A boca é local de frequentes complicações relacionadas ao transplante de células tronco hematopoiéticas (TCTH) tais como xerostomia, disgeusia, disfagia, mucosite, infecções oportunistas e doença do enxerto contra hospedeiro (DECH). Sabe-se que estas complicações podem comprometer a qualidade de vida do paciente e interferir na morbidade pós-TCTH. O dentista é o profissional da saúde que deverá intervir no momento correto para tratar e minimizar esses efeitos secundários do TCTH. Para tanto é importante conhecermos o momento em que cada complicação ocorre para que a intervenção seja pronta e eficiente. O objetivo principal deste estudo foi identificar e quantificar as alterações bucais em indivíduos submetidos ao TCTH em cinco momentos consecutivos desde antes do início do condicionamento pré-TCTH até o dia 100 pós-TCTH. Como objetivos secundários buscamos investigar possíveis relações entre a severidade da mucosite oral e a manifestação da DECH com dados demograficos (sexo, idade), com o status de saude bucal (por meio dos índices IHO-S, CPOD, número de dentes cariados) e com a realização de adequação bucal pré-TCTH, e ainda, somente para a DECH, também foi investigada a possível relação entre esta doença com infecção sistêmica por citomegalovírus e com a manifestação de mucosite oral severa. Foram incluídos no estudo 27 indivíduos com doenças hematológicas do Serviço de Transplante de Medula Óssea do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), com idade 12 anos que receberam TCTH alogênico. Os indivíduos foram examinados em cinco momentos consecutivos. No primeiro momento, pré-TCTH, foi realizada a coleta de índices de saúde bucal e aplicação de questionário sobre o histórico de tratamentos odontológico prévios. Nos momentos de 10, 20, 60 e 100 dias pós-TCTH foram avaliadas as manifestações bucais presentes. A incidência de mucosite oral foi de 82,6% considerando todos os momentos avaliados. Mucosite oral severa, ou seja, graus 3 e 4 (OMS) foi observada em 57,9% dos pacientes avaliados nos momentos 2 e 3. Dez (37%) pacientes apresentaram GVHD em algum órgão, e destes, 8 (80%) apresentaram GVHD de boca. Infecção sistêmica por CMV foi diagnosticada em 6 (22,2%) pacientes. Concluímos que entre as queixas levantadas, dor bucal e disfagia foram as mais referidas. O período de maior incidência das complicações bucais foi nos segundo e terceiro momentos, ou seja, D+10 e D+20, representando deste forma, o período de maior morbidade do tratamento. Não houve associação entre a severidade de mucosite oral e idade, sexo, fonte de células, regime de condicionamento, número de dentes cariados, IHO-S, CPOD e preparo bucal pré-TCTH. Para a DECH a única relação encontrada foi para fonte de células, tendo sido observada menor chance de ocorrer DECH quando a fonte de células foi o sangue periférico. / The mouth is a well-known site of complications of the hematopoietic stem cell transplantation (HSCT) such as dry mouth, dysgeusia, dysphagia, mucositis, opportunistic infections and graft versus host disease (GVDH). It is known that these complications can compromise the patients quality of life and morbidity post-HSCT. The dentist is the health professional who should interfere at the right time to treat and minimize these side effects of HSCT. Thus, it is important to know the time at which each complication occurs to be dynamic and efficient. The main objective of this study was to identify and quantify the oral complications in patients treated with HSCT in five consecutive moments starting before conditioning chemotherapy until day 100 post-HSTC. As secondary objectives we seek to investigate possible relationships between the severity of oral mucositis and the manifestation of GVHD with demographic data (gender, age), with the oral health status (IHO-S, CPOD, number of decayed teeth) and dental treatment previously HSCT, and, only for GVHD, was also investigated the possible relationship between this disease with systemic cytomegalovirus infection and the manifestation of severe oral mucositis. It was included in the study 27 patients with hematologic diseases who were admitted in the Unit of Bone Marrow Transplantation, Hospital of Clinics, Faculty of Medicine, University of Sao Paulo (HC-FMUSP), 12 years old whom received allogeneic HSCT. The subjects were examined in five consecutive moments. At the first moment, before HSCT, the oral health índex evaluation and a questionnaire about history of previous dental treatments were performed. Besides that, 10, 20, 60 and 100 days after HSCT they were evaluated for oral manifestations. Oral mucositis incidence was 82,6% and 57,9% of these patients presented severe mucositis. Ten (37%) patients had GVHD in any organ, and of these, 8 (80%) had oral GVHD. Infection by CMV was diagnosed in 6 (22.2%) patients. We conclude that among the complaints raised, mouth pain and dysphagia were the most mentioned. The period of increased incidence of oral complications was the second and third times (D +10 and +20), representing the increased morbidity period. There was no association between the severity of oral mucositis and age, sex, cell source, conditioning regimen, number of decayed teeth, IHO-S, CPOD and dental treatment pre-HSCT. For GVHD the only relation found was with source of cells, in which, GVHD was less likely to occur when the source of cells was peripheral blood.

Introdução: Pacientes com câncer na região de cabeça e pescoço normalmente são tratados por combinação de cirurgia, radioterapia (RT) e quimioterapia. Em muitos casos, a reabilitação oral com próteses implanto-suportadas representa a melhor opção para uma recuperação funcional adequada. Entretanto, em pacientes irradiados procedimentos como exodontias e instalações de implantes dentários são fatores de risco ao desenvolvimento de osteorradionecrose. Diversos estudos experimentais têm demonstrado que o uso de células-tronco mesenquimais (CTMs) associadas a fatores de crescimento como plasma rico em plaquetas (PRP) proporciona melhora no reparo ósseo e na osseointegração, podendo ser considerada uma alternativa viável para defeitos ósseos ou injúria. Objetivos: Isolar e caracterizar as CTMs da medula óssea (MO) de miniporcos brasileiros (Minipigs BR-1), avaliar a interferência da RT e o efeito da associação de CTMs-MO+PRP no processo de osseointegração de implantes instalados em alvéolos frescos em mandíbulas de miniporcos, por análise histológica e histomorfométrica da interface osso-implante. Métodos: CTMs-MO de 12 miniporcos adultos machos foram isoladas da crista ilíaca. Após 21 dias de cultura, o potencial de diferenciação celular foi avaliado por meio de coloração e RT-PCR. O perfil imunofenotípico foi caracterizado por citometria de fluxo. Os animais foram divididos em três grupos: Grupo A (grupo controle, sem RT), Grupo B (implantes instalados 15 dias antes da RT) e Grupo C (implantes instalados três meses após a RT). A dose total de radiação para cada lado da mandíbula foi de 24 Gy, divididos em três doses de 8 Gy com intervalo de 7 dias entre as doses, a qual equivale biologicamente a aproximadamente 56 Gy, com 28 exposições de 2 Gy cada. Quatro implantes de titânio foram instalados nos alvéolos frescos, imediatamente após as extrações dos terceiro e quarto pré-molares, totalizando 48 implantes controles e 48 experimentais (uso de CTM-MO+PRP). Os animais foram eutanasiados 90 dias pós-implantação. Foram analisados o percentual de implantes perdidos (PIP), o contato osso-implante (COI), e a densidade óssea no interior das roscas (DOIR). Resultados: A eficiência de isolamento das CTMs-MO foi de 100% e em cultura as células apresentaram morfologia fibroblastóide. As células foram positivas para CD90 (88,6%), CD29 (89,8%), CD44 (86,9%) e negativas para CD34 (1,6%), CD45 (1,8%), CD14 (1,8%) e MHC-II (2,7%). As células foram diferenciadas em adipócitos, demonstrado pela presença de vacúolos lipídicos no interior das células; osteoblastos, pela mineralização da matriz extracelular e condrócitos pela presença de lacunas ao redor dos condrócitos jovens. A maior expressão gênica de AP2, ALP e COL II em células induzidas também confirmou o potencial de diferenciação (p < 0,001; p < 0,001; p = 0,031; respectivamente). Os PIP nos lados controle e experimental foram respectivamente 25,0% e 18,7% no grupo A (p = 0,686), 31,2% e 25,0% no grupo B (p=0,686) e 68,7% e 68,7% no grupo C (p =1,000). Na comparação entre os três grupos, o PIP apresentou diferença estatisticamente significante tanto no lado controle (p=0,041) como no experimental (p = 0,047). Os percentuais de COI nos lados controle e experimental foram respectivamente 39,0 e 27,7 no grupo A (p = 0,110); 20,9 e 16,7 no grupo B (p=0,347) e 16,0 e 7,1 no grupo C (p = 0,310), com diferença estatística entre os grupos tanto no lado controle (p = 0,033) quanto no experimental (p=0,046). As DOIR nos lados controle e experimental foram respectivamente 46,8 e 36,5 no grupo A (p = 0,247); 29,3 e 24,1 no grupo B (p = 0,379) e 21,0 e 11,6 no grupo C (p = 0,421), porém com diferença estatisticamente significante entre os três grupos somente no lado controle (p=0,025). Conclusões: As CTMs-MO de Minipigs BR-1, obtidas com o protocolo utilizado neste estudo são células-tronco, podendo ser aplicadas em ensaios pré-clínicos na medicina regenerativa. Os resultados mostraram um efeito negativo da radiação ionizante na neoformação óssea periimplantar tanto no grupo B quanto no C. Após a RT a perda de implantes foi três vezes maior que em osso não irradiado. A RT realizada 15 dias após a instalação dos implantes não interferiu na perda de implantes, sugerindo que este seria o melhor momento para reabilitação bucal com implantes dentários. Com a metodologia empregada, o uso da associação CTMs-MO+PRP previamente à instalação de implantes não apresentou efeito positivo significante na neoformação óssea periimplantar / Introduction: Patients with head and neck cancer are usually treated by a combination of surgery, radiotherapy (RT) and chemotherapy. In many cases, oral rehabilitation with implant-supported prostheses is the best option for a proper functional recover. However, in irradiated patients procedures as dental extractions and implants are risk factors for developing osteoradionecrosis. Several experimental studies have shown that the use of mesenchymal stem cells (MSCs) associated with growth factors such as platelet-rich plasma (PRP) provides improvement in bone regeneration and osseointegration, being considered an alternative to bone defects or injury. Objectives: To isolate and characterize MSCs from bone marrow (BM) of Brazilian minipigs (Minipigs BR-1), to evaluate the effect of RT and of BM-MSCs+PRP in the osseointegration of implants placed in fresh sockets, by histological and histomorphometric analysis of the bone-implant interface. Methods: BM-MSCs from 12 adult male minipigs were isolated from the iliac crest. After 21 days of culture, cell differentiation potential was assessed by staining and RT-PCR. The immunophenotypic profile was characterized by flow cytometry. The animals were divided into three groups: Group A (control group, no RT), Group B (implants placement 15 days before RT) and Group C (implants placement three months after RT). The total radiation dose for each side of the mandible was 24 Gy, divided into 3 doses of 8 Gy with a 7 dayinterval for each dose, which is biologically equivalent to approximately 56 Gy, with 28 sections of 2 Gy each. Four titanium implants were installed in the alveoli fresh, immediately after the extraction of the third and fourth premolars of each hemimandible, totalling 48 implants on the control side and 48 on the experimental side (using BM-MSCs+PRP). The animals were euthanized 90 days post-implantation. The implant loss rate (ILR), the bone-implant-contact (BIC) and bone density inside the threads (BDIT) were determined in each group. Results: The efficiency of the isolation of BM-MSCs was 100%, and in culture, the cells showed fibroblastoid morphology. Cells were positive for CD90 (88.6%), CD29 (89.8%), CD44 (86.9%) and negative for CD34 (1.6%), CD45 (1.8%), CD14 (1.8%) and MHC-II (2.7%). Cells were differentiated into adipocytes, as demonstrated by the presence of lipid vacuoles in the cells, osteoblasts, by mineralization of extracellular matrix and chondrocytes, by the presence of gaps around the young chondrocytes. The higher gene expression of AP2, ALP and COL II at induced cells also confirmed the differentiation potential (p < 0.001, p < 0.001, p=0.031; respectively). The ILR in control and experimental sides were respectively 25.0% and 18.7% in group A (p=0.686), 31.2% and 25.0% in group B (p = 0.686) and 68.7% and 68.7% in group C (p =1.000), with a statistically significant difference between the three groups at the control side (p = 0.041) and at the experimental side (p = 0.047). The percentage of BIC in control and experimental sides were respectively 39.0 and 27.7 in group A (p = 0.110), 20.9 and 16.7 in group B (p = 0.347) and 16.0 and 7.1 in group C (p = 0.310), with statistical significance between the groups at the control side (p = 0.033) and at the experimental side (p = 0.046). The BDIT in experimental and control sides were respectively 46.8 and 36.5 in group A (p = 0.247), 29.3 and 24.1 in group B (p = 0.379) and 21.0 and 11.6 in group C (p = 0.421), with statistical significance between the three groups only at the control side (p = 0.025). Conclusions: The BM-MSCs of Minipigs BR-1 obtained with this protocol can be used in pre-clinical regenerative medicine since they are stem cells. The results showed a negative effect of RT in peri-implant bone regeneration in group B and C. The implant loss was three times higher in irradiated bone than in non-irradiated one. The RT performed 15 days after implant placement did not interfere with implant loss, suggesting that this would be the best time for oral rehabilitation with dental implants. With this methodology, the use of BM-MSCs+PRP before the implant placement did not show any significant positive effect on peri-implant bone regeneration

Die vorliegende Arbeit beschäftigt sich mit der Bildgebung magnetisch markierter Stammzellen im ZNS mittels Magnetresonanztomographie. Dazu wurden Stammzellen mit Eisenoxidnanopartikeln (VSOP, very small superparamagnetic iron-oxide particles) in vitro effizient und ohne zusätzliche Lipofektionsagenzien magnetisch markiert. Es zeigte sich keine wesentliche Beeinflussung der Vitalität, Proliferation und Differenzierungsfähigkeit sämtlicher untersuchter Zellpopulationen. Zur Evaluierung der Grenzen der zellulären MR-Bildgebung wurde das Detektionslimit magnetisch markierter embryonaler Stammzellen in vivo nach intrastriataler Injektion im Gehirn der Ratte untersucht. Es ließen sich bei einer Feldstärke von 17,6 T weniger als 100 magnetisch markierte Zellen sicher vom Hirnparenchym abgrenzen. Die histologische Korrelation bestätigte den zellulären Ursprung der beobachteten T2*-Hypointensitäten. In einem Rattenmodel des Morbus Parkinson konnte eine spezifische Detektion der intrastriatal injizierten magnetisch markierten embryonalen Stammzellen über einen Zeitraum von 6 Monaten erreicht werden. Es konnte keine signifikante Migration der Zellen festgestellt werden, jedoch fanden sich große interindividuelle Unterschiede in ihrer räumlichen Verteilung. In der histologische Analyse stellten sich auch sechs Monate nach der Transplantation im Bereich des Stichkanals eisenoxidmarkierte Stammzellen dar. In einem Mausmodell der cerebralen Ischämie wurde erstmals die Anreicherung systemisch injizierter magnetisch markierter mononukleärer Zellen kernspintomographisch erfasst. 24 - 48 h nach der Injektion magnetisch markierter Zellen stellten sich T2*-gewichtete Signalhypointensitäten im Randbereich der Ischämie dar. Insgesamt zeigte sich in dieser Studie die zelluläre Magnetresonanztomographie zu einem nicht-invasiven Nachweis einer geringen Anzahl magnetisch markierter Zellen über einen langen Zeitraum mit hoher Sensitivität in der Lage. / This thesis is dealing with the imaging of magnetically labeled stem cells in the CNS using magnetic resonance imaging (MRI). Stem cells were efficiently magnetically labeled with very small superparamagnetic iron-oxide particles (VSOP), without any lipofection agents. No significant impact on vitality, proliferation and ability to differentiate could be observed after the magnetic labeling of all cell populations investigated. Magnetically labeled embryonic stem cells were injected into the striatum of rats to evaluate their detection limit by MRI. At field strengths of 17.6 T, less than 100 cells could be discriminated from the brain parenchyma as T2*-weighted hypointensities. Histology proved the cellular origin of MRI-signal changes. In a rat model of Parkinsons’s Disease, magnetically labeled embryonic stem cells could be detected by MRI after intrastriatal injection for a time period of more than 6 months. No significant migration of transplanted cells could be observed, however significant inter-individual differences concerning the spatial distribution of cells could be found. Histologically, transplanted iron-oxide-labeled cells could still be detected in the vicinity of the injection tract six months after transplantation. In a mouse model of cerebral ischemia, the enrichment of systemically injected magnetically labeled mononuclear cells was detected non-invasively by MRI. 24 to 48 hours after injection of magnetically labeled cells, T2*-weighted hypointense signal changes could be observed in the border zone of the ischemia. Over all, this study showed that cellular MRI is capable of the sensitive non-invasive detection of small numbers of magnetically labeled cells over a long period of time.

No description available.

La greffe de sang de cordon est de plus en plus utilisée et a permis de traiter avec succès chez l’enfant des déficits immunitaires ainsi que des hémopathies malignes comme les leucémies. Malgré d’importants avantages tels que l’absence de risque pour le donneur ou la plus faible incidence de maladie du greffon contre l’hôte (GvHD), utiliser le sang de cordon comporte certains inconvénients. En effet, une reconstitution immunitaire retardée, des infections opportunistes en plus grand nombre et un risque de rechute sont des complications qui peuvent survenir et engendrer un risque pour le pronostic vital du patient. Par conséquent, de nouvelles stratégies d’immunothérapies doivent être envisagées. Dans le cadre de ce travail, nous nous sommes particulièrement intéressés aux cellules dendritiques plasmacytoides (pDC) dont les fonctions sont importantes pour l’initiation des réponses immunitaires innée et adaptative et particulièrement pour leur capacité à activer les cellules NK. Afin d’élucider le rôle et l’impact de ces cellules dans les greffes de sang de cordon, le nombre et la fonction des pDC et des NK a été suivi longitudinalement chez des patients ayant subi une greffe de sang de cordon comparativement à des patients transplantés avec de la moelle osseuse. Nous avons ainsi démontré que les pDC et les NK apparaissent précocement suite à une greffe de sang de cordon et que ces cellules sont fonctionnelles. Ces résultats mettent donc en lumière que ces cellules pourraient être de bons outils pour l’établissement d’une immunothérapie après greffe de sang de cordon. De plus, la caractérisation fonctionnelle des pDC du greffon de sang de cordon a permis de révéler une plus faible production d’IFN-α par les pDC, comparativement aux pDC de sang d’adulte. Cette différence pourrait jouer un rôle dans la plus faible incidence de GvHD après les greffes de sang de cordon. Dans le but de préciser les mécanismes moléculaires de régulation négative de la production d’IFN-α par les pDC de sang de cordon, nous avons étudié les protéines de la voie de signalisation TLR9-IRF7. L’expression similaire de l’ARN du TLR9, MyD88, IRAK1 et IRF7 contraste avec la plus faible expression des protéines correspondantes. De plus, l’expression des MicroARNs miR-146a et miR-155 est plus élevé dans les pDC de sang de cordon comparativement aux pDC de sang d’adultes. Ensemble, ces données pointent une régulation négative post-transcriptionnelle de la voie TLR9-IRF7 qui pourrait expliquer la plus faible production d’IFN-α des pDC du sang de cordon. L’ensemble des ces travaux suggère que les pDC pourraient représenter une cible de choix dans le développement de nouvelles approches thérapeutiques dans les greffes de sang de cordon. / Umbilical cord blood transplantation has increasingly been used as a source of hematopoietic stem cells to successfully treat immunodeficiencies and malignant diseases such as leukemia in pediatric patients. Despite important advantages, namely lack of risk for the donor and low incidence of GvHD, use of cord blood is associated with several drawbacks. Specifically, delayed immune reconstitution, more opportunistic infections and a relative risk of relapse are complications that may occur and lead to a poor prognosis. Consequently, new immunotherapeutic strategies should be considered. In this study, we were interested in plasmacytoid dendritic cells (pDC), whose functions are important for initiation of innate and adaptive immune responses and, in particular, for their ability to activate natural killer cells (NK). In order to elucidate the role and the impact of these cells in cord blood transplantation, pDC and NK numbers and function have been longitudinally followed in cord blood and bone marrow recipients. We showed that pDC and NK cells appeared early after umbilical cord blood transplantation and that these cells retained functional activity. Thus, these cells may constitute a good tool for immunotherapy in umbilical cord blood transplantation. Moreover, the functional characterization of pDC in cord blood revealed a lower production of IFN-α by cord blood pDC, which may play a role in the lower incidence of GvHD after umbilical cord blood transplantations. In order to determine the molecular mechanism for the negative regulation of IFN-α production by cord blood pDC, we studied the expression of TLR9-IRF7 pathway. The stable expression of TLR9, MyD88, IRAK1 and IRF7 mRNA contrasts with the lower expression of corresponding proteins. Interestingly, expression of microRNA miR-146a and miR-155 is higher in cord blood pDC. Together, these results point to a post-transcriptionnal negative regulation of TLR9-IRF7 pathway which may explain the lower IFN-α production by cord blood pDC. This work reinforces the idea that pDCs constitute a target of choice for developing new therapeutic approaches in cord blood transplantations.

Dissertation (Ph.D.)--University of South Florida, 2007. / Includes vita. Includes bibliographical references. Also available online.

Dissertation (Ph.D.)--University of South Florida, 2009. / Includes vita. Includes bibliographical references. Also available online.

The transplantation of allogeneic cells and tissues for the treatment of human disease has been a life-saving procedure for many thousands of patients worldwide. However, to date, neither solid organ transplantation nor bone marrow transplantation have reached their full clinical potential. Significant limitations to the advancement of clinical transplantation stem from our current inability to prevent the rejection of allogeneic tissues by the immune system of the host. Similarly, in patients that receive allogeneic bone marrow transplants, we cannot permanently prevent the engrafted immune system from mounting a response against the patient. This problem, termed graft versus host disease is the most prevalent cause of morbidity and mortality in recipients of allogeneic bone marrow transplants. Clinically, we rely on lifelong immunosuppression to prolong survival of allogeneic tissues within the host. Our currently available therapeutics burden patients with side-effects that range from being unpleasant to life-threatening, while in most cases offering only a temporary solution to the problem of alloimmunity. Efforts are underway to develop protocols and therapeutics that more effectively prevent the pathology associated with alloimmunity. To minimize patient risk, extensive pre-clinical studies in laboratory animals are conducted to predict clinical responses. In the case of immunologic studies, many of these pre-clinical studies are carried out in murine models. Unfortunately, studies of murine immunity often do not predict outcomes in the clinic. One approach to overcome this limitation is the development of a small animal model of the human immune system. In this dissertation, we hypothesized that NOD-scid IL2rγnull mice engrafted with human peripheral blood mononuclear cells (PBMC), termed the hu-PBMC-NOD-scid IL2rγnull model, would provide a model that more accurately reflects human immunity in vivo than other models currently available. To investigate this possibility, we first investigated whether NOD-scid IL2rγnull mice were able to support the engraftment of human PBMC. We found that NOD-scid IL2rγnull mice engraft with human PBMC at much higher levels then the previous gold standard model, the NOD-scid mouse. We then investigated the kinetics of human cell engraftment, determined the optimal cell dose, and defined the influence of injection route on engraftment levels. Even at low PBMC input, NOD-scid IL2rγnullmice reproducibly support high levels of human PBMC engraftment. In contrast to previous stocks of immunodeficient mice, we observed low intra- and interdonor variability of engraftment. We next hypothesized that the human PBMC engrafted in NOD-scid IL2rγnull mice were functional and would reject transplanted allogeneic human tissues. To test this, human islets were transplanted into the spleen of chemically diabetic NOD-scid IL2rγnull mice with or without intravenous injection of HLA-mismatched human PBMC. In the absence of allogeneic PBMC, the human islets were able to restore and maintain normoglycemia. In contrast, human islet grafts were completely rejected following injection of HLA-mismatched human PBMC as evidenced by return to hyperglycemia and loss of human C-peptide in the circulation. Thus, PBMC engrafted NOD-scid IL2rγnull mice are able to provide an in vivomodel of a functional human immune system and of human islet allograft rejection. The enhanced ability of NOD-scid IL2rγnull mice to support human cell engraftment gave rise to the possibility of creating a model of graft versus host disease mediated by a human immune system. To investigate this possibility, human PBMC were injected via the tail vein into lightly irradiated NOD-scid IL2rγnull mice. We found that in contrast to previous models of GVHD using human PBMC-injected immunodeficient mice, these mice consistently (100%) developed GVHD following injection of as few as 5x106PBMC, regardless of the PBMC donor used. We then tested the contribution of host MHC in the development of GVHD in this model. As in the human disease, the development of GVHD was highly dependent on host expression of MHC class I and class II molecules. To begin to evaluate the extent to which the PBMC-engrafted NOD-scid IL2rγnull humanized mouse model of GVHD represents the clinical disease, we tested the ability of a therapeutic in clinical trials to modulate GVHD in these mice. In agreement with the clinical experience, we found that interrupting the TNFα signaling cascade with etanercept delayed the onset and severity of disease in this model. In summary, we conclude that humanized NOD-scid IL2rγnull mice represent an important surrogate for investigating in vivo mechanisms of both human islet allograft rejection and graft versus host disease.

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Agradecemos a compreensão. on 2018-09-03T17:01:07Z (GMT) / Submitted by Cesar Martins da Costa (cesarmt_costa@hotmail.com) on 2018-09-04T02:44:43Z No. of bitstreams: 1 Repositório_03_09.pdf: 1792756 bytes, checksum: 66827eabf8f9f93bf0427b25dd02e0e2 (MD5) / Approved for entry into archive by ROSANGELA APARECIDA LOBO null (rosangelalobo@btu.unesp.br) on 2018-09-04T19:18:59Z (GMT) No. of bitstreams: 1 costa_cm_me_bot.pdf: 1792756 bytes, checksum: 66827eabf8f9f93bf0427b25dd02e0e2 (MD5) / Made available in DSpace on 2018-09-04T19:18:59Z (GMT). No. of bitstreams: 1 costa_cm_me_bot.pdf: 1792756 bytes, checksum: 66827eabf8f9f93bf0427b25dd02e0e2 (MD5) Previous issue date: 2018-05-02 / O Transplante de Células Progenitoras Hematopoiéticas (TCPH) é um método terapêutico utilizado no tratamento de diversas doenças que envolvem o tecido linfo-hematopoiético, doenças autoimunes e condições não-malignas. As evidências apontam que o reconhecimento precoce de pacientes em grupos de risco nutricional no TCPH e a elaboração de um plano terapêutico para tal tem impacto positivo na redução da mortalidade. A monitorização diária das necessidades energéticas, proteicas e de nutrientes é um dos pontos cruciais da terapia, pois o paciente que é incapaz de suprir mais do que 60% das necessidades nutricionais diárias por via oral torna-se candidato a outras modalidades de terapia (enteral ou parenteral), a depender da viabilidade do trato gastrointestinal, das contra-indicações relativas a cada método (plaquetopenia na introdução de sonda nasoenteral, por exemplo) e das complicações associadas aos procedimentos (aumento das taxas de infecção de corrente sanguínea na nutrição parenteral). Se o paciente atingir mais do que 60% das necessidades nutricionais por via oral e mantiver esse aporte por pelo menos 3 dias, o suporte por nutrição enteral ou parenteral pode ser descontinuado. A literatura científica ainda não elucidou todos os questionamentos quanto à melhor abordagem nutricional em pacientes submetidos a TCPH, podendo-se observar grande variação entre as condutas orientadas pelas diretrizes internacionais mais recentes e o que se adota como prática clínica diária, chamando atenção para a necessidade da elaboração de protocolos nutricionais que diminuam essas divergências. Objetivos​: elaboração de um manual de avaliação do risco nutricional e de implementação de terapia nutricional para pacientes que serão submetidos ao Transplante de Células Progenitoras Hematopoiéticas no Hospital das Clínicas de Botucatu, facilitando a tomada de decisões de acordo com as evidências científicas mais recentes e contribuindo para minimizar as divergências de condutas através de um protocolo nutricional hospitalar. Casuística e Métodos​: o manual foi elaborado por meio de uma revisão narrativa da literatura científica, utilizando-se de artigos e diretrizes relevantes contidos nas bases de dados Pubmed, Lilacs e Scielo, assim como de livros textos e de consensos desde o ano 2000 até 2017. Para a busca, os termos utilizados foram “nutrition assessment", "nutrition therapy", "nutrition risk", “undernutrition”, "malnutrition", “obesity”, "chemotherapy", “blood 8 marrow transplantation”, “haematopoietic stem cell transplantation”, “body composition”, “phase angle”. Resultados​: há escassez de estudos específicos relacionados a terapia nutricional e a TCPH. A busca resultou na utilização de 20 trabalhos científicos que embasam a produção desta dissertação. Considerando a estrutura e a dinâmica do Hospital das Clínicas de Botucatu, a padronização de condutas deste Manual levou à elaboração de um protocolo em forma de fluxograma que abrange a avaliação do Risco Nutricional e de aplicação da Terapia Nutricional em pacientes submetidos ao TCPH neste serviço de saúde. Conclusão​: o protocolo de avaliação de Risco e de aplicação de Terapia Nutricional, redigido em forma de fluxograma, facilita a aplicabilidade do conteúdo do Manual para os profissionais que dele se utilizarão, simplifica a classificação dos grupos de risco nutricional, disponibiliza elaboração rápida de condutas e evita divergências de prescrição quanto à melhor Terapia Nutricional em pacientes submetidos ao TCPH. / Hematopoietic Stem Cell Transplantation (HSCT) is a therapeutic method used for treatment of various diseases involving lymphohematopoietic tissue, autoimmune diseases and non-malignant conditions. Evidence indicates that the early recognition of nutritional risk in HSCT patients and the elaboration of a therapeutic plan for them has a positive impact in reducing mortality. Monitoring daily needs of energy, protein and nutrient is one of the crucial points of therapy, because individuals who are unable to supply more than 60% of the daily nutritional needs orally become candidates for other modalities of therapy (enteral or parenteral), depending on the viability of the gastrointestinal tract, contraindications for each method (thrombocytopenia in the introduction of nasoenteral probe, for example) and complications associated with procedures (increased bloodstream infection rates in parenteral nutrition) . If the patient reaches more than 60% of nutritional needs orally and maintains this intake for at least 3 days, enteral or parenteral nutrition support may be discontinued. The scientific literature has not yet elucidated all the questions regarding the best nutritional approach in patients undergoing HSCT and a great variation between the conducts guided by the most recent international guidelines and what is adopted as daily clinical practice can be observed, drawing attention to the need for nutritional protocols that could reduce these divergences. Objectives​: elaboration of a manual of nutritional therapy and nutritional risk assessment for patients in the Hematopoietic Progenitor Cell Transplantation program at the Hospital das Clínicas de Botucatu, facilitating decision-making according to the latest scientific evidence and contributing to minimize differences of conduct guided by a hospital nutritional protocol. Materials and Methods​: the manual is a narrative review of the scientific literature, using relevant articles and guidelines contained in the Pubmed, Lilacs and Scielo databases, as well as textbooks and consensus books from year 2000 to 2017. The terms used for the research were “nutrition assessment”, “nutrition therapy”, “nutrition risk”, “undernutrition”, “malnutrition”, “obesity”, “chemotherapy”, “blood marrow transplantation”, “haematopoietic stem cell transplantation","Body composition","phase angle". Results: ​there are few specific studies related to nutritional therapy and HSCT. The search resulted in the use of 20 scientific papers that support the production of this dissertation. Considering the structure and dynamics of Hospital das Clínicas de Botucatu, 10 the standardization of conducts in this Manual led to the elaboration of a protocol in the form of flowchart that includes the evaluation of Nutritional Risk and Nutritional Therapy in patients undergoing HSCT. Conclusion​: the risk assessment and nutrition therapy application protocols, built in the form of a flowchart, facilitate the applicability of the manual contents, simplify the classification of nutritional risk groups, provide rapid pipeline elaboration and avoid divergences of prescription regarding the best nutritional therapy in patients undergoing HSCT.

Orientador: Paula Schmidt Azevedo Gaiolla / Resumo: O Transplante de Células Progenitoras Hematopoiéticas (TCPH) é um método terapêutico utilizado no tratamento de diversas doenças que envolvem o tecido linfo-hematopoiético, doenças autoimunes e condições não-malignas. As evidências apontam que o reconhecimento precoce de pacientes em grupos de risco nutricional no TCPH e a elaboração de um plano terapêutico para tal tem impacto positivo na redução da mortalidade. A monitorização diária das necessidades energéticas, proteicas e de nutrientes é um dos pontos cruciais da terapia, pois o paciente que é incapaz de suprir mais do que 60% das necessidades nutricionais diárias por via oral torna-se candidato a outras modalidades de terapia (enteral ou parenteral), a depender da viabilidade do trato gastrointestinal, das contra-indicações relativas a cada método (plaquetopenia na introdução de sonda nasoenteral, por exemplo) e das complicações associadas aos procedimentos (aumento das taxas de infecção de corrente sanguínea na nutrição parenteral). Se o paciente atingir mais do que 60% das necessidades nutricionais por via oral e mantiver esse aporte por pelo menos 3 dias, o suporte por nutrição enteral ou parenteral pode ser descontinuado. A literatura científica ainda não elucidou todos os questionamentos quanto à melhor abordagem nutricional em pacientes submetidos a TCPH, podendo-se observar grande variação entre as condutas orientadas pelas diretrizes internacionais mais recentes e o que se adota como prática clínica diária, cham... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Hematopoietic Stem Cell Transplantation (HSCT) is a therapeutic method used for treatment of various diseases involving lymphohematopoietic tissue, autoimmune diseases and non-malignant conditions. Evidence indicates that the early recognition of nutritional risk in HSCT patients and the elaboration of a therapeutic plan for them has a positive impact in reducing mortality. Monitoring daily needs of energy, protein and nutrient is one of the crucial points of therapy, because individuals who are unable to supply more than 60% of the daily nutritional needs orally become candidates for other modalities of therapy (enteral or parenteral), depending on the viability of the gastrointestinal tract, contraindications for each method (thrombocytopenia in the introduction of nasoenteral probe, for example) and complications associated with procedures (increased bloodstream infection rates in parenteral nutrition) . If the patient reaches more than 60% of nutritional needs orally and maintains this intake for at least 3 days, enteral or parenteral nutrition support may be discontinued. The scientific literature has not yet elucidated all the questions regarding the best nutritional approach in patients undergoing HSCT and a great variation between the conducts guided by the most recent international guidelines and what is adopted as daily clinical practice can be observed, drawing attention to the need for nutritional protocols that could reduce these divergences. Objectives​: elabora... (Complete abstract click electronic access below) / Mestre