Introdução: Rosiglitazone (RGL) é um ligante dos receptores PPAR e vem sendo usada no tratamento do Diabetes Mellitus tipo 2 e nas doenças inflamatórias. Mas, RGL pode reduzir a filtração glomerular (FG), a carga excretada de sódio na urina (UVNa) e aumentar a expressão da Na+,K+- ATPase na medula renal. Então, RGL pode causar edema e insuficiência cardíaca congestiva. Entretanto, não tem sido reportado se RGL pode induzir insuficiência renal aguda (IRA). Objetivo: Verificar se a redução da FG causada pelo tratamento com RGL predispõe à IRA em ratos. Avaliar em condições basais e de vasoconstrição renal e se há diferenças entre ratos normocolesterolêmicos (NC) e hipercolesterolêmicos (HC). Métodos: A FG foi medida pelo clearance de inulina no 8º dia em ratos (~200g) NC e HC tratados ou não com RGL (48 mg/kg/dieta) na situação basal e durante a infusão endovenosa de Ang II (40 ng/kg/min). Além disso, a atividade da Na+,K+-ATPase foi avaliada em homogenato renal em outra série de animais. Resultados: Na situação basal, NC e HC apresentaram FG semelhante e o tratamento com RGL reduziu a FG apenas em NC de 0,78±0,03 para 0,50±0,05* ml/min/100g, *p<0,001. Apesar da redução da FG, a UVNa em NC+RGL não se modificou. Durante a infusão de Ang II, a FG de NC, HC e HC+RGL reduziu-se para o mesmo patamar de NC+RGL e um significante aumento da UVNa foi observada apenas em NC+RGL (NC= 3,32±0,88; NC+RGL=5,86±1,04*; HC= 2,63±0,43 e HC+RGL= 2,23±0,39 uEq/min, *p<0,01). Além disso, RGL induziu aumento na atividade da Na+,K+-ATPase em HC+RGL e não modificou em NC+RGL. Os valores expressos em M Pi/mg proteína.h-1 foram de 45±7 em NC, 43±5 em NC+RGL, 48±7 em HC e 64±4* em HC+RGL, *p<0,05. Analisando todos os resultados em conjunto, a redução da FG associada com a alta natriurese e ausência da modulação da atividade da Na+,K+-ATPase em NC+RGL sugerem lesão renal neste grupo. Conclusão: Os mecanismos de ação da RGL diferem de acordo com a condição metabólica. Então, RGL deve ser prescrita com cautela na ausência de hipercolesterolemia e requer a monitoração da função renal principalmente nas situações de vasoconstrição / Introduction: Rosiglitazone (RGL) is a ligand for PPAR used to treat type 2 Diabetes Mellitus and inflammatory diseases. However, RGL can reduce the glomerular filtration rate (GFR), urinary sodium excretion (UVNa) and increase the expression of Na+, K+-ATPase in renal medulla. Thus, RGL may induce edema and congestive heart failure. However, acute renal failure (ARF) provoked by RGL treatment has not been reported. Aim: To test whether reduced GFR by RGL may predispose to ARF at baseline and during a renal vasoconstriction state, and if the findings differ between normocholesterolemic (NC) and hypercholesterolemic (HC) rats. Methods: GFR was measured by inulin clearance on the 8th day in NC and HC rats (~200g) treated or not with RGL (48 mg/kg diet) at baseline and during intravenous infusion of Ang II (40 ng/kg/min). Furthermore, the Na+,K+- ATPase activity was determined in renal homogenates in other series of animals. Results: At baseline, NC and HC had similar GFR and the treatment with RGL reduced GFR only in NC from 0.78±0.03 to 0.50±0.05* ml/min/100g, *p<0.001. Although GFR was reduced, UVNa was unchanged in NC+RGL. During Ang II infusion, GFR was significantly reduced in NC, HC and HC+RGL and it remained at the same reduced level in NC+RGL. At this time, when GFR was reduced the same range in all groups, a significant increment in UVNa was only observed in NC+RGL (NC = 3.32±0.88; NC+RGL = 5.86±1.04*; HC = 2.63±0.43 and HC+RGL = 2.23±0.39 Eq/min, *p<0.01). Moreover, RGL induced an increase in the activity of Na+, K+-ATPase in HC+RGL, but it did not modify the activity of this enzyme in NC+RGL. The values expressed in M Pi/mg.protein.h-1 were 45±7 in NC, 43±5 in NC+RGL, 48±7 in HC and 64±4* in HC+RGL, *p<0.05. Taken together, reduction in GFR associated with high natriuresis and without changes in the Na+, K+-ATPase activity in renal medulla of NC+RGL may suggest renal injury in this group. Conclusion: RGL may act distinctly in normocholesterolemia and in hypercholesterolemia. Thus, RGL may be prescribed with caution in absence of hypercholesterolemia and requires monitoring of renal function specially if a renal vasoconstriction state is associated.

Introdução: O carcinoma de células escamosas da via aerodigestiva superior (VADS) geralmente é unifocal e advém da progressão das lesões pré-neoplásicas. O risco de segundos tumores primários é de 3 a 7% ao ano para pacientes tratados previamente de câncer da VADS, sendo importante avançar em estratégias de quimioprevenção. Nos estudos clínicos realizados, as drogas promissoras mostraramse ineficazes quando aplicadas em doses baixas para minimizar a toxicidade. Neste trabalho, ácidos graxos poliinsaturados ômega-3 (óleo de peixe) e pioglitazone, um agonista PPAR-?, foram utilizados com intenção quimiopreventiva, em modelo animal de carcinogênese da VADS, induzida com o uso de 4- nitroquinolina-1-óxido (4-NQO). Métodos: Camundongos Swiss foram submetidos à indução tumoral com 4-NQO nas doses: 25, 50 ou 100 g/ml diluído em água por 8 semanas. Quimioprevenção foi testada com óleo de peixe nas concentrações de 10% ou 5%. Também foi realizada, em outros grupos, quimioprevenção com pioglitazone nas concentrações de 300 ppm ou 100 ppm. A quimioprevenção foi realizada na iniciação e pós-iniciação tumorais (por 32 semanas) ou apenas na pós- iniciação (por 24 semanas). Resultados: As incidências de neoplasias oral e esofágica foram, respectivamente, similares entre os grupos 4-NQO 100 77,7% e 55,5% e 4-NQO 50 72,9% e 37,8%. O grupo 4-NQO 25, ao ser observado 24 semanas a mais, obteve 78,2% de neoplasia oral e 34,7% de esofágica. A mortalidade por câncer nas 24 semanas após o término do 4-NQO foi de 55,6% no grupo 4-NQO 100, de 11,6% no 4-NQO 50 e de 13,6% no 4-NQO 25; sendo significante na comparação entre os grupos 100 com 50 (p<0,01) e 100 com 25 (p<0,01). Assim, foi observado que 4- NQO 100 g/ml gerou uma mortalidade mais acelerada neste grupo. A maioria dos animais desenvolvia lesões invasoras em mais de um órgão ou a associação destas com pré-neoplásicas. A incidência de neoplasia oral foi similar na comparação entre o grupo 4-NQO 100 (77,7%) com óleo de peixe 10% (80%) p=1,00 e com o grupo pioglitazone 300 ppm (61,1%) p=0,27. Entre os grupos 4-NQO 50 com óleo de peixe 5% (controle - 72,9%, com óleo de peixe na pós- iniciação - 84,2% e com óleo de peixe na iniciação e pós- iniciação - 64,7%) p=0,34 e entre os grupos 4-NQO 50 com pioglitazone 100 ppm (controle - 72,9%, com pioglitazone na pós-iniciação - 76,1% e com pioglitazone na iniciação e pós-iniciação - 62,5%) p=0,63, a incidência de neoplasia oral foi semelhante na comparação entre os grupos. A presença de neoplasia esofágica não diferiu entre o grupo 4-NQO 100 (55,5%) com óleo de peixe 10% (50%) p=0,73 e com o grupo pioglitazone 300 ppm (50%) p=0,73; e foi também similar entre os grupos 4-NQO 50 com pioglitazone 100 ppm (controle - 37,8%, com pioglitazone na pós- iniciação - 57,1% e com pioglitazone na iniciação e pós- iniciação - 31,2%) - p=0,22; porém diferiu nos grupos 4-NQO 50 com óleo de peixe 5% (controle37,8%, com óleo de peixe na pós-iniciação68,4% e com óleo de peixe na iniciação e pós- iniciação29,4%), sendo estatisticamente significante - p=0,02. Interessante foi a observação de que o grupo que realizou quimioprevenção com pioglitazone desenvolveu câncer gástrico na mesma proporção dos demais grupos, porém apresentou uma doença mais agressiva, com disseminação metastática, fato não observado nos outros grupos. Considerando-se a sobrevida, não foi observada diferença estatística significante nas 24 semanas comparando-se os grupos 4-NQO 100 e entre os grupos 4-NQO 50 com ou sem quimioprevenção com óleo de peixe ou com pioglitazone. Conclusão: A indução tumoral com 4-NQO, independente da dose, foi obtida com sucesso em camundongos Swiss. Neste estudo, não foram observados efeitos de quimioprevenção do óleo de peixe e do pioglitazone nas diferentes fases da carcinogênese estudadas. O óleo de peixe na pós-iniciação pode ter potencializado a ação carcinogênica do 4-NQO no esôfago, assim como a associação do 4-NQO com o pioglitazone possa ter criado um novo modelo de carcinogênese gástrica, não vista nos grupos que não receberam esta associação. / Introduction: The squamous cell carcinoma of the upper aerodigestive tract (UADT) is generally unifocal and arises from the progression of premalignant lesions. Between 3% to 7% of patients with head and neck carcinoma will develop subsequent primary tumors of the UADT annually; therefore, the importance of advancing in new chemopreventive strategies is unquestionable. In clinical studies, promising drugs were ineffective when used at low doses to minimize toxicity. In the present study, the potential chemopreventive effects of polyunsaturated fatty acids omega-3 (fish oil) and of a PPAR-? ligand (pioglitazone) were tested in an animal model of UADT carcinogenesis induced by 4-nitroquinoline-1-oxide (4-NQO) in Swiss mice. Methods : The animals underwent tumor induction with 25, 50 or 100 g/ml of 4-NQO diluted in water for eight weeks. Chemoprevention was tested with 10% or 5% fish oil and with 300 ppm or 100 ppm pioglitazone in other groups. Chemoprevention was conducted on tumor initiation and postinitiation for 32 weeks or only on postinitiation for 24 weeks. Results : The incidence rates of oral and esophageal neoplasms were similar between groups 4-NQO 100 (77,7% and 55,5%, respectively) and 4-NQO 50 (72,9% and 37,8%, respectively). Group 4-NQO 25 was followed for 24 weeks longer than the others and showed incidence rates of 78,2% for oral neoplasia and 34,7% for esophageal neoplasia. Cancer-related mortality rates in the 24 weeks following the conclusion of the tumor induction phase were 55,6%, 11,6% and 13,6% in groups 4-NQO 100, 4-NQO 50 and 4-NQO 25, respectively. The differences were statistically significant when comparing groups 100 with 50 (p<0,01) and 100 with 25 (p<0,01). The dose of 100 g/ml 4-NQO led to faster mortality compared with 50 g/ml or 25 g/ml 4-NQO. Most animals developed invasive lesions in more than one site of the UADT or, more frequently, an association of premalignant and malignant lesions. The incidence of oral neoplasia was similar in the comparison of the control group 4-NQO 100 with 10% fish oil (77,7% vs 80%, p=1,00) or with 300 ppm pioglitazone (77,7% vs 61,1%, p=0,27). Results were also similar when comparing 4-NQO 50 groups with 5% fish oil (control72,9%, fish oil on postinitiation84,2%, and fish oil on initiation and postinitiation64,7%, p=0,34), and between 4-NQO 50 groups with 100 ppm pioglitazone (control72,9%, pioglitazone on postinitiation76,1%, and pioglitazone on initiation and postinitiation62,5%, p=0,63). The incidence of esophageal neoplasia reached no statistical difference either when 4-NQO 100 control group was compared with 10% fish oil (55,5% vs 50%, p=0,73) or with 300 ppm pioglitazone (55,5% vs 50%, p=0,73). The same was true between 4-NQO 50 groups with 100 ppm pioglitazone (control37,8%, pioglitazone on postinitiation57,1%, and pioglitazone on initiation and postinitiation31,2%, p=0,22). Statistically significant differences were found between 4-NQO 50 groups with 5% fish oil (control37,8%, fish oil on postinitiation68,4%, and fish oil on initiation and postinitiation29,4%, p=0,02). Interestingly, the group receiving chemoprevention with 300 ppm pioglitazone had a gastric cancer incidence rate comparable to that of other groups, but with more aggressive disease and metastatic dissemination, unlike the others. No statistically significant differences were found in the survival rates for the 24-week period after induction when comparing the control groups 4-NQO 100 and 4-NQO 50 with their respective experimental groups, which received chemoprevention with fish oil or pioglitazone. Conclusions : Tumor induction with 4-NQO was successfully achieved in Swiss mice, regardless of the dose. In this study, no chemopreventive effects of fish oil or pioglitazone were observed either on postinitiation or on initiation and postinitiation. The introduction of fish oil on the postinitiation phase may have potentialized the carcinogenic action of 4-NQO on the esophageal epithelium; the same can be said about the association of 4-NQO and pioglitazone, which may have created a new model of gastric carcinogenesis not seen in the groups that did not receive that combination of drugs.

L'un des enjeux majeurs de la recherche anti-cancéreuse est de développer de nouvelles thérapies en direction des tumeurs réfractaires aux traitements conventionnels. Dans ce contexte, l'identification récente de l'activité anti-tumorale PPARgamma-indépendante des thiazolidinediones ouvre de nouvelles perspectives thérapeutiques. Au sein du laboratoire, il a été montré qu'un analogue inactif de la TGZ, la delta2-TGZ, induit une dégradation protéasome-dépendante du récepteur alpha aux oestrogènes de manière PPARgamma-indépendante. A partir de ces données, les objectifs de ma thèse ont été 1) de participer à la caractérisation de nouveaux composés à activité anti-cancéreuse 2) de mieux comprendre les mécanismes PPARgamma-indépendants mis en jeu dans l'effet anti-cancéreux des TZD. Lors de ce travail de thèse, nous avons caractérisé de nouveaux composés plus efficaces que la delta2-TGZ pour l'inhibition de la prolifération des cellules cancéreuses mammaires MCF-7 et MDA-MB-231 et faiblement toxiques sur des cultures primaires d'hépatocytes humains. De plus, nous avons montré que la delta2-TGZ est capable d'induire un stress du réticulum endoplasmique à des temps précoces dès 3 heures et une apoptose à des temps plus tardifs 48 heures. Cependant, nous n'avons pas pu conclure à l'existence d'un lien entre les deux mécanismes. Enfin, nous avons montré que la biotinylation d'un ligand naturel de PPARgamma, la 15d-PGJ2, accroît son effet anti-prolifératif sur les cellules cancéreuses mammaires MCF-7 et MDA-MB-231 et conduit à un stress du réticulum endoplasmique et à une mort par apoptose. Ces effets sont partiellement dépendants de PPARgamma pour le stress du réticulum endoplasmique mais strictement PPARgamma-indépendants pour l'apoptose. Ce travail pourrait permettre de constituer de nouveaux outils thérapeutiques dans le traitement du cancer du sein / One of the main goals of the anti-cancer research is to develop new therapeutic option for resistant tumor. In this context, the recent discovery of thiazolidinedione devoid of PPARgamma activity with a strong anti-cancer effect opens new perspectives. In a previous study, the laboratory showed that an inactive derivative of PPARgamma, the delta2-TGZ, induce a proteasome-dependent degradation of estrogen receptor alpha in PPARgamma-independent way. Thus, during my thesis we aimed 1) to participate in the study of new compounds less toxic and more effective to inhibit the proliferation of mammary cancer cells, 2) to better understand PPARgamma-independent mechanisms involved in the anti-cancer effect of the TZD. In the present work, we characterise new compounds more effective than delta2-TGZ to inhibit the proliferation of the breast cancer cells MCF-7 and MDA-MB-231 and are less toxic on primary culture of human hepatocytes. We pursued the study on mechanisms involved in PPARgamma-independent anti-proliferative activity of delta2-TGZ. We showed that delta2-TGZ is able to induce endoplasmic reticulum stress as soon as 3 hours and apoptosis in later times 48 hours of treatment. Nevertheless we could not conclude of the existence of a link between these two pathways. Finally, we studied the effect of the biotinylation of a natural ligand of PPAR?: the 15d-PGJ2. This modification drive to an increased effect of the 15d-PGJ2 on the anti-proliferative effect of breast cancer cells, reticulum endoplasmic stress and death by apoptosis. These effects are partially PPARgamma-dependent for reticulum endoplasmic stress and only PPARgamma-independent for apoptosis. This work highlighted new promising tools of breast cancers treatment

Introdução: O carcinoma de células escamosas da via aerodigestiva superior (VADS) geralmente é unifocal e advém da progressão das lesões pré-neoplásicas. O risco de segundos tumores primários é de 3 a 7% ao ano para pacientes tratados previamente de câncer da VADS, sendo importante avançar em estratégias de quimioprevenção. Nos estudos clínicos realizados, as drogas promissoras mostraramse ineficazes quando aplicadas em doses baixas para minimizar a toxicidade. Neste trabalho, ácidos graxos poliinsaturados ômega-3 (óleo de peixe) e pioglitazone, um agonista PPAR-?, foram utilizados com intenção quimiopreventiva, em modelo animal de carcinogênese da VADS, induzida com o uso de 4- nitroquinolina-1-óxido (4-NQO). Métodos: Camundongos Swiss foram submetidos à indução tumoral com 4-NQO nas doses: 25, 50 ou 100 g/ml diluído em água por 8 semanas. Quimioprevenção foi testada com óleo de peixe nas concentrações de 10% ou 5%. Também foi realizada, em outros grupos, quimioprevenção com pioglitazone nas concentrações de 300 ppm ou 100 ppm. A quimioprevenção foi realizada na iniciação e pós-iniciação tumorais (por 32 semanas) ou apenas na pós- iniciação (por 24 semanas). Resultados: As incidências de neoplasias oral e esofágica foram, respectivamente, similares entre os grupos 4-NQO 100 77,7% e 55,5% e 4-NQO 50 72,9% e 37,8%. O grupo 4-NQO 25, ao ser observado 24 semanas a mais, obteve 78,2% de neoplasia oral e 34,7% de esofágica. A mortalidade por câncer nas 24 semanas após o término do 4-NQO foi de 55,6% no grupo 4-NQO 100, de 11,6% no 4-NQO 50 e de 13,6% no 4-NQO 25; sendo significante na comparação entre os grupos 100 com 50 (p<0,01) e 100 com 25 (p<0,01). Assim, foi observado que 4- NQO 100 g/ml gerou uma mortalidade mais acelerada neste grupo. A maioria dos animais desenvolvia lesões invasoras em mais de um órgão ou a associação destas com pré-neoplásicas. A incidência de neoplasia oral foi similar na comparação entre o grupo 4-NQO 100 (77,7%) com óleo de peixe 10% (80%) p=1,00 e com o grupo pioglitazone 300 ppm (61,1%) p=0,27. Entre os grupos 4-NQO 50 com óleo de peixe 5% (controle - 72,9%, com óleo de peixe na pós- iniciação - 84,2% e com óleo de peixe na iniciação e pós- iniciação - 64,7%) p=0,34 e entre os grupos 4-NQO 50 com pioglitazone 100 ppm (controle - 72,9%, com pioglitazone na pós-iniciação - 76,1% e com pioglitazone na iniciação e pós-iniciação - 62,5%) p=0,63, a incidência de neoplasia oral foi semelhante na comparação entre os grupos. A presença de neoplasia esofágica não diferiu entre o grupo 4-NQO 100 (55,5%) com óleo de peixe 10% (50%) p=0,73 e com o grupo pioglitazone 300 ppm (50%) p=0,73; e foi também similar entre os grupos 4-NQO 50 com pioglitazone 100 ppm (controle - 37,8%, com pioglitazone na pós- iniciação - 57,1% e com pioglitazone na iniciação e pós- iniciação - 31,2%) - p=0,22; porém diferiu nos grupos 4-NQO 50 com óleo de peixe 5% (controle37,8%, com óleo de peixe na pós-iniciação68,4% e com óleo de peixe na iniciação e pós- iniciação29,4%), sendo estatisticamente significante - p=0,02. Interessante foi a observação de que o grupo que realizou quimioprevenção com pioglitazone desenvolveu câncer gástrico na mesma proporção dos demais grupos, porém apresentou uma doença mais agressiva, com disseminação metastática, fato não observado nos outros grupos. Considerando-se a sobrevida, não foi observada diferença estatística significante nas 24 semanas comparando-se os grupos 4-NQO 100 e entre os grupos 4-NQO 50 com ou sem quimioprevenção com óleo de peixe ou com pioglitazone. Conclusão: A indução tumoral com 4-NQO, independente da dose, foi obtida com sucesso em camundongos Swiss. Neste estudo, não foram observados efeitos de quimioprevenção do óleo de peixe e do pioglitazone nas diferentes fases da carcinogênese estudadas. O óleo de peixe na pós-iniciação pode ter potencializado a ação carcinogênica do 4-NQO no esôfago, assim como a associação do 4-NQO com o pioglitazone possa ter criado um novo modelo de carcinogênese gástrica, não vista nos grupos que não receberam esta associação. / Introduction: The squamous cell carcinoma of the upper aerodigestive tract (UADT) is generally unifocal and arises from the progression of premalignant lesions. Between 3% to 7% of patients with head and neck carcinoma will develop subsequent primary tumors of the UADT annually; therefore, the importance of advancing in new chemopreventive strategies is unquestionable. In clinical studies, promising drugs were ineffective when used at low doses to minimize toxicity. In the present study, the potential chemopreventive effects of polyunsaturated fatty acids omega-3 (fish oil) and of a PPAR-? ligand (pioglitazone) were tested in an animal model of UADT carcinogenesis induced by 4-nitroquinoline-1-oxide (4-NQO) in Swiss mice. Methods : The animals underwent tumor induction with 25, 50 or 100 g/ml of 4-NQO diluted in water for eight weeks. Chemoprevention was tested with 10% or 5% fish oil and with 300 ppm or 100 ppm pioglitazone in other groups. Chemoprevention was conducted on tumor initiation and postinitiation for 32 weeks or only on postinitiation for 24 weeks. Results : The incidence rates of oral and esophageal neoplasms were similar between groups 4-NQO 100 (77,7% and 55,5%, respectively) and 4-NQO 50 (72,9% and 37,8%, respectively). Group 4-NQO 25 was followed for 24 weeks longer than the others and showed incidence rates of 78,2% for oral neoplasia and 34,7% for esophageal neoplasia. Cancer-related mortality rates in the 24 weeks following the conclusion of the tumor induction phase were 55,6%, 11,6% and 13,6% in groups 4-NQO 100, 4-NQO 50 and 4-NQO 25, respectively. The differences were statistically significant when comparing groups 100 with 50 (p<0,01) and 100 with 25 (p<0,01). The dose of 100 g/ml 4-NQO led to faster mortality compared with 50 g/ml or 25 g/ml 4-NQO. Most animals developed invasive lesions in more than one site of the UADT or, more frequently, an association of premalignant and malignant lesions. The incidence of oral neoplasia was similar in the comparison of the control group 4-NQO 100 with 10% fish oil (77,7% vs 80%, p=1,00) or with 300 ppm pioglitazone (77,7% vs 61,1%, p=0,27). Results were also similar when comparing 4-NQO 50 groups with 5% fish oil (control72,9%, fish oil on postinitiation84,2%, and fish oil on initiation and postinitiation64,7%, p=0,34), and between 4-NQO 50 groups with 100 ppm pioglitazone (control72,9%, pioglitazone on postinitiation76,1%, and pioglitazone on initiation and postinitiation62,5%, p=0,63). The incidence of esophageal neoplasia reached no statistical difference either when 4-NQO 100 control group was compared with 10% fish oil (55,5% vs 50%, p=0,73) or with 300 ppm pioglitazone (55,5% vs 50%, p=0,73). The same was true between 4-NQO 50 groups with 100 ppm pioglitazone (control37,8%, pioglitazone on postinitiation57,1%, and pioglitazone on initiation and postinitiation31,2%, p=0,22). Statistically significant differences were found between 4-NQO 50 groups with 5% fish oil (control37,8%, fish oil on postinitiation68,4%, and fish oil on initiation and postinitiation29,4%, p=0,02). Interestingly, the group receiving chemoprevention with 300 ppm pioglitazone had a gastric cancer incidence rate comparable to that of other groups, but with more aggressive disease and metastatic dissemination, unlike the others. No statistically significant differences were found in the survival rates for the 24-week period after induction when comparing the control groups 4-NQO 100 and 4-NQO 50 with their respective experimental groups, which received chemoprevention with fish oil or pioglitazone. Conclusions : Tumor induction with 4-NQO was successfully achieved in Swiss mice, regardless of the dose. In this study, no chemopreventive effects of fish oil or pioglitazone were observed either on postinitiation or on initiation and postinitiation. The introduction of fish oil on the postinitiation phase may have potentialized the carcinogenic action of 4-NQO on the esophageal epithelium; the same can be said about the association of 4-NQO and pioglitazone, which may have created a new model of gastric carcinogenesis not seen in the groups that did not receive that combination of drugs.

Un défi majeur en cancérologie est le traitement des tumeurs mammaires dites triple-négatives (ER-, PR-, HER2-). Elles sont le plus souvent résistantes aux traitements conventionnels et présentent un haut risque de récidive. De plus, l’absence de cibles thérapeutiques ne permet pas le développement de thérapie spécifique. 78% de ces tumeurs expriment faiblement la claudine 1 et sont de très mauvais pronostic. Cette protéine est impliquée dans l'adhérence des cellules entre elles et pourrait jouer un rôle suppresseur de tumeur dans les cancers mammaires. Dans ce contexte, nous étudions si sa réexpression pourrait être une piste de traitement. Au laboratoire, nous avons développé des dérivés de la famille des thiazolidinediones (TZD) qui stimulent l’expression de la claudine 1 et induisent l’apoptose des cellules cancéreuses mammaires. Les objectifs de ma thèse ont consisté 1) à déterminer l’implication de la claudine 1 dans l’effet pro-apoptotique de ces composés 2) à l’étude de leurs mécanismes d’action 3) évaluer si l’expression de la claudine 1 pourrait sensibiliser les cellules cancéreuses triple-négatives aux agents de chimiothérapie. Au cours de cette thèse, nous avons montré que la surexpression de la claudine 1 et le composé Δ2-TGZ induisent l’apoptose des cellules triple-négatives « claudin 1-low » MDA-MB-231 et Hs578T. De plus, la claudine 1 est impliquée dans l’effet pro-apoptotique de la Δ2-TGZ dans les cellules MDA-MB-231. Par ailleurs, nous avons démontré que les dérivés TGZ, la Δ2-TGZ et l’AB186, agissent de manière précoce en modifiant la morphologie des cellules suivie d’une réexpression de la claudine 1 membranaire et d’une inhibition de la migration cellulaire avant même d’induire la mort cellulaire par apoptose. De plus, la surexpression de la claudine 1 inhibe la migration cellulaire associée à la perte des fibres de stress et la formation des jonctions intercellulaires. Nous avons également montré que la réexpression de la claudine 1 sensibilise les cellules MDA-MB-231 à l’agent de chimiothérapie, le 5-FU. L’ensemble des résultats de thèse a permis de mieux comprendre le mécanisme d’action de la Δ2-TGZ et de l’AB186 sur les cellules cancéreuses mammaires mais aussi d’identifier la claudine 1 comme cible potentielle prometteuse dans les cellules triple-négatives « claudin 1-low » / A major challenge in oncology is the treatment of triple-negative breast cancer (ER-, PR-, HER2-) as no targeted therapy are available. These tumors present often a chemotherapy resistance and a higher relapse incidence. 78% of them do not express claudin 1 and display a poor prognosis. Claudin 1 is involved in cell-cell adhesion and may be a tumor suppressor gene in breast cancer. In this context, we study if claudin 1 re-expression could be a possible approach. In the laboratory, we developed derivatives thaziolidinediones (TZD) compounds, which increase claudin 1 expression and lead to apoptosis of breast cancer cells. The goals of my thesis is 1) to characterize the involvement of claudin 1 in their pro-apoptotic effect 2) to study their mechanism of action 3) to determine if claudin 1 could sensitize the TNBC cells to the chemotherapy agents. During my thesis, we showed that claudin 1 overexpression and the compound Δ2-TGZ induce apoptosis of TNBC « claudin 1-low » MDA-MB-231 and Hs578T cells. Claudin 1 is involved in the pro-apoptotic effect of Δ2-TGZ in MDA-MB-231 cells. Then, we demonstrated that Δ2-TGZ and AB186 lead to early action through a modification of cell morphology followed an expression of claudin 1 at the membrane and an inhibition of cell migration before the apoptosis process. In addition, claudin 1 overexpression decreases the cell migration through the loss of stress fibers and the formation of cell junctions. We showed that claudin 1 overexpression potentialize the pro-apoptotic effect of Δ2-TGZ in MDA-MB-231 cells. Finally, we observed that claudin 1 sensitize the MDA-MB-231 cells to 5-FU. In fine, our data allowed a better understanding of Δ2-TGZ and AB186 mechanism of action and identification of claudin 1 as a promising target in TNBC « claudin 1-low »

Thesis (M.Sc. (Pharmaceutics))--Mahidol University, 2007. / LICL has E-Thesis 0025 ; please contact computer services.

Orientador: Marcos Antonio Tambascia / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-10T07:54:38Z (GMT). No. of bitstreams: 1 Murro_AdaLeticiaBarbosa_M.pdf: 2083799 bytes, checksum: 96b1643449081526943a964fd9850136 (MD5) Previous issue date: 2007 / Resumo: A principal causa de mortalidade entre os portadores de Diabetes tipo 2 é a doença cardiovascular. Estudos têm cada vez mais procurado alterações inerentes ao diabetes tipo 2 que justifiquem a maior incidência de doença cardiovascular nesse grupo. A presença de resistência à insulina, redução de adiponectina, aumento de PCR, disfunção endotelial e aumento de PAI-1 são candidatos possivelmente relacionados a esse aumento. A redução da resistência à insulina com uso de tiazolidinedionas, entre elas a rosiglitazona, tem potencial de reduzir o risco cardiovascular em diabéticos tipo 2, uma vez que altera citocinas relacionadas a risco cardiovascular de forma positiva. O objetivo desse estudo é avaliar o efeito clínico e laboratorial (sensibilidade à insulina, função de célula ß, lípides, PCR, adiponectina, resistina e PAI-1) e o efeito sobre a espessura da íntima-média carotídea da administração, por 12 semanas, de 8mg de rosiglitazona ao dia, em pacientes diabéticos tipo 2 virgens de tratamento anti-diabético, atendidos no Ambulatório de Diabetes Mellitus tipo 2, do Hospital das Clínicas da Faculdade de Ciências Médicas da UNICAMP. Os pacientes foram submetidos a uma avaliação inicial com dosagem de glicemia, hemoglobina glicada, insulinemia, colesterol total, HDL, LDL, triglicérides, ácidos graxos livres, AST, ALT, adiponectina, resistina, PAI-1, PCR, ácido úrico e fibrinogênio, após jejum de 12 horas. A sensibilidade à insulina e a função de célula ß foram avaliadas pela fórmula matemática do HOMA e a espessura da íntima média carotídea foi avaliada pelo ultrassom doppler. Os pacientes iniciavam o uso de Rosiglitazona na dose de 8 mg/dia dividida em duas tomadas diárias. Após 12 semanas de tratamento todas as avaliações foram novamente realizadas. Para a análise estatística foi realizado o teste de Wilcoxon para estudar as variações pré e pós Rosiglitazona e o coeficiente de correlação de Spearman. O nível de significância adotado foi de 5 % (p<0,05). Dos 15 pacientes inicialmente incluídos, 13 completaram o tratamento. Houve redução estatisticamente significante dos níveis de PCR, ácido úrico e aumento de adiponectina. Houve redução de HOMA IR e resistina, não estatisticamente significante e aumento do HOMA ß A análise das correlações possíveis mostrou relação inversa entre HOMA ß e ácidos graxos livres. Não houve alteração significante da espessura da íntima-média carotídea. O tratamento do Diabetes Mellitus com rosiglitazona tem potencial de reduzir o risco cardiovascular à medida que reduz marcadores de risco, como a PCR, e aumenta a adiponectina. Apesar de não ter sido estatisticamente significante, possivelmente devido ao tamanho da amostra, houve redução de 25% do valor médio da resistina, sugerindo uma relação entre resistina e resistência à insulina, controversa na literatura. Além da melhora da sensibilidade à insulina houve notável aumento do HOMA ß mostrando melhora da função da célula ß. Esse dado sugere que o tratamento com rosiglitazona desacelera a progressão da doença. A relação entre o aumento do HOMA ß e a redução dos ácidos graxos livres fala a favor da melhora da lipotoxicidade como um dos fatores de melhora da função da célula ß. Mais estudos populacionais de longa duração são necessários para comprovar o efeito da rosiglitazona sobre eventos cardiovasculares / Abstract: Cardiovascular disease is the major mortality cause among diabetic patients. Most studies are trying to find disturbances typical of diabetes that could explain the grater incidence of cardiovascular disease in this group. Insulin resistance, adiponectin reduction, CRP elevation, endothelial dysfunction and PAI-1 elevation are candidates possibly related to this prevalence. Reducing insulin resistance with thiazolidinediones, including rosiglitazone, probably reduces cardiovascular risk among type 2 diabetic patients once it alters cytokines related to cardiovascular risk in a positive manner. The aim of this study is to evaluate clinical and laboratorial effects (insulin sensitivity, lipids profile, ß-cell function, CRP, adiponectin, resistin and PAI-1) and the effects on carotid intima media thickness of 12 weeks use of rosiglitazone 4 mg BID for type 2 diabetic drug naïve patients currently assisted at Hospital das Clínicas da Faculdade de Ciências Médicas da UNICAMP Type 2 diabetes out-clinics. At the first visit we evaluated glycemia, glicated hemoglobin, insulin, total cholesterol, LDL, HDL, triglycerides, AST, ALT, free fatty acids, uric acid, PAI-1, fibrinogen, CRP, adiponectin and resistin after a twelve hours fasting. Insulin sensitivity and ß cell function were estimated using the HOMA model and intima media thickness was evaluated by a Doppler ultrasound. Patients started using Rosiglitazone 4 mg BID and after 12 weeks the same parameters were evaluated again. The statistical analyses used Wilcoxon test to study variations before and after rosiglitazone treatment and Spearman correlation coefficient. We considered p<0,05 as statistical significant. From the 15 patients included, 13 completed treatment. We observed a statistically significant reduction on CRP and acid uric levels and an adiponectin levels elevation. Non statistical significant HOMA IR and resistin reductions and HOMA ß improvement occurred. Correlations analyses showed negative correlation between HOMA ß and free fatty acids. It was observed no change in intima media thickness. Treating type 2 diabetes mellitus with rosiglitazone has a potencial to reduce cardiovascular risk once it reduces cardiovascular risk markers as CRP and increases adiponectin. Although is was no statistically significant, possibly due to sample size, there was a 25% reduction in medium resistin levels, suggesting relation between resistin and insulin resistance, still unproved in the literature. Besides the improvement in insulin sensitivity there was a notable increase in HOMA ß showing improvement in ßcell function. This data suggests that rosiglitazone treatment slows disease progression. Correlation between HOMA ß improvement and free fatty acid agrees with improvement in lipotoxicity as one factor that leeds to improvement in ß cell function. We need more long term epidemiological studies to attest rosiglitazone effect in cardiovascular events / Mestrado / Clinica Medica / Mestre em Clinica Medica

Introdução: Rosiglitazone (RGL) é um ligante dos receptores PPAR e vem sendo usada no tratamento do Diabetes Mellitus tipo 2 e nas doenças inflamatórias. Mas, RGL pode reduzir a filtração glomerular (FG), a carga excretada de sódio na urina (UVNa) e aumentar a expressão da Na+,K+- ATPase na medula renal. Então, RGL pode causar edema e insuficiência cardíaca congestiva. Entretanto, não tem sido reportado se RGL pode induzir insuficiência renal aguda (IRA). Objetivo: Verificar se a redução da FG causada pelo tratamento com RGL predispõe à IRA em ratos. Avaliar em condições basais e de vasoconstrição renal e se há diferenças entre ratos normocolesterolêmicos (NC) e hipercolesterolêmicos (HC). Métodos: A FG foi medida pelo clearance de inulina no 8º dia em ratos (~200g) NC e HC tratados ou não com RGL (48 mg/kg/dieta) na situação basal e durante a infusão endovenosa de Ang II (40 ng/kg/min). Além disso, a atividade da Na+,K+-ATPase foi avaliada em homogenato renal em outra série de animais. Resultados: Na situação basal, NC e HC apresentaram FG semelhante e o tratamento com RGL reduziu a FG apenas em NC de 0,78±0,03 para 0,50±0,05* ml/min/100g, *p<0,001. Apesar da redução da FG, a UVNa em NC+RGL não se modificou. Durante a infusão de Ang II, a FG de NC, HC e HC+RGL reduziu-se para o mesmo patamar de NC+RGL e um significante aumento da UVNa foi observada apenas em NC+RGL (NC= 3,32±0,88; NC+RGL=5,86±1,04*; HC= 2,63±0,43 e HC+RGL= 2,23±0,39 uEq/min, *p<0,01). Além disso, RGL induziu aumento na atividade da Na+,K+-ATPase em HC+RGL e não modificou em NC+RGL. Os valores expressos em M Pi/mg proteína.h-1 foram de 45±7 em NC, 43±5 em NC+RGL, 48±7 em HC e 64±4* em HC+RGL, *p<0,05. Analisando todos os resultados em conjunto, a redução da FG associada com a alta natriurese e ausência da modulação da atividade da Na+,K+-ATPase em NC+RGL sugerem lesão renal neste grupo. Conclusão: Os mecanismos de ação da RGL diferem de acordo com a condição metabólica. Então, RGL deve ser prescrita com cautela na ausência de hipercolesterolemia e requer a monitoração da função renal principalmente nas situações de vasoconstrição / Introduction: Rosiglitazone (RGL) is a ligand for PPAR used to treat type 2 Diabetes Mellitus and inflammatory diseases. However, RGL can reduce the glomerular filtration rate (GFR), urinary sodium excretion (UVNa) and increase the expression of Na+, K+-ATPase in renal medulla. Thus, RGL may induce edema and congestive heart failure. However, acute renal failure (ARF) provoked by RGL treatment has not been reported. Aim: To test whether reduced GFR by RGL may predispose to ARF at baseline and during a renal vasoconstriction state, and if the findings differ between normocholesterolemic (NC) and hypercholesterolemic (HC) rats. Methods: GFR was measured by inulin clearance on the 8th day in NC and HC rats (~200g) treated or not with RGL (48 mg/kg diet) at baseline and during intravenous infusion of Ang II (40 ng/kg/min). Furthermore, the Na+,K+- ATPase activity was determined in renal homogenates in other series of animals. Results: At baseline, NC and HC had similar GFR and the treatment with RGL reduced GFR only in NC from 0.78±0.03 to 0.50±0.05* ml/min/100g, *p<0.001. Although GFR was reduced, UVNa was unchanged in NC+RGL. During Ang II infusion, GFR was significantly reduced in NC, HC and HC+RGL and it remained at the same reduced level in NC+RGL. At this time, when GFR was reduced the same range in all groups, a significant increment in UVNa was only observed in NC+RGL (NC = 3.32±0.88; NC+RGL = 5.86±1.04*; HC = 2.63±0.43 and HC+RGL = 2.23±0.39 Eq/min, *p<0.01). Moreover, RGL induced an increase in the activity of Na+, K+-ATPase in HC+RGL, but it did not modify the activity of this enzyme in NC+RGL. The values expressed in M Pi/mg.protein.h-1 were 45±7 in NC, 43±5 in NC+RGL, 48±7 in HC and 64±4* in HC+RGL, *p<0.05. Taken together, reduction in GFR associated with high natriuresis and without changes in the Na+, K+-ATPase activity in renal medulla of NC+RGL may suggest renal injury in this group. Conclusion: RGL may act distinctly in normocholesterolemia and in hypercholesterolemia. Thus, RGL may be prescribed with caution in absence of hypercholesterolemia and requires monitoring of renal function specially if a renal vasoconstriction state is associated.

The prevalence of type 2 diabetes mellitus is increasing worldwide and is considered one of the top health concerns globally. The occurrence of type 2 diabetes is linked to the rapidly increasing trend of obesity in both adults and children, which is proposed to be a contributing factor in the development of insulin resistance and type 2 diabetes. White adipose tissue, an insulin target tissue, is an important endocrine organ involved in the control of energy homeostasis through its direct influence on metabolism, insulin sensitivity and food intake. To better understand these functions, we studied adipocyte differentiation in 3T3-Ll cells, a white adipose tissue cell line. Many mitochondrial proteins exhibit an increase in expression levels during adipogenesis as identified by mass spectrometry. Moreover, increased mitochondrial mass and altered morphology was observed by light microscopy. Qualitative changes in mitochondrial gene expression were also observed during adipogenesis as revealed by Affymetrix GeneChip analysis. Additionally, striking changes in mitochondrial protein expression and morphology were identified following treatment with the insulin sensitizing agent, rosiglitazone. These results suggest that mitochondrial biogenesis and remodeling is inherent to white adipocyte differentiation. To investigate the physiological relevance of these findings, mRNA and protein expression profiles and mitochondrial morphology were studied during the development of insulin resistance and obesity and following treatment with rosiglitazone in ob/ob mice. These studies reveal a marked decrease in transcript levels for over 50% of mitochondrial genes with the onset of obesity in ob/ob mice. Rosiglitazone treatment stimulates enhanced expression in approximately half of these genes, as well as changes in mitochondrial mass and remodeling. Furthermore, these studies reveal that depressed oxygen consumption and fatty acid oxidation occur with obesity development and these alterations can be reversed with rosiglitazone treatment. This work identifies the previously underscored plasticity of mitochondria in white fat and suggests that mitochondrial biogenesis and remodeling in white adipose tissue may lead to systemic changes in insulin sensitivity and energy homeostasis. Lastly, these studies suggest that mitochondria may be an important therapeutic target for antidiabetic drugs.

Loh Shwu Chun. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2005. / Includes bibliographical references (leaves [109]-120). / Abstracts in English and Chinese; appendix also in Chinese. / Acknowledgements --- p.i / Abstract --- p.ii / Abstract (in Chinese) --- p.iv / List of Abbreviations --- p.v / List of Tables --- p.vii / List of Figures --- p.ix / Table of Contents / Chapter Chapter One: --- Introduction and Study Objectives / Chapter 1. --- Introduction --- p.1 / Chapter 1.1 --- Definition and diagnostic criteria of the metabolic syndrome --- p.2 / Chapter 1.2 --- Clinical states of the metabolic syndrome --- p.5 / Chapter 1.2.1 --- Impaired Glucose Tolerance (IGT) and Impaired Fasting Glucose (IFG) --- p.6 / Chapter 1.2.2 --- The metabolic syndrome and type 2 diabetes mellitus --- p.7 / Chapter 1.2.3 --- Dyslipidaemia --- p.8 / Chapter 1.2.4 --- Hypertension --- p.10 / Chapter 1.2.5 --- Obesity --- p.11 / Chapter 1.3 --- Effects of weight loss on the metabolic syndrome --- p.13 / Chapter 1.4 --- Ethnic differences in the prevalence of the metabolic syndrome --- p.15 / Chapter 1.5 --- Treatment of the metabolic syndrome --- p.16 / Chapter 1.6 --- Oral Hypoglycaemic agents and their failure in the metabolic syndrome --- p.17 / Chapter 1.6.1 --- Sulphonylureas --- p.17 / Chapter 1.6.2 --- Biguanides --- p.18 / Chapter 1.6.3 --- Alpha-glucosidase Inhibitors --- p.20 / Chapter 1.6.4 --- Peroxisome Proliferator-Activated Receptors (PPARs) --- p.21 / Chapter 1.6.4.1 --- Thiazolinedinediones --- p.22 / Chapter 1.6.4.1.1 --- Rosiglitazone --- p.24 / Chapter 1.6.4.1.1.1 --- Mode of Action --- p.24 / Chapter 1.6.4.1.1.2 --- Adverse events and current status --- p.26 / Chapter 1.7 --- Orlistat --- p.27 / Chapter 1.7.1 --- Mode of Action --- p.28 / Chapter 1.7.2 --- Adverse events and current status --- p.28 / Chapter 1.7.3 --- Therapeutic Potential in the Metabolic Syndrome --- p.29 / Chapter 1.8 --- Study Hypothesis --- p.30 / Chapter 1.9 --- Study Objectives --- p.30 / Chapter Chapter Two: --- Research Design and Methods / Chapter 2 --- Study Protocol --- p.31 / Chapter 2.1 --- Overall Design --- p.31 / Chapter 2.1.1 --- Patients Selection Criteria --- p.31 / Chapter 2.1.1.1 --- Inclusion Criteria --- p.31 / Chapter 2.1.1.2 --- Exclusion Criteria --- p.33 / Chapter 2.1.2 --- Recruitment Period --- p.34 / Chapter 2.1.2.1 --- Screening Period --- p.34 / Chapter 2.1.2.2 --- Run- In Period (Visit 0) --- p.35 / Chapter 2.1.2.3 --- Randomisation --- p.35 / Chapter 2.1.2.4 --- Evaluation Periods (Visit 2 to 4) --- p.37 / Chapter 2.2 --- Investigations --- p.37 / Chapter 2.2.1 --- Oral Glucose Tolerance Test (OGTT) --- p.38 / Chapter 2.2.2 --- Anthropometric measurements --- p.38 / Chapter 2.3 --- Analytical Methods --- p.39 / Chapter 2.3.1 --- Determinations of insulin levels in plasma samples --- p.39 / Chapter 2.3.1.1 --- Principle of the Insulin assay --- p.40 / Chapter 2.3.2 --- Determinations of glucose concentrations in samples --- p.42 / Chapter 2.3.2.1. --- Principle of the glucose assay --- p.42 / Chapter 2.4 --- Calculations --- p.43 / Chapter 2.4.1 --- Insulin (hepatic) sensitivity (HOMA) --- p.43 / Chapter 2.4.2 --- Area Under the Curves --- p.44 / Chapter 2.4.3 --- Sample Size Calculations --- p.45 / Chapter 2.5 --- Statistical Analysis --- p.46 / Chapter Chapter Three: --- Results / Chapter 3.1 --- Study Population --- p.48 / Chapter 3.2 --- Randomisation --- p.49 / Chapter 3.3 --- Study Results --- p.50 / Chapter 3.3.1 --- Indices of Glycaemic Control --- p.54 / Chapter 3.3.1.1 --- HbAlc --- p.54 / Chapter 3.3.1.2 --- Fasting Plasma Glucose --- p.58 / Chapter 3.3.1.3 --- Fasting Insulin --- p.58 / Chapter 3.3.1.4 --- 75g Oral Glucose Tolerance Test --- p.59 / Chapter 3.3.1.4.1 --- Glucose --- p.59 / Chapter 3.3.1.4.1.1 --- 2hr-Glucose --- p.61 / Chapter 3.3.1.4.1.2 --- GlucoseAuc --- p.62 / Chapter 3.3.1.4.2 --- Insulin --- p.63 / Chapter 3.3.1.4.2.1 --- 2-hr insulin --- p.63 / Chapter 3.3.1.4.2.2 --- InsulinAuc --- p.65 / Chapter 3.3.1.5 --- HOMA score --- p.67 / Chapter 3.3.2 --- Clinical Determinants --- p.69 / Chapter 3.3.2.1 --- Lipid Profiles --- p.69 / Chapter 3.3.2.1.1. --- Total Cholesterol --- p.69 / Chapter 3.3.2.1.2 --- HDL-Cholesterol --- p.70 / Chapter 3.3.2.1.3 --- LDL-Cholesterol --- p.71 / Chapter 3.3.2.1.4 --- Triglycerides --- p.72 / Chapter 3.3.2.2 --- Anthropometric Evaluations --- p.74 / Chapter 3.3.2.2.1 --- Body Weight --- p.74 / Chapter 3.3.2.2.2 --- Waist Circumference Difference --- p.75 / Chapter 3.3.2.2.3 --- Hip --- p.76 / Chapter 3.3.2.2.4 --- Body Fat --- p.78 / Chapter 3.3.2.2.5 --- BMI --- p.78 / Chapter 3.3.2.3 --- Blood Pressure --- p.79 / Chapter 3.3.2.4 --- RCCA and LCCA --- p.79 / Chapter 3.3.2.5 --- Other outstanding measurements --- p.82 / Chapter 3.4 --- Side Effects experienced --- p.82 / Chapter Chapter Four: --- Discussion and Conclusion / Chapter 4.1 --- Summary of the results --- p.83 / Chapter 4.1.1 --- Effects of Diet and Lifestyle Changes --- p.83 / Chapter 4.1.2 --- Effects of Orlistat --- p.84 / Chapter 4.1.3 --- Effects of Rosiglitazone --- p.35 / Chapter 4.2 --- Implications for therapy --- p.86 / Chapter 4.2.1 --- Management of metabolic syndrome --- p.87 / Chapter 4.2.2 --- Early Diagnosis --- p.88 / Chapter 4.2.3 --- Lifestyle Modification --- p.89 / Chapter 4.2.4 --- Pharmacological Targets --- p.92 / Chapter 4.2.4.1 --- Statins --- p.92 / Chapter 4.2.4.2 --- Fibrates --- p.93 / Chapter 4.2.4.3 --- ACE Inhibitors --- p.93 / Chapter 4.2.4.4 --- Thiazolidinediones --- p.94 / Chapter 4.2.4.4.1 --- Economic Evaluations of Thiazolidinediones --- p.97 / Chapter 4.2.4.5 --- Orlistat --- p.98 / Chapter 4.2.4.5.1 --- Economic Evaluations of Orlistat --- p.102 / Chapter 4.3 --- Limitations of the study --- p.104 / Chapter 4.3.1 --- Small sample size --- p.104 / Chapter 4.3.2 --- Short period of study --- p.105 / Chapter 4.3.3 --- Adherence to lifestyle modifications --- p.105 / Chapter 4.3.4 --- Analytical assays --- p.106 / Chapter 4.3.5 --- Follow up end of study --- p.106 / Chapter 4.3.6 --- Ultrasound measurement of the common carotid arteries --- p.106 / Chapter 4.3.7 --- Availability of thiazolinediones --- p.107 / Chapter 4.4 --- Conclusion and Implications for future studies --- p.107 / References --- p.110 / Appendix I --- p.121 / Appendix II --- p.122 / Appendix III --- p.125