Sensory input from the laryngeal mucosa is vital for triggering protective airway reflexes. The laryngeal adductor reflex (LAR) is a brief vocal fold adductor reflex in response to stimulation of the laryngeal mucosa. Depressed LAR may lead to aspiration of foreign substances into the airway. Loss of laryngeal sensation has thus been considered as one of the risk factors associated with aspiration and airway complications in patients with dysphagia. Laryngeal sensation can be endoscopically tested by lightly and briefly touching a patient’s arytenoids or epiglottis with the tip of a flexible laryngoscope (the touch method). In a preliminary study, we endoscopically investigated the laryngeal sensation and swallowing ability of healthy adults and patients with dysphagia. The results indicated an association between sensory deficits as determined by the touch method and penetration/aspiration of trial boluses in both healthy adults and patients with dysphagia. However, the pressure applied to the larynx using this touch method might not be consistent, and the expected responses elicited by this method were uncertain. Study 1 of this dissertation investigated the variability in the pressure delivered by clinicians using the touch method. The study also reported on the types of various subject responses to the touches. The results revealed that there was a wide range of pressure levels exerted by examiners. This suggested the need for further research to establish the validity of this diagnostic tool. The study also showed that the LAR always occurred in response to touch in normal volunteers, suggesting that this technique may be quite sensitive at detecting sensory deficits in a person who does not exhibit an LAR in response to touch. Study 2 examined hospitalized patients with symptoms of dysphagia. The question of interest was whether an absent LAR in response to touch was associated with aspiration or pneumonia. No significant association was found between absent LAR and aspiration of food or liquid; however, a significant association was observed between absent LAR and the occurrence of pneumonia. The study indicated that the touch method has potential for predicting pneumonia in patients with swallowing problems. / 2017-11-07T00:00:00Z

Made available in DSpace on 2014-06-11T19:22:14Z (GMT). No. of bitstreams: 0 Previous issue date: 2005Bitstream added on 2014-06-13T20:48:33Z : No. of bitstreams: 1 pinotti_kf_me_botfm.pdf: 691624 bytes, checksum: 91a24e4114a1154568a2a8f616cecf0b (MD5) / Fundação para o Desenvolvimento Médico e Hospitalar (Famesp) / A radiografia simples de tórax (RX) é um exame já consagrado, no derrame pleural parapneumônico (DPP), mas através dela não é possível determinar a viscosidade do líquido, presença de loculações ou encarceramento pulmonar, que podem ser avaliados pela ultrassonografia torácica (US). Avaliar prospectivamente a utilidade da US feita antes da drenagem em crianças internadas com DPP. Todas as crianças internadas com diagnóstico de DPP após RX deveriam passar pela US onde eram avaliadas: loculação pleural, ecogenicidade e quantidade de líquido estimada. Após punção era avaliado o aspecto, pH e bioquímicos do líquido pleural. Nos drenados era aferido o volume do líquido drenado para comparação com o volume estimado pela US. Os pacientes sem melhora clínica ou radiológica após drenagem eram encaminhados para procedimento cirúrgico maior. De agosto de 2001 a julho de 2003 foram avaliadas 52 crianças (31?, 21?) com idade de 5 meses a 13 anos, predominando a faixa etária menor que 2 anos. Destas, foi realizada US em 48, das quais 35 foram drenadas e 13 tratadas clinicamente. Dois dos drenados necessitaram de cirurgia maior. A US mostrou derrame livre em 38 e loculado em 10 casos. Dos livres foram drenados 25 (65,8%) e dos loculados 10 (100%). Quanto à ecogenicidade13 eram anecóicos, 18 espessos com septações e 17 espessos sem septações; foram drenados 6 anecóicos (46,15%), 15 espessos com septação (83,33%) e 14 espessos sem septação (82,35%). O volume de líquido estimado pela US variou de 20 a 860 ml. Quanto à ecogenicidade, o volume do líquido foi significativamente maior nos espessos com septação, e quanto à loculação foi significativamente maior nos loculados. Não houve diferença significante nos bioquímicos quando os grupos foram separados pela ecogenicidade, mas o pH e glicose pleurais foram significantemente menores e o DHL significativamente... / Utility of thoracic ultrasound in the management of parapneumonic effusions in children. Thoracic radiography, a well-known procedure in parapneumonic effusion (PPE), cannot evaluate fluid viscosity, the presence of loculations or trapped lung, all of which can be established by thoracic ultrasound (US). Prospectively evaluate the utility of US before pleural drainage in children with PPE. All children hospitalized for PPE, identified by thoracic radiography, underwent US to assess pleural loculation, echogenicity, and amount of pleural fluid. After thoracocentesis, the extracted fluid was examined for gross appearance and was submitted to biochemical analysis. Among patients who underwent pleural drainage, the amount of fluid obtained from the procedure was compared to the amount estimated by US. Patients without clinical or radiological improvement underwent a more significant surgical procedure. From August 2001 to July 2003, 52 children (31 male, 21 female) were examined. These children ranged in age from 5 months to 13 years with the majority under the age of two. An US was performed on 48 of these children, 35 of whom received chest tube drainage and 13 of whom only received clinical treatment. Two pleural drainage patients, required a more significant surgical procedure. US identified 38 patients with free-flowing pleural fluid and 10 with loculated pleural fluid. Twenty five of the patients (65.8%) with free-flowing pleural fluid and 10 (100%) with loculation received chest tube drainage. Among patients with echogenicity, 13 were anechoic, 17 echoic without septations and 18 echoic with septations; 6 anaechoic (46.15%), 14 echoic without septations (82.35%) and 15 echoic with septations (83.33%) required chest tube drainage. The amount of fluid estimated by US varied from 20 to 860 ml. The volume of fluid was higher among patients that were echoic with... (Complete abstract click electronic access below)

Pseudomonas aeruginosa (Pa) est un pathogène opportuniste responsable d’infections pulmonaires aigues graves chez les malades prédisposés. Devant l’émergence croissante de la résistance aux antibiotiques, le développement de thérapeutiques alternatives adjuvantes est indispensable et nécessite la compréhension des interactions hôte-pathogènes au cours de l’infection. La voie métabolique de dégradation du tryptophane appelée voie des kynurénines produit chez l’hôte des métabolites aux propriétés immunomodulatrices connues. Récemment, l’existence de cette voie a été mise en évidence chez Pa, bien que la nature et la quantité de métabolites produits ne soient pas parfaitement connus. La production bactérienne de kynurénines pourrait interférer avec la mise en place de la réponse immunitaire de l’hôte et sa régulation au cours des différentes phases de l’infection, altérant la balance immunitaire pulmonaire au profit du pathogène. A ce titre, la voie des kynurénines de Pa constituerait une cible thérapeutique potentielle. L’objectif de ce travail de thèse est d’étudier l’implication de la voie des kynurénines de Pa dans la virulence bactérienne et la réponse immune de l’hôte dans un modèle murin d’agression respiratoire aiguë. Pour cela, les souris sont infectées avec des souches sauvages de Pa, avec des souches mutantes ΔkynA, non productrices de kynurénines, et des souches ΔkynU, surproductrices de kynurénines. Les interactions potentielles avec la voie des kynurénines de l’hôte sont explorées en inhibant la première enzyme de la voie métabolique, l’indoleamine-2,3-dioxygenase (IDO). Enfin, le rôle du récepteur arylhydrocarbone (AhR), récepteur connu des kynurénines et impliqué dans l’immunité pulmonaire, est exploré en comparant la réponse à l’infection de souris AhR KO à celle des souris sauvages. Dans ce travail, nous décrivons tout d’abord la production des différents métabolites de la voie des kynurénines de Pa in vitro et in vivo dans le modèle d’infection respiratoire aigue, en décrivant pour la première fois la production d’acide kynurénique et de 3-hydroxy-kynurénine pour cette bactérie. Ensuite, nous montrons que les kynurénines bactériennes interfèrent avec la réponse immune de l’hôte, en majorant le recrutement cellulaire alvéolaire, tout en atténuant le niveau d’inflammation et l’activation des cellules présentatrices d’antigènes. Enfin, nous rapportons que l’IDO et l’AhR sont impliqués dans cette immunomodulation, faisant des kynurénines bactériennes des agents du dialogue hôte-pathogène au cours de l’infection respiratoire aigue. A la lumière de ces résultats, la voie des kynurénines pourrait constituer une cible thérapeutique d’intérêt dans les infections respiratoires à P. aeruginosa. / Pseudomonas aeruginosa (Pa) is a Gram-negative bacteria frequently involved in healthcare-associated pneumonia and considered as a « problem-pathogen ». To face the announced post-antibiotic era due to increasing resistance and lack of new antibiotics, new treatment strategies have to be developed. During pneumonia, lung injury results from both bacterial-mediated virulence and host response. Modulation of an overreacting host response could be an alternative therapeutic target in Pa-induced lung infection. Kynurenines are small molecules resulting from tryptophan degradation with reported immunomodulatory properties. Pa is known to produce kynurenine, but the functional enzymes, types and amounts of secreted metabolites are poorly known. Interestingly, many host cells also possess the kynurenine pathway, whose metabolites are known to control immune system homeostasis. The following experiments aim to determine whether bacterial metabolites can interfere with the host’s immune response, leading to a possible immunomodulatory interplay between bacteria and host kynurenine pathways, impacting on the pathophysiology of P. aeruginosa infection. To that goal, we use a murin model of acute lung injury. Mice were infected with WT strain of Pa, compared to mutant strains unable to produce kynurenine (ΔkynA), and mutant strains overproducing them (ΔkynU). Moreover, we studied the interactions between bacterial and host kynurenine pathways by inhibiting the first enzyme of the host pathway called indoleamine-2,3-dioxygenase (IDO). Finally, we assessed the role of the arylhydrocarbon receptor (AhR), a known receptor to kynurenine involved in lung immunity, using AhR KO mice. First, we assess types and levels of metabolites produced by Pa in an in vitro model, and the relevance of this production in vivo. We show for the first time that Pa is able to secrete kynurenine at clinically relevant levels, and other metabolites such as kynurenic acid and 3 OHkynurenine, what was unknown to date. Second, we show that bacterial metabolites were able to modulate the host innate immune response, by increasing alveolar recruitment of neutrophils, associated with decreased inflammatory cytokines levels and impairment of antigen-presenting cells activation. Finally, we report that IDO and AhR are involved in this kynurenine-mediated immunomodulation. These data suggest that pulmonary infection with a bacteria highly expressing the kynurenine pathway enzymes could lead to an imbalance in the immune response to infection, thus constituting a potential therapeutic target to improve Pa-induced pneumonia outcome.

Dentre as principais preocupações relacionadas à cadeia de produção do biodiesel está o excedente de glicerina bruta. Esta corresponde a cerca de 10% da massa total resultante do processo de produção do biodiesel e vem sendo acumulada e armazenada nas usinas, formando grandes estoques de resíduos e deixando diversas empresas diante de um passivo ambiental agravante. Uma forma de diminuir esse problema é utilizá-la para formulação de meios de fermentação para obtenção de produtos de interesse econômico. Exemplos são as produções de dióis como; 1,3-Propanodiol (1,3-PD) e 2,3-Butanodiol (2,3-BD). Estes são monômeros de grande aplicação no mercado, sendo o 1,3-PD usado para fabricação de poliuretanos, compostos cíclicos e novos tipos de poliésteres. O 2,3-BD é utilizado como anticongelante, biocombustível e como um importante aromatizante. Assim, no presente trabalho propõe-se valorizar a glicerina residual da fabricação de biodiesel, visando sua bioconversão em 2,3-BD e 1,3-PD, pela bactéria Klebsiella pneumoniae NRRL B199. Para tanto, a proposta deste trabalho compreendeu quatro etapas conjuntas: 1. Estabelecer um tratamento adequado para a glicerina residual de forma a permitir o crescimento bacteriano e formação dos dióis. 2. Adequar à composição do meio de fermentação, quanto às concentrações de glicerol, com suplementação de glicose, extrato de levedura e elementos traço Fe2+, Zn2+ e Mn2+ no processo fermentativo. 3. Definir a melhor condição de transferência de oxigênio em sistema descontínuo, associada à concentração de substrato, para a melhor formação de produtos. 4. Avaliar o procedimento de separação dos produtos do meio pela técnica de salting-out. Os estudos da etapa 1 e 2 foram realizados em frascos Erlenmeyer de 250 mL com 50 mL de meio. Na etapa 3, o estudo de aeração e agitação foi realizado em fermentador Bioflo III (New Brunswick Sci. Co.) de 1,25 L. Com os resultados obtidos, concluiu-se que o tratamento realizado foi adequado para o emprego da glicerina residual como fonte de carbono para o crescimento da bactéria Klebsiella pneumoniae. Além disso, os trabalhos realizados em frascos revelaram uma produção máxima, em agitação de 200 rpm, de 0,545 g/L.h de 2,3-BD e produção de 0,180 g/L.h de 1,3-PD em agitação de 160 rpm. Sendo que a glicose e o extrato de levedura tiveram efeitos positivos e significativos na produtividade de 2,3-BD e 1,3-PD. Nos ensaios onde foram utilizados maiores transferência de oxigênio observou-se decréscimos na produção de 1,3-PD e uma melhora significativa na produção de 2,3-BD. No estudo de recuperação dos dióis, foi possível recuperar 82% dos dióis utilizando carbonato de potássio 70% na temperatura de 20 ºC e no tempo de reação de 6 horas. / Among the main concerns related to the production of biodiesel is the surplus of crude glycerine. This corresponds to approximately 10% of the total mass of the biodiesel production process and has been accumulated and stored in the biodiesel plants, creating enormous amounts of waste and serious environmental problems. A way to lessen this problem is to use it for the formulation of fermentation medium to obtain products of economic interest. Examples are the production of diols such as, 1,3-propanediol (1,3-PD) and 2,3-butanediol (2,3-BD). These monomers are large market application, and the 1,3-PD used for the manufacture of polyurethanes, cyclic compounds and new types of polyesters. The 2,3-BD is used as antifreeze, biofuel and as an important flavoring. Thus, in present work aims to enrich the residual glycerine from biodiesel production to its bioconversion in 2,3-BD and 1,3-PD by bacterium Klebsiella pneumoniae NRRL B199. Therefore, the purpose of this consisted of four joint steps: 1st. Establish an appropriate treatment for residual glycerine to allow bacterial growth and diols formation. 2nd. To adapt the composition of fermentation medium, as concentrations of residual glycerine, with glucose supplementation, yeast extract and trace elements of Fe2+, Zn2+ e Mn2+ in the fermentation process. 3rd. Define the best condition of oxygen transfer in a batch system, associated with substrate concentration for the best product formation. 4th. To evaluate the separation procedure of products through the of salting-out technique. Studies of step 1 and 2 were conducted in 250 mL Erlenmeyer flasks with 50 mL medium. In step 3, the study aeration and agitation was performed in Bioflo III fermentor (New Brunswick Sci Co.) was 1,25 L. With the results, it was concluded that the treatment was adequate for use of residual glycerine as carbon source for growth of the bacterium Klebsiella pneumoniae. Furthermore, the work carried out on bottles showed a maximum production 2,3-BD of 0.545 g/L.h in agitation of 200 rpm and production 1,3-PD of 0.180 g/Lh in agitation of 160 rpm. With glucose and yeast extract had positive and significant effects on productivity of 2,3-BD and 1,3-PD. For tests were used higher oxygen transfer observed decrease in the production of 1,3-PD and a significant improvement in the production of 2,3-BD. In the study of recovery of diols, it was possible to recover 82% of diols using 70% potassium carbonate at temperature of 20 °C and in reaction time of 6 hours.

INTRODUÇÃO: A relevância do parênquima pulmonar distal na fisiopatologia da asma tem sido intensamente enfatizada. Vários estudos sugerem a inibição da Rho quinase como uma intervenção benéfica e promissora na asma. Entretanto, não há estudos anteriores que avaliaram os efeitos destes inibidores na modulação da mecânica do parênquima pulmonar e suas alterações histopatológicas em um modelo animal de inflamação pulmonar alérgica crônica. OBJETIVO: Avaliar a inibição da Rho quinase (Y-27632) na modulação da responsividade, inflamação, remodelamento da matriz extracelular e ativação do estresse oxidativo no parênquima pulmonar de cobaias com inflamação pulmonar alérgica crônica. MÉTODOS: As cobaias receberam sete inalações de ovalbumina (1-5 mg / ml; grupo OVA) ou salina (grupo SAL) ao longo de quatro semanas. A partir da quinta inalação, os animais do grupo Rho quinase foram submetidos a inalação com Y-27632, 10 minutos antes de cada inalação com OVA ou SAL. Setenta e duas horas após a sétima inalação, os animais foram anestesiados e exanguinados, e das tiras do tecido pulmonar foram realizadas a mecânica oscilatória, sob condições basais e após o desafio de ovalbumina (0,1%). Após a mecânica, as fatias de pulmão foram submetidas a análise histológica por meio da morfometria. RESULTADOS: A inibição de Rho quinase nos animais expostos à ovalbumina atenuou a elastância e a resistência tecidual, o número de eosinófilos, a expressão de IL-2, IL-4, IL-5, IL-13, TIMP-1, MMP-9, TGF-, IFN-g, NF-kB e iNOS e o conteúdo de 8-iso-PGF2, fibras elásticas, fibras colágenas e actina em comparação com o grupo OVA (P<0,05). CONCLUSÃO: A inibição da Rho quinase contribui para o controle da capacidade de responsividade do parênquima pulmonar, da inflamação eosinofílica, das respostas Th1/Th2, ao controle do remodelamento da matriz extracelular em um modelo animal de inflamação pulmonar alérgica crônica. Podendo ser considerada uma futura ferramenta farmacológica para o tratamento de doenças pulmonares crónicas. / RATIONALE: Previous studies with Rho-kinase inhibitors suggest a beneficial influence of these drugs in asthma. The relevance of distal lung tissue in functional asthmatic impairment has been intensely emphasized. There have not been any previous studies evaluating the effects of these inhibitors on the modulation of distal lung mechanics and histopathological alterations in an animal model of chronic pulmonary inflammation. OBJECTIVE: To evaluate if Rho-kinase inhibition (Y- 27632) modulates distal lung responsiveness, inflammation, extracellular matrix remodeling and oxidative stress activation in guinea pigs with chronic allergic inflammation. METHODS: Guinea pigs received seven inhalations of ovalbumin (1-5 mg/ml; OVA group) or saline (SAL group) over 4 wk. From the 5th inhalation, the Rho-kinase group animals were submitted to Y-27632 inhalation 10 min before each inhalation with OVA or SAL. Seventy-two hours after the seventh inhalation, the animals were anesthetized and exsanguinated, and oscillatory mechanics of the lung tissue strips were performed under the baseline condition and after the ovalbumin challenge (0.1%). Afterwards, the lung slices were submitted to morphometry. RESULTS: The Rho-kinase inhibition in the ovalbumin-exposed animals attenuated the tissue elastance and resistance, eosinophils, the IL-2, IL-4, IL-5, IL-13, TIMP-1, MMP-9, TGF-, IFN-g, NF-kB, iNOS-positive cells and the 8-iso-PGF2, elastic, collagen and actin content compared with the OVA group (P<0.05). CONCLUSION: Rho-kinase inhibition contributes to the control of distal lung responsiveness and the eosinophilic and Th1/Th2 responses to the control of extracellular matrix remodeling in an animal model of chronic allergic inflammation. It may be considered a future pharmacological tool for the treatment of chronic pulmonary diseases.

Ventilator associated pneumonia (VAP) and acute respiratory distress syndrome (ARDS) are two respiratory conditions unique to mechanically ventilated patients. The diagnosis of these conditions, and therefore any subsequent treatment, are befuddled by uncertainty. VAP rates vary considerably according to the diagnostic or surveillance criteria used. The pathogenesis of ARDS is well understood but when the internationally agreed consensus criteria are employed, the histological hallmarks are absent about half the time, indicating a disconnection between the clinical diagnosis and what is known about the biology of this condition. It is argued that tests of biological function should be considered in addition to clinical characteristics in order to improve the utility of diagnosis. Given that the pathological sequelae of both VAP and ARDS are driven by an over exuberant host neutrophil response, the activated neutrophil was selected as a potential biological imaging target. Optical molecular imaging uses visible and near visible wavelengths from the electromagnetic spectrum to derive or visualize information based on the optical properties of the target tissue. Optical wavelengths are safe and cheap to work with, producing much higher resolution images than those relying on x-rays or gamma radiation. The imaging modality can be coupled with exogenously applied chemistry to identify specific biological targets or processes. The hypothesis that optical molecular imaging could be used to detect activated neutrophils in real time in the alveolar region of patients was tested. A bespoke optical molecular imaging agent called Neutrophil Activation Probe (NAP), designed in-house, was used to test the hypothesis. NAP is a dendrimeric compound delivered to the alveolar region of a patient in microdoses (≤100 micrograms), becoming fluorescent only on contact with activated neutrophils, and can be detected by optical endomicroscopy. Both the imaging agent and the endomicroscope are delivered to the distal lung via routine bronchoscopy. The agent was tested extensively in the laboratory to demonstrate function, specificity, and safety. Ex vivo testing took place using human and ovine lungs. A regulated dose escalation Phase I clinical trial of investigational medicinal product (CTIMP) in healthy volunteers, patients with bronchiectasis, and mechanically ventilated patients with a pulmonary infiltrate on chest radiography (NCT01532024) was designed and conducted. The aim of the Phase I study was to demonstrate the safety of the technique and to confirm proof of concept. In order to support the requirement for a technique that interrogates alveolar neutrophils two supplementary clinical studies were performed. Firstly, two VAP surveillance techniques (CDC surveillance and HELICS European VAP surveillance) were compared with clinically diagnosed VAP across consecutive admissions in two large tertiary centres for one year. Secondly, the utility of circulating neutrophils to permit discrimination between acute respiratory illnesses was examined. Blood samples from mechanically ventilated patients with and without ARDS underwent flow cytometric assessment using eight clusters of differentiation and internal markers of activation to determine neutrophil phenotype. All clinical studies received the appropriate regulatory, ethical, and/or Caldicott guardian approval prior to commencement. NAP became fluorescent only in the presence of three processes specific to neutrophil activation: active pinocytosis, progressive alkalinization of the phagolysosome, and the activity of human neutrophil elastase. High optical signal was detected following the application of NAP in the alveolar regions of explanted lungs from patients with cystic fibrosis, known to be rich in activated neutrophils. Using an ex vivo ovine lung ventilation and perfusion model optical signal was demonstrated following segmental lung injury. The safety and specificity of the technique in a small cohort of healthy volunteers and mechanically ventilated patients was demonstrated. The technique was tested on a small cohort of patients with bronchiectasis, which provided the first opportunity to obtain broncho-alveolar lavage samples for laboratory correlation. Fluorescent signal was shown in the lavaged neutrophils, labeling that could only have taken place in the alveolar region. The supportive clinical studies found the concordance between actual VAP events was virtually zero even though the reported VAP rates were similar. Furthermore, the rate at which clinicians initiate antibiotics for VAP was approximately five times higher than either surveillance VAP rate. The study of circulating neutrophils from the blood of healthy volunteers and mechanically ventilated patients with and without ARDS indicated circulating neutrophil activation phenotype was not capable of discriminating between clinically diagnosed ARDS and other acute respiratory illnesses. In summary, an ambitious programme of work was completed to develop and support an optical molecular imaging technique that meets the rigorous requirements for human application and can be applied at the bedside to yield immediate visual results. The spatiotemporal relationship of neutrophil activation in real time both in the laboratory and in volunteers and patients was visualized. The visualization of neutrophil activation at such a resolution has never been achieved before in humans, healthy or unhealthy. The Phase I study was not powered to determine utility but recruitment has begun to a Phase II CTIMP (NCT02804854) to investigate the utility, accuracy, and precision of the imaging technique in a large cohort of mechanically ventilated patients. Ultimately, it is proposed that the technique will facilitate diagnosis, stratify patients for treatment and monitor treatment response using this technique.

Um estudo de coorte prospectivo foi realizado com o objetivo de comparar a eficácia da polimixina B à de outros antibióticos. Foram estudados pacientes com pneumonia ou traqueobronquite associadas à ventilação mecânica causadas por Pseudomonas aeruginosa ou Acinetobacter baumannii. Critérios de inclusão para este estudo foram idade igual ou superior a dezoito anos e uso de terapia antimicrobiana apropriada por período igual ou superior a 48 horas. O desfecho primário avaliado foi mortalidade em 30 dias. Variáveis clínicas foram comparadas entre os pacientes que utilizaram polimixina B e os que utilizaram outras drogas. O modelo de regressão de Cox foi realizado. Um total de 67 episódios ocorridos em 63 pacientes foi analisado: 45(67,2%) foram tratados com polimixina B e 22 (32,8%) com comparadores. A maior parte dos comparadores (72,7%) era de beta-lactâmicos. A maioria dos episódios foi de pneumonia associada à ventilação mecânica (PAV). As infecções foram causadas por P. aeruginosa em 28 casos (41,8%), por A. baumannii em 35 casos (52,2%) e por ambos em 4 casos (6%). A mortalidade geral em 30 dias foi de 44,8% (30 de 67): 53,3% (24 de 45) no grupo da polimixina B e 27,3% (6 de 22) no grupo dos comparadores (p=0,08). A taxa de mortalidade no grupo da polimixina e comparadores foi de 65,6 e 12,0 por 1000 pacientes-dia, respectivamente (p=0,02). A análise multivariada mostrou que o uso de polimixina B foi fator independente associado à mortalidade em 30 dias (Hazard Ratio ajustada, 4,3; Intervalo de Confiança de 95%, 1,39-13,03), após ajuste para tempo de internação hospitalar antes da infecção e aumento > 100% da creatinina em relação ao valor basal durante o tratamento. O escore APACHE II no inicio da infecção foi mantido no modelo final, embora não tenha atingido significância estatística, para ajuste de possível fator confundidor residual. Não houve diferenças significativas nos desfechos secundários, incluindo tempo de ventilação mecânica após terapia adequada, superinfecção e erradicação bacteriana nas secreções respiratórias. A terapia com polimixina B foi inferior comparada a outras drogas na pneumonia e traqueobronquite associadas à ventilação mecânica causadas por P. aeruginosa e A. baumannii. / To compare the efficacy of polymyxin B with other antimicrobials in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT) by Pseudomonas aeruginosa or Acinetobacter baumannii, a prospective cohort study was performed. Patients who received appropriate therapy for ≥48h were analyzed. The primary outcome was 30-day mortality. A total of 67 episodes were analyzed: 45 (67.2%) treated with polymyxin B and 22 (32.8%) with comparators. Thirty-day mortality was 44.8%: 53.3% (24 of 45) in the polymyxin B group and 27.3% (6 of 22) in the comparator group, P=0.08. The mortality rates in the polymyxin B and comparator group were 65.6 and 12.0 per 1000-patients-day, respectively (P=0.02) Treatment with polymyxin B was independently associated with 30-day mortality in multivariate model, with similar results in the subgroup of patients with VAP, suggesting that this antibiotic may be inferior to other drugs in the treatment of VAP and VAT by these organisms.

No description available.

Background: Azithromycin polarizes macrophages into an alternative phenotype and promotes a regulated immunity. Arginase is an important effector of these macrophages believed to play an essential role in decreasing injury and promoting repair. Hypothesis: Decreases in inflammation in response to Pseudomonas aeruginosa (PA) pneumonia achieved by polarizing macrophages to an alternative phenotype is dependent upon the production of arginase. Methods: Requirement of arginase was examined by pharmacological inhibition using S-(2-boronoethyl)- l-cysteine (BEC) or l-norvaline and by infecting arginase-1 conditional knock-out mice (Arg1flox/flox;Lyz2-cre (Arg1Δm)) with PA intratracheally. Arg1ΔM and control Arg1flox/flox mice were then dosed with azithromycin daily via oral gavage beginning four days prior to infection. Analysis of weight loss in addition to characterization of inflammatory cells and cytokine production via flow cytometry was performed. Macrophages were then stimulated with LPS and polarized with IL4/13, IFNγ, or azithromycin plus IFNγ. Western blot for signaling mediators, p65 translocation assay, and immunofluorescence were performed. Results: Myeloid arginase-1 deletion resulted in greater morbidity along with more severe inflammatory response compared to the Arg1flox/flox mice. Arg1Δm mice had greater numbers of neutrophils, macrophages, and lymphocytes in their airways and lymph nodes compared to the Arg1flox/flox mice. Conversely, global arginase inhibition resulted in greater weight loss along with greater neutrophil and macrophage infiltration compared to Arg1Δm mice. BEC and l-norvaline treated mice had higher numbers of lymphocytes in their lymph nodes with variable effects on airway lymphocyte counts. Azithromycin treatment comparably reduced the acute inflammatory responses in both Arg1Δm and Arg1flox/flox mice. To evaluate this mechanism, we show in vitro that azithromycin decreases NF-κB activation by preventing p65 nuclear translocation and by decreasing STAT1 activation in a concentration-dependent manner. These effects were reversed with IKKβ inhibition. Conclusions: Myeloid arginase is essential for control of inflammatory responses in PA pneumonia with potentially different effects of other cellular sources demonstrated with global arginase inhibition. Azithromycin reduces excessive inflammation even in the absence of arginase, potentially through a cross-inhibitory mechanism involving STAT1 and NF-κB pathways through IKKβ.

Thesis (Ph.D.)--McMaster University, 2006. / Supervisor: Susan J. Elliott. Includes bibliographical references (leaves 166-171).