Le myélome multiple (MM) est une néoplasie B caractérisée par l’accumulation d’un clone plasmocytaire dans la moelle osseuse. Des études ont démontré que les modifications épigénétiques comme la méthylation de l’ADN jouent un rôle dans la régulation d’expression de différents gènes associés au cancer. Dans une étude récente, nous avons pu décrire un score génique de méthylation de l’ADN permettant de prédire la sensibilité des cellules de MM aux inhibiteurs de DNMT (DNA methyltranfexrase) (Moreaux, et al 2012). Parmi les gènes dont l’expression est inhibée par les inhibiteurs de DNMT et associés avec un pronostic péjoratif chez les patients atteints de MM, nous avons identifié RECQ1. RECQ1 est une hélicase de la famille RECQ qui s’associe aux origines de réplication durant la phase S du cycle cellulaire et joue un rôle important dans l’élongation des fourches de réplication. RECQ1 est fortement exprimé dans différents types de tumeurs solides et l’inhibition de RECQ1 conduit à la catastrophe mitotique et inhibe la croissance de tumeurs solides. Le but de notre projet a été de caractériser la fonction de RECQ1 dans la physiopathologie du MM et les mécanismes de résistance aux traitements. Afin d’étudier le rôle biologique de RECQ1 dans les plasmocytes tumoraux, nous avons utilisé des vecteurs lentiviraux pour induire de façon inductible la surexpression ou l'inhibition de RECQ1. La déplétion de RECQ1 dans les cellules de MM entraîne une inhibition de la croissance, une induction significative d’apoptose et la formation de foyers 53BP1 indiquant la présence de cassures d’ADN double brin. Une forte expression de RECQ1 étant associée à un mauvais pronostic et la déplétion de RECQ1 conduisant à une induction de cassures d’ADN double brin, nous nous sommes demandé si l’inhibition de l’expression de RECQ1 pourrait sensibiliser les cellules de MM aux agents génotoxiques utilisés dans le traitement du MM. La déplétion de RECQ1 sensibilise, de façon significative, les cellules de MM au melphalan suggérant que l’association d’un inhibiteur de DNMT pour cibler RECQ1 et du melphalan pourrait avoir un effet synergique chez les patients RECQ1++. La surexpression de RECQ1 protège les lignées cellulaires de myélome contra l'apoptose induite par melphalan et bortézomib. De plus, l'épuisement RECQ1 sensibilise les cellules de myélome de traitement est démontré que RECQ1 interagit avec des protéines impliquées dans différentes voies de réparation des dommages de l’ADN : PARP1 (NHEJ/BER), RAD51 (HR), MSH2 et MSH6 (Mismatch repair). RECQ1 interagit avec PARP1 dans la fraction chromatinienne des cellules de MM mais pas avec RAD51 ni MSH2. Cette interaction est significativement induite en présence de melphalan. Des inhibiteurs de PARP sont actuellement en développement préclinique ou en essai clinique. De façon intéressante, la déplétion de RECQ1 sensibilise significativement les cellules de MM à un inhibiteur de PARP in vitro suggérant que l’association d’un inhibiteur de DNMT pour cibler RECQ1 et d’un inhibiteur de PARP pourrait avoir un intérêt thérapeutique dans le MM. Nous avons également confirmé que des doses sous-létales d’inhibiteur de DNMT sensibilisent les cellules de MM au melphalan in vitro. / Multiple myeloma (MM) is a plasma cell cancer with poor survival, characterized by the clonal expansion of multiple myeloma cells (MMCs), primarily in the bone marrow. Using a microarray-based genome-wide screen for genes responding to DNA methyltransferases (DNMT) inhibition in MM cells, we identified RECQ1 among the genes downregulated by DNMT inhibitor. RECQ helicase are DNA unwinding enzymes involved in the maintenance of chromosome stability. RECQ1 silencing in cancer cells results in mitotic catastrophe and prevents tumor growth in murine models. RECQ1 is significantly overexpressed in primary myeloma cells compared to normal plasma cells and in myeloma cell lines compared to primary myeloma cells of patients. High RECQ1 expression is associated with a poor prognosis in two independent cohorts of patients. RECQ1 knock down inhibits growth of myeloma cells and induces apoptosis. Given the known role of RECQ1 in replication and DNA repair activation, the effect of RECQ1 depletion in DNA damage response was investigated. RECQ1 depletion induced spontaneous accumulation of DNA double strand breaks (DSBs) evidenced by the phosphorylation of ATM and H2AX histone and detection of 53BP1 foci. Using an alkaline comet assay, a significant increase in DNA strand breaks was confirmed in RECQ1 depleted cell lines compared to control. RECQ1 depletion was associated with CHK1 and CHK2 phosphorylation in MM cells. Since RECQ1 depletion is associated with DNA damage response activation and DNA strand breaks formation, a link between RECQ1 expression and drug sensitivity was hypothesized. RECQ1 overexpression significantly protects myeloma cell lines from melphalan and bortezomib-induced apoptosis. Furthermore, RECQ1 depletion sensitizes myeloma cells to treatment. Using immunoprecipitation, RECQ1 was shown to interact with PARP1 but not RAD51 or MSH2. An increased association of the two proteins was found upon DNA damages induced by melphalan. In agreement, RECQ1 depletion sensitizes myeloma cell lines to PARP inhibitor. We identified RECQ1 as a miR-203 target. Interestingly, aberrant methylation of miR-203 was reported in MM cells and treatment with 5-aza-2’-deoxycitidine led to promoter demethylation and miR-203 re-expression. Furthermore, anti-miR-203 treatment induced a significant increase of RECQ1 mRNA level in MM cells.In conclusion, RECQ1 represent a biomarker of drug resistance in MM, which is targeted by DNMT inhibitors. This suggests association of alkylating agents and/or PARP inhibitors with DNMT inhibitor may represent a therapeutic approach in RECQ1high patients associated with a poor prognosis.

Le lymphome folliculaire (LF) représente le 2ème lymphome par ordre de fréquence et reste considéré à l’heure actuelle comme incurable. De nombreuses questions sur le processus de lymphomagénèse sont encore non résolues et il n’existe aucun marqueur génomique ou moléculaire unanimement reconnu permettant de prédire l’évolution des patients. Nos travaux de recherche s’inscrivent dans l’objectif de mieux comprendre l’impact des altérations moléculaires identifiées dans ces tumeurs, grâce à une approche intégrative visant à combiner des données génomiques, transcriptomiques et mutationnelles. Ce travail a permis de construire un score, basé sur l’expression d’un panel de gènes, prédictif du risque de progression de la maladie. Ce score a été confirmé sur une seconde cohorte de patients, validant son utilité potentielle en pratique clinique. Par ailleurs, nos résultats suggèrent que les cellules tumorales peuvent acquérir des propriétés évocatrices d’un profil de cellules souches et associées à un pronostic particulièrement défavorable. Une 2ème partie de notre travail a porté sur les altérations touchant le gène EZH2, muté chez 25% des patients. Nous avons démontré qu’un gain génomique au niveau du locus EZH2 pouvait également avoir des conséquences sur le profil transcriptomique et un impact pronostique, soulignant l’importance de prendre en compte l’ensemble des anomalies touchant ce gène. Enfin, nous rapportons qu’un polymorphisme constitutionnel situé dans ce gène est associé au risque de progression des patients traités par un anticorps anti-CD20. L’ensemble de ces résultats apporte un éclairage nouveau sur la biologie du LF et peut contribuer à améliorer la prise en charge des patients / Follicular Lymphoma (FL) is the 2nd most frequent lymphoma subtype and is usually considered incurable with current strategies. Several questions regarding the lymphomagenesis process are still pending, and no molecular or genomic marker has been unanimously recognized yet to predict outcome. We performed an integrative analysis combining genomic, transcriptomic and mutational data in the view to bringing new highlights in the molecular alterations acting in FL. Based on gene-expression profiling data we developed a model able to predict progression-free survival in FL patients. We confirmed its predictive value in another cohort of patients, thereby allowing its potential use in clinical practice. Furthermore, our results highlight that some tumors show a stem-cell-like gene-expression profile that was associated with highly unfavorable outcome. In the second part of our work, we focused on alterations of the gene EZH2. Although mutations have been reported in 25% of FL patients, we questioned whether genomic gains at EZH2 locus could also contribute to lymphomagenesis. We showed that such gain may impact the transcriptional profile and have a prognostic significance, thus highlighting the crucial interest of determining both kinds of alterations. Finally, we report that a germ-line polyporphism in the EZH2 gene was significantly associated with progression-free survival in patients treated by anti-CD20 therapy. Taken together, these results bring new highlights on FL biology and may help to improve the clinical management of FL patients

Population ageing is one of the most important current problems in developed countries. The goal of my work is the analysis of economic and social problems occasioned by population ageing, population prognosis and the possibility of compensation a population loss and changes in age structure through replacement migration. This is all in the Czech Republic. For my work I will use readily available information databases, mainly the database provided by Czech Statistical Office and the databases of relevant ministries in the Czech Republic. At first I will make demographic predictions using a component method without migration and then I will use replacement migration to compensate a population loss and changes in selected demoeconomic characteristics. The contribution of my work is in the concretization of methodology for calculating the replacement migration and in the results obtained from this study, which will show feasibility of this concept in practice. Last but not least I will look for solutions to the adverse economic impact of population ageing. In my study at first I will explain the concept of an ageing population and analyze past demographic trends in the Czech Republic. The entire chapter I will attend to migration and migration policy. Then I will focus on demographic forecast and especially replacement migration. At the end of my work I will analyze the economic impacts of an ageing population and the possibilities for their solution.

This dissertation deals with current trends in insurance. The aim of this thesis is to find and analyse the development trends, which has affected the insurance market the most in the last years and to attempt a prognosis of the future development in insurance. The first part of the thesis is focused on the main factors, which has been caused by current Global trends. There are also detected significant changes that occurred by entering of the Czech Republic to the European Union. The last subhead informs about possible indicators which we can consider the development in the Czech insurance system on and possibly compare with development in international insurance market. The crucial part of the dissertation, concerning the trends in the insurance market, is divided into 3 parts -- Trends in life insurance, Trends in non-life insurance and Trends in services which are closely connected to the insurance market. The thesis also deals with the influence of the recent economic crisis on development trends in insurance, and there is an analysis made separately for life and non-life insurance. The last part is focused on the prognosis of the future development and so outlining of possible ways the insurance market could be wending in the future.

L'insuffisance cardiaque (IC) est une maladie dont la prévalence est élevée, cette prévalence augmente avec l'âge. La découverte de la maladie se fait le plus souvent lors d'un épisode de décompensation (ou insuffisance) cardiaque aiguë (ICA). L'ICA est très fréquente chez les sujets âgés et est caractérisée par des difficultés diagnostiques quand le patient est admis avec une dyspnée aiguë. L'apport de biomarqueurs plasmatiques tels que le BNP ou le NT-proBNP a été majeur pour le diagnostic de l'ICA. La décompensation cardiaque aiguë est suivie d'un taux de réhospitalisations et d'une mortalité très élevés. Les objectifs de la thèse était 1- de préciser l'épidémiologie de l'ICA en France lors d'un observatoire d'une journée des hospitalisations pour ICA dans 170 hôpitaux français (OFICA), 2- d'identifier la puissance diagnostiques et pronostiques des peptides natriurétiques lors de l'ICA, 3-de définir l'importance des modifications post-transcriptionnelles de ces PNs lors de l'ICA, 4- de rechercher de nouveaux biomarqueurs.La comparaison des propriétés diagnostiques et pronostiques des peptides natriurétiques révèle que les 4 peptides natriurétiques commercialement accessibles (BNP, NT-proBNP, proBNP et MR-proANP) ont des qualités diagnostiques et pronostiques globalement très similaires. Néanmoins, proBNP et BNP semblent meilleurs pour le diagnostic tandis que MR-proANP apparaît meilleur pour son association avec la mortalité à 5 ans.Parmi les modifications post-transcriptionnelles du BNP, nous avons étudié l'impact de la glycosylation du pro-BNP. La O glycosylation en 71 inactive proBNP, qui est libéré hors de la cellule sans action préalable des enzymes de « cleavage » la corine ou la furine. En revanche, le proBNP non-glycosylé est scindé en BNP et NT-proBNP par la corine ou la furine. Nous avons pu montrer que la non-glycosylation du proBNP et l'activation de la furine étaient deux mécanismes très importants d'accélération de la production de peptides natriurétiques lors de l'ICA. On a pu également montrer que la production du NT-proBNP était beaucoup plus liée au niveau glycosylation du proBNP que ne l'est la production de BNP. Ainsi, nos résultats suggèrent fortement d'utiliser le NT-proBNP pour toute étude future souhaitant explorer le concept de « biomarker-guided therapy » dans l'ICA.Pour la recherche de nouveaux biomarqueurs, nous avons exploré 1-la concentration plasmatique de 5 microRNAs (miR-l/-21/-23/-126/-423-5p), chez des patients avec dyspnée aiguë. Aucun de ces miR n'a de valeur diagnostique, en revanche, le miR-423-5p apparaît être un marqueur pronostique de réhospitalisation à un an ; 2-les conséquences de la congestion cardiaque sur le foie. Les marqueurs hépatiques étudiés étaient la phosphatase alcaline et les transaminases : les marqueurs de la cholestase étaient associés à une congestion hépatique tandis que ceux de la nécrose cellulaires (transaminases) étaient liés à l'hypotension artérielle et au bas débit cardiaque. L'augmentation des transaminases a été associée à divers critères dont une surmortalité à court terme / Heart failure (HF) is highly prevalent disease, and prevalence increases with age. HF is generally discovered on presentation of an acute episode of decompensation (or insufficiency). Acute decompensated heart failure (ADHF) is very frequent in elderly subjects and is difficult to diagnose when the patient is admitted with acute dyspnoea. The advent of plasma biomarkers, such as BNP or NT-proBNP represents a major advancement in the diagnostic of ADHF. ADHF leads to high rates of re-admission and mortality. The objectives of this doctoral thesis were: (1) to describe the epidemiology of ADHF in France in a one-day observational study of admissions for ADHF in 170 French hospitals; (2) to evaluate the prognostic and diagnostic value of natriuretic peptides (NPs) in ADHF; (3) to describe the extent of post-transcriptional modifications in these NPs in ADHF; and (4) to search for new biomarkers.The comparison of the prognostic and diagnostic properties of NPs showed that the 4 commercially available NPs (namely BNP, NT-proBNP, proBNP and MR-proANP) overall have very similar prognostic and diagnostic abilities. However, proBNP and BNP seem to be more useful for diagnosis, while MR-proANP appears to be better for the association with 5-year mortality.Amongthe post-transcriptional modifications of BNP, we studied the impact of glycosylation of pro¬BNP. Threonin 71 0-glycosylation prevents cleavage of proBNP into BNP and NT-proBNP, resulting in the release of proBNP from the cell without being cleaved. Conversely, non-glycosylated proBNP is cleaved into BNP and NT-proBNP by corin or furin. We showed that non-glycosylation of proBNP and activation of furin are two important mechanisms in the acceleration of production of NPs during ADHF. We also showed that production of NT-proBNP was more closely linked to the rate of glycosylation of proBNP than to the production of BNP. Thus, our results strongly suggest that NT-proBNP should be used in future studies exploring the concept of "biomarker-guided therapy" in ADHF.To investigate new biomarkers, we explored plasma concentrations of 5 microRNAs (miR-l/-21/-23/-126/-423-5p), in patients with acute dyspnoea. None of these microRNAs were shown to have any diagnostic value. Conversely, miR-423-5p appears to be a prognostic marker for re-admission at 1 year. Secondly, we investigated the consequences of cardiac congestion on the liver. The hepatic markers studied were alkaline phosphatise and transaminases. Markers of cholestasis were associated with hepatic congestive while markers of cellular necrosis (transaminases) were related to arterial hypertension and low cardiac output. An increase in transaminases was associated with various criteria of excess mortality in the short term

Prognostic factors come in a variety of forms and may be patient, tumour or environmental related. This thesis examines the interaction of prognostic factors for a variety of tumour types. It particularly focuses on single nucleotide polymorphisms (SNPs) of the vascular endothelial growth factor (VEGF) gene. The first section on meningiomas describes the frequency of sex steroid receptors in meningiomas. In this study, absence of progesterone receptors is associated with high tumour grade and male gender. Tumours that are progesterone receptor negative have an odds ratio for recurrence of 5.Choroid plexus carcinomas are aggressive malignant tumours generally occurring in young children. Gross total surgical resection has been shown to be a highly significant factor in tumour recurrence and survival. This study describes a treatment paradigm of neoadjuvant ICE chemotherapy in these children which decreases the vascularity and increase the chance of a complete removal. The operative blood loss with this regimen is reduced to 0.22 blood volumes from 1.11 blood volumes without neoadjuvant chemotherapy. The VEGF gene is highly polymorphic and SNPs of the region have previously been shown to influence VEGF protein expression. This study looks at cohorts of both adult gliomas and a variety of paediatric brain tumours; comparing them to controls. There are several associations described between the development of certain tumours and specific SNP genotypes. In addition to this, certain genotypes and haplotypes have an influence on survival of adult grade 2 astrocytomas and paediatric medulloblastomas and ependymomas. There are consistent themes to the prognostic genotypes throughout both the adult and the paediatric tumours.Prognostic factors come in a variety forms as described in this thesis. It is vital to understand the complex interaction between factors to best utilise them for the benefit of patients.

The study explored whether certain factors might be used to distinguish between people with cancer who do or do not want detailed information about their disease progress, do or do not want to be informed if their disease is no longer considered curable, and who do or do not want an estimation of life expectancy if their disease is no longer considered curable. The factors included whether an individual has an internal versus external locus of control, uses an active coping strategy or a planning coping strategy, the level of spirituality, and age. Participants consisted of 51 people with cancer from a cancer center in the state of Washington. Results indicated that 98% wanted detailed information about their disease progress, 94% wanted to be informed if their disease was no longer considered curable, and 78% wanted an estimation of life expectancy if their disease was no longer considered curable. Due to the majority of the participants endorsing the need for prognostic information none of the factors (e.g. coping strategies, locus of control, spirituality) were able to predict the information needs of the patients with cancer. Clinical implications of this study suggest that physicians have an ongoing, open dialogue with their patients about their prognostic information needs. The dialogue might be especially important for patients undergoing active treatment for cancer, since it could affect treatment decisions.

Submitted by Fabio Sobreira Campos da Costa (fabio.sobreira@ufpe.br) on 2016-04-19T11:21:33Z No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) DISSERTAÇAO-GIULLIANA_NOBREGA.pdf: 1803238 bytes, checksum: 3e84c45ed9de31b5cd10607f9f195dca (MD5) / Made available in DSpace on 2016-04-19T11:21:33Z (GMT). No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) DISSERTAÇAO-GIULLIANA_NOBREGA.pdf: 1803238 bytes, checksum: 3e84c45ed9de31b5cd10607f9f195dca (MD5) Previous issue date: 2015-06-15 / CNPq / INTRODUÇÃO: O carcinoma diferenciado de tireoide (CDT) é avaliado e tratado de acordo com fatores prognósticos. Embora tenha um bom prognóstico, 14% dos pacientes considerados como de baixo risco de recorrência podem apresentar doença persistente mesmo com tratamento adequado. Por isso, estudos têm sido realizados no intuito de encontrar outros possíveis preditores de persistência do CDT. OBJETIVO: Avaliar que fatores clínicos, laboratoriais e anatomopatológicos estão associados à persistência do CDT um ano após radioiodoterapia (RIT). METODOLOGIA: Foi realizada uma revisão de prontuários, na qual foram incluídos 375 pacientes portadores de CDT. Foram coletados dos registros os dados clínicos (gênero e idade), resultados de dosagens de hormônio tireoestimulante (TSH), tireoglobulina (Tg) e anticorpo anti-tireoglobulina (AATg) antes e um ano após RIT, resultados de varredura de corpo inteiro (PCI) após dose ablativa de radioiodo (131I) e um ano após tratamento inicial, além de laudos dos exames histopatológicos. A partir dos dados obtidos, foi realizada análise bivariada e as variáveis que apresentaram significância inferior a 20,0% (p < 0,20) foram submetidas à análise multivariada através do modelo de regressão de Poisson. Para se chegar a um valor de Tg estimulada (TgE) capaz de predizer os pacientes que teriam maior chance de persistência de doença, foi realizada uma curva ROC. RESULTADOS: Observou-se associação significativa entre persistência de doença e idade inferior a 45 anos (p=0,001), multifocalidade (p=0.008) e tamanho tumoral entre 2 a 4 cm (p=0,002). Além disso, verificou-se associação significativa entre da TgE e persistência do CDT (p<0,001). O ponto de corte de TgE pré-dose com maior sensibilidade e especificidade para prever persistência de doença foi de 7,4 ng/mL. Utilizando este valor encontramos um valor preditivo negativo (VPN) de 87,5%. CONCLUSÃO: Neste estudo encontramos uma forte associação entre persistência do CDT e faixa etária, tamanho tumoral, multifocalidade e Tg estimulada pré-ablação. A Tg estimulada pré-ablação mostrou-se um valioso preditor de persistência de CDT um ano após RIT. Valores de 7,4 ng/mL ou mais mostraram maior sensibilidade e especificidade para prever este desfecho. / BACKGROUND: Differentiated thyroid carcinoma (CDT) is evaluated and treated according to prognostic factors. Although it has a good prognosis, 14% of the patients which are considered at low risk of recurrence, might have persistent disease despite suitable treatment. Hence, studies have been realized in order to find other possible prognostic predictors for CDT persistence. OBJECTIVE: Assess which clinical, laboratory and pathological factors are associated with persistence of CDT one year after radioiodine therapy (RIT). METHODS: It was performed a chart review, in which was included 375 patients with CDT. Were collected clinical data (age and sex), results of thyroid-stimulating hormone (TSH), thyroglobulin (Tg) and antithyroglobulin antibody (AATg) before and one year after RIT, whole body scan (PCI) results after ablative dose of 131I and one year later and, also histopathological exam reports. From these data, was performed a bivariate analysis and the variables that were significant lower than 20.0% (p <0.20) were submitted to multivariate analysis using Poisson regression model. To achieve a stimulated Tg (TgE) value able to predict which patients would have a greater chance of persistent disease, a ROC curve was performed. RESULTS: A significant association was found between persistence of disease and age less than 45 years (p = 0.001), multifocality (p = 0.008) and tumor size between 2-4 cm (p = 0.002). In addition, there was a significant association between TgE and persistence of CDT (p <0.001). The pre-ablation TgE cutoff with greater sensitivity and specificity in predicting persistence of disease was 7.4 ng / mL. Using this value, we found a negative predictive value (VPN) of 87.5%. CONCLUSION: We found a significant association between persistent CDT and age, tumor size, multifocality and pre-ablation TgE in this study. TgE pre-ablation was shown to be a valuable predictor of persistence CDT one year after RIT. Values of 7.4 ng / ml or more showed greater sensitivity and specificity to predict this outcome.

INTRODUÇÃO: A doença de Chagas (DC) persiste como um importante problema de saúde na América Latina, onde o envolvimento cardíaco é responsável pela elevada morbidade e mortalidade. A identificação dos pacientes de maior risco representa, portanto, um grande desafio. A ressonância magnética cardiovascular (RMC) é uma metodologia de elevada acurácia na avaliação da morfologia e da função ventricular e permite a detecção da fibrose miocárdica pela técnica do realce tardio, podendo ser útil na estratificação de risco dos pacientes chagásicos. OBJETIVOS: Avaliar as características morfológicas e funcionais dos ventrículos esquerdo e direito nas formas clínicas da DC; avaliar a fibrose miocárdica pela RMC e sua relação com as formas clínicas da DC; investigar o valor prognóstico da fibrose miocárdica, através de sua correlação com o escore de Rassi. MÉTODOS: Foram estudados 39 pacientes, sendo 20 do sexo masculino. A população de pacientes foi dividida em dois grupos: com cardiopatia aparente (CCA) e sem cardiopatia aparente (SCA). Todos os pacientes foram submetidos a estudo de RMC para avaliação morfológica e funcional; e detecção da fibrose miocárdica. Visando à obtenção do escore de Rassi, os pacientes realizaram avaliação clínica, eletrocardiograma, radiografia do tórax, ecodopplercardiograma e eletrocardiografia dinâmica de 24 horas (Holter). Os pacientes foram classificados, de acordo com o escore de Rassi, em: de baixo, de médio e de alto risco, e foi realizada a correlação desse escore com os parâmetros obtidos pela RMC. RESULTADOS: Os aspectos morfológicos e funcionais do VE apresentaram uma diferença significante entre as formas clínicas estudadas, e a quantificação de fibrose miocárdica na DC apresentou uma forte correlação com o escore de Rassi (r=0,76 p<0,001). CONCLUSÕES: O ventrículo esquerdo apresentou comprometimento morfológico e funcional no grupo com cardiopatia aparente; a extensão da fibrose miocárdica foi maior no grupo com cardiopatia aparente; a quantificação de fibrose miocárdica pela RMC apresentou forte correlação com o escore de Rassi, denotando o valor prognóstico da RMC nesse grupo de paciente chagásico / INTRODUCTION: Chagas disease (CD) still remains an important health problem in Latin America. One of the major challenges is to identify high risk patients. Considering that magnetic resonance imaging (MRI) has a very high accuracy to assess morphology and ventricular function and that myocardial delayed enhancement (MDE) technique is well established to detect myocardial fibrosis, we believe that MRI may have an important role to stratify patients with CD. OBJECTIVES: Evaluate morphological and functional ventricular characteristics, as well as the extent of myocardial fibrosis (MF) in patients with Chagasdisease, by magnetic resonance imaging (MRI); and search the prognostic value of myocardial fibrosis detected by MRI, comparing these findings with the recently developed Rassi`s score. METHODS: 39 patients were evaluated (male sex = 20), divided in two main groups: a) with apparent cardiomyopathy (AC) and without apparent cardiomyopathy (WAC). All patients were submitted to MRI, using the technique of myocardial delayed enhancement (MDE) and the results were compared with the Rassi`s score (RS), which was obtained by analyzing the following parameters: 12-lead electrocardiogram, chest x-ray, echodopplercardiography and 24-hour dynamic electrocardiography (Holter). Patients were stratified as belonging to the low, medium or high risk group, and then each one was compared with data obtained by MRI. RESULTS: Regarding the morphological and functional analysis, significant differences were observed in both groups (p< 0.001). Furthermore, there was a strong correlation between the extent of myocardial fibrosis and the Rassi`s score (r= 0.76). CONCLUSIONS: MRI is an important technique in the evaluation of patients with CD, stressing morphological and functional differences in all clinical presentations. The strong correlation with the Rassi`s score and the extent of myocardial fibrosis detected by MRI, emphasizes its role in the prognostic stratification of patients with CD

INTRODUÇÃO: A estenose aórtica, doença valvar de grande prevalência, tem na avaliação clínica e ecocardiográfica as principais ferramentas para avaliação dos pacientes. Ferramentas auxiliares de avaliação são desejáveis e neste contexto surgem os peptídeos natriuréticos. Os peptídeos natriuréticos BNP e NT-proBNP podem ser usados como marcadores diagnósticos e prognósticos em diversas situações clínicas. Postulamos que os peptídeos pudessem ter papel diagnóstico, mas principalmente valor prognóstico em pacientes com estenose aórtica grave. OBJETIVO: primariamente, definir o papel prognóstico de sobrevida dos peptídeos natriuréticos BNP e NT-proBNP no acompanhamento prospectivo de uma população de pacientes com estenose aórtica grave. Secundariamente, comparar os níveis séricos de BNP e NT-proBNP entre pacientes com EAo grave assintomáticos e sintomáticos. MÉTODOS: Foram incluídos de forma consecutiva 66 pacientes com estenose aórtica grave, definida pela presença de gradiente médio de pressão transvalvar aórtica maior que 40 mmHg. Os critérios de exclusão foram fibrilação atrial, outra valvopatia, cardiopatia associada, infecções ativas, neoplasias, doenças auto-imunes ou inflamatórias, insuficiência renal e obesidade. Dos 66 pacientes incluídos, 76% eram sintomáticos (50/66). Os sintomas foram definidos como dispnéia aos esforços, síncope ou angina. Na inclusão, todos os pacientes foram submetidos à avaliação clínica inicial, realização de ecocardiograma e dosagem de BNP e NT-proBNP. Os pacientes sintomáticos recebiam a indicação de tratamento cirúrgico e os pacientes assintomáticos eram conduzidos clinicamente. Os pacientes foram acompanhados prospectivamente. O desfecho clínico avaliado foi óbito cardiovascular, definido por morte súbita, morte por insuficiência cardíaca e óbito peri-operatório. RESULTADOS: Os pacientes foram acompanhados por 869 + 397 dias. Houve 11 óbitos durante o acompanhamento. Na inclusão, os níveis de BNP e NT-proBNP foram similares em assintomáticos e sintomáticos: BNP 72 (41-175) pg/mL versus 104 (46-270) pg/mL; p = 0,275 e NT-proBNP 676 (235-1356) pg/mL vs. 871 (310-2230) pg/mL; p = 0,226. Houve diferença entre os níveis de BNP e NT-proBNP e classe funcional (p < 0,001 e p < 0,001, respectivamente). Através da curva ROC foi determinado um valor de corte de BNP (105 pg/mL) e NT-proBNP (1500 pg/mL) capazes de predizer classe funcional III e IV (New York Heart Association), com área sob a curva de 0,806 e 0,786 respectivamente. BNP e NT-proBNP foram preditores de mortalidade (p=0,007 e p=0,001 respectivamente). BNP > 105 pg/mL aumentou o risco de óbito cardiovascular de forma independente [OR= 6,3 (IC95%: 1,36 - 29,25)]. NT-proBNP > 1500 pg/mL aumentou o risco de óbito cardiovascular de forma independente [OR = 6,5 (IC95%: 1,73 - 24,63)]. CONCLUSÃO: O BNP e o NTproBNP foram preditores independentes de mortalidade em pacientes com estenose aórtica grave em um acompanhamento de quatro anos. O BNP e o NT-proBNP foram preditores de classe funcional III e IV (New York Heart Association) em pacientes com estenose aórtica grave. O BNP e o NT-proBNP não permitiram diferenciar pacientes sintomáticos de assintomáticos / BACKGROUND: Aortic valve stenosis is a high prevalent cardiac valve disease, in which clinical and echocardiographic parameters are the most common approach of diagnosis and risk evaluation. Complementary methods are desirable and the natriuretic peptides BNP and NT-proBNP, both diagnostic and prognostic markers in multiple clinical situations, could improve patient assessment. We postulate that these peptides may have diagnostic purpose, but mainly a prognostic value in patients with severe aortic stenosis. OBJECTIVE: primarily, define the survival prognostic role of natriuretic peptides BNP and NT-proBNP in monitoring a population of patients with severe aortic stenosis prospectively. Secondarily, compare the serum levels of BNP and NT-proBNP among patients with symptomatic and asymptomatic severe aortic stenosis. METHODS: 66 consecutive patients with severe aortic stenosis, defined by the presence of gradient mean transvalvular aortic pressure greater than 40 mmHg were included. Exclusion criteria were concomitant atrial fibrillation, other valve disease, other myocardiopathies, active infections, autoimmunity diseases, inflammatory diseases, neoplasia, renal failure or obesity. 76% of patients were symptomatic (50/66), defined as dyspnea on exertion, syncope or angina. All patients underwent initial clinical evaluation, echocardiography and BNP and NT-proBNP measurement. Symptomatic patients were referred for surgical treatment and asymptomatic patients were clinically managed. (Patients were followed up prospectively). The clinical outcome was cardiovascular death, defined by sudden death, death from heart failure and peri-operative death. RESULTS: Patients were followed up for 869 + 397 days. There were 11 deaths during followup. On admission, levels of BNP and NT-proBNP were similar in asymptomatic and symptomatic individuals: BNP 72 (41-175) pg / mL vs. 104 (46-270) pg / mL, p = 0.275 and NT-proBNP 676 (235-1356) pg / mL vs. 871 (310-2230) pg / ml, p = 0.226. There were differences between the levels of BNP and NT-proBNP and functional class (p <0.001 p <0.001, respectively). ROC-curve analysis demonstrated a cut-off value of BNP (105 pg / mL) and NT-proBNP (1500 pg / mL) capable of predicting NYHA functional class III and IV, with an area under the curve of 0.806 and 0.786 respectively. BNP and NT-proBNP could predict mortality (p = 0.007 and p = 0.001 respectively). BNP > 105 pg/mL independently increased the risk of cardiovascular death [OR = 6.3 (95% CI: 1.36 to 29.25)]. NT-proBNP > 1500 pg/mL independently increased the risk of cardiovascular death [OR = 6.5 (95% CI: 1.73 to 24.63)]. CONCLUSION: BNP and NT-proBNP were independent predictors of mortality in patients with severe aortic stenosis after a follow up of 4 years. BNP and NT-proBNP were predictors of NYHA functional class III and IV in patients with severe aortic stenosis. BNP and NT-proBNP alone did not distinguish symptomatic from asymptomatic patients