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Les Maladies Inflammatoires Chroniques de l’Intestin (MICI) comprennent la maladie de Crohn (MC) et la rectocolite hémorragique (RCH). Ce sont des inflammations chroniques du tube digestif dont les causes sont inconnues. Une meilleure connaissance de leur épidémiologie pourrait orienter vers des pistes étiologiques. Jusqu’à la création du Registre EPIMAD en 1988, il n’existait en France aucune donnée d’incidence. Nous avons créé en 1988 une étude prospective d’incidence des MICI, reconnu «Registre» par l’Inserm et l’InVS en 1992. Le territoire couvert par Epimad comporte le Nord, le Pas-de-Calais, la Somme et la Seine-Maritime avec près de 6 millions d’habitants soit 9,3% de la population française. La collection des cas repose sur une collaboration multidisciplinaire incluant les gastroentérologues (GE) (libéraux, hospitaliers, adultes et pédiatres; n=262), les services d’Epidémiologie de Lille et Rouen, la plateforme d’aide méthodologique en Biostatistiques du CHRU de Lille et les Centres Hospitalo-Universitaires de Lille, Amiens et Rouen. Neuf enquêteurs se déplacent sur les lieux de consultation des GE et recueillent les informations nécessaires à la validation des diagnostics. Deux GE experts revoient chaque dossier indépendamment et posent le diagnostic final de MC ou RCH certaine, probable ou possible, de colite indéterminée, de colite aiguë ou de colite inclassée. Pour les cas atypiques et non classés, un suivi systématique est effectué pour le classement définitif (MICI ou non MICI). Un croisement des bases du Registre et des bases hospitalières est effectué une fois par an pour mesurer l’exhaustivité. 80% des cas incidents sont diagnostiqués par les GE libéraux, 13% par les GE des hôpitaux généraux et 7% par les GE universitaires. Entre 1988 et 2008, l’incidence moyenne des MICI était de 11,3/105 habitants (6,4 pour la MC, 4,4 pour la RCH et 0,5 pour IBDU). Pendant cette période, l’incidence de la MC a augmenté de 30% (100% chez l’adolescent) alors que celle de la RCH est restée stable. Le délai diagnostique médian était de 3 mois dans la MC et de 2 mois dans la RCH. Le pourcentage de patients ayant un diagnostic posé plus de 9 mois après l’apparition des symptômes a diminué avec le temps. La validité diagnostique dans les cas non classant d’emblée a été assurée par un suivi de 2 ans et a montré que seul l’âge < 40 ans était prédictif d’une évolution vers une MICI chez un patient présentant une colite aiguë. Nous avons aussi mis en évidence des présentations cliniques différentes en fonction de l’âge. Ainsi, chez l’adulte jeune, la MC est plus étendue que chez les sujets > 60 ans au diagnostic. Grâce à un nombre élevé de cas incidents, une hétérogénéité spatiale de l’incidence des MICI a été montrée dans les zones agricoles et suburbaines sans lien avec le niveau social des populations. En utilisant la méthode des statistiques de scan rajoutant la dimension temporelle à l’analyse spatiale, nous avons trouvé plusieurs clusters de sur et sous incidence constants dans le temps. Nos perspectives sont: 1) Poursuivre l’enregistrement des cas incidents et établir des données de prévalence; 2) Etudier les facteurs de risque environnementaux par des études d’épidémiologie analytique (corrélations écologiques, études cas témoins, études exposés-non exposés); 3) Etudier les facteurs de risque génétiques (fréquence des variants NOD2) dans la population du Registre; 4) Créer une étude prospective sur les paramètres prédictifs (profil génétique, profil métagénomique du microbiote intestinal, profil sérologique) de développer une MC dans une population de sujets à haut risque (sujets indemnes de MC âgés de 10 à 35 ans et appartenant à une famille multiplexe, à la descendance de formes conjugales ou à une paire de jumeaux discordants). Conclusions: EPIMAD est le plus gros Registre mondial sur les MICI en population générale, reconnu pour la qualité de ses travaux, rendu possible par la création d’un réseau-ville-hôpital unique. / Inflammatory Bowel Disease (IBD) including Crohn’s disease (CD) and ulcerative colitis (UC) are among the most serious and perplexing of digestive diseases. Their pathophysiology remains poorly understood. Geographic variations in the incidence of IBD could offer new clues about environmental risk factors. There were no data concerning the incidence of IBD in France. We created the first French prospective study on IBD incidence in 1988. This study became “Registre” recognized by Inserm and InVS in 1992. This prospective study was performed through all gastroenterologists (GE) (n=262) of the region of Nord, Pas-de-Calais, Somme and Seine-Maritime including near of 6 million of inhabitants corresponding to 9.3% of the whole French population. Collection of new cases is based on a close multidisciplinary collaboration including GE (whatever their practice), Epidemiology Unit of Hospital and University of Lille and Rouen, Biostatistics Unit of Lille Hospital and University and Academic Hospitals of Amiens, Lille and Rouen. Each GE referred patients consulting for the first time with clinical symptoms compatible with IBD. Data are collected by 9 interviewer practitioners present at the GE’s consulting room. Two independent experts GE assessed each case independently and made a final diagnosis of definite, probable, possible CD, UC or ulcerative proctitis (UP); Inflammatory Bowel Disease unclassifiable (IBDU); acute colitis or unspecified colitis. Possible cases of IBD, acute colitis and unspecified colitis are systematically followed-up and when a new event is recorded the chart is reviewed by the experts and a new final diagnosis is made. A control of the completeness collection is made each year by crossing data from Hospital Health databases. 80% of incident cases have been reported by private GE, 13% by general hospitals and 7% by academic centres. From 1988 to 2008 the mean annual incidence was 11.3/105 inhabitants for IBD including 6.4 for CD, 4.4 for UC and 0.5 for IBDU with a ratio CD/UC of 1.45. During this period CD incidence increased by 30% (100% in young adults) while that of UC remained stable. Valuable clinical information has been obtained; median time between onset of symptoms and diagnosis was 3 months in CD and 2 months in UC. The number of patients with a diagnosis delay > 9 months decreased over time. Age < 40 years at diagnosis was the only clinical predictor for subsequent IBD in patients with an initial diagnosis of acute colitis. Clinical presentation according to age at diagnosis may influence clinical course of IBD. In younger patients IBD had a more disabling course than in the elderly-onset IBD patients. Thanks to the large number of incident cases, we assessed spatial IBD incidence variation at the canton level and analyzed its association with a deprivation index. A spatial heterogeneity was found with a noteworthy predominance of CD in agricultural areas but no significant link with deprivation. We completed the spatial analysis using spatial scan statistics methods allowing revealing several time-constant (since 1988) clusters and other time-varying clusters. Perspectives: 1) To continue to record incident cases and establish prevalence data of IBD; 2) To study environmental risk factors using epidemiological analytic studies; 3) To study genetic risk factors establishing a geographic map of NOD2 variants in the EPIMAD’s area and 4) To assess the predictiveness of patient microbiota and host factors in a prospective, longitudinal study enrolling yet-healthy subjects at risk to develop CD (healthy patients aged 10-35 years and belonging to discordant twins, to offspring of IBD affected couples and to IBD multiplex families). In conclusion, since 1988, the EPIMAD registry has been recognized as a valuable tool for studies on genetic and environmental risk factors. It has also made it possible to reinforce networking between private practices, general and university hospitals at a regional level.

ABSTRACT This study was designed to screen antiretroviral therapy (ART)-naïve human immunodeficiency virus (HIV) infected patients for proteinuria, using urine dipsticks, at the HIV outpatient clinic at Johannesburg Hospital in an attempt to detect and treat early renal disease. In those with persistent proteinuria, a marker of kidney disease, renal biopsy was performed, ART with and without angiotensin-converting enzyme inhibitors (ACE-I) was initiated and patients were followed up for immunological and renal responses. After a minimum period of 12 months, a repeat biopsy was performed, where possible, to determine whether the histological lesions had responded to treatment. During urinary screening, proteinuria, leucocyturia and microscopic haematuria were common. Sterile leucocyturia may be associated with co-morbid sexually transmitted infection or tuberculosis. In the group that underwent renal biopsy with treatment, the renal and immunological response, before and after ART was highly statistically significant. Renal and immunological responses to ART were assessed by reduction in proteinuria with increased GFR, increased CD4 count with reduction in HIV viral load, respectively. On biopsy, HIV-associated immune complex disease was more common than HIVAN, a finding that contradicts international and some local data. Resolution of proteinuria was relatively rapid in comparison to the histological response to treatment, an effect not previously shown. This is the first study of its kind, to the author’s knowledge, that prospectively evaluates the effect of ART with/ ACE-I in ART-naïve HIV infected patients with both clinicopathological and histological criteria. It has shown unequivocally, that renal disease, particularly if detected and treated early in HIV infection, is responsive to treatment. These findings suggest screening for early detection and treatment of HIV-associated renal disease should be mandatory in HIV clinics in South Africa.

Alzheimer’s Disease (AD) is the most prevalent neurodegenerative disease. The candidate aetiological agent for this disease is the 4kDa amyloid beta (Ab) peptide which is derived from the proteolytic cleavage of the amyloid precursor protein (APP) by the b- and g- secretase, respectively. As cellular prion proteins (PrPc) both regulate the cleavage of APP and mediate Ab induced neurotoxicity, a study was undertaken to establish whether the cellular receptor for PrPc, namely the 37kDa/67kDa laminin receptor (LRP/LR) also played a role in AD pathology. Anti LRP/LR specific antibody (IgG1-iS18) blocking LRP/LR resulted in a significant reduction of both Ab and sAPPb levels (the cleavage products of b-secretase), while APP, b- and g-secretase cell surface levels remained unaltered. LRP/LR was found to co-localise with APP, b- and g-secretase both on the cell surface and intracellularly. Furthermore, FRET demonstrated that an interaction existed between presenilin 1 (PS1) of the g-secretase and LRP/LR, while co-immunoprecipitation confirmed that LRP/LR interacted with both b-secretase and PS1. These results indicate that LRP/LR is implicated in the amyloidogenic processing of APP, through an indirect interaction with the b-secretase and a direct interaction with the g-secretase. These findings also suggest the possibility of utilising IgG1-iS18 as a possible therapeutic for the treatment of AD.

A dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Master of Science in Medicine Johannesburg, 2005 / ABSTRACT INTRODUCTION The risk of cardiovascular disease in patients with end stage renal disease (ESRD) is far greater than in the general population. Amongst patients with ESRD, the prevalence of coronary artery disease (CAD) and congestive heart failure is approximately 40% compared with 5-12% in the general population. The excess risk is caused by multiple traditional and non-traditional risk factors for ischaemic heart disease present in these patients. There is little information on CAD and its risk factors in black haemodialysis patients as most of these studies were carried out in the white population. This study is therefore aimed at determining the risk factors for atherosclerosis in Black and non-black (White and Indian) South African patients on haemodialysis. METHODS Fifty-eight black patients and twenty-six non-black patients on haemodialysis were recruited. Sixty-three age and sex matched controls (staff, students and kidney donors) were also recruited. Fasting venous blood samples were drawn for measurement of Creactive protein, homocysteine, Lp (a), serum lipids and adiponectin. Carotid intima-media thickness and plaque occurrence was measured by B-mode ultrasonography. Echocardiography was used to determine LVH. vi RESULTS Haemodialysis (HD) patients had significantly lower total cholesterol, LDL cholesterol and triglycerides compared with controls (p<0.001; p= 0.042). Hs-CRP, adiponectin and homocysteine levels were significantly higher in patients compared with controls (p< 0.001). The prevalence of plaques was significantly higher among HD patients (32%) compared with controls (7%) X2 = 60.72 p< 0.001. LVMI was significantly higher among HD patients (194.25± 7.69gm/m2) compared with controls (93.21 ± 3.27 gm/m2) p < 0.001. No significant difference between patients (Black or Asian/White) and controls with respect to CIMT was found. CVD risk factors in black haemodialysis patients and black controls showed a similar pattern to the whole study population combined. Risk factors associated with CIMT on regression analysis were total cholesterol, LDL-cholesterol, age, Hs-CRP, family history of CKD. Risk factors associated with plaque occurrence on logistic regression analysis were age, systolic blood pressure, male gender, smoking, calcium phosphate product and serum phosphate. CONCLUSION HD patients have a high prevalence of traditional and non-traditional risk factors for atherosclerosis and this is independent of race. Traditional risk factors like lipids were much lower in ESRD patients. HD patients showed a high prevalence of atherosclerosis as measured by increased carotid intima-media thickness and plaque occurrence in carotid arteries. Hs-CRP correlated significantly with a surrogate marker of atherosclerosis (CIMT).

A!dissertation submitted to the Faculty of Science, University of the Witwatersrand, Johannesburg, in the fulfillment of the requirements for the degree of Master of Science. 2013. / Alzheimer’s disease (AD) is the most prevalent neurodegenerative disease affecting in excess of 26.6 million individuals globally. The neuropathological features of AD include extracellular deposition of amyloid beta (Aβ) plaques and intracellular neurofibrillary tangle formation. The cellular prion protein (PrPC) regulates the amyloidogenic cleavage pathway involved in Aβ shedding and interacts with the Aβ peptide. Given these interactions, the aim of this study was to investigate the influence of the 37kDa/67kDa laminin receptor (LRP/LR)- the cellular receptor for prion proteins- on Aβ shedding. Transfection of HEK293 cells with short hairpin RNAs (shRNAs) directed against LRP mRNA significantly decreased LRP levels in addition to Aβ shedding. Flow cytometric analysis revealed unchanged cell surface levels of the amyloid precursor protein (APP), β-secretase and γ-secretase after transfection of cells with shRNAs, suggesting a role of LRP/LR in Aβ shedding via a mechanism independent of gene-expression modulation of these key proteins. LRPshRNA treatment significantly reduced sAPPβ expression, implicating LRP/LR in APP processing specifically via augmenting the activity of β-secretase. Colocalisation of LRP/LR with APP, β- and γ-secretase, respectively, alludes to a possible interaction between said proteins. Therefore, LRP-shRNAs are suggested as alternative therapeutic tools for AD treatment.

Thesis (M.S.)--Boston University

Huntington's disease (HD) and Parkinson's disease (PD) are devastating neurodegenerative disorders that are characterized pathologically by degeneration of neurons in the brain and clinically by loss of motor function and cognitive decline in mid to late life. The cause of neuronal degeneration in these diseases is unclear, but both are histologically marked by aggregation of specific proteins in specific brain regions. In HD, fragments of a mutant Huntingtin protein aggregate and cause medium spiny interneurons of the striatum to degenerate. In contrast, PD brains exhibit aggregation of toxic fragments of the alpha synuclein protein throughout the central nervous system and trigger degeneration of dopaminergic neurons in the substantia nigra. Considering the commonalities and differences between these diseases, identifying common biological patterns across HD and PD as well as signatures unique to each may provide significant insight into the molecular mechanisms underlying neurodegeneration as a general process. State-of-the-art high-throughput sequencing technology allows for unbiased, whole genome quantification of RNA molecules within a biological sample that can be used to assess the level of activity, or expression, of thousands of genes simultaneously. In this thesis, I present three studies characterizing the RNA expression profiles of post-mortem HD and PD subjects using high-throughput mRNA sequencing data sets. The first study describes an analysis of differential expression between HD individuals and neurologically normal controls that indicates a widespread increase in immune, neuroinflammatory, and developmental gene expression. The second study expands upon the first study by making methodological improvements and extends the differential expression analysis to include PD subjects, with the goal of comparing and contrasting HD and PD gene expression profiles. This study was designed to identify common mechanisms underlying the neurodegenerative phenotype, transcending those of each unique disease, and has revealed specific biological processes, in particular those related to NFkB inflammation, common to HD and PD. The last study describes a novel methodology for combining mRNA and miRNA expression that seeks to identify associations between mRNA-miRNA modules and continuous clinical variables of interest, including CAG repeat length and clinical age of onset in HD.

This study aims to discover whether there is a correlation between atypical clinical presentations of Alzheimer’s disease (AD) and atypical distribution patterns of AD pathology. To provide a measure of the atypical clinical presentations, we obtained standardized neuropsychological test scores for a group of 345 subjects of the Boston University Alzheimer’s Disease Center cohort that had received a clinical or pathological diagnosis of AD. Each of the neuropsychological test scores included in our analyses was classified into one of five cognitive domains, according to the primary domain each test assesses: memory, executive function, attention, visuospatial function, and language. From these test scores, global cognitive performance scores and individual domain performance scores were calculated for a subset of 53 subjects that had brain tissue slides available for pathological analysis. Difference scores were computed for each domain, providing a within-subject comparison of performance between each individual cognitive domain and overall cognitive performance. For these same 53 subjects, tissue slides from six brain regions were obtained and digitally scanned. Neurofibrillary tangle (NFT) quantification was performed for all tissue slides using a computer algorithm modified to recognize AT8 staining patterns. NFT densities were then calculated for five general brain regions (frontal, parietal, temporal, limbic and occipital). In addition, a global NFT density score was computed for each subject, averaging NFT densities across all regions. From these densities, difference scores were calculated for each brain region individually, providing a measure of how each region’s NFT density compares to the overall brain NFT density. Multiple linear regressions analyses were performed with five pairs of cognitive domain difference scores and region NFT density difference scores: memory difference scores and limbic difference scores, executive function difference scores and frontal difference scores, attention difference scores and parietal difference scores, visuospatial difference scores and occipital difference scores, and language difference scores and occipital difference scores. Though we expected to observe significant negative correlations between each of the five difference score pairs, the only statistically significant correlation observed was between memory difference scores and limbic difference scores (β= -0.361, p<0.05). These results suggest that poorer performance in memory-related neuropsychological tests, when compared to global cognitive performance, can predict higher NFT densities in limbic regions when compared to the overall brain pathology. Although no other difference score pairs showed any statistically significant correlations, many study limitations, including small sample size and simplifications in analysis, should be addressed in the future to provide better understanding of these atypical presentations of AD and their underlying pathologies.

Biosecurity practices for Mycobacterium avium subsp. paratuberculosis (Mptb), the etiologic agent for Johne's disease (JD), are predicated on the fact that fecal-oral is the major route of infection and that Mptb is present in the environment of affected farms. The objectives of these studies were to describe perceived benefits of testnegative Level 4 status in the Voluntary Bovine Johne's Disease Control Program (VBJDCP), describe producer and veterinarian attitudes towards JD relevant biosecurity practices, compare 5 JD control options using a Markov model, determine if tangential flow filtration (TFF) increases the detection sensitivity for Mptb and describe the distribution of environmental predictors for Mptb survival. Twenty-five percent and 39% of beef producers in the VBJDCP reported that they received substantial or marginal benefits (financial and non-financial), respectively, from program participation. Producers suggested increased marketing opportunities to improve the VBJDCP. Producers in a cross-sectional mailed survey of attitudes towards biosecurity practices were more likely than veterinarians to agree that separating JD clinical or suspects from calves or heifers; acquiring replacements or additions from JD low-risk herds, testing for JD every 10 to 14 months and test and culling clinical suspects only were useful for control of JD. A state transition Markov model, with the environment as the source of Mptb, was used to compare 6 alternative control strategies for JD. Management and the probability of Mptb surviving 1 year in the environment were important determinants of the prevalence of subclinical JD on beef farms under the analyzed control strategies. Heterogenous distribution of environmental predictors for Mptb survival was observed in spatial risk maps. In conclusion, although some beef producers experienced gains from participation in the VBJDCP, the perceived program benefits could be improved by increased marketing and education on the advantages of participation. Specific problem areas should be addressed. The length of time Mptb survived in the environment was an important parameter in the Markov chain model. Additionally, due to the heterogenous distribution of environmental predictors, a multiscale approach to sampling and analysis should be useful.