Influenzavirus (IV)-Infektionen der unteren Atemwege induzieren virale Pneumonien, die häufig in akutem Lungenversagen resultieren. Merkmale einer IV-induzierten Pneumonie sind Schädigungen des Alveolarepithels und eine Ansammlung von Ödemflüssigkeit im Alveolarraum, wodurch der Gasaustausch beeinträchtigt wird. In Abhängigkeit eines Natriumgradienten, aufgebaut durch die basolaterale Na,K-ATPase (NKA) und den apikalen epithelialen Natriumkanal (ENaC), wird unter normalen Bedingungen die Ödemflüssigkeit aus dem Alveolarraum entfernt. In Folge einer IV-Infektion werden verschiedene Membranionenkanäle dysreguliert und eine verringerte alveoläre Flüssigkeitsresorption (AFC) beobachtet. Eine IV-Infektion führt u.a. zu einer reduzierten NKA-Expression in nicht-infizierten Nachbarzellen, sowie zu einer Dislokation der NKA zur apikalen Zellmembran in infizierten Zellen. Co-Immunopräzipitationsstudien identifizierten das virale M2-Protein als NKA-Bindepartner. Mittels Mutationsanalyse konnten drei Aminosäuren im zytoplasmatischen Teil von M2 als kritisch für die NKA-Bindung identifiziert werden. Rekombinante IV mit gestörter NKA Bindung zeigten im Vergleich zu IV WT in polarisierten Calu 3 Zellen in vitro sowie in Mäusen in vivo eine verbesserte AFC. Eine mutationsbedingte Glykosylierung des M2-Proteins führte jedoch unerwartet zu einer verstärkten Immunantwort in vivo, die trotz verbesserter AFC zu einem schwereren Krankheitsverlauf führte. Grund dafür könnte eine Aktivierung der Unfolded Protein Response aufgrund der Glykosylierung sein. Die Erkenntnis, dass M2 ein wichtiger Modulator in der Regulation der alveolären Flüssigkeitshomöostase ist, könnte dennoch helfen, neue therapeutische Ansätze für IV-induzierte Pneumonien zu definieren. Darüber hinaus unterstreicht es die Relevanz einer in der vorliegenden Arbeit durchgeführten Surfactome-Analyse zur Identifizierung neuer potentieller Angriffspunkte an der Zelloberfläche IV-infizierter Zellen, die in der antiviralen Therapie von Bedeutung sein könnten. / Influenza Virus (IV) infections of the lower respiratory tract can induce viral pneumonia resulting in acute lung injury (ALI/ARDS) with fatal outcome. Characteristics of an IV-induced pneumonia are alveolar epithelial cell (AEC) damage and accumulation of protein-rich edema fluid in the alveolar compartment impairing gas exchange. Depending on a sodium gradient established by the basolateral Na,K-ATPase (NKA) and the apical epithelial sodium channel (ENaC) edema fluid is removed from the alveolar space under normal conditions. However, after IV-infection various ion channels are dysregulated and reduced alveolar fluid clearance (AFC) is observed. An IV-infection leads to a reduced NKA expression in the non-infected neighbouring cells and to a mistargeting of the NKA to the apical cell membrane in IV-infected cells. Co immunoprecipitation (co-IP) studies identified the viral M2 protein as NKA binding partner and mutational analysis presented three amino acids in the cytoplasmic tail of M2 directly abutting the transmembrane domain as critical for NKA binding. A recombinant IV mutant with disrupted NKA binding showed in comparison to IV WT an increased fluid transport in polarized Calu 3 cells in vitro as well as in mice in vivo. However, mutation-induced glycosylation of the M2 protein unexpectedly led to an enhanced immune response in vivo, resulting in a more severe disease course despite improved AFC. The reason for this could be an activation of the unfolded protein response by the glycosylation of M2. Nevertheless, the finding that M2 appears to be an important modulator in the regulation of alveolar fluid homeostasis might provide new potential approaches for therapeutics of an IV induced pneumonia. Moreover, it highlights the relevance of a surfactome analysis performed in the present work to identify novel potential targets on the cell surface of IV-infected cells which could play an important role in antiviral therapy.

ortalidad en niños menores de 5 años, a pesar de contar con medidas preventivas como la vacunación.  Objetivo: Evaluar el impacto de la vacuna antineumocócica conjugada sobre la incidencia de neumonía en niños menores de 5 años, a nivel nacional y departamental, así como las hospitalizaciones y mortalidad a nivel nacional, desde 2001-2019 en el Perú. Además, realizar un análisis entre departamentos con coberturas altas de vacunación y aquellos que alcanzan coberturas bajas.  Metodología: Diseño: Series de tiempo definidas por la introducción de la vacuna antineumocócica heptavalente (PCV7) en el periodo de tiempo entre 2009 y 2011 a nivel nacional y departamental. Posteriormente, se realizó un análisis multivariado contrastando la incidencia de casos entre los departamentos con alta y baja cobertura de vacunación. Procedimiento de obtención de datos: Los datos agrupados sobre la incidencia, hospitalización y mortalidad por neumonía fue obtenida de la CDC (Centro de Enfermedades Contagiosas); la cobertura de vacunación fue obtenida como base de datos del Ministerio de Salud (MINSA) Análisis específicos: se realizó un análisis multivariado contrastando la incidencia de casos de neumonía entre los departamentos con alta y baja cobertura de vacunación.  Resultados: Para las hospitalizaciones a nivel nacional, la tendencia de cambio post vacunación fue negativa y significativa (p <0.001). La incidencia y mortalidad tuvieron cambios no significativos. A nivel regional, Callao, Lima, Moquegua, Cusco, Huancavelica, Pasco, Loreto, San Martín y Ucayali tuvieron tendencia de cambio post vacunación negativa y significativa (p <0.001). Conclusiones: La vacunación ha demostrado ser efectiva para disminuir hospitalizaciones por neumonía en algunos departamentos y a nivel nacional. Sin embargo, existen factores individuales que pueden alterar la efectividad de la intervención, propias de la estrategia aplicada y del tipo de estudio utilizado. / Introduction: Pneumonia is an acute respiratory infection, the most common bacterial cause is Streptococcus pneumoniae and represents one of the major causes of mortality in children under 5 years of age, despite preventive measures. Objective: Assess the impact of the pneumococcal vaccine on the incidence of pneumonia in children under 5 years of age, at the national and departmental level, as well as hospitalizations and mortality at the national range, over 2001-2019 in Peru. In addition, perform an analysis between departments that achieve high vaccination coverage and those with low coverage.  Methodology: Study design: Time series interrupted by the inclusion of the heptavalent pneumococcal vaccine (PCV7) in the period between 2009 and 2011 at the national and departmental level. Multivariate analysis, contrasting the incidence of cases between departments with high and low vaccination coverage. Data collection procedure: Pooled data on pneumonia incidence, hospitalization, and mortality obtained from the CDC (Center for Communicable Diseases); vaccination coverage obtained as a database from the Ministry of Health (MINSA) Specific analyzes: multivariate contrasting the incidence of pneumonia cases between departments with high and low vaccination coverage. Results: Hospitalizations at the national level had a negative trend of change after vaccination (p <0.001). At regional level, Callao, Lima, Moquegua, Cusco, Huancavelica, Pasco, Loreto, San Martín and Ucayali had a negative and significant change trend post vaccination (p <0.001). Conclusions: Vaccination has proven to be effective in some departments and at the national level. However, there are individual factors and limitations of the study that may affect the outcome. / Tesis

Philosophiae Doctor - PhD / In the decade since first identified, the Acquired Immunodeficiency syndrome (AIDS) has become a serious global disease. The nature of the Human Immunodeficiency Virus (HIV) that causes AIDS, whereby a carrier may be asymptomatic yet remain infectious, has enabled its dramatic spread. The number of AIDS cases is increasing exponentially, averaging a doubling time of between 8-15 months in different countries. Of the millions of HIV carriers, it is now estimated that all will eventually go on to develop full-blown AIDS and probably die within 15 years. Unlike other infectiqus diseases, there is currently no known vaccine or cure. Further, HIV is now virtually completely dependent on volitional sexual behaviours for transmission to occur. It is therefore an entirely preventable disease. However, since the behaviours that contribute to HIV-transmission are influenced by biological, psychological, and social factors, their alteration in line with safer sexual practices has been shown to be considerably complex and difficult. Intervention strategies that have relied on imparting knowledge about the disease have achieved limited success in influencing behaviour change. Unsafe sexual practices, and the risk of HIV-infection, often continue even when knowledge regarding prevention is adequate. It has therefore become apparent that other variables intrude which may mediate between knowledge acquisition, attitude formation, and consequent sexual behaviours. There appear to be no models which adequately explain the complexities in this area, and which enable adequate intervention strategies to be developed. The present study was undertaken to redress this problem, and to explore those variables that mediate in the area. Various psychological and social factors appear to be implicated in influencing sexual attitudes and behaviours. In order to adequately test the impact of psychosocial variables that were found to have significant associations in an exploratory study, a measuring instrument was developed. The AIDS Psychosocial Scale was statistically validated using content, frequency, factor, and reliability analyses and included psychological factors of self concept, defenses of denial, repression, and rationalisation, perceived empowerment in the form of locus of control and selfefficacy, and the social factor of peer pressure susceptibility. The impact of these psychosocial variables on indices of knowledge, condom attitude, and sexual practices, and on other epidemiological variables was tested using a sample of students at the University of the Western Cape (n=308). Results indicated a number of correlational and causal links between variables, confirming the mediational role psychosocial factors have in influencing knowledge acquisition, attitude formation, and behaviour outcome. A profile of lower self concept, higher defenses, lower self-efficacy, more external locus of control, and higher peer pressure susceptibility emerged which was associated with poorer knowledge, more negative attitudes, and higher unsafe sex. Based on this study, a model of psychosocial mediation is developed and its implications for intervention strategies discussed.

Inflammaging is a hallmark of human aging. Defined as low-grade, chronic inflammation, it is characterized by heightened proinflammatory cytokines in the blood and tissues and predicts morbidity and mortality. Despite this, the etiology of inflammaging and its role in infection have remained elusive, an issue this thesis addressed. First, we provided a comprehensive overview of an intranasal Streptococcus pneumoniae colonization model (Chapter 2). We described in detail the colonization technique, and demonstrated how to isolate and phenotype recruited cells, quantify bacterial load and measure production of immune mediators in the nasopharynx. Since both myeloid cell recruitment and tumour necrosis factor (TNF) production were increased following S. pneumoniae colonization with age, we investigated whether TNF directly augmented monocyte frequency (Chapter 3). TNF increased CCR2 expression on monocytes in old mice, leading to their enhanced egress from the bone marrow, resulting in enrichment of this population in the circulation. Monocyte numbers directly influenced plasma IL-6 levels, and this negatively impacted anti-bacterial responses, as monocyte blockade improved pneumococcal clearance in old mice. Lastly, to better understand the fundamental source of inflammaging, we studied the impact of the host microbiome on its development. This work was rooted in Elie Metchnikoff’s early predictions that leakage of intestinal bacterial products could dysregulate macrophage function, resulting in inflammation that would progress aging (Chapter 4). We showed that old mice had increased intestinal permeability, aberrant expression of cellular junction genes and increased microbial translocation from the gut to the blood. Germ-free mice lived longer than their conventionally colonized counterparts, and were protected from the development of inflammaging and defective macrophage function. Together, these studies resolve a major disparity in the field by demonstrating that systemic TNF production is initiated by increased levels of circulating bacterial products, driving functional defects in myeloid cells, which ultimately impairs anti-bacterial immunity. / Thesis / Candidate in Philosophy

No description available.

Значительная доля людей, столкнувшихся с коронавирусной инфекцией имеют осложнение в виде COVID-19-ассоциированной пневмонии и нуждаются в доступной и квалифицированной реабилитации. Цель работы - оценить влияние программы физической реабилитации на толерантность к физическим нагрузкам и функциональное состояние кардио-респираторной системы пациентов, перенесших COVID-19-ассоциированную пневмонию. В исследовании приняли 20 пациентов, перенесших COVID-19-ассоциированную пневмонию. В работе использовались следующие методы исследования: оценка толерантности к физической нагрузке оценивалась с помощью теста шестиминутной ходьбы, для оценки степени одышки после нагрузки использовалась шкала Борга, определяли сатурацию в покое и после проведения теста шестиминутной ходьбы, оценивалась частота сердечных сокращений до и после тестирования, а также выраженность одышки при повседневной деятельности оценивалась по шкале mMRC. Согласно полученным результатам, разработанная программа реабилитации повлияла на повышение толерантности к физическим нагрузкам, улучшение функционального состояния кардио-респираторной системы и субъективной переносимости физической нагрузки у пациентов, перенесших COVID-19-ассоциированную пневмонию. / A significant proportion of people who have experienced coronavirus infection have a complication in the form of COVID-19-associated pneumonia and need affordable and qualified rehabilitation. The aim of the work was to evaluate the impact of the physical rehabilitation program on exercise tolerance and the functional state of the cardio-respiratory system in patients who had undergone COVID-19-associated pneumonia. The study included 20 patients with COVID-19-associated pneumonia. Research methods were used in the work: assessment of exercise tolerance was assessed using a six-minute walk test, the Borg scale was used to assess the degree of dyspnea after exercise, saturation was determined at rest and after a six-minute walk test, heart rate was assessed before and after testing, as well as the severity of dyspnea during daily activities was assessed using the mMRC scale. According to the results obtained, the developed rehabilitation program influenced the increase in exercise tolerance, the improvement of the functional state of the cardio-respiratory system and the subjective exercise tolerance in patients who underwent COVID-19-associated pneumonia.

No description available.

Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection in the intensive care unit, resulting in a high burden of illness, mortality and increased cost. The literature around the cost-effectiveness of probiotics in prevention of health-care associated infections has not been previously well-described, and a definitive health economic evaluation alongside a well-designed randomized control trial assessing probiotic prophylaxis has not been previously performed. This thesis consists of 3 separate manuscripts (with 2 published in peer-reviewed journals and 1 pending). The theme of this thesis was to: (1) describe the literature about the cost-effectiveness of probiotics in hospitalized patients in preventing healthcare-associated infections; (2) design a protocol for an economic evaluation alongside a randomized control trial (RCT) examining probiotic prophylaxis of VAP; and then (3) perform and analyze the health economic evaluation presented in the protocol. The first component of this thesis is a systematic review of probiotic prophylaxis of healthcare-associated infections in hospitalized patients. We performed an extensive search including multiple databases which found 7 studies. Probiotics demonstrated favourable cost-effectiveness in 6 of 7 (86%) economic evaluations, with 3 studies being manufacturer-supported, all suggesting cost-effectiveness. Certainty of cost-effectiveness evidence was very low due to risk of bias, imprecision and inconsistency using the GRADE approach. Hence further RCTs with economic evaluations were stated as a solution. The second component of this thesis is a study protocol for an economic evaluation alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT), which assessed the efficacy of probiotic prophylaxis in the prevention of healthcare-associated infections (specifically VAP). The third component of this thesis is the cost-effectiveness analysis performed utilizing the individual patient data from PROSPECT to produce the economic evaluation (E-PROSPECT). As of the date of thesis submission, PROSPECT is still pending publication, and hence E-PROSPECT is also pending analysis and publication. However, I have prepared a draft manuscript (along with figures and tables) that will be produced at the conclusion of E-PROSPECT for thesis committee review. / Thesis / Master of Health Sciences (MSc) / Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection in the intensive care unit, resulting in a high burden of illness, mortality and increased cost. The literature around the cost-effectiveness of probiotics in prevention of health-care associated infections has not been previously well-described, and a definitive health economic evaluation alongside a well-designed randomized control trial assessing probiotic prophylaxis has not been previously performed. This thesis consists of 3 separate manuscripts (with 2 published in peer-reviewed journals and 1 pending). The theme of this thesis was to: (1) describe the literature about the cost-effectiveness of probiotics in hospitalized patients in preventing healthcare-associated infections; (2) design a protocol for an economic evaluation alongside a randomized control trial (RCT) examining probiotic prophylaxis of VAP; and then (3) perform and analyze the health economic evaluation presented in the protocol. The first component of this thesis is a systematic review of probiotic prophylaxis of healthcare-associated infections in hospitalized patients. We performed an extensive search including multiple databases which found 7 studies. Probiotics demonstrated favourable cost-effectiveness in 6 of 7 (86%) economic evaluations, with 3 studies being manufacturer-supported, all suggesting cost-effectiveness. Certainty of cost-effectiveness evidence was very low due to risk of bias, imprecision and inconsistency using the GRADE approach. Hence further RCTs with economic evaluations were stated as a solution. The second component of this thesis is a study protocol for an economic evaluation alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT), which assessed the efficacy of probiotic prophylaxis in the prevention of healthcare-associated infections (specifically VAP). The third component of this thesis is the cost-effectiveness analysis performed utilizing the individual patient data from PROSPECT to produce the economic evaluation (E-PROSPECT). As of the date of thesis submission, PROSPECT is still pending publication, and hence E-PROSPECT is also pending analysis and publication. However, I have prepared a draft manuscript (along with figures and tables) that will be produced at the conclusion of E-PROSPECT for thesis committee review.

There are few data on mortality after discharge with community-acquired pneumonia (CAP). Therefore, we evaluated risk factors for 30-day post-discharge mortality after CAP. We included all patients of the prospective multi-national CAPNETZ study between 2002 and 2018 with (1) hospitalized CAP, (2) survival until discharge, and (3) complete follow-up data. The study endpoint was death within 30 days after discharge. We evaluated risk factors including demographics, comorbidities, admission CAP severity, and laboratory values and treatment-related factors in uni- and multivariable analyses. A total of 126 (1.6%) of 7882 included patients died until day 30 after discharge, corresponding to 26% of all 476 deaths. After multivariable analysis, we identified 10 independent risk factors: higher age, lower BMI, presence of diabetes mellitus, chronic renal or chronic neurological disease (other than cerebrovascular diseases), low body temperature or higher thrombocytes on admission, extended length of hospitalization, oxygen therapy during hospitalization, and post-obstructive pneumonia. By addition these factors, we calculated a risk score with an AUC of 0.831 (95%CI 0.822–0.839, p < 0.001) for prediction of post-discharge mortality. Early post-discharge deaths account for ¼ of all CAP-associated deaths and are associated with patient- and CAP-severity-related risk factors. Additional studies are necessary to replicate our findings in independent cohorts. Study registration: NCT 02139163.

Os objetivos deste estudo foram identificar os fatores de risco para complicações pulmonares pós-operatórias em pacientes laringectomizados por carcinoma espinocelular de laringe, assim como os fatores de risco para apresentação de metástases pulmonares e os fatores de risco para apresentação de segundo tumores primários em pulmão destes pacientes no período de 1985 a 1996. O estudo consistiu em uma análise retrospectiva de 291 pacientes admitidos no Hospital do Câncer A. C. Camargo, no período de 1985 a 1996, portadores de carcinoma espinocelular de laringe, submetidos a tratamento cirúrgico com intenção curativa seguido ou não de radioterapia. Foram analisados as variáveis demográficas, as comorbidades, a localização do sítio primário, o estadiamento clínico, o tratamento do tumor primário e do pescoço, o tratamento radioterápico, a diferenciação celular, as margens cirúrgicas, as recidivas locais, as recidivas regionais, a presença de complicações maiores, de complicações menores, as metástases pulmonares e a presença de múltiplos tumores primários pulmonares. O teste de associação do qui-quadrado foi utilizado para análise univariada descritiva das diversas variáveis comparando-se os grupos com complicação pulmonar e sem complicação pulmonar. A análise multivariada através da regressão logística foi utilizada na determinação dos fatores de risco para apresentação de metástases pulmonares e múltiplos tumores primário pulmonares. A incidência de complicações pulmonares foi de 31,3%, foram identificados como fatores de risco para complicações pulmonares somente a epiglote (p=0,004; RR 2,1), tendo a variável gênero associação marginal (p=0,081; RR 2,8). As metástases pulmonares tiveram incidência de 7,2%, na análise univariada foram identificados como fatores de risco o estadiamento N (p=0,032), diferenciação histológica (p=0,004), margens cirúrgicas (p=0,017) e recidivas locoregionais (0,002). Os múltiplos tumores primários pulmonares apresentaram incidência de 3,1% e na análise univariada foram identificados como fatores de risco o estadiamento N (p=0,048) e sítio aritenóide (p=0,001). Na análise multivariada foram significativos somente a diferenciação histológica: moderamente diferenciado (p=0,007; RR 2,9) e pouco diferenciado (p=0,032; RR 4,0); e as margens cirúrgicas: exíguas (p=0,003; RR 6,4) para apresentação de metástases pulmonares e múltiplos tumores pulmonares. Este estudo demonstra a importância do estadiamento clínico como fator de risco para complicações pulmonares, metástases à distância e múltiplos tumores primário em pulmão. Os fatores de risco determinantes para aparecimento de metástases pulmonares e múltiplos tumores primários pulmonares foram a diferenciação histológica e as margens cirúrgicas / Objective: To identify the risk factors to postoperative pulmonary complications in laryngeal cancer patients submitted to surgical treatment, the risk factors to development of lung metastasis and second lung primary tumor. Patients and Methods: Retrospective study of a cohort of 291 patients admitted at Hospital do Câncer A.C.Camargo from January, 1985 to December 1996. All patients were submitted to some kind of laryngectomy with curative intent as part of treatment of a proven laryngeal cancer, followed or not by radiotherapy. The following variables were analized: demographic, comorbidities, primary site, clinical stage, primary and neck surgical treatment, histopathologic differentiation grade, surgical margins, recurrences, postoperative pulmonary complications, lung metastasis and second lung primary tumor. The univariate and multivariate analysis were utilized to built the model to predict the risks factors and the factors of prognostic significance. Results: The overall pulmonary complications incidence were 31,3%, epiglottis were identified as significant single risk factor to pulmonary complications (p=0.004; RR 2,1). Lung metastasis had 7,2% incidence to this, the risk factors were N stage (p=0.032 ), histopathologic differentiation grade (p=0.004), surgical margins (p=0.017) and locoregional recurrence (p=0.002). The second lung primary tumor incidence were 3,1%, univariate analysis showed N stage (p=0,048) and arithenoid site (p=0,001) as significant risk factors. The multivariate analysis showed the histopathologic differentiation: moderate grade (p=0.007 RR 2,9) and poor grade (p=0.032 RR 4,0) and surgical margins: close (p=0.003 RR 6,4) as prognostic factors to deveopment of lung metastasis and second lung primary tumor. Conclusions: This study showed the clinical stage importance as risk factor to development of postoperative pulmonary complication, lung metastasis and second lung primary tumor in laryngectomy cancer patients. The prognostic factors associated with lung metastasis and second lung primary tumor were the histopathologic differentiation and the surgical margins