Compromised calcium homeostasis in the central nervous system (CNS) is implicated as a major contributor in the pathology of neurodegeneration. Dysregulation of Ca2+ homeostasis initiates downstream Ca2+–dependent events that lead to apoptotic and/or necrotic cell death. Increases in the intracellular free calcium concentration ([Ca2+]i) may be the result of Ca2+ influx from the extracellular environment or Ca2+ release from intracellular Ca2+ stores such as the endoplasmic reticulum (ER). Influx from the extracellular environment is controlled predominantly by voltage gated calcium channels (VGCC), such as L–type calcium channels (LTCC) and ionotropic glutamate receptors, such as the N–methyl–D–aspartate (NMDA) receptors. Ca2+ release from the ER occurs through the inositol–1,4,5–triphosphate receptors (IP3Rs) or ryanodine receptors (RyRs) via IP3–induced or Ca2+–induced mechanisms. Mitigation of Ca2+ overload through these Ca2+ channels offers an opportunity for pharmacological interventions that may protect against neuronal death. In the present study the ability of a novel series of polycyclic compounds, both the pentacycloundecylamines and triquinylamines, to regulate calcium influx through LTCC was evaluated in PC12 cells using calcium imaging with Fura–2/AM in a fluorescence microplate reader. We were also able for the first time to determine IC50 values for these compounds as LTCC blockers. In addition, selected compounds were evaluated for their ability to offer protection in apoptosis–identifying assays such as the lactate dehydrogenase release assay (LDH–assay), trypan blue staining assay and immunohistochemistry utilizing the Annexin V–FITC stain for apoptosis. We were also able to obtain single crystal structures for the tricyclo[6.3.0.02,6]undecane–4,9–dien–3,11–dione (9) and tricyclo[6.3.0.02,6]undecane–3,11–dione (10) scaffolds as well as a derivative, N–(3–methoxybenzyl)–3,11–azatricyclo[6.3.0.02,6]undecane (14f). We also evaluated the possibility that the polycyclic compounds might be able to modulate Ca2+ flux through intracellular Ca2+ channels. Computational methods were utilized to accurately predicted IC50 values and develop a QSAR model with marginal error. The linear regression model delivered r2 = 0.83, which indicated a favorable correlation between the predicted and experimental IC50 values. This model could thus serve as valuable predictor for future structural design and optimization efforts. Data obtained from the crystallographic analysis confirmed the NMR–data based structural assignments done for these compounds in previous studies. Obtaining structural information gave valuable insight into the differences in size and geometric constrains, which are key features for the LTCC activity of these compounds. vii In conclusion, we found that all of the compounds evaluated were able to attenuate Ca2+ influx through the LTCC, with some compounds having IC50 values comparable with known LTCC blockers such as nimodipine. Representative compounds were evaluated for their ability to afford protection against apoptosis induced by 200 ?M H2O2. With the exception of compound 14c (the most potent LTCC blocker in the series, IC50 = 0.398 ?M), most compounds were able to afford protection at two or more concentrations evaluated. Compound 14c displayed inherent toxicity at the highest concentrations evaluated (100 ?M). We concluded that compounds representing both types of structures (pentacycloudecylamines and triquinylamines) have the ability to attenuate excessive Ca2+ influx through the LTCC. In general the aza–pentacycloundecylamines (8a–c) were the most potent LTCC blocker which also had the ability to offer protection in the cell viability assays. However, NGP1–01 (7a) had the most favorable pharmacological profile overall with good activity as an LTCC blocker (IC50 = 86 ?M) and the ability to significantly attenuate cell death in the cell viability assays, exhibiting no toxicity. In addition to their ability to modulate Ca2+ influx from the extracellular environment, these compounds also displayed the ability to modulate Ca2+ flux through intracellular Ca2+ channels. The mechanisms by which they act on intracellular Ca2+ channels still remains unclear, but from this preliminary study it would appear that these compounds are able to partially inhibiting Ca2+–ATPase activity whilst possibly simultaneously inhibiting the IP3R. In the absence of extracellular Ca2+ these compounds showed the ability in inhibit voltage–induced Ca2+ release (VICaR), possibly by modulating the gating charge of the voltage sensor being the dihydropyridine receptors. In future studies it might be worthwhile to do an expanded QSAR study and evaluate the aza–pentacycloundecylamines. To clarify the mechanisms by which the polycyclic compounds interact with intracellular Ca2+ channels we should examine the direct interaction with the individual Ca2+ channels independently. The polycyclic compounds evaluated in this study demonstrate potential as multifunctional drugs due to their ability to broadly regulate calcium homeostasis through multiple pathways of Ca2+ entry. This may prove to be more effective in diseases where perturbed Ca2+ homeostasis have devastating effects eventually leading to excitotoxicity and cell death. / Thesis (Ph.D. (Pharmaceutical Chemistry))--North-West University, Potchefstroom Campus, 2012.

Compromised calcium homeostasis in the central nervous system (CNS) is implicated as a major contributor in the pathology of neurodegeneration. Dysregulation of Ca2+ homeostasis initiates downstream Ca2+–dependent events that lead to apoptotic and/or necrotic cell death. Increases in the intracellular free calcium concentration ([Ca2+]i) may be the result of Ca2+ influx from the extracellular environment or Ca2+ release from intracellular Ca2+ stores such as the endoplasmic reticulum (ER). Influx from the extracellular environment is controlled predominantly by voltage gated calcium channels (VGCC), such as L–type calcium channels (LTCC) and ionotropic glutamate receptors, such as the N–methyl–D–aspartate (NMDA) receptors. Ca2+ release from the ER occurs through the inositol–1,4,5–triphosphate receptors (IP3Rs) or ryanodine receptors (RyRs) via IP3–induced or Ca2+–induced mechanisms. Mitigation of Ca2+ overload through these Ca2+ channels offers an opportunity for pharmacological interventions that may protect against neuronal death. In the present study the ability of a novel series of polycyclic compounds, both the pentacycloundecylamines and triquinylamines, to regulate calcium influx through LTCC was evaluated in PC12 cells using calcium imaging with Fura–2/AM in a fluorescence microplate reader. We were also able for the first time to determine IC50 values for these compounds as LTCC blockers. In addition, selected compounds were evaluated for their ability to offer protection in apoptosis–identifying assays such as the lactate dehydrogenase release assay (LDH–assay), trypan blue staining assay and immunohistochemistry utilizing the Annexin V–FITC stain for apoptosis. We were also able to obtain single crystal structures for the tricyclo[6.3.0.02,6]undecane–4,9–dien–3,11–dione (9) and tricyclo[6.3.0.02,6]undecane–3,11–dione (10) scaffolds as well as a derivative, N–(3–methoxybenzyl)–3,11–azatricyclo[6.3.0.02,6]undecane (14f). We also evaluated the possibility that the polycyclic compounds might be able to modulate Ca2+ flux through intracellular Ca2+ channels. Computational methods were utilized to accurately predicted IC50 values and develop a QSAR model with marginal error. The linear regression model delivered r2 = 0.83, which indicated a favorable correlation between the predicted and experimental IC50 values. This model could thus serve as valuable predictor for future structural design and optimization efforts. Data obtained from the crystallographic analysis confirmed the NMR–data based structural assignments done for these compounds in previous studies. Obtaining structural information gave valuable insight into the differences in size and geometric constrains, which are key features for the LTCC activity of these compounds. vii In conclusion, we found that all of the compounds evaluated were able to attenuate Ca2+ influx through the LTCC, with some compounds having IC50 values comparable with known LTCC blockers such as nimodipine. Representative compounds were evaluated for their ability to afford protection against apoptosis induced by 200 ?M H2O2. With the exception of compound 14c (the most potent LTCC blocker in the series, IC50 = 0.398 ?M), most compounds were able to afford protection at two or more concentrations evaluated. Compound 14c displayed inherent toxicity at the highest concentrations evaluated (100 ?M). We concluded that compounds representing both types of structures (pentacycloudecylamines and triquinylamines) have the ability to attenuate excessive Ca2+ influx through the LTCC. In general the aza–pentacycloundecylamines (8a–c) were the most potent LTCC blocker which also had the ability to offer protection in the cell viability assays. However, NGP1–01 (7a) had the most favorable pharmacological profile overall with good activity as an LTCC blocker (IC50 = 86 ?M) and the ability to significantly attenuate cell death in the cell viability assays, exhibiting no toxicity. In addition to their ability to modulate Ca2+ influx from the extracellular environment, these compounds also displayed the ability to modulate Ca2+ flux through intracellular Ca2+ channels. The mechanisms by which they act on intracellular Ca2+ channels still remains unclear, but from this preliminary study it would appear that these compounds are able to partially inhibiting Ca2+–ATPase activity whilst possibly simultaneously inhibiting the IP3R. In the absence of extracellular Ca2+ these compounds showed the ability in inhibit voltage–induced Ca2+ release (VICaR), possibly by modulating the gating charge of the voltage sensor being the dihydropyridine receptors. In future studies it might be worthwhile to do an expanded QSAR study and evaluate the aza–pentacycloundecylamines. To clarify the mechanisms by which the polycyclic compounds interact with intracellular Ca2+ channels we should examine the direct interaction with the individual Ca2+ channels independently. The polycyclic compounds evaluated in this study demonstrate potential as multifunctional drugs due to their ability to broadly regulate calcium homeostasis through multiple pathways of Ca2+ entry. This may prove to be more effective in diseases where perturbed Ca2+ homeostasis have devastating effects eventually leading to excitotoxicity and cell death. / Thesis (Ph.D. (Pharmaceutical Chemistry))--North-West University, Potchefstroom Campus, 2012.

This dissertation consists of six essays in health economics.The first essay, “Economic evaluations in health care: Basic principles and special topics”, serves as an introduction to economic evaluations in health care, including estimations of costs, health effects, and the discount rate. Special topics of interest for the rest of the studies are also discussed, e.g. the role of modelling in cost-effectiveness analysis, and methods for dealing with incomplete observations in clinical trial data. The main theme of the second essay, “Consumption and production by age in Sweden: Basic facts and health economic implications”, is a fairly detailed compilation of consumption and production figures by age in Sweden. The purpose of this is to use the difference between consumption and production in each age group as a measure of the average costs of added years of life in the general population. In economic evaluations of health care interventions, only future costs for related ill­nesses have typically been included in the analysis. However, the health economist David Meltzer has argued that future costs for un­related illnesses and general consumption should also be in­cluded in eco­nomic evaluations. Otherwise, the analysis will not be consistent with expected utility maximiza­tion. The third essay is entitled “The possibility of predicting health care costs in the future from predicted changes in age structure and age specific mortality: The case of Sweden”. Changes in the age structure, especially the growing number of elderly people, have raised concerns about increasing costs for health and elderly care in the future. However, the number of elderly per se is not the main problem, since the growing number of elderly people is a result of better health and hence lower morta­lity. The main purpose of the study is to investigate if future health care costs can be predicted based on forecasts of future changes in age structure and mortality rates. It is shown here that at least in Sweden and in the U.S., there is a linear relationship between age-specific mortality and age-specific health care costs. When these relationships are applied retrospectively to old data, however, the predictions are underestimates of the actual costs. These results are in line with earlier studies, which show that the future age structure is not likely to have a great impact on the future health care costs. The fourth essay is called “Cost effectiveness of bisoprolol in the treatment of chronic congestive heart failure in Sweden: Analysis using data from the Cardiac Insufficiency Bisoprolol Study II” (with Niklas Zethraeus and Bengt Jönsson). Treatment of heart failure with beta blockers was introduced in Sweden already in the 1970s, but it was not until the 1990s that large-scale clinical trials established the efficacy of beta blockers in reducing heart failure mortality. The study consists of an economic evaluation of the beta blocker bisoprolol added to standard treatment of chronic heart failure, compared with placebo added to the same standard treatment. The study raises a number of methodological issues. At the forefront are the inclusion of costs of added years of life, and the question of how to model health effects that extend beyond the clinical trial on which the economic evaluation is based. The results indi­cate that treatment with bisoprolol is cost-effective. A drawback of the analysis in the fourth study was that the expected survival after the end of follow-up was modelled deterministically. This makes it impossible to assess the uncertainty of the cost-effectiveness estimate in a realistic way. The fifth essay is entitled “Assessing uncertainty in cost-effectiveness analysis by combining resampling of clinical trial data with stochastic modelling: The economic evaluation of bisoprolol for heart failure revisited”. Here, the drawback with the fourth study that was mentioned above is addressed by using resamp­ling of the clinical trial data in combination with stochastic modelling of the expected survival after the end of follow-up in the clinical trial. The methodology is inspired by the bootstrap method, which is a simulation technique whereby various statistics, like the mean and variance, can be estimated through repeated resampling from the original sample. The difference from the traditional boot­strap method is that resampling of observations from the clinical trial data is combined with stochastic modelling of the expected remaining lifetime of the patients who were alive at the end of the clinical trial. Cost-effectiveness acceptability curves for treatment of heart failure with bisoprolol were obtained as a result of the analysis. The sixth essay, “Survival analysis techniques for estimating the costs attributable to head and neck cancer in Sweden”, concerns the estimation of average treatment cost attri­butable to a disease when the data contain censored, i.e. incomplete, observations. For various reasons, censored observations are common in medical and epidemiological studies. As a result, the length of the survival time or the size of the costs for those who are alive at the end of follow-up are not exactly known. This is of course problematic if we want to estimate the average survival time or the average cost for all patients, both survivors and non-survivors included. In this study, the Kaplan-Meier sample-average estimator is used for overcoming the problem with censored observations. It is a method that has been proposed specifically for handling censored cost data. / Diss. Stockholm: Handelshögsk., 2002

Diss. Stockholm: Handelshögsk., 2002.

No description available.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2017-03-24T14:56:20Z No. of bitstreams: 1 josemarcosgirardi.pdf: 1287766 bytes, checksum: 075ed2df1583d07329df989c3ebc4738 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-03-27T17:36:27Z (GMT) No. of bitstreams: 1 josemarcosgirardi.pdf: 1287766 bytes, checksum: 075ed2df1583d07329df989c3ebc4738 (MD5) / Made available in DSpace on 2017-03-27T17:36:27Z (GMT). No. of bitstreams: 1 josemarcosgirardi.pdf: 1287766 bytes, checksum: 075ed2df1583d07329df989c3ebc4738 (MD5) Previous issue date: 2011-06-09 / Alterações no remodelamento miocárdico, vascular, inflamatório, proteinúria e inflamação glomerular em ratos deficientes de óxido nítrico (NO), tratados com olmesartana medoxomila (OLM) e/ou rosuvastatina cálcica (ROS) foram estudadas após 28 dias com o objetivo de avaliar o impacto destes fármacos. Veículo (G1), Lnitro-arginina-metil-éster (L-NAME) 30mg/kg/dia (G2), OLM 5mg/kg/dia (G3), ROS 20mg/kg/dia (G4), OLM 0,5mg/kg/dia (G5), ROS 2mg/kg/dia (G6), OLM 0,5+ROS 2mg/kg/dia (G7), OLM 5+ROS 20mg/kg/dia (G8) administrados oralmente a ratos Wistar. Pressão sistólica (PS) mensurada semanalmente. Análises hematológica, bioquímica {colesterol total (CT), triglicérides (Tg), aminotransferases (AMT), fosfatase alcalina (FA), creatinina (Cr), nitrito/nitrato (NOx), Interleucina-6 (IL-6), Fator de Necrose Tumoral-alfa (TNF-α)}, urinária: {relação albumina/creatinina (RACU)}. Cortes de ventrículo esquerdo, aorta, rins (hematoxilina/eosina e Masson), analisados morfometricamente: análise transversa de cardiomiócitos (ATC), relação média e íntima sobre o lúmen arterial (MILA), fibrose perivascular de arteríolas intramiocárdicas (FPAI). Macrófagos glomerulares (MG) analisados por imunohistoquímica. L-NAME elevou a PS, ATC, MILA, FPVAI, IL-6, MG (p < 0,0001), TNFα, RACU, reduziu NOx (p < 0,01). OLM reduziu PS (p < 0,001), TNF-α (p < 0,05), IL6, ATC, MILA, FPVAIM (p < 0,0001), MG (p < 0,01), RACU (G3) (p < 0,05). ROS elevou NOx (G6), reduziu TNF-α, RACU (G4) (p< 0,05), IL-6, ATC, MILA (G4), FPAI (p < 0,0001), MG (p < 0,001). ROS potencializou efeito de OLM sobre a RACU. OLM e ROS exercem efeitos benéficos no remodelamento miocárdico, vascular, inflamatório e renal em ratos deficientes de NO. Efeitos pleiotrópicos de ROS independentes da PS e CT, mediados por suas propriedades antioxidantes / Changes in myocardial remodeling, vascular inflammation, proteinuria, and glomerular inflammation in nitric oxide (NO)-deficient rats, treated with olmesartan medoxomil (OLM) and / or rosuvastatin calcium (ROS) were studied after 28 days in order to assess the impact of these drugs. Vehicle (G1), nitro-L-arginine methyl ester (L-NAME) 30mg/kg/dia (G2), OLM 5mg/kg/day (G3), ROS 20mg/kg/day (G4), OLM 0,5mg/kg/day (G5), ROS 2mg/kg/day (G6), OLM 0.5+ROS 2mg/kg/day (G7), OLM 5+ROS 20mg/kg/day (G8) orally administered to Wistar rats. Systolic pressure (SBP) measured weekly. Haematological, biochemical {total cholesterol (TC), triglycerides (Tg), aminotransferase (AMT), alkaline phosphatase (ALP), creatinine (Cr), nitrite / nitrate (NOx), Interleukin-6 (IL-6), Tumor Necrosis Factor-alpha (TNFα)}, urinary {albumin / creatinine ratio (UACR)}. Cuts from the left ventricle, aorta, kidneys (hematoxylin / eosin and Masson) were morphometrically analyzed: crosssectional area of cardiomyocytes (Acmy), intima-media thickness on the arterial lumen (IMT), perivascular fibrosis of intramyocardial arterioles ratio (PFR). Glomerular macrophages (GM) were analyzed by immunohistochemistry. L-NAME increased the SBP, Acmy, IMT, PFR, IL-6, GM (p <0.0001), TNF-α, UACR reduced NOx (p <0.01). OLM reduced SBP (p <0.001), TNF-α (p <0.05), IL-6, Acmy, IMT, PFR (p <0.0001), GM (p <0.01), UACR (G3) (p <0.05). ROS increased NOx (G6), reduced TNF-α, UACR (G4) (p <0.05), IL-6, Acmy, IMT (G4), PFR (p <0.0001), GM (p <0.001). ROS potentiated the effect of OLM on UACR. OLM and ROS exert beneficial effects on myocardial, vascular, inflammatory and renal remodeling in nitric oxide deficient rats. The pleiotropic effects of ROS were independent of SBP and TC, mediated by its antioxidant properties.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / β-Blockers are an important group of prescription drugs; as a consequence of the large and continuous use, they are commonly found in the environment. This study assessed, preliminary, the inherent risk of the β-blockers Atenolol, Metoprolol and Propranolol, mostly used in the University Hospital of Santa Maria (HUSM), and showed that Propranolol has high Risk Quotient (RQ) of 0.56. HPLC-FLD and SPE methodologies were developed and optimized with the aid of experimental design in order to analyze the occurrence of β-blockers in the HUSM sewage system. The average concentration for Atenolol, Metoprolol and Propranolol found for a week sampling were 2.45, 4.67 and 0.70 μg L-1 in the sewage of the Emergence; 0.95, 0.70 and 0.315 μg L-1 in the HUSM main sewage, and 1.26, 1.27 and 0.56 μg L-1 in the water course receptor, respectively, As possible remediation methodologies for the Hospital Wastewater (HWW) were investigated Advanced Oxidation Process (AOPs) such as photo-Fenton, K2FeO4, Ozonation and O3/Fe2+. The operational parameters were optimized by Response Surface Methodology (RSM). Using optimized conditions for photo-Fenton, Atenolol, Metoprolol and Propranolol were totally degraded in 5 min in aqueous solution, and the mineralization achieved 80% after 120 min of treatment. In HWW, the β-blockers were also totally degraded, however, only 26.5% of the organic matter and 38.6% of the aromaticity were removed. The ready biodegradability and toxicity of the photo-Fenton s samples were estimated by official methods, which indicated an increase in the biodegradability and toxicity. This behavior may be correlated to the formation of degradation products (DPs), relatively, more toxic. The DPs were identified with aid of Liquid Chromatography tandem Mass Spectrometry (LC-MSn). Other proposed degradation process was oxidation-coagulation using Fe(VI), which achieved above 90% degradation for Atenolol, Metoprolol and Propranolol in HWW, while only 17% COD and 60% aromaticity removal. In aqueous solution this process led to 71.7%, 24.7% and 96.5% degradation of Atenolol, Metoprolol and Propranolol, respectively. No mineralization was found, indicating the formation of DPs, identified by LC-MSn. The ready biodegradability of the post-process samples was tested and the results showed that the oxidation-coagulation with Fe(VI) increased the biodegradability. The applicability of ozonation was evaluated varying the pH (3-11) for HWW and aqueous solution. More than 95% of the β-blockers were degraded independently of the initial pH, while above 50% of the aromaticity was removed. In aqueous solution the β-blockers were degraded in 10 min treatment and the identification of the DPs were carried out for process pH 5, 7 and 9. Catalytic ozonation (O3/Fe2+) was applied to HWW and a mineralization of 49% was achieved, with 77.9% aromaticity removal. The β-blockers were totally degraded. Therefore, the present study represents a high qualified analytical information contribution concerning the occurrence of β-blockers in HWW. The studied AOPs/Fe(VI) processes demonstrated to be suitable to degrade Atenolol, Metoprolol and Propranolol. Moreover, high removal of organic matter and aromaticity were achieved by appling O3/Fe2+ process. In many aspects, this work can be considered original, in especial, by regarding the application of Ferrate(VI) and Catalytic Ozonation to the degradation of β-blockers in HWW. / Os β-bloqueadores são uma importante classe de fármacos prescritos na terapia de doenças cardiovasculares e como consequência de seu grande e contínuo uso são comumente encontrados no meio ambiente. O presente estudo avaliou preliminarmente o risco inerente dos β-bloqueadores mais usados no Hospital Universitário de Santa Maria (HUSM), Atenolol, Metoprolol e Propranolol, evidenciando que Propranolol apresentou maior risco inerente com Quociente de Risco teórico de 0,56 (risco médio). Métodos HPLC-FLD e de clean-up/pré-concentração por SPE foram desenvolvidos e otimizados com auxílio de Metodologia de Superfície de Resposta (RSM) para avaliar a ocorrência de β-bloqueadores no sistema de esgotos do HUSM. A concentração ambiental mensurada para Atenolol, Metoprolol e Propranolol durante um ciclo semanal no ponto de lançamento Efluente PA foi 2,45; 4,67 e 0,70 μg L-1, no ponto HUSM principal 0,95; 0,70 e 0,32 μg L-1 e para o Córrego onde os efluentes são lançados de 1,26; 1,27 e 0,56 μg L-1, respectivamente. Como metodologia de remediação da contaminação de β-bloqueadores em Efluente Hospitalar (EH) foram investigados os Processos Avançados de Oxidação (PAOs) Foto-Fenton, K2FeO4, Ozonização e O3/Fe2+. Os parâmetros operacionais foram otimizados por RSM. Usando as condições otimizadas para o processo Foto-Fenton, Atenolol, Metoprolol e Propranolol foram totalmente degradados em 120 min de tratamento, contudo somente 26,5 e 38,6% da carga orgânica e aromaticidade, respectivamente, foram removidos em EH. A pronta biodegradabilidade e toxicidade para amostras aquosas do processo Foto-Fenton foram analisadas por métodos oficiais e indicaram aumento na biodegradabilidade e toxicidade. Este comportamento esta relacionado à formação de Produtos de Degradação (PD) relativamente mais tóxicos. Os PDs foram identificados por Cromatografia Líquida acoplada a Espectrometria de Massas (LC-MSn). Outro processo proposto foi oxidação-coagulação com Fe(VI) que alcançou degradação de Atenolol, Metoprolol e Propranolol acima de 90% em EH, enquanto apenas 17 e 60% da matéria orgânica e aromaticidade foram removidos, respectivamente. Em solução aquosa este processo conduziu a degradação de 71,7; 24,7 e 96,5% de Atenolol, Metoprolol e Propranolol, respectivamente. Nenhuma mineralização foi encontrada indicando a formação de PDs, identificados por LC-MSn. A pronta biodegradabilidade para as amostras aquosas pós-processo foram avaliadas e os resultados encontrados mostraram que houve aumento na biodegradabilidade. A aplicabilidade de ozonização foi avaliada variando o pH de 3-11 em EH e solução aquosa. Mais de 95% dos β-bloqueadores foram degradados independente do pH inicial, enquanto mais de 50% da aromaticidade e 30% da matéria orgânica foram. Em solução aquosa todos os β-bloqueadores foram degradados em menos de 10 min e para os processos em pH 5, 7 e 9 foram identificados os PDs. O processo de O3/Fe2+ alcançou 49% de remoção de matéria orgânica, 77,9% de redução da aromaticidade e completa degradação de Atenolol, Metoprolol e Propranolol em EH. Portanto, o presente estudo contribui com informação analítica qualificada sobre a ocorrência de β-bloqueadores em EH. Os processos de degradação estudados mostraram-se adequados para a degradação de Atenolol, Metoprolol e Propranolol. Ademais, a maior remoção de matéria orgânica e aromaticidade foram observadas para o processo de O3/Fe2+. Em muitos aspectos, este trabalho pode ser considerado original, em especial sobre a aplicação de ferrato(VI) e ozonização catalítica para a degradação de β-bloqueadores em EH.

Pulmonary circulation is a high flow, low resistance, and low pressure system. Several pathologies, including mitral stenosis, may elevate the impedance of this blood circuit and lead to a pulmonary arterial hypertension. Such syndrome is usually related to a high morbity and patient s death may occur because of the ischemic failure of right ventricle. The use of systemic vasodilating drugs to treat this syndrome is limited by the simultaneous systemic arterial hypotension they often produce. More selective agents to the pulmonary vasculature, such as synthetic analogs of prostacyclin, endothelin receptor inhibitors, and phosphodiesterase III inhibitors, have been choosen for medium and long-term treatment. Unfortunately, the most selective pulmonary hypotensive agent, the inhaled nitric oxide, which is used for short-term treatment, requires special and costly equipment for its administration, making it inaccessible to many hospitals. Furthermore, some degree of toxicity was associated with that substance. The lack of an ideal substance that simultaneously shows pulmonary selectivity, atoxicity, easy handling, accessibility and low cost, motivated the present study to test the effects of clonidine on pulmonary circulation. Clonidine is an alfa-2 adrenergic agonist. It promotes a systemic cardiocirculatory balance by modulating the adrenergic discharge at both central and peripheral levels. When used in clinical doses it presents no toxicity. Furthermore, it is easy to handle, accessible, and inexpensive. However, little has been reported about its pulmonary effect. Therefore, this work aimed to evaluate the effects of clonidine on the pulmonary arterial pressure, on the hemodynamics parameters concerned to the pulmonary circulatory system, as well as on the right ventricular function. At the same time, the action of clonidine on the systemic hemodynamics, cardiac rate, cardiac index and stroke index was also evaluated. This investigation took into account the degree of selectivity of this agent to the pulmonary vessels as well as the presence of a biphasic effect on the pulmonary arterial pressure. This effect has been largely reported on the vascular periferal system. The present research was performed as a prospective clinical trial developed on a group of 16 patients with pulmonary hypertension caused by mitral stenosis of rheumatic origin. Data were obtained before the anesthetic induction, but under the patient sedation. During the control phase, the variations of hemodynamic parameters under the action of a placebo were evaluated. During the test phase, the behavior of these parameters was evaluated under the clonidine effect. The time schedule for data measurements was the following: T0 (initial control); T1 (10 minutes after placebo administration); T2 (20 minutes after placebo administration); T3 (10 minutes after clonidine administration); T4 (20 minutes after clonidine administration). T2 was used as the control time to study the clonidine effects. Statistical analysis showed that during the control phase the variables remained unchanged, but under the effect of clonidine there was a significant reduction of the mean values concerned to the following parameters: pulmonary arterial mean pressure (27.1%) and systemic arterial mean pressure (20%), pulmonary vascular resistance index (34%) and systemic vascular resistance index (14.6%), right and left ventricular systolic work indexes (19.9% and 10%, respectively), right atrium pressure (11.5%), pulmonary arterial wedge pressure (21.5%), heart rate and cardiac index (15.8% and 7.9%, respectively). Besides that, a significant increase of the stroke index (10.2%) occured. The biphasic effect on the sistemic arterial pressure occured in 50% of the studied patients, whereas the same effect on the pulmonary arterial pressure was observed in 20% of the same sample. Clonidine also exerted a moderately selective action on the pulmonary circulation, demonstrated through the reduction of the relationship between mean value of the pulmonary vascular resistance index and mean value of the systemic vascular resistance index evaluated at the times T2 and T3. / A circulação pulmonar é um sistema de alto fluxo, baixa resistência e baixa pressão. Patologias diversas, dentre elas a estenose mitral, podem elevar a impedância desse circuito, desencadeando a síndrome de hipertensão arterial pulmonar. Esta cursa com elevada morbidade, podendo levar ao óbito pela falência isquêmica do ventrículo direito. A utilização de drogas vasodilatadoras periféricas no tratamento dessa síndrome ficou limitada pela simultânea hipotensão arterial sistêmica que provoca. Agentes mais seletivos sobre a vasculatura pulmonar, como os análogos sintéticos da prostaciclina, os inibidores dos receptores de endotelina e os inibidores da fosfodiesterase III, têm sido as drogas de eleição para o tratamento de médio e de longo prazo. O mais seletivo dos agentes hipotensores pulmonares, o óxido nítrico inalado, aplicado ao tratamento de curto prazo, exige equipamento especial e oneroso para a sua administração, tornando-o inacessível a muitos nosocômios. Paralelamente, possui potencial toxicidade. A inexistência de um fármaco ideal que apresente, simultaneamente, seletividade sobre a pequena circulação, atoxicidade, fácil manuseio e disponibilidade, além de ser pouco oneroso, conduziu ao estudo da clonidina sobre a árvore circulatória pulmonar. Este agente terapêutico é um agonista alfa-2 adrenérgico, com efeitos favoráveis reconhecidos sobre o equilíbrio circulatório sistêmico por modular a descarga adrenérgica em níveis central e periférico. É atóxico quando utilizado em doses clínicas. Além disso, oferece fácil manuseio, boa acessibilidade e baixo custo. Os estudos a respeito da sua ação pulmonar são escassos. Assim, a presente investigação teve como objetivo avaliar os efeitos da clonidina sobre a pressão arterial pulmonar, sobre os demais parâmetros hemodinâmicos da pequena circulação e sobre a função ventricular direita. Paralelamente, analisou as ações sobre a hemodinâmica sistêmica, a freqüência cardíaca, o índice cardíaco e o índice de ejeção. Foi também investigado o grau de seletividade pulmonar desse agente, bem como a presença de um efeito bifásico sobre a pressão arterial pulmonar, pois este efeito tem sido amplamente relatado no sistema vascular periférico. Para a execução dos objetivos propostos, um ensaio clínico prospectivo, realizado antes da indução anestésica, mas sob sedação, foi desenvolvido num grupo de 16 pacientes, todos portadores de hipertensão pulmonar resultante de estenose mitral de origem reumática. Durante a fase controle foram analisadas as variações dos parâmetros hemodinâmicos sob a ação de um placebo. Durante a fase teste foi avaliado o comportamento dos mesmos parâmetros sob a ação da clonidina. A padronização dos tempos nos quais se fez a coleta de dados foi a seguinte: T0 (controle inicial); T1 (10 min após a administração do placebo); T2 (20 min após o placebo); T3 (10 min após a administração da clonidina); T4 (20 min após a clonidina). A análise estatística dos resultados demonstrou não haver alteração das variáveis estudadas durante a fase controle. Todavia, sob o efeito da clonidina houve variações estatisticamente significantes dos mesmos parâmetros nos seus valores médios: redução da pressão arterial pulmonar média (27,1%) e da pressão arterial sistêmica média (20%), dos índices de resistência vascular pulmonar (34%) e sistêmica (14,6%), dos índices de trabalho sistólico dos ventrículos direito (19,9%) e esquerdo (10%), da pressão do átrio direito (11,5%), da pressão de oclusão da artéria pulmonar (21,5%), da freqüência cardíaca (15,8%) e do índice cardíaco (7,9%), ao lado de uma elevação significante do índice de ejeção (10,2%). O efeito bifásico sobre a pressão arterial sistêmica ficou evidente em 50% dos pacientes estudados, enquanto que o mesmo efeito sobre a pressão arterial pulmonar ocorreu em 20% da amostra estudada. A clonidina também exerceu uma ação moderadamente seletiva sobre a circulação pulmonar, demonstrada através da diminuição do quociente obtido entre o valor médio do índice de resistência vascular pulmonar e valor médio do índice de resistência vascular sistêmica, ambos avaliados nos tempos T2 e T3.

De nombreuses données suggèrent que le succès thérapeutique de certaines chimiothérapies conventionnelles, radiothérapies, ainsi que des thérapies ciblées est dû à leur capacité a induire la mort cellulaire immunogène (ICD), ce qui stimule la libération ou l'exposition des motifs moléculaires associés à un dommage (DAMPs) conduisant à leur reconnaissance par le système immunitaire, rétablissant ainsi l'immunosurveillance. En utilisant un criblage non polarisé, le crizotinib a été identifié en tant qu'inhibiteur de tyrosine-kinase ayant la capacité de stimuler la libération de caractéristiques distinctives de l’ICD. Des expériences faites par la suite ont montréque le crizotinib induit l'exposition de la calreticulin, la sécrétion d'ATP et la libération d’HMGB1, ainsi que le stress du réticulum endoplasmique dans les lignées cellulaires cancéreuses murines et humaines, notamment en combinaison avec les agents non immunogènes tel que le cisplatine. L’ICD causée par la combinaison du crizotinib avec la chimiothérapie a aussi été observée dans les cellules du cancer bronchique non à petites cellules (NSCLC), cellules ne possédant pas de mutations activatrices d’ALK ou ROS1 ; cela suggère un mode d'action hors-cible. Des études comparatives ont montré que seule la conformation utilisée en clinique, l’isoforme (R)-crizotinib, a la capacité de stimuler l’ICD ; le (S)-énantiomère ne possède pas ces caractéristiques. Combinées au cisplatine, les cellules fibrosarcome MCA205 et les cellules cancéreuses du poumon TC-1 traitées avec le crizotinib ont vacciné efficacement les souris immunocompétentes syngéniques contre la croissance des cellules vivantes de même type. Le crizotinib a amélioré l'efficacité de la chimiothérapie dans trois modèles de cancer du poumon orthotopiques : transplantable, induit par des carcinogènes et induites par les oncogènes. De façon remarquable, l’effet du crizotinib est aboli si un des signaux de l’ICD est bloqué. L'efficacité anticancéreuse dans chaque modèle s’est révélé être lié à l'infiltration de lymphocytes T, montrant l’implication d’une réaction immunitaire. Cela a été confirmé par des expériences chez des souris immunodéficientes (nu/nu, déficientes en thymodépendantes lymphocytes T) et dans des souris immunocompétentes dans lesquelles l’interféron gamma a été neutralisé à l’aide d’un anticorps ; l’effet du crizotinib était aboli dans les deux modèles. La combinaison du crizotinib avec le cisplatine a entraîné un accroissement de l'expression de PD-1, PDL-1 et CTLA-4 dans la tumeur, s’accompagnant par conséquent d'une sensibilisation importante des NSCLC à l'immunothérapie avec des anticorps anti-PD-1 et CTLA-4. Ainsi, la combinaison du crizotinib avec la chimiothérapie conventionnelle et les inhibiteurs des points de contrôle immunitaire peuvent être actifs contre le NSCLC. Les données présentées dans cette thèse pourraient faciliter la conception d’essais cliniques afin d’établir de nouvelles stratégies combinatoires pour le traitement des NSCLC. / Accumulating evidence suggests that certain conventional chemotherapies, radiotherapies, as well as targeted therapies mediate their long-term therapeutic success by inducing immunogenic cell death (ICD), which stimulate the release or exposure of danger-associated molecular patterns from or on cancer cells, causing their recognition by the immune system, thus reinstating immunosurveillance. An unbiased screen identified crizotinib as a tyrosine kinase inhibitor that is potent in provoking hallmarks of ICD. In subsequent low-throughput validation experiments, crizotinib promoted Calreticulin exposure, ATP secretion, HMGB1 release, as well as ER stress in both human and murine cancer cells, especially if it is combined with normally non-ICD inducing chemotherapeutics such as cisplatin. ICD induced by the combination of chemotherapy and crizotinib was also observed in non-small cell lung carcinoma (NSCLC) cells lacking activating mutations of the crizotinib targets ALK and ROS1, suggesting an off-target-mediated mode of action. Comparative studies indicated that exclusively the clinically used (R) isoform of crizotinib was efficient in inducing cell death and stimulating ICD hallmarks whereas the (S) enantiomer lacked those characteristics. When combined with cisplatin, crizotinib-killed fibrosarcoma MCA205 cells as well as lung cancer TC-1 cells efficiently vaccinated syngeneic immunocompetent mice against a re-challenge with live cancer cells of the same types. Crizotinib improved the efficacy of chemotherapy with non-ICD inducers (such as cisplatin and mitomycin C) on three distinct (transplantable, carcinogen- or oncogene induced) orthotopic NSCLC models, none of which relied on the activation of ALK or ROS1. Of note these anticancer effects were completely lost if any of the ICD signals was blocked. These anticancer efficacies in different models were linked to an increased T lymphocyte infiltration as a sign of an immune response and were lost if such tumors grew on immunodeficient (nu/nu) mice that are athymic and hence lack thymus-dependent T lymphocytes, or on immunocompetent mice with a neutralization of interferon-. The combination of cisplatin and crizotinib led to an increase in the expression of CTLA-4, PD-1 and PD-L1 in tumors, coupled to a strong sensitization of NSCLC to immunotherapy with antibodies blocking CTLA-4 and PD-1. Hence, a combination of crizotinib, conventional chemotherapy and immune checkpoint blockade may be active against NSCLC, and these data might facilitate the design of clinical trials to evaluated novel combination regiments for the treatment of NSCLC.

La pharmacogénomique (PGx) étudie le concept selon lequel les déterminants génétiques peuvent aider à prédire la réponse clinique d’un patient aux médicaments. Les concentrations plasmatiques de ces derniers sont essentielles pour déterminer l’exposition, les profils pharmacocinétiques (PK), les effets cliniques et éventuellement les doses des médicaments, dont la plupart sont métabolisés par des enzymes hépatiques, les cytochromes P450 (CYPs). Néanmoins, la plupart des découvertes en matière de PGx concernant la prédiction des profils de concentrations des médicaments ont généralement recours à des plans d’études PK traditionnels avec une approche fonctionnelle. Bien qu’utile, cette méthodologie comporte des limites pour les études PGx, notamment le nombre restreint de sujets inclus, qui réduit la puissance statistique des associations PGx et limite l’identification de nouveaux variants génétiques moins fréquents. À l’inverse, les grandes cohortes observationnelles sont largement utilisées pour identifier des marqueurs génétiques physiopathologiques. Cette thèse de doctorat visait donc à 1) synthétiser les données publiées concernant les effets cliniques des polymorphismes génétiques de l’enzyme CYP2D6 sur le traitement au métoprolol, un agent β-bloquant. Les concentrations plasmatiques de métoprolol ont montré à plusieurs reprises qu’elles étaient fortement influencées par la PGx du CYP2D6; 2) développer une nouvelle méthode bioanalytique capable de quantifier les concentrations chirales de métoprolol des patients dans un contexte clinique; 3) mener une étude clinique en utilisant une grande cohorte observationnelle, ou biobanque, comme preuve de concept pour recréer l’association précédemment établie entre les phénotypes inférés des génotypes du CYP2D6 et les concentrations plasmatiques de métoprolol. Ces projets sont présentés en tant que chapitres de thèse et sous forme de manuscrits publiés. Le premier projet consistait en une revue systématique qui a permis d’extraire toutes les études relatives à la PGx du métoprolol-CYP2D6. La synthèse qualitative a suggéré que les métaboliseurs lents du CYP2D6, dépourvus de capacité enzymatique, avaient des valeurs plus élevées concernant les réductions de la fréquence cardiaque et de tension artérielle, ainsi que la survenue d’épisodes bradycardiques relativement aux autres phénotypes. Une méta-analyse ultérieure a confirmé la significativité de ces associations. Le deuxième projet a combiné des techniques bioanalytiques telles que la dérivation, l’extraction en phase solide et la chromatographie liquide avec spectrométrie de masse en tandem. Une méthode permettant de surmonter les limites analytiques antérieures a été validée avec succès pour mesurer les concentrations plasmatiques de (S)-métoprolol, l’énantiomère pharmacologiquement actif, et de son métabolite spécifique au CYP2D6. L’applicabilité d’une telle méthode a ensuite été démontrée grâce aux échantillons d’un groupe de patients issus de la Cohorte Hospitalière de l’Institut de Cardiologie de Montréal (ICM). Puis, le troisième projet présente la réalisation de l’étude LEVEL-PGx (LEVEraging Large observational cohort studies to identify pharmacogenetic determinants of drug dosing : A proof-of-concept study in the Montreal Heart Institute Hospital Cohort). L’étude portait sur un échantillon de >1000 patients sélectionnés dans la cohorte hospitalière de l’ICM, incluant leur génotypage pour CYP2D6 et la quantification du métoprolol racémique et de son métabolite spécifique au CYP2D6 dans des échantillons provenant de la Biobanque de l’ICM. Un seul échantillon unique et aléatoire par patient a été utilisé. Le recours à des modèles multivariables a validé le concept selon lequel de grandes cohortes transversales recueillant des échantillons biologiques pouvaient être utilisées afin d’identifier des associations PGx de concentrations de médicaments et ce, à des valeurs satisfaisant les seuils de significativité d’essais pangénomiques. D’autres analyses de cette cohorte ont indiqué que cette méthodologie parvenait à identifier des associations PGx qui influençaient la fréquence cardiaque au repos et la posologie du métoprolol à-travers les phénotypes du CYP2D6 et pour les déterminants génétiques uniques, même en présence de co-médications. Cependant, ces associations PGx avec les paramètres cliniques n’ont pas atteint une significativité applicable aux seuils pangénomiques. En résumé, par la reproduction d’une association PGx préalablement démontrée, l’ensemble des travaux présentés dans cette thèse suggère que l’identification et la découverte de nouveaux déterminants génétiques prédictifs des concentrations et des doses des médicaments pourrait s’effectuer par le biais de grandes cohortes observationnelles à l’échelle du génome. Ces approches permettraient de développer des modèles prédictifs plus précis de l’exposition et de la réponse aux médicaments, ce qui pourrait favoriser les découvertes PGx et, dans certains cas, éventuellement développer le potentiel translationnel d’une approche thérapeutique personnalisée selon le profil génétique des patients. / Pharmacogenomics (PGx) studies the concept that genetic determinants can help predict a patient’s clinical response to therapies. Drug concentrations are an essential component to determining the exposure, pharmacokinetic (PK) profiles, clinical effects, and potentially drug doses, most of which are metabolized through the cytochrome P450 (CYPs) liver enzymes. Nevertheless, most PGx discoveries regarding the prediction of drug concentration profiles have generally resorted to traditional PK study designs with a functional approach. Though useful, this methodology contains limitations for gene-drug interaction studies, most notably the restricted number of subjects included, which reduces the statistical power for PGx associations and limits the identification of new, less frequent genetic variants. On the opposite, large observational cohorts have long been utilized for identifying genetic markers of disease. This doctoral thesis therefore aimed to 1) synthesize published data regarding the clinical effects of CYP2D6 genetic polymorphism on metoprolol therapy. A β-blocker, metoprolol plasma concentrations have shown repeatedly to be heavily influenced by the PGx of the CYP2D6 enzyme; 2) develop a new bioanalytical method able to quantify patients’ chiral concentrations of metoprolol in a clinical setting; 3) conduct a clinical study using a large observational cohort, or biobank, as a proof of concept to recreate the previously established association between CYP2D6 genotype-inferred phenotypes and metoprolol plasma concentrations. Those projects are presented as thesis chapters in the form of published manuscripts. The first project was a systematic review that allowed us to find all studies pertaining to the PGx of metoprolol. The qualitative synthesis suggested that CYP2D6 poor metabolizers (PMs), without enzymatic capacity, had greater values regarding reductions in heart rate, blood pressures, and occurrences in bradycardia relative to non-PMs. A subsequent meta-analysis confirmed the significance of those associations. The second project combined bioanalytical techniques such as derivatization, solid phase extraction, and liquid chromatography-tandem mass spectrometry. A method overcoming previous analytical shortcomings was successfully validated to measure (S)-metoprolol plasma concentrations and its CYP2D6-specific metabolite. Its application was later demonstrated in a group of patients from the Montreal Heart Institute (MHI) Hospital Cohort. Then, the third project presents the conduct of the LEVEL-PGx study (LEVEraging Large observational cohort studies to identify pharmacogenetic determinants of drug dosing: A proof-of-concept study in the Montreal Heart Institute Hospital Cohort). The study implicated a sample of >1000 selected patients selected from the MHI Hospital Cohort, along with the genotyping of CYP2D6, and the quantification of racemic metoprolol and its CYP2D6-specific metabolite in samples from the MHI Biobank. A single, random sample per patient was used. Multivariable modeling validated the concept that large observational cohorts collecting biospecimens could be utilized to identify PGx associations of drug concentrations with genome-wide significance. Further analyses in our cohort indicated that the tested PGx associations influenced resting heart rate and metoprolol daily drug dosage across CYP2D6 phenotypes and for single genetic determinants, regardless of interfering comedications. However, such PGx associations with clinical parameters could not achieve genome-wide significance. In summary, the body of work presented in this thesis suggested that, using a previously validated PGx association, the identification of novel genetic determinants predictive of drug concentrations and dosage could be discovered and identified at the genome-wide level with large observational cohorts. These approaches would help develop more accurate predictive models of drug exposure and response, which could favor PGx discoveries and the translational potential of a personalized approach to treatments according to a patient’s genetic profile.