFGE molecular typing was employed in order to determine the prevalent clusters. The univariate and multivariate linear regression was carried out so that the risk factors ... / Mestre

Made available in DSpace on 2014-11-10T11:09:45Z (GMT). No. of bitstreams: 0 Previous issue date: 2013-02-22Bitstream added on 2014-11-10T11:58:26Z : No. of bitstreams: 1 000747680_20150920.pdf: 1466507 bytes, checksum: cb29b6ba55c009106980d77e8d233fc2 (MD5) Bitstreams deleted on 2015-09-21T13:18:53Z: 000747680_20150920.pdf,. Added 1 bitstream(s) on 2015-09-21T13:19:50Z : No. of bitstreams: 1 000747680.pdf: 2678639 bytes, checksum: e24657234d93469753d524eb03f006fd (MD5) / Estudos recentes apontam para elevação da incidência e da gravidade das infecções por Staphylococcus aureus. Esse fato é agravado pela ampla disseminação de isolados de Staphylococcus aureus resistentes à meticilina (MRSA) nos hospitais, além de sua recente introdução na comunidade. A colonização nasal de indivíduos assintomáticos é o principal fator responsável pela persistência e disseminação de S. aureus nas populações humanas. Assim sendo, inquéritos de carreamento nasal são importantes para estimar a “carga” (burden) de S. aureus como um todo e de MRSA na comunidade. Além disso, a compreensão da relação bactéria-hospedeiro e dos fatores de virulência envolvidos se faz necessária para o combate às infecções que colocam em risco a vida da população em geral. O presente trabalho teve como objetivo investigar a distribuição de clones de Staphylococcus aureus e MRSA na população da área urbana de Botucatu, SP, identificando a prevalência dos determinantes de virulência junto aos fatores de risco associados em isolados obtidos da nasofaringe de indivíduos hígidos do município. Um total de 223 amostras de S. aureus isoladas de secreções nasais foi submetido a testes de susceptibilidade antimicrobiana à oxacilina e cefoxitina através da técnica de discodifusão. O método de E-test foi empregado para determinar a Concentração Inibitória Miníma (CIM) em amostras resistentes. Em seguida, foram realizadas reações de PCR para a detecção dos genes mecA, genes codificadores de fatores de virulência das enterotoxinas (sea, seb e sec) e toxina associada à síndrome do choque tóxico (tst); toxinas esfoliativas A e B (eta, etb), leucocidina de Panton-Valentine (lukS-PV e lukF-PV), hemolisinas alfa e delta (hla e hld); e biofilme (icaA e icaD). A tipagem molecular para a determinação dos clusters foi realizada pela técnica de PFGE. Para avaliar os fatores ... / Recent findings show an increase on the incidence and severity of Staphylococcus aureus infection. This fact is worsened by the wide dissemination of the methicillin-resistant S. aureus (MRSA) isolates in hospitals and its recent introduction in the community settings. The nasal colonization in asymptomatic individuals remains the main factor responsible for the persistence and dissemination of S. aureus in the human population. Thereby, nasal carriage surveys are an important tool in order to estimate the total S. aureus burden and the MRSA in the community. Besides, understanding the bacterial-host relationship and the virulence factors involved is necessary in order to manage the infections that jeopardize the population’s health. The present study aims at investigating the clonal distribution of S. aureus and MRSA strains in an urban population area in Botucatu, SP, identifying both the prevalence of the virulence determinants together to the associated risk factors in samples obtained from the nasopharynx of healthy individuals from Botucatu. A total of 223 S. aureus samples isolated from nasal secretions were submitted to the antimicrobial susceptibility tests through the disk-difusion method with oxacillin and cefoxitin disks. The E-test method with oxacillin was applied in order to obtain the Minimum Inhibitory Concentration (MIC) among oxacillin disk resistant samples. Afterwards, PCR (Polimerase Chain Reaction) was carried out for the detection of the mecA gene and of the following virulence genes: enterotoxins (sea, seb and sec), toxic shock syndrome toxin (tst), exfoliative toxin A and B (eta, etb), Panton-Valentine Leukocidin (lukS-PV and lukF-PV), alphaand delta-hemolysins (hla and hld), and biofilms (icaA and icaD). The PFGE molecular typing was employed in order to determine the prevalent clusters. The univariate and multivariate linear regression was carried out so that the risk factors ...

Introdução: A patogenia da rinossinusite crônica com polipose nasossinusal não está completamente estabelecida e existem algumas explicações para essa doença como os superantigenos, o desequilíbrio inflamatório e, mais recentemente, o biofilme. Objetivos: Avaliar a associação entre a presença do biofilme e a presença de rinossinusite crônica com polipose nasossinusal. Avaliar o quadro clínico e radiológico pré-operatória e pós-operatória segundo a presença do biofilme. Métodos: Este é uma estudo realizado em um hospital terciário universitário. A primeira parte foi um estudo caso-controle com um grupo de 33 pacientes consecutivos com rinossinusite crônica com polipose nasossinusal submetidos a cirurgica endoscópica nasossinusal e um grupo controle de 27 pacientes submetidos a septoplastia para tratamento de obstrução nasal. As amostras da mucosa foram coletadas no intra-operatório para avaliação por microscopia eletrônica de varredura para determinar a presença do biofilme. A segunda parte foi um estudo prospectivo em que dados pré-operatórios e pós-operatórios foram registrados, incluindo avaliações padronizadas da qualidade de vida doença-específica relacionadas à obstrução nasal e à rinossinusite, da endoscopia nasal e da tomografia de cavidades paranasais. A análise estatísca foi realizada. Para todos os testes um p=0.05 foi considerado significativo. Resultados: Os biofilmes foram encontrados em 72.7% (24/33) dos pacientes com rinossinusite crônica com polipose nasossinusal e 48.1% (13/27) dos pacientes submetidos a septoplastia (Odd ratio=2.87, IC95% 0.9796-8.419, p=0.051). Este foi o primeiro estudo a analisar o efeito da presença do biofilme nos resultados pós-operatórios com medidas padronizadas de um grupo de pacientes apenas com rinossinusite crônica com polipose nasossinusal. O biofilme estava presente em 72.4% (21/29) dos pacientes que completaram o seguimento. Os pacientes com biofilmes apresentaram uma pior pontuação pré-operatória NOSE e Lund-Kennedy estatísticamente significativos, mas uma mediana semelhante na pontuação total do SNOT-20. Os pacientes com biofilme apresentaram uma melhor resultado na pontuação Lund-Kennedy (p=0.036). Estes pacientes apresentaram piores resultados no SNOT-20 e resultados similares quanto ao NOSE e o Lund-Mackay. Conclusão: Os biofilmes foram demonstrados presentes nos pacientes submetidos a cirurgia endoscópica funcional para rinossinusite crônica com polipose nasossinusal mas também nos controles. Embora a prevalência não tenha sido diferente significativamente, o intervalo de confiança extremamente amplo de 95%, que apenas cruza a unidade, sugere que uma diferença significativa pode ter sido perdida por causa do baixo poder estatístico e estudos futuros serão necessários. Os biofilmes estiveram relacionados com pior qualidade de vida doença-específica pré-operatória NOSE e avaliação endoscópica (Lund-Kennedy), e melhores resultados endoscópicos. Nossos resultados sugerem que nos pacientes com uma melhora clínica significativa após a cirurgia, o biofilme representou um papel mais predominante na fisiopatologia da doença. Neste subgrupo, a cirurgia provavelmente removeu a quantidade de biofilme necessária para restaurar o desequilíbrio inflamatório na mucosa / Introduction: The pathogenesis of chronic rhinosinusitis with nasal polyps is not completely established and there are some explanations for this disease, such as superantigens, inflammatory imbalance and, more recently, biofilms. Objective: Evaluate the association of biofilms presence and chronic rhinosinusitis with nasal polyps. Evaluate outcomes after sinus surgery for chronic rhinosinusitis with nasal polyps according to the presence of biofilms. Methods: This is a University based-tertiary care center study. The first part was a case-control study that evaluated a group of 33 consecutive patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps and a control group of 27 patients undergoing septoplasty for nasal obstruction treatment. Mucosal samples were harvested intra-operatively for scanning electron microscopic examination to determine biofilms presence. The second part was a prospective study. Preoperative and follow up data were recorded, including standardized evaluations of disease-specific quality of life related to nasal obstruction and rhinosinusitis, of nasal endoscopy and sinus computer tomography scan. Statistical analysis was performed. For all statistical tests p=0.05 was considered significant. Results: Biofilms were found in 72.7% (24/33) of chronic rhinosinusitis with nasal polyps patients and in 48.1%(13/27) of septoplasty patients (Odds ratio = 2.87, CI95% from 0.9796 to 8.419, p=0.051). This was the first report to analyze the effect of biofilms in outcomes with standardized measures of a group of only chronic rhinosinusitis with nasal polyps patients. Biofilms were present in 72.4% (21/29) of these patients. Patients with biofilms had a statistically significant worst preoperative score related to nasal obstruction and nasal endoscopy, but a similar median sinusitis total score. Patients with biofilms presented better Lund-Kennedy outcome (-3[5]vs.-1[2],U=46.0,p=0.036), but the best endoscopic improvement might reflect the worst clinical preoperative status. These patients had worst outcomes in SNOT-20 (-0.75[1.15]vs.-1.30[1.32],U=69.0,p=0.21) and similar outcomes in NOSE(-55.0[50.0] vs. -60.0[50.0], U=81.0,p=0.67) and Lund-Mackay (-4[5]vs.-4[4]),U=75.5,p=0.49). Patients with biofilms presented better Lund-Kennedy outcome (p=0.036). There was a correlation among some QoL outcome scores in both groups. Conclusion: Biofilms were demonstrated to be present in patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps but also in controls. Although the prevalence was not significantly different, the extremely wide 95% confidence interval, which just crosses unity, suggests that a meaningful clinical difference may have been missed because of low statistical power and that further study is necessary. Biofilms were related with worst preoperative disease-specific quality of life questionnaire (NOSE) and endoscopic evaluation (Lund-Kennedy), and better endoscopic outcome. Our findings suggest that in patients with a significant clinical improvement after surgery, the biofilm had a more predominant role in the pathophysiology of the disease. In this subgroup, the surgery probably removed the amount of biofilms needed to restore the mucosal inflammatory imbalance

INTRODUÇÃO: Embora seja reconhecida a existência do espessamento da membrana basal e da fibrose da concha nasal na rinite alérgica, não há estudos descritivos do comportamento da mucosa nasal nos pacientes com rinite idiopática. O propósito desse estudo é descrever possíveis alterações na membrana basal e na lâmina própria da concha nasal inferior em pacientes com rinite alérgica ou idiopática, além do estudo quantitativo das fibras colágenas nesta localização. MÉTODOS: Analisou-se na concha nasal inferior obtida através de turbinectomia bilateral em 28 pacientes - 14 com rinite alérgica e 14 com rinite idiopática - a área ocupada pelo colágeno, a espessura da membrana basal e o diâmetro das fibrilas de colágeno através do uso de microscopia óptica (coloração Hematoxilina-eosina e Picrossírius-hematoxilina), microscopia eletrônica e imunoistoquímica para laminina e colágeno IV. RESULTADOS: 1) pacientes com rinite alérgica apresentaram significantemente maior área da concha nasal ocupada por colágeno do que o grupo com rinite idiopática. 2) a membrana basal de pacientes com rinite alérgica foi significantemente mais espessa. 3) a lâmina reticular da membrana basal dos pacientes com rinite alérgica apresentaram fibrilas de colágeno com menor diâmetro que os pacientes com rinite idiopática. 4) não houve diferenças significativas entre os grupos na distribuição de laminina e de colágeno IV. CONCLUSÕES: Alterações na mucosa nasal ocorrem na rinite alérgica, sendo caracterizadas pelo aumento da espessura da membrana basal e por fibrose. Na rinite idiopática, observou-se uma mucosa com aspecto estrutural semelhante aos pacientes normais / INTRODUCTION: Despite our knowledge about nasal conchae fibrosis and basement membrane thickening in allergic rhinitis, there are no descriptive studies on nasal mucosa behavior in patients with idiopathic rhinitis. The aim of our study was to describe possible changes in the basement membrane and lamina propria of the inferior concha in patients with idiopathic or allergic rhinitis, in addition to a quantitative study of collagen fibers in this site. METHODS: The inferior nasal concha obtained from 28 patients submitted to bilateral turbinectomy was examined - 14 with allergic rhinitis and 14 with idiopathic rhinitis; analyzing the collagen area, the basement membrane thickness and the collagen fibrils diameter using optical microscopy (Hematoxylin-eosin and Picrosirius-hematoxylin staining), electron microscopy and immunohistochemistry for laminin and collagen IV. RESULTS: 1) patients with allergic rhinitis had a significantly larger area of the nasal concha occupied by collagen than the group with idiopathic rhinitis. 2) the basement membrane of patients with allergic rhinitis was significantly thicker. 3) the reticular lamina of the basement membrane of patients with allergic rhinitis had collagen fibrils with diameters which were smaller than those from patients with idiopathic rhinitis. 4) there were no significant differences between the groups concerning the distribution of laminin and collagen IV. CONCLUSIONS: Alterations to the nasal mucosa that happen in allergic rhinitis are characterized by basement membrane thickening and fibrosis. In idiopathic rhinitis the patients\' mucosae were structurally similar to those from normal patients

O tabagismo está fortemente associado ao desenvolvimento da Doença Pulmonar Obstrutiva Crônica, porém poucos estudos que relatam alterações funcionais ou inflamatórias nas vias aéreas superiores em jovens são encontrados na literatura. Nosso objetivo foi investigar as alterações funcionais e inflamatórias nas vias aéreas superiores e inferiores em jovens tabagistas com idade igual ou inferior a 35 anos. Setenta e dois indivíduos participaram do estudo: 32 jovens não tabagistas (JNT) saudáveis (21±4 anos, 29 homens) e 40 jovens tabagistas subdivididos de acordo com a carga tabágica: menor que 2,5 anos-maço (< 2,5) (19±2 anos, 20 homens) e igual ou maior que 2,5 anos-maço (>= 2,5) (24 ± 5 anos, 17 homens e três mulheres). Foram avaliados os dados demográficos, os dados clínicos, os sintomas de desconforto das vias aéreas por meio do questionário SNOT-20, os volumes e capacidades pulmonares por meio do teste de função pulmonar, o transporte mucociliar nasal por meio do teste de tempo de trânsito da sacarina, a propriedade de superfície do muco nasal por meio do ângulo de contato, a inflamação na cavidade nasal por meio da contagem total e diferencial das células e citocinas em lavado nasal e a inflamação de vias aéreas inferiores por meio do pH do condensado do ar exalado. Observamos neste estudo que os jovens tabagistas >= 2,5 foram mais velhos comparados aos JNT e com os tabagistas < 2,5 (p < 0,01). Comparados com os JNT, os tabagistas >= 2,5 apresentaram maior índice de massa corporal (p=0,036), de frequência cardíaca (p=0,001) e de pressão arterial sistólica (p=0,036). Os tabagistas >= 2,5 apresentaram maior queixa sobre tosse (p=0,05) e secreção nasal escorrendo para a garganta (p=0,016) quando comparados com os JNT e tabagistas < 2,5. Não encontramos diferenças significativas na pontuação total do questionário SNOT-20 (p=0,140), nos valores do teste de função pulmonar e nos valores do ângulo de contato (p=0,803) entre os grupos. O tempo de trânsito da sacarina foi significativamente menor nos jovens tabagistas (5,9 ± 3,1 minutos) quando comparados aos JNT (7,7 ± 4,1 minutos, p=0,033). Na análise do lavado nasal encontramos maior número de células totais em tabagistas < 2,5 (48+-14) e tabagistas >= 2,5 (37+-25) comparados aos JNT (24+-12, p < 0,001). Encontramos também maior número de macrófagos (p=0,001), células ciliadas (p=0,008) e células caliciformes (p=0,004) nos tabagistas < 2,5 e tabagistas >= 2,5 quando comparados aos JNT, e maiores concentrações de mieloperoxidase nos tabagistas < 2,5 comparados aos tabagistas >= 2,5 (p=0,005). Os valores do pH do EBC foram menores em tabagistas >= 2,5 (7,65 ± 0,42) comparados com os tabagistas < 2,5 (7,83 ± 0,26) e com os JNT (7,90 ± 0,21, p=0,038). Por meio de análise de regressão linear, verificamos um efeito dose-dependente significativo do tabagismo sobre a redução dos valores do pH do EBC (r=-0,47, p < 0,001). Concluímos que o tabagismo em jovens tabagistas com idade igual ou inferior a 35 anos induz alterações do transporte mucociliar nasal, inflamação nasal e inflamação em vias aéreas inferiores e que essas alterações estão associadas à carga tabágica / Cigarette smoking is strongly associated with the development of Chronic Obstructive Pulmonary Disease, but few studies that reported functional or inflammatory changes in upper airway in young are found in the literature. We aimed to evaluate the effects of smoking on nasal mucociliary clearance, the mucus surface property and if there is inflammation in the nasal cavity and lower airways in young smokers aged less than 35 years. Of the 200 individuals contacted by telephone, 72 individuals entered in the study: 32 healthy young nonsmokers (YNS) (21 ± 4 years, 29 male) and 40 young smokers, subdivided according to smoking history: less than 2.5 pack-years (< 2.5) (19 ± 2 years, 20 male) and 2.5 pack-years or more ( >= 2.5) (24 ± 5 years, 17 male and three female). We assessed demographic data, clinical data, SNOT-20 questionnaire for symptoms of airway discomfort, the volumes and lung capacities by the pulmonary function test, the nasal mucociliary clearance using the saccharine transit test, the mucus surface property by the contact angle, the inflammation in the nasal cavity by the total and differential count of cells and cytokines in nasal lavage and inflammation of the lower airways by the exhaled breath condensate pH. In this study, we observed that young smokers >= 2.5 were older compared to YNS and smokers < 2.5 (p < 0.01). Compared with YNS, smokers >= 2.5 had higher body mass index (p=0.036), heart rate (p=0.001) and systolic blood pressure (p=.036). Smokers >= 2.5 complained more about cough (p = 0.05) and post-nasal discharge (p=0.016) when compared to YNS and smokers < 2.5. No significant differences were found in the total score of the SNOT-20 (p=0.140), in the pulmonary function test and mucus contact angle (p=0.803) between groups. The saccharine transit time was significantly lower in young smokers (5.9 ± 3.1 minutes) compared to YNS (7.7 ± 4.1 minutes, p=0.033). The number of total cells in nasal lavage fluid were greater in smokers < 2.5 (48±14) and smokers >= 2.5 (37 ± 25) compared to YNS (24 ± 12, p < 0.001). We also found greater number of macrophages (p=0.001), ciliated cells (p=0.008) and goblet cells (p = 0.004) in smokers < 2.5 and smokers >= 2.5 compared to YNS and a higher concentration of myeloperoxidase in smokers < 2.5 compared to smokers >= 2.5 (p=0.005). The EBC pH were lower in smokers >= 2.5 (7.65 ± 0.42) compared with smokers < 2.5 (7.83 ± 0.26) and with YNS (7.90 ± 0.21, p=0.038). Linear regression analysis confirmed a significant dose-dependent effect of smoking in decreasing EBC pH (r= -0.47, p < 0.001). We conclude that cigarette smoking induces changes in nasal mucociliary clearance, nasal inflammation and inflammation in the lower airways in young smokers aged less than 35 years and these changes are associated with smoking history

O tabagismo está fortemente associado ao desenvolvimento da Doença Pulmonar Obstrutiva Crônica, porém poucos estudos que relatam alterações funcionais ou inflamatórias nas vias aéreas superiores em jovens são encontrados na literatura. Nosso objetivo foi investigar as alterações funcionais e inflamatórias nas vias aéreas superiores e inferiores em jovens tabagistas com idade igual ou inferior a 35 anos. Setenta e dois indivíduos participaram do estudo: 32 jovens não tabagistas (JNT) saudáveis (21±4 anos, 29 homens) e 40 jovens tabagistas subdivididos de acordo com a carga tabágica: menor que 2,5 anos-maço (< 2,5) (19±2 anos, 20 homens) e igual ou maior que 2,5 anos-maço (>= 2,5) (24 ± 5 anos, 17 homens e três mulheres). Foram avaliados os dados demográficos, os dados clínicos, os sintomas de desconforto das vias aéreas por meio do questionário SNOT-20, os volumes e capacidades pulmonares por meio do teste de função pulmonar, o transporte mucociliar nasal por meio do teste de tempo de trânsito da sacarina, a propriedade de superfície do muco nasal por meio do ângulo de contato, a inflamação na cavidade nasal por meio da contagem total e diferencial das células e citocinas em lavado nasal e a inflamação de vias aéreas inferiores por meio do pH do condensado do ar exalado. Observamos neste estudo que os jovens tabagistas >= 2,5 foram mais velhos comparados aos JNT e com os tabagistas < 2,5 (p < 0,01). Comparados com os JNT, os tabagistas >= 2,5 apresentaram maior índice de massa corporal (p=0,036), de frequência cardíaca (p=0,001) e de pressão arterial sistólica (p=0,036). Os tabagistas >= 2,5 apresentaram maior queixa sobre tosse (p=0,05) e secreção nasal escorrendo para a garganta (p=0,016) quando comparados com os JNT e tabagistas < 2,5. Não encontramos diferenças significativas na pontuação total do questionário SNOT-20 (p=0,140), nos valores do teste de função pulmonar e nos valores do ângulo de contato (p=0,803) entre os grupos. O tempo de trânsito da sacarina foi significativamente menor nos jovens tabagistas (5,9 ± 3,1 minutos) quando comparados aos JNT (7,7 ± 4,1 minutos, p=0,033). Na análise do lavado nasal encontramos maior número de células totais em tabagistas < 2,5 (48+-14) e tabagistas >= 2,5 (37+-25) comparados aos JNT (24+-12, p < 0,001). Encontramos também maior número de macrófagos (p=0,001), células ciliadas (p=0,008) e células caliciformes (p=0,004) nos tabagistas < 2,5 e tabagistas >= 2,5 quando comparados aos JNT, e maiores concentrações de mieloperoxidase nos tabagistas < 2,5 comparados aos tabagistas >= 2,5 (p=0,005). Os valores do pH do EBC foram menores em tabagistas >= 2,5 (7,65 ± 0,42) comparados com os tabagistas < 2,5 (7,83 ± 0,26) e com os JNT (7,90 ± 0,21, p=0,038). Por meio de análise de regressão linear, verificamos um efeito dose-dependente significativo do tabagismo sobre a redução dos valores do pH do EBC (r=-0,47, p < 0,001). Concluímos que o tabagismo em jovens tabagistas com idade igual ou inferior a 35 anos induz alterações do transporte mucociliar nasal, inflamação nasal e inflamação em vias aéreas inferiores e que essas alterações estão associadas à carga tabágica / Cigarette smoking is strongly associated with the development of Chronic Obstructive Pulmonary Disease, but few studies that reported functional or inflammatory changes in upper airway in young are found in the literature. We aimed to evaluate the effects of smoking on nasal mucociliary clearance, the mucus surface property and if there is inflammation in the nasal cavity and lower airways in young smokers aged less than 35 years. Of the 200 individuals contacted by telephone, 72 individuals entered in the study: 32 healthy young nonsmokers (YNS) (21 ± 4 years, 29 male) and 40 young smokers, subdivided according to smoking history: less than 2.5 pack-years (< 2.5) (19 ± 2 years, 20 male) and 2.5 pack-years or more ( >= 2.5) (24 ± 5 years, 17 male and three female). We assessed demographic data, clinical data, SNOT-20 questionnaire for symptoms of airway discomfort, the volumes and lung capacities by the pulmonary function test, the nasal mucociliary clearance using the saccharine transit test, the mucus surface property by the contact angle, the inflammation in the nasal cavity by the total and differential count of cells and cytokines in nasal lavage and inflammation of the lower airways by the exhaled breath condensate pH. In this study, we observed that young smokers >= 2.5 were older compared to YNS and smokers < 2.5 (p < 0.01). Compared with YNS, smokers >= 2.5 had higher body mass index (p=0.036), heart rate (p=0.001) and systolic blood pressure (p=.036). Smokers >= 2.5 complained more about cough (p = 0.05) and post-nasal discharge (p=0.016) when compared to YNS and smokers < 2.5. No significant differences were found in the total score of the SNOT-20 (p=0.140), in the pulmonary function test and mucus contact angle (p=0.803) between groups. The saccharine transit time was significantly lower in young smokers (5.9 ± 3.1 minutes) compared to YNS (7.7 ± 4.1 minutes, p=0.033). The number of total cells in nasal lavage fluid were greater in smokers < 2.5 (48±14) and smokers >= 2.5 (37 ± 25) compared to YNS (24 ± 12, p < 0.001). We also found greater number of macrophages (p=0.001), ciliated cells (p=0.008) and goblet cells (p = 0.004) in smokers < 2.5 and smokers >= 2.5 compared to YNS and a higher concentration of myeloperoxidase in smokers < 2.5 compared to smokers >= 2.5 (p=0.005). The EBC pH were lower in smokers >= 2.5 (7.65 ± 0.42) compared with smokers < 2.5 (7.83 ± 0.26) and with YNS (7.90 ± 0.21, p=0.038). Linear regression analysis confirmed a significant dose-dependent effect of smoking in decreasing EBC pH (r= -0.47, p < 0.001). We conclude that cigarette smoking induces changes in nasal mucociliary clearance, nasal inflammation and inflammation in the lower airways in young smokers aged less than 35 years and these changes are associated with smoking history

Introduction: Endoscopic sinus surgery (ESS) is at present the gold standard therapeutic modality for chronic rhinosinusitis (CRS) resistant to medical therapy. Whilst results from ESS for CRS are generally good, postoperative bleeding and impaired wound healing with adhesion formation remains a concern. Due to patient discomfort and the detrimental effects on wound healing caused by most packing materials, many surgeons no longer routinely use nasal packing. Surgeons have in the past sought agents which would provide post-operative haemostasis without detrimentally affecting wound healing. Antifibrinolytics have been available for many years, however, their topical application has only been explored in the last few years. Recently different forms of chitosan have separately shown significant promise as powerful haemostatic and anti-adhesion agents. The aim of this thesis was to explore the progressive understanding of the interaction between haemostasis and wound healing with possible development of a novel agent. Methods: The first step to scientifically assess bleeding after sinus surgery was to develop a standardised method of video endoscopy and grading the surgical field during ESS. This was done as a multinational collaborative trial. Once this assessment tool was validated a randomised controlled trial evaluating the effect of two antifibrinolytics (epsilon aminocaproic acid and tranexamic acid) was conducted. Further evaluation was then conducted on other possible hemostatic and antiadhesion substances. This included various combinations of a novel chitosan gel. These gels were trialled in vitro to determine their effect on human nasal fibroblasts derived from CRS patients. Fibroblast adhesion and proliferation as well as closure of standardised wounds were studied. The most promising of these gels was then used in an in vivo sheep model. Once effectiveness of the chitosan-dextran gel was shown in the laboratory, this was evaluated against a number of currently available hemostatic and anti-adhesion substances in a standardised model of wound healing in sheep with CRS. This model had been previously extensively validated in our department. Full thickness mucosal injuries were created on the lateral nasal wall and ethmoids of twenty sheep and recombinant tissue factor (rTF), SprayGel or Chitosan-Dextran derivative gel applied topically in a randomized fashion. Adhesion formation and severity as well as microscopic wound healing and ciliary function were analysed at day 28, 56, 84 and 112 post initial surgery. A further sheep study was conducted applying chitosan dextran gel to standardised mucosal injuries and comparing its effect on the control of bleeding to control. Bleeding time and grade were recorded and wound healing monitored via serial videoendoscopy over two weeks and objectively measured. Results: a) Assessment of the bleeding scales showed that inter and intra observer reliability for both scales tested were significantly improved by employing a standardized video-endoscopy technique. The Wormald scale proved to be more reliable and sensitive to changes in the most common surgical fields encountered in ESS. b) Tranexamic acid showed a modest but clinically significant improvement in the surgical field at 2, 4 and 6 minutes after application. Epsilon aminocaproic acid did not effectively improve the surgical field. c) Nasal fibroblast adhesion and proliferation were significantly impaired with dextran and chitosan. The most effective ratio that delayed but did not prevent wound closure were 5 % chitosan: 5 % dextran gel. d) In a standardised sheep model of mucosal wound healing the chitosan gel significantly decreased lateral nasal wall and ethmoidal adhesions at all time points. The chitosan group had a significantly greater percentage of re-epithelialisation and reciliation than control and rTF. In addition the mean cilial grade in the chitosan group was significantly better than control. e) The chitosan dextran gel was significantly more haemostatic at 2,4, and 6 minutes after injury with no significant difference noted in wound healing. Conclusions: Standardised methods of videoendoscopy and grading the surgical field in ESS are valuable tools for further research. Tranexamic acid significantly improved the surgical field to a moderate degree in ESS compared to control. Chitosan gel is a promising new powerful haemostatic bio-polymer which has a mild inhibitory effect on fibroblast attachment and proliferation. This may partially explain the significant improvement in microscopic wound healing and reduction in adhesion formation seen in a sheep model of chronic sinusitis. Future work evaluating this gel in the setting of a human trial is currently underway. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1375402 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2009

Introduction: Endoscopic sinus surgery (ESS) is at present the gold standard therapeutic modality for chronic rhinosinusitis (CRS) resistant to medical therapy. Whilst results from ESS for CRS are generally good, postoperative bleeding and impaired wound healing with adhesion formation remains a concern. Due to patient discomfort and the detrimental effects on wound healing caused by most packing materials, many surgeons no longer routinely use nasal packing. Surgeons have in the past sought agents which would provide post-operative haemostasis without detrimentally affecting wound healing. Antifibrinolytics have been available for many years, however, their topical application has only been explored in the last few years. Recently different forms of chitosan have separately shown significant promise as powerful haemostatic and anti-adhesion agents. The aim of this thesis was to explore the progressive understanding of the interaction between haemostasis and wound healing with possible development of a novel agent. Methods: The first step to scientifically assess bleeding after sinus surgery was to develop a standardised method of video endoscopy and grading the surgical field during ESS. This was done as a multinational collaborative trial. Once this assessment tool was validated a randomised controlled trial evaluating the effect of two antifibrinolytics (epsilon aminocaproic acid and tranexamic acid) was conducted. Further evaluation was then conducted on other possible hemostatic and antiadhesion substances. This included various combinations of a novel chitosan gel. These gels were trialled in vitro to determine their effect on human nasal fibroblasts derived from CRS patients. Fibroblast adhesion and proliferation as well as closure of standardised wounds were studied. The most promising of these gels was then used in an in vivo sheep model. Once effectiveness of the chitosan-dextran gel was shown in the laboratory, this was evaluated against a number of currently available hemostatic and anti-adhesion substances in a standardised model of wound healing in sheep with CRS. This model had been previously extensively validated in our department. Full thickness mucosal injuries were created on the lateral nasal wall and ethmoids of twenty sheep and recombinant tissue factor (rTF), SprayGel or Chitosan-Dextran derivative gel applied topically in a randomized fashion. Adhesion formation and severity as well as microscopic wound healing and ciliary function were analysed at day 28, 56, 84 and 112 post initial surgery. A further sheep study was conducted applying chitosan dextran gel to standardised mucosal injuries and comparing its effect on the control of bleeding to control. Bleeding time and grade were recorded and wound healing monitored via serial videoendoscopy over two weeks and objectively measured. Results: a) Assessment of the bleeding scales showed that inter and intra observer reliability for both scales tested were significantly improved by employing a standardized video-endoscopy technique. The Wormald scale proved to be more reliable and sensitive to changes in the most common surgical fields encountered in ESS. b) Tranexamic acid showed a modest but clinically significant improvement in the surgical field at 2, 4 and 6 minutes after application. Epsilon aminocaproic acid did not effectively improve the surgical field. c) Nasal fibroblast adhesion and proliferation were significantly impaired with dextran and chitosan. The most effective ratio that delayed but did not prevent wound closure were 5 % chitosan: 5 % dextran gel. d) In a standardised sheep model of mucosal wound healing the chitosan gel significantly decreased lateral nasal wall and ethmoidal adhesions at all time points. The chitosan group had a significantly greater percentage of re-epithelialisation and reciliation than control and rTF. In addition the mean cilial grade in the chitosan group was significantly better than control. e) The chitosan dextran gel was significantly more haemostatic at 2,4, and 6 minutes after injury with no significant difference noted in wound healing. Conclusions: Standardised methods of videoendoscopy and grading the surgical field in ESS are valuable tools for further research. Tranexamic acid significantly improved the surgical field to a moderate degree in ESS compared to control. Chitosan gel is a promising new powerful haemostatic bio-polymer which has a mild inhibitory effect on fibroblast attachment and proliferation. This may partially explain the significant improvement in microscopic wound healing and reduction in adhesion formation seen in a sheep model of chronic sinusitis. Future work evaluating this gel in the setting of a human trial is currently underway. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1375402 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2009

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 5 uppsatser.

INTRODUÇÃO: Embora seja reconhecida a existência do espessamento da membrana basal e da fibrose da concha nasal na rinite alérgica, não há estudos descritivos do comportamento da mucosa nasal nos pacientes com rinite idiopática. O propósito desse estudo é descrever possíveis alterações na membrana basal e na lâmina própria da concha nasal inferior em pacientes com rinite alérgica ou idiopática, além do estudo quantitativo das fibras colágenas nesta localização. MÉTODOS: Analisou-se na concha nasal inferior obtida através de turbinectomia bilateral em 28 pacientes - 14 com rinite alérgica e 14 com rinite idiopática - a área ocupada pelo colágeno, a espessura da membrana basal e o diâmetro das fibrilas de colágeno através do uso de microscopia óptica (coloração Hematoxilina-eosina e Picrossírius-hematoxilina), microscopia eletrônica e imunoistoquímica para laminina e colágeno IV. RESULTADOS: 1) pacientes com rinite alérgica apresentaram significantemente maior área da concha nasal ocupada por colágeno do que o grupo com rinite idiopática. 2) a membrana basal de pacientes com rinite alérgica foi significantemente mais espessa. 3) a lâmina reticular da membrana basal dos pacientes com rinite alérgica apresentaram fibrilas de colágeno com menor diâmetro que os pacientes com rinite idiopática. 4) não houve diferenças significativas entre os grupos na distribuição de laminina e de colágeno IV. CONCLUSÕES: Alterações na mucosa nasal ocorrem na rinite alérgica, sendo caracterizadas pelo aumento da espessura da membrana basal e por fibrose. Na rinite idiopática, observou-se uma mucosa com aspecto estrutural semelhante aos pacientes normais / INTRODUCTION: Despite our knowledge about nasal conchae fibrosis and basement membrane thickening in allergic rhinitis, there are no descriptive studies on nasal mucosa behavior in patients with idiopathic rhinitis. The aim of our study was to describe possible changes in the basement membrane and lamina propria of the inferior concha in patients with idiopathic or allergic rhinitis, in addition to a quantitative study of collagen fibers in this site. METHODS: The inferior nasal concha obtained from 28 patients submitted to bilateral turbinectomy was examined - 14 with allergic rhinitis and 14 with idiopathic rhinitis; analyzing the collagen area, the basement membrane thickness and the collagen fibrils diameter using optical microscopy (Hematoxylin-eosin and Picrosirius-hematoxylin staining), electron microscopy and immunohistochemistry for laminin and collagen IV. RESULTS: 1) patients with allergic rhinitis had a significantly larger area of the nasal concha occupied by collagen than the group with idiopathic rhinitis. 2) the basement membrane of patients with allergic rhinitis was significantly thicker. 3) the reticular lamina of the basement membrane of patients with allergic rhinitis had collagen fibrils with diameters which were smaller than those from patients with idiopathic rhinitis. 4) there were no significant differences between the groups concerning the distribution of laminin and collagen IV. CONCLUSIONS: Alterations to the nasal mucosa that happen in allergic rhinitis are characterized by basement membrane thickening and fibrosis. In idiopathic rhinitis the patients\' mucosae were structurally similar to those from normal patients