Made available in DSpace on 2016-01-26T12:51:37Z (GMT). No. of bitstreams: 1 eumildodecampos junior_tese.pdf: 1761590 bytes, checksum: 07f0e6564f9169c180cc6baf09d6de84 (MD5) Previous issue date: 2011-12-16 / Dysphagia caused by chagasic megaesophagus compromises the clinical status and quality of life of patients. In this context, the Serra Dória s operation is a useful procedure in cases of advanced or recurrent disease. Little is known about the cardiovascular complications related to this surgery. Objective: This study aim to identify preoperative risk factors associated with cardiovascular complications after Serra Dória s operation in patients with megaesophagus caused by Chagas disease at the hospital period to document the data in order to better preoperative evaluating of these of these patients. Methods: This is a retrospective study evaluating patients who underwent the Serra Dória s operation at the General Surgery Service of Hospital de Base (FUNFARME), Faculty of Medicine of Sao Jose do Rio Preto (FAMERP) from 1998 to 2010. Initially, we assessed 103 medical records and excluded from the study 16 patients with idiopathic achalasia and 11 incomplete charts; therefore, the study population consisted of 76 patients with chagasic megaesophagus who underwent Serra Dória s procedure. The study was approved by the Ethics in Research Committee No. 254/2011. The following preoperative variables were included in the multivariate stepwise regression analysis: the model: age, sex, degrees of megaesophagus, operation for recurrence of symptoms, need for transfusion of red blood cells, blood pressure, electrolytes, comorbidities, electrocardiographic findings and degree of surgical risk. Cardiovascular complications were as follows: levels of hypotension and hypertension and cardiac arrhythmias without hemodynamic instability observed during the surgery and in the postoperative period. Student s t test was used in the comparison of continuous variables, whereas the chi-squared test was used in the comparison of categorical variables. Variables associated with the presence of cardiovascular complications at the p<0.05 were included in multivariate logistic stepwise regression. Those that remained associated with the presence of cardiovascular complications were considered independent variables to predict the appearance of cardiovascular complications. Results: The mean age was 61 ±10 years with male predominance (42, 55%). Most patients were classified as advanced megaesophagus (65, 86%); 36(47%) of them had relapsed megaesophagus. In 22(29%) of cases there was at least one comorbidity, with hypertension being the most frequently found (25, 30%). In 34(45%) patients the surgical risk was classified as moderate to severe. Among the electrocardiographic findings found preoperatively, sinus rhythm was found in 68(89%) patients, and right bundle-branch block in 28(37%). Cardiovascular complication was observed in 29(38%) patients, with prevalence of hypotension in various levels (14, 41%), followed by cardiac arrhythmias in 12(35%). The largest number of cardiovascular complications occurred during the immediate postoperative period. Variables associated with the presence of complications in the univariate model were age (p=0.003) and left bundle-branch block (p= 0.02). However, only the aged above 61 years of age was an independent predictor of cardiovascular complications in the postoperative Serra Dória s operation. Conclusion: Age is an independent predictor of cardiovascular complications following the Serra Dória s procedure. / A disfagia causada pelo megaesôfago chagásico compromete o estado geral e a qualidade de vida dos pacientes. Neste contexto, a cirurgia de Serra Dória é um procedimento útil nos casos avançados ou de recidiva da doença. Pouco se sabe a respeito das complicações cardiovasculares relativas a esta cirurgia. Objetivo: O estudo buscou identificar fatores de risco pré-operatórios associados às complicações cardiovasculares após a cirurgia de Serra Dória no período hospitalar para documentar os dados visando melhorar a avaliação pré-operatória destes pacientes. Casuística e Métodos: Estudo retrospectivo que analisou pacientes submetidos à cirurgia de Serra Dória no Serviço de Cirurgia Geral do Hospital de Base (FUNFARME) da Faculdade de Medicina de São Jose do Rio Preto (FAMERP) no período de 1998 a 2010. Inicialmente foram analisados 103 prontuários e excluídos do estudo 16 portadores de acalasia idiopática e 11 prontuários incompletos; portanto, a amostra consistiu de 76 pacientes portadores de megaesôfago chagásico submetidos à cirurgia de Serra Dória. O estudo foi aprovado pelo Comitê de Ética e Pesquisa parecer nº 254/2011. As seguintes variáveis pré-operatórias foram incluídas na análise de regressão logística multivariada passo-a-passo: idade, sexo, graus do megaesôfago, operação por recidiva dos sintomas, necessidade de transfusão de hemácias, níveis de pressão arterial, eletrólitos, comorbidades, achados eletrocardiográficos e grau de risco cirúrgico. As complicações cardiovasculares consideradas foram: níveis de hipotensão e hipertensão arterial e arritmias cardíacas com ou sem instabilidade hemodinâmica, observadas durante o período transoperatório, pós-operatório imediato e enfermaria. Para análise das variáveis contínuas utilizou-se o Test t de student não pareado, e para as variáveis descontínuas, o teste de qui-quadrado. Variáveis associadas à presença de complicações cardiovasculares com p <0,05 foram incluídas no modelo multivariado de regressão logística passo-a-passo. Aquelas que se mantiveram associadas à presença de complicações cardiovasculares foram consideradas variáveis de predição independente para o aparecimento dessas complicações. Resultados: A idade média da amostra foi de 61 ± 10 anos com predomínio do sexo masculino (42, 55%). A maioria dos pacientes apresentou megaesôfago avançado (65, 86%), e 36(47%) com recidiva dos sintomas que necessitaram de novo procedimento. Em 22(29%) dos casos houve pelo menos uma comorbidade, sendo a hipertensão arterial a mais frequente (25, 30%). O risco cirúrgico em 34(45%) pacientes foi considerado como moderado a grave. Nos achados eletrocardiográficos do pré-operatório, os mais frequentemente encontrados foram 68(89%) com ritmo sinusal seguido pelo bloqueio completo do ramo direito do feixe de His em 28(37%). Observou-se complicação cardiovascular em 29(38%) pacientes, com predomínio de hipotensão arterial em vários níveis (14, 41%), seguida de arritmias cardíacas em 12(35%). O maior número de complicações cardiovasculares ocorreu no período pós-operatório imediato. As variáveis associadas à presença de complicações no modelo univariado foram a idade (p=0,003) e o bloqueio de ramo esquerdo do feixe de His (p=0,02). No modelo multivariado, apenas a idade igual ou superior a 61 anos mostrou-se variável de predição independente para o aparecimento de complicações cardiovasculares no pós-operatório da cirurgia de Serra Dória. Conclusão: A idade é um fator de predição independente de complicações cardiovasculares após a cirurgia de Serra Dória.

A doença Inflamatória Intestinal (DII) é uma desordem caracterizada pela inflamação crônica do trato gastrointestinal. Os dois principais tipos de DII são a Retocolite Ulcerativa (RCU) e a Doença de Crohn (DC) e ambas cursam com importantes alterações no estado nutricional (EN). O objetivo deste estudo foi identificar as diferenças na composição corporal entre pacientes com DC, RCU e indivíduos saudáveis, além de comparar o estado nutricional dos três grupos de pacientes, ajustando para fatores que podem interferir no EN, como o uso atual de corticosteróides, a atividade física, a atividade de doença, a idade e o sexo. Foi realizado um estudo transversal que incluiu 101 pacientes com DII (50 com DC e 51 com RCU) e 35 indivíduos saudáveis, selecionados no Ambulatório do Hospital Universitário Pedro Ernesto (HUPE) da Universidade do Estado do Rio de Janeiro (UERJ). Foram colhidas informações sócio-demográficas e pessoais, tais como: prática de atividade física, tabagismo, doenças pregressas e procedimentos cirúrgicos prévios. Outras informações necessárias à pesquisa foram coletadas em prontuário médico. A avaliação antropométrica foi realizada por meio das seguintes medidas: peso corporal; altura; circunferências do braço, da cintura (CC) e do quadril; dobras cutâneas do tríceps, subescápula, supra-ilíaca e da coxa; e circunferência muscular do braço (CMB). A análise da composição corporal foi realizada por meio da bioimpedância elétrica (BIA), utilizando-se o aparelho Biodynamics modelo 450. As variáveis laboratoriais analisadas foram: glicose, hemograma completo, perfil lipídico, proteínas totais, albumina, globulina, velocidade de hemossedimentação e proteína C reativa. O peso, o índice de massa corporal, a CC e o percentual de gordura corporal calculado a partir da aferição das dobras cutâneas, foram menores nos pacientes com DC, quando comparados aos indivíduos saudáveis e/ou aos pacientes com RCU. A CMB foi menor nos pacientes com DC e RCU quando comparados aos indivíduos saudáveis, porém sem apresentar diferenças entre os dois grupos de pacientes. Por BIA, verificou-se que os pacientes com DC apresentaram valores de massa magra, massa celular corpórea, massa extracelular, água corporal total e água extracelular menores quando comparados aos indivíduos saudáveis. Os níveis séricos de colesterol total, proteínas totais e albumina, e a contagem total de hemácias foram menores nos indivíduos com DC quando comparados aos indivíduos do grupo controle e/ou aos indivíduos do grupo da RCU. Os pacientes com RCU exibem composição corporal semelhante à da população saudável. Em contraposição, os pacientes com DC apresentam EN amplamente comprometido com depleção de gordura corporal e massa magra em relação aos demais indivíduos / Inflammatory Bowel Disease (IBD) is a disorder characterized by diffuse inflammation of the gastrointestinal tract. The two main types of IBD are ulcerative colitis (UC) and Crohn's disease (CD), both coursing with important changes in nutritional status (NS). The objective of this study was to identify differences in body composition between patients with CD, UC, and healthy subjects and to compare the NS of these three groups of patients, adjusting for factors that can interfere in NS such as current use of corticosteroids, physical activity, disease activity, age and sex. It was conducted a cross-sectional study which included 101 patients with IBD (50 with CD and 51 with UC) and 35 healthy subjects, selected at the Ambulatory of Pedro Ernesto University Hospital (HUPE) of the Rio de Janeiro State University (UERJ). Socio-demographic and personal information such as physical activity, smoking, prior diseases and previous surgical procedures were collected. Other necessary information for the research were collected from medical records. The anthropometric evaluation was carried out through the following measures: body weight; height; mid-arm, waist and hip circumferences; skinfold thickness of the triceps, subscapular, suprailiac, and thigh; and mid-arm muscle circumference (MAMC). The body composition analysis was performed by bioelectrical impedance (BIA) using the equipment Biodynamics model 450. The laboratory variables analyzed, included: glucose, complete blood count, lipid profile, total protein, albumin, globulin, erythrocyte sedimentation rate, and C-reactive protein. Weight, body mass index, waist circumference, and percentage body fat calculated from skinfold measurements were lower in CD patients compared to healthy subjects and/or the patients with UC. The MAMC was lower in patients with CD and UC compared to healthy subjects, but without showing differences between the two groups of patients. Through BIA, it was found that CD patients had values of lean body mass, body cell mass, extracellular mass, total body water, and extracellular water smaller when compared to healthy subjects. Seric levels of total cholesterol, total protein, and albumin, as well as red blood cell count and relative count of lymphocytes were lower in the individuals with CD than the individuals of the control group and/or the patients with UC. Patients with UC exhibit body composition similar to that of the healthy population. In contrast, CD patients have widely NS committed with depletion of body fat and lean mass in relation to other individuals.

A doença Inflamatória Intestinal (DII) é uma desordem caracterizada pela inflamação crônica do trato gastrointestinal. Os dois principais tipos de DII são a Retocolite Ulcerativa (RCU) e a Doença de Crohn (DC) e ambas cursam com importantes alterações no estado nutricional (EN). O objetivo deste estudo foi identificar as diferenças na composição corporal entre pacientes com DC, RCU e indivíduos saudáveis, além de comparar o estado nutricional dos três grupos de pacientes, ajustando para fatores que podem interferir no EN, como o uso atual de corticosteróides, a atividade física, a atividade de doença, a idade e o sexo. Foi realizado um estudo transversal que incluiu 101 pacientes com DII (50 com DC e 51 com RCU) e 35 indivíduos saudáveis, selecionados no Ambulatório do Hospital Universitário Pedro Ernesto (HUPE) da Universidade do Estado do Rio de Janeiro (UERJ). Foram colhidas informações sócio-demográficas e pessoais, tais como: prática de atividade física, tabagismo, doenças pregressas e procedimentos cirúrgicos prévios. Outras informações necessárias à pesquisa foram coletadas em prontuário médico. A avaliação antropométrica foi realizada por meio das seguintes medidas: peso corporal; altura; circunferências do braço, da cintura (CC) e do quadril; dobras cutâneas do tríceps, subescápula, supra-ilíaca e da coxa; e circunferência muscular do braço (CMB). A análise da composição corporal foi realizada por meio da bioimpedância elétrica (BIA), utilizando-se o aparelho Biodynamics modelo 450. As variáveis laboratoriais analisadas foram: glicose, hemograma completo, perfil lipídico, proteínas totais, albumina, globulina, velocidade de hemossedimentação e proteína C reativa. O peso, o índice de massa corporal, a CC e o percentual de gordura corporal calculado a partir da aferição das dobras cutâneas, foram menores nos pacientes com DC, quando comparados aos indivíduos saudáveis e/ou aos pacientes com RCU. A CMB foi menor nos pacientes com DC e RCU quando comparados aos indivíduos saudáveis, porém sem apresentar diferenças entre os dois grupos de pacientes. Por BIA, verificou-se que os pacientes com DC apresentaram valores de massa magra, massa celular corpórea, massa extracelular, água corporal total e água extracelular menores quando comparados aos indivíduos saudáveis. Os níveis séricos de colesterol total, proteínas totais e albumina, e a contagem total de hemácias foram menores nos indivíduos com DC quando comparados aos indivíduos do grupo controle e/ou aos indivíduos do grupo da RCU. Os pacientes com RCU exibem composição corporal semelhante à da população saudável. Em contraposição, os pacientes com DC apresentam EN amplamente comprometido com depleção de gordura corporal e massa magra em relação aos demais indivíduos / Inflammatory Bowel Disease (IBD) is a disorder characterized by diffuse inflammation of the gastrointestinal tract. The two main types of IBD are ulcerative colitis (UC) and Crohn's disease (CD), both coursing with important changes in nutritional status (NS). The objective of this study was to identify differences in body composition between patients with CD, UC, and healthy subjects and to compare the NS of these three groups of patients, adjusting for factors that can interfere in NS such as current use of corticosteroids, physical activity, disease activity, age and sex. It was conducted a cross-sectional study which included 101 patients with IBD (50 with CD and 51 with UC) and 35 healthy subjects, selected at the Ambulatory of Pedro Ernesto University Hospital (HUPE) of the Rio de Janeiro State University (UERJ). Socio-demographic and personal information such as physical activity, smoking, prior diseases and previous surgical procedures were collected. Other necessary information for the research were collected from medical records. The anthropometric evaluation was carried out through the following measures: body weight; height; mid-arm, waist and hip circumferences; skinfold thickness of the triceps, subscapular, suprailiac, and thigh; and mid-arm muscle circumference (MAMC). The body composition analysis was performed by bioelectrical impedance (BIA) using the equipment Biodynamics model 450. The laboratory variables analyzed, included: glucose, complete blood count, lipid profile, total protein, albumin, globulin, erythrocyte sedimentation rate, and C-reactive protein. Weight, body mass index, waist circumference, and percentage body fat calculated from skinfold measurements were lower in CD patients compared to healthy subjects and/or the patients with UC. The MAMC was lower in patients with CD and UC compared to healthy subjects, but without showing differences between the two groups of patients. Through BIA, it was found that CD patients had values of lean body mass, body cell mass, extracellular mass, total body water, and extracellular water smaller when compared to healthy subjects. Seric levels of total cholesterol, total protein, and albumin, as well as red blood cell count and relative count of lymphocytes were lower in the individuals with CD than the individuals of the control group and/or the patients with UC. Patients with UC exhibit body composition similar to that of the healthy population. In contrast, CD patients have widely NS committed with depletion of body fat and lean mass in relation to other individuals.

Kalprotektin är ett protein som bygger upp 60 % av neutrofila granulocyters granula. Vid inflammationer i tarmen vandrar neutrofila granulocyter ut genom mukosan och följer med faeces ut ur kroppen. Proteinet är kalciumbindande och surt och dessa egenskaper utnyttjas i moderna extraktionskit för att mäta mängden kalprotektin i faeces (F-kalprotektin). Thermofisher är ett företag som utvecklat en metod för analys av F-kalprotektin och den kallas för EliA Extraction kit 2 där Kalprotektin extraheras med hjälp av bufferten i röret och analyseras därefter av Phadia 250. Syftet med studien var att utföra en metodjämförelse mellan två metoder. I den första metoden kommer den rutinmetod som används på laboratoriet användas för att upparbeta faeces. I den andra kommer patienterna som skickar sin faeces direkt samlade i extraktionsrören till analys. Syftet är att jämföra analysresultaten för att se om de är lika. Studien utfördes på 26 vuxna patienter varav 11 var kvinnor och 15 var män. Innan analys av prover analyserades tre kontroller för att kontrollera om metoden för analys av F-kalprotektin fick analyseras. Under studien utfördes fyra olika inom-serie precision på fyra olika patienter med 25 replikat för att beräkna variationskoefficienten (CV). Metodens CV varierade mellan 19 - 27 %. Efter att en reparation på instrumentet utförts analyserades två prover med inom-serie precision och CV blev 8 – 13 %. Metodernas resultat hade stark korrelation (R = 0,9055) och vid beräkning av resultat med Mann-Whitney U-test sågs ingen signifikant skillnad (p = 0,3059). Det fanns dock en del prover som hade stor skillnad på resultatet vilket kan ge fel diagnos/klassning. För att kunna bedöma om den nya metoden kan användas som ett alternativ till rutinmetoden måste en större population analyseras. / Calprotectin is a protein that makes up 60 % of the granules of neutrophilic granulocytes. In inflammation of the intestine, neutrophilic granulocytes migrate out through the mucosa and follow the feces out of the body. The protein is calcium-binding and acidic and these properties are used in modern extraction kits to measure the amount of calprotectin in feces  (F-calprotectin). Thermofisher is a company that has developed a method for analysis of F-calprotectin and it is called EliA Extraction kit 2 which is analyzed by Phadia 250. The purpose of the study was to perform a method comparison between two methods. In the first method, the routine method used in the laboratory will be used to process feces. In the second, the patients who send their feces directly collected in the extraction tubes come for analysis. The purpose is to compare the analysis results to see if they are similar. The study was performed on 26 individuals of which 11 were women and 15 were men. Before analyzing, three controls were analyzed to check the method of analysis of F-calprotectin. A negative check and a positive check as well as a calibration check. During the study, four different within-run precision were performed on four different patients with 25 replicates to calculate the coefficient of variation (CV). The CV of the method varied between 19 – 27 %. After a repair on the instrument was performed, the CV was 8 – 13 %. The results of the methods had a strong correlation (R = 0.9055) and when calculating the results with Mann-Whitney U-test, no significant difference was seen (p = 0.3059). In order to be able to assess whether the new method can be used as an alternative to the routine method, a larger population must be analyzed.

P-glycoprotein (P-gp) protects the mammalian intestinal epithelium by effluxing toxins from the epithelial cells as well as release of human endocannabinoids that inhibit neutrophil infiltration. Diminished or dysfunctional P-gp is associated with intestinal inflammation including ulcerative colitis (UC). Due to the microbiome dysbiosis associated with UC, we hypothesize that the healthy microbiota promote colonic P-gp expression. Utilizing mouse models of antibiotic treatment, microbiota reconstitution, and metabolite perturbation, we have shown butyrate and secondary bile acids, dependent on vancomycin-sensitive bacteria, induce P-gp expression in vivo. We have shown these metabolites together potentiate induction of P-gp in intestinal epithelial cell lines in vitro, which is sufficient to inhibit primary human neutrophil transmigration. Furthermore, in UC patients we find diminished P-gp expression is coupled to reduction of anti-inflammatory endocannabinoids and luminal content with reduced capability to induce P-gp expression. Additionally, we have found butyrate contributes to P-gp expression via histone deacetylase inhibition, and secondary bile acids regulate P-gp expression via nuclear receptors pregnane X receptor and vitamin D receptor. Employing RNA sequencing (RNAseq) in IECs uncovered signaling networks that are uniquely triggered with the combination of butyrate and secondary bile acids, suggesting additional pathways required for maximal P-gp expression in the colon. Together we identify a mechanistic link between cooperative functional outputs of the complex microbial community and suppression of intestinal inflammation. These data emphasize the importance of the intestinal microbiome in driving the P-gp axis to suppress aberrant neutrophil infiltration and identify potential therapeutic targets for promoting P-gp expression in an inflamed colon to reset homeostasis.

<p>Food allergies are immune system-driven diseases that lead to reproducible adverse reactions which can be fatal. These severe systemic reactions are primary mediated by immunoglobulin E (IgE) that is derived from B cells which have been activated by T helper type 2 (Th2) cells. While much work has advanced the clinical and pharmacological management of patients with allergic diseases, much remains to be elucidated about how individuals initially acquire allergy. This Thesis details a mechanism linking initial gastrointestinal exposure to peanut (PN) allergen, to the generation of Th2 cells: PN allergen activates epithelial cell secretion of interleukin (IL)-33 and eosinophil degranulation of eosinophil peroxidase, which causes CD103+ dendritic cell (DC) activation and migration to mesenteric lymph nodes where DC OX40L engages naïve T cells to secrete IL-4 in an autocrine/paracrine manner to promote and consolidate Th2 cell differentiation. These events are followed by B cell activation and PN-specific IgE production, which sensitizes mast cells to be hypersensitive to PN re-exposure by causing immediate allergic reactions including anaphylaxis. This is later followed by eosinophilic inflammation that is partially mediated by innate lymphoid cells. As food allergy also serves as a unique model to better understand mechanisms of adaptive immunity, especially Th2 immunobiology, both basic science and clinical implications are discussed in this Thesis. Major themes include Th2 and disease heterogeneity, identification of ‘the original source of IL-4’, an unprecedented <em>in vivo </em>requirement for eosinophils in priming adaptive immune responses, and the need to weigh basic science findings against the human disease <em>in natura </em>litmus test. Looking forward, many questions remain to be answered in the field of food allergy research, but the findings of this Thesis may be one step towards the prevention, management or cure of a disease with growing public concern, potentially fatal consequences, and an unmet need in understanding its pathogenesis.</p> / Doctor of Philosophy (Medical Science)

Background & Aims: Despite advances in surgical care and chemotherapeutic regimens, the five-year survival rate for Stage IV Hepatoblastoma (HB), the predominant pediatric liver tumor, remains at 27%. YAP1 and β-Catenin co-activation occurs in 80% of children’s HB; however, a lack of conditional genetic models precludes exploration of tumor maintenance and therapeutic targets. Thus, the clinical need for a targeted therapy remains unmet. Given the predominance of YAP1 and β-catenin activation in children’s tumors, I sought to evaluate YAP1 as a therapeutic target in HB. Approach & Results: Herein, I engineered the first conditional murine model of HB using hydrodynamic injection to deliver transposon plasmids encoding inducible YAP1S127A, constitutive β-CateninDelN90, and a luciferase reporter to murine liver. Tumor regression was evaluated using in vivo bioluminescent imaging, and tumor landscape characterized using RNA sequencing, ATAC sequencing and DNA foot-printing. Here I show that YAP1 withdrawal in mice mediates >90% tumor regression with survival for 230+ days. Mechanistically, YAP1 withdrawal promotes apoptosis in a subset of tumor cells and in remaining cells induces a cell fate switch driving therapeutic differentiation of HB tumors into Ki-67 negative “hbHep cells.” hbHep cells have hepatocyte-like morphology and partially restored mature hepatocyte gene expression. YAP1 withdrawal drives formation of hbHeps by modulating liver differentiation transcription factor (TF) occupancy. Indeed, tumor-derived hbHeps, consistent with their reprogrammed transcriptional landscape, regain partial hepatocyte function and can rescue liver damage in mice. Conclusions: YAP1 withdrawal, without modulation of oncogenic β-Catenin, significantly regresses hepatoblastoma, providing the first in vivo data to support YAP1 as a therapeutic target for HB. Modulating YAP1 expression alone is sufficient to drive long-term regression in hepatoblastoma because it promotes cell death in a subset of tumor cells and modulates transcription factor occupancy to reverse the fate of residual tumor cells to mimic functional hepatocytes.