La maladie rénale chronique (MRC) induit des anomalies du métabolisme phosphocalcique, avec des conséquences à la fois osseuses, vasculaires et biologiques. La prise en charge optimale de ces désordres représente un challenge quotidien pour le néphrologue pédiatre, à la fois sur le court terme (équilibre biologique) et sur le long terme (prévention des fractures, optimisation de la croissance et limitation de l’apparition des calcifications vasculaires). Peu d’outils sont actuellement disponibles pour évaluer ces atteintes, et de nouveaux outils prometteurs, à la fois biologiques (FGF23) et radiologiques (HR-pQCT) apparaissent. Néanmoins, les données pédiatriques sur ces outils restent rares. Cette thèse de doctorat a permis d’évaluer ces nouveaux moyens chez ces enfants MRC, notamment en évaluant l’HR-pQCT dans cette population, et en déterminant des valeurs de référence du FGF23 en fonction de l’âge, du sexe et de la fonction rénale. Nous avons pu aussi montrer que les concentrations circulantes de FGF23 ne sont pas dépendantes du sexe dans une population pédiatrique, mais qu’elles augmentent avec l’âge et l’indice de masse corporelle, mais aussi en cas d’antécédent de transplantation d’organe solide ou de traitement par corticostéroïdes. D’un point de vue plus fondamental, nous avons pu montrer que dans des monocytes issus de donneurs sains, une exposition au FGF23 induit une diminution de l’expression des 2 enzymes principales impliquées dans le métabolisme de la vitamine D (1α hydroxylase et 24 hydroxylase), en induisant également une diminution du peptide antimicrobien cathélicidine. Ces résultats permettent donc de décrire un nouveau rôle pour le FGF23 dans la régulation de l’immunité innée / Chronic kidney disease can induce mineral and bone disorders (CKD-MBD), with deleterious consequences for bone and vessels. The management of such abnormalities can be challenging, from the daily biological balance between calcium, phosphorus and PTH levels, to the long-term prevention of morbidities such as fractures, growth impairment and vascular calcifications. Some tools can help to accurately assess CKD-MBD, e.g., new bone imaging techniques (HR-pQCT) and FGF23, but they are rarely used in pediatric populations. In addition to evaluating HR-pQCT in CKD children and healthy controls, this PhD thesis allowed us to determine reference values for circulating FGF23 levels depending on age, gender and renal function; we also showed that FGF23 levels increased not only with age and BMI, but also in cases of solid organ transplant or corticosteroids therapy. We have also showed in vitro that FGF23 could inhibit the two key enzymes of vitamin D metabolism (1α hydroxylase et 24 hydroxylase) in monocytes issued from healthy donors, with in turn a decreased synthesis of the antimicrobial cathelicidin. These later results highlight a new role for FGF23 in innate immunity, and may bring new insights in the understanding of FGF23 deregulation during CKD

NTRODUÇÃO: Neoplasias mucinosas primárias do ovário apresentam muitos pontos de controvérsias em relação ao seu padrão de diferenciação, sendo classificadas como tumores benignos, borderline e malignos.Elas também são classificadas em diferentes fenótipos, recentemente designadas como gastrointestinal e seromucinoso. Sua heterogeneidade tem produzido não somente dificuldades na classificação morfológica e no diagnóstico diferencial com neoplasias metastáticas, mas também na compreensão da patogênese e na interpretação imunoistoquímica. O fenótipo gastrointestinal tem sido pouco explorado em relação a possíveis diferenças entre os padrões de diferenciação gástrico e intestinal, desde que os dois são geralmente analisados juntos. Os tumores mucinosos borderline, considerado um estágio precoce da carcinogênese dos tumores mucinosos, são freqüentemente associados com pseudomixoma peritoneal (PMP), o qual foi recentemente relacionado a neoplasias mucinosas do apêndice cecal. O propósito deste estudo foi analizar os diferentes padrões morfológicos de apresentação dos tumores mucinosos do ovário e sua associação com o potencial de malignidade e o perfil imunoistoquímico. MATERIAL E MÉTODOS: Este estudo retrospectivo incluiu 72 tumores de 63 pacientes com diagnóstico patológico presumido de tumor mucinoso primário de ovário selecionados dos arquivos da Divisão de Patologia Cirúrgica da Faculdade de Medicina da Universidade de São Paulo, de 1996 a 2005. Todos as lâminas da população de pacientes foram revisadas e classificadas de acordo com os critérios da WHO. Marcação imunoistoquímica para produtos do gene de mucina (MUC1, MUC2, MUC5AC e MUC6), RE, RP, CK7, CK20, CA19.9 e CA125 foram feitos em tissue microarrays. RESULTADOS: Nossos resultados mostraram 28 tumores benignos, 35 borderline e 9 malignos distribuídos nos fenótipos: pilórico (11), intestinal (30), gastrointestinal (20), mülleriano (4) e misto (gastrointestinal e mülleriano) (7). Seis pacientes tinham PMP associados. O estudo imunoistoquímico foi realizado em 67 tumores. Os tumores pilóricos apresentaram-se mais freqüentemente como tumores benignos (72.7%) e tiveram um perfil imunoistoquímico diferente de MUC2 (p= 0.003) e CA19.9 (p= 0.04) quando comparado com o fenótipo intestinal. MUC1 foi mais expresso entre os tumores com diferenciação mülleriana (pura ou mista) (100%, p= 0.02) quando comparado aos tumores de outros fenótipos. Os receptores hormonais foram positivos somente no fenótipo mülleriano. Os tumores borderline foram mais freqüentes nos fenótipos intestinal e gastrointestinal (37.1% e 40%), e estavam associados a PMP em 25% dos casos. Todos os tumores ovarianos associados a PMP eram de tipo histológico borderline e com fenótipo intestinal. O perfil dos tumores borderline de tipo intestinal, mesmo nos casos sem PMP, foi distinto dos outros tumores mucinosos de tipo intestinal e caracterizado pela expressão XVII de MUC2 e CK20. A média de idade das pacientes com tumores borderline de tipo intestinal sem PMP foi menor que daquelas com PMP. CONCLUSÃO: O subgrupo de tumores mucinosos de ovário de fenótipo gastrointestinal é o mais freqüente, mas é hetetogênio e composto por uma população de células de tipos pilórico e intestinal que diferem entre si em relação ao potencial de malignidade e perfil imunoistoquímico. Os tumores de fenotipo intestinal são mais freqüentemente malignos e borderline. Os tumores ovarianos associados com PMP e provavelmente também a maioria dos tumores borderline de fenótipo intestinal, mesmo sem PMP, devem ser considerados como tumores secundários, quando uma origem em apêndice cecal parece a mais provável. / NTRODUCTION: Primary ovarian neoplasms of mucinous type carry many controversial points regarding their pattern of differentiation, classified as benign, borderline and malignant tumors. They are also classified into different morphological phenotypes, recently called as gastrointestinal and seromucinous. Their heterogeneity has produced not only difficulty into morphological classification and differential diagnostic with metastatic neoplasms, but also on understanding the pathogenesis and immunohistochemical interpretation. The gastrointestinal phenotype has been little explored with respect to possible differences between the gastric and intestinal morphological patterns of differentiation, since the two have generally been analyzed together. The mucinous borderline tumors, thought to be an intermediary stage of mucinous carcinogenesis, were frequently associated with pseudomyxoma peritonei (PMP), which was recently linked to appendiceal mucinous neoplasms. The purpose of the study was to analyze the different morphological patterns of presentation of mucinous ovarian tumors and their association with malignant potential and immunohistochemical profile. MATERIAL AND METHODS: This retrospective study included 72 tumors from 63 patients with pathological diagnosis of presumed primary mucinous ovarian tumor selected from the files of the Division of Surgical Pathology of University of Sao Paulo Medical School, from 1996 to 2005. All slides from the patient cohort were reviewed and classified according to WHO criteria. Immunohistochemical staining for mucin genes products (MUC1, MUC2, MUC5AC and MUC6), ER, PR, CK7, CK20, CA19.9 and CA125 were performed in tissue microarrays. RESULTS: Our results showed 28 benign, 35 borderline and 9 malignant tumors distributed in phenotypes: pyloric (11), intestinal (30), gastrointestinal (20), müllerian (4) and mixed (7) gastrointestinal and müllerian). Six patients had PMP associated. The immunohistochemical study was performed in 67 tumors. The pyloric tumors presented more frequently as benign tumors (72.7%) and had a differential immunohistochemical profile of MUC2 (p= 0.003) and CA19.9 (p= 0.04) when compared with intestinal phenotype. MUC1 was more expressed between tumors with müllerian differentiation (pure or mixed) (100%, p= 0.02) when compared with the others. The hormonal receptors were positive only in müllerian phenotype. Borderline tumors were more frequently of intestinal and gastrointestinal phenotypes (37.1% and 40%), and were associated to PMP in 25% of the cases. All ovarian tumors associated to PMP were of borderline histology and of intestinal type. The profile of intestinal borderline tumors, even in cases without PMP, was distinct from that of other primary mucinous tumors of the intestinal type and characterized by MUC2 and CK20 expression. The median age of patients with intestinal borderline tumors without PMP was lower than those with PMP. XIX CONCLUSION: The gastrointestinal subgroup of mucinous ovarian tumors is the more frequent, but it is heterogeneous and composed of pyloric, and intestinal cell population that differ regarding malignant potential and immunoprofile. The intestinal tumors are more frequently malignant and borderline. Ovarian tumors associated with PMP and probably most intestinal borderline tumors, even without PMP, should be considered as secondary tumor when the appendiceal origin seems the most probable.

Les cancers ovariens se distinguent par leur faible incidence, associée à une mortalité élevée, et représente la cinquième cause de mortalité par cancer pour la population féminine. Cette mortalité est due principalement à l’absence de symptômes aux stades précoces des cancers ovariens, retardant leur diagnostic, majoritairement posé lorsqu’une carcinomatose péritonéale est installée. La cavité abdominale est alors envahie par de nombreuses métastases. Le traitement de référence est la chirurgie de cytoréduction complète et la chimiothérapie par voie intraveineuse. Lors de la chirurgie, le chirurgien doit inspecter la totalité de la surface de la cavité péritonéale, et éliminer des tumeurs de toutes tailles, mêmes submillimétriques. Faute de pouvoir détecter toutes les métastases, la cytoréduction est souvent partielle, avec pour conséquence une diminution des chances de guérison. Afin de guider le chirurgien et améliorer le pourcentage de cytoréduction complète, des sondes fluorescentes, conçues pour marquer spécifiquement les tumeurs, ont été développées. Malgré des résultats encourageants, ces sondes souffrent de nombreuses limitations en termes de brillance, de stabilité, et de modularité. Dans ce contexte, de nombreuses nanoparticules, capables de passer outre ces limitations, suscitent un grand intérêt. Parmi celles-ci, des nanocristaux semi-conducteurs, appelés quantum dots, se distinguent par une brillance exceptionnelle. Notre étude s’est basée sur ces quantum dots, associés à un agent de ciblage de référence pour les cancers ovariens, le folate. D’abord testées sur modèles cellulaires et tumoraux in vitro, ces nanoparticules ont démontré de bonnes capacités d’imagerie. Ces propriétés ont ensuite été expérimentées sur modèle murin de carcinomatose péritonéale. Enfin, la bioaccumulation des quantum dots restant un obstacle à leur application clinique, différentes alternatives ont été appliquées pour tenter d’obtenir leur excrétion / Ovarian cancers have a low incidence but a high mortality rate, making them the fifth cause of death by cancer for female population. This high mortality rate is associated with the absence of symptom at the early stage of ovarian cancer, often delaying the diagnosis to advanced stages, mainly peritoneal carcinomatosis. At this stage, metastases have already invaded the abdominal cavity. The reference treatment combines a complete cytoreduction surgery and intravenous chemotherapy. During the cytoreduction, the surgeon must inspect the whole peritoneal surface, and remove all of all sizes, even sub-millimetric. Because of the difficulty to detect and to remove every cancerous tissue, cytoreduction is frequently incomplete, thus reducing the recovery rate. To guide the surgeon and to increase the percentage of complete cytoreduction, fluorescent probes have been developed to target tumors specifically. Despite encouraging results, these probes suffer from many limitations such as low brightness, weak stability and cumbersome modularity. In this context, nanoparticles, that are able to outpass these limitations, have generated a growing interest. Among these nanoparticles, semiconductor nanocristals, called quantum dots, display an exceptional brightness. We investigated these quantum dots, associated with folate, a reference targeting agent for ovarian cancers. Firstly investigated on in vitro cellular and tumor model, folate targeted nanoparticles show encouraging imaging capabilities. These capabilites were also experimented on peritoneal carcinomatosis murine model. Finally, the main obstacle to quantum dot clinical application remains their bioaccumulation, therefore, different alternatives were explored to achieve excretion

NTRODUÇÃO: Neoplasias mucinosas primárias do ovário apresentam muitos pontos de controvérsias em relação ao seu padrão de diferenciação, sendo classificadas como tumores benignos, borderline e malignos.Elas também são classificadas em diferentes fenótipos, recentemente designadas como gastrointestinal e seromucinoso. Sua heterogeneidade tem produzido não somente dificuldades na classificação morfológica e no diagnóstico diferencial com neoplasias metastáticas, mas também na compreensão da patogênese e na interpretação imunoistoquímica. O fenótipo gastrointestinal tem sido pouco explorado em relação a possíveis diferenças entre os padrões de diferenciação gástrico e intestinal, desde que os dois são geralmente analisados juntos. Os tumores mucinosos borderline, considerado um estágio precoce da carcinogênese dos tumores mucinosos, são freqüentemente associados com pseudomixoma peritoneal (PMP), o qual foi recentemente relacionado a neoplasias mucinosas do apêndice cecal. O propósito deste estudo foi analizar os diferentes padrões morfológicos de apresentação dos tumores mucinosos do ovário e sua associação com o potencial de malignidade e o perfil imunoistoquímico. MATERIAL E MÉTODOS: Este estudo retrospectivo incluiu 72 tumores de 63 pacientes com diagnóstico patológico presumido de tumor mucinoso primário de ovário selecionados dos arquivos da Divisão de Patologia Cirúrgica da Faculdade de Medicina da Universidade de São Paulo, de 1996 a 2005. Todos as lâminas da população de pacientes foram revisadas e classificadas de acordo com os critérios da WHO. Marcação imunoistoquímica para produtos do gene de mucina (MUC1, MUC2, MUC5AC e MUC6), RE, RP, CK7, CK20, CA19.9 e CA125 foram feitos em tissue microarrays. RESULTADOS: Nossos resultados mostraram 28 tumores benignos, 35 borderline e 9 malignos distribuídos nos fenótipos: pilórico (11), intestinal (30), gastrointestinal (20), mülleriano (4) e misto (gastrointestinal e mülleriano) (7). Seis pacientes tinham PMP associados. O estudo imunoistoquímico foi realizado em 67 tumores. Os tumores pilóricos apresentaram-se mais freqüentemente como tumores benignos (72.7%) e tiveram um perfil imunoistoquímico diferente de MUC2 (p= 0.003) e CA19.9 (p= 0.04) quando comparado com o fenótipo intestinal. MUC1 foi mais expresso entre os tumores com diferenciação mülleriana (pura ou mista) (100%, p= 0.02) quando comparado aos tumores de outros fenótipos. Os receptores hormonais foram positivos somente no fenótipo mülleriano. Os tumores borderline foram mais freqüentes nos fenótipos intestinal e gastrointestinal (37.1% e 40%), e estavam associados a PMP em 25% dos casos. Todos os tumores ovarianos associados a PMP eram de tipo histológico borderline e com fenótipo intestinal. O perfil dos tumores borderline de tipo intestinal, mesmo nos casos sem PMP, foi distinto dos outros tumores mucinosos de tipo intestinal e caracterizado pela expressão XVII de MUC2 e CK20. A média de idade das pacientes com tumores borderline de tipo intestinal sem PMP foi menor que daquelas com PMP. CONCLUSÃO: O subgrupo de tumores mucinosos de ovário de fenótipo gastrointestinal é o mais freqüente, mas é hetetogênio e composto por uma população de células de tipos pilórico e intestinal que diferem entre si em relação ao potencial de malignidade e perfil imunoistoquímico. Os tumores de fenotipo intestinal são mais freqüentemente malignos e borderline. Os tumores ovarianos associados com PMP e provavelmente também a maioria dos tumores borderline de fenótipo intestinal, mesmo sem PMP, devem ser considerados como tumores secundários, quando uma origem em apêndice cecal parece a mais provável. / NTRODUCTION: Primary ovarian neoplasms of mucinous type carry many controversial points regarding their pattern of differentiation, classified as benign, borderline and malignant tumors. They are also classified into different morphological phenotypes, recently called as gastrointestinal and seromucinous. Their heterogeneity has produced not only difficulty into morphological classification and differential diagnostic with metastatic neoplasms, but also on understanding the pathogenesis and immunohistochemical interpretation. The gastrointestinal phenotype has been little explored with respect to possible differences between the gastric and intestinal morphological patterns of differentiation, since the two have generally been analyzed together. The mucinous borderline tumors, thought to be an intermediary stage of mucinous carcinogenesis, were frequently associated with pseudomyxoma peritonei (PMP), which was recently linked to appendiceal mucinous neoplasms. The purpose of the study was to analyze the different morphological patterns of presentation of mucinous ovarian tumors and their association with malignant potential and immunohistochemical profile. MATERIAL AND METHODS: This retrospective study included 72 tumors from 63 patients with pathological diagnosis of presumed primary mucinous ovarian tumor selected from the files of the Division of Surgical Pathology of University of Sao Paulo Medical School, from 1996 to 2005. All slides from the patient cohort were reviewed and classified according to WHO criteria. Immunohistochemical staining for mucin genes products (MUC1, MUC2, MUC5AC and MUC6), ER, PR, CK7, CK20, CA19.9 and CA125 were performed in tissue microarrays. RESULTS: Our results showed 28 benign, 35 borderline and 9 malignant tumors distributed in phenotypes: pyloric (11), intestinal (30), gastrointestinal (20), müllerian (4) and mixed (7) gastrointestinal and müllerian). Six patients had PMP associated. The immunohistochemical study was performed in 67 tumors. The pyloric tumors presented more frequently as benign tumors (72.7%) and had a differential immunohistochemical profile of MUC2 (p= 0.003) and CA19.9 (p= 0.04) when compared with intestinal phenotype. MUC1 was more expressed between tumors with müllerian differentiation (pure or mixed) (100%, p= 0.02) when compared with the others. The hormonal receptors were positive only in müllerian phenotype. Borderline tumors were more frequently of intestinal and gastrointestinal phenotypes (37.1% and 40%), and were associated to PMP in 25% of the cases. All ovarian tumors associated to PMP were of borderline histology and of intestinal type. The profile of intestinal borderline tumors, even in cases without PMP, was distinct from that of other primary mucinous tumors of the intestinal type and characterized by MUC2 and CK20 expression. The median age of patients with intestinal borderline tumors without PMP was lower than those with PMP. XIX CONCLUSION: The gastrointestinal subgroup of mucinous ovarian tumors is the more frequent, but it is heterogeneous and composed of pyloric, and intestinal cell population that differ regarding malignant potential and immunoprofile. The intestinal tumors are more frequently malignant and borderline. Ovarian tumors associated with PMP and probably most intestinal borderline tumors, even without PMP, should be considered as secondary tumor when the appendiceal origin seems the most probable.

La carcinose péritonéale est une atteinte néoplasique métastatique de la séreuse péritonéale caractérisée par la diffusion de multiples nodules tumoraux. Son pronostic est sombre, marqué par une chimiorésistance. Les traitements intrapéritonéaux, développés pour délivrer des drogues de chimiothérapie anti-cancéreuse directement au contact de ces nodules, ont permis d’améliorer en partie les résultats oncologiques de cette pathologie. Le principe est de mettre à profit la barrière péritonéo-plasmatique pour administrer des posologies plus élevées de drogues, directement au contact des nodules, et ainsi majorer leur cytotoxicité. En stratégie curative, la chimiothérapie intrapéritonéale est associée à une chirurgie de cytoréduction (CRS) complète et son efficacité est majorée par l’adjonction d’une hyperthermie (ChimioHyperthermie IntraPéritonéale - CHIP). Si ce traitement combiné a transformé le pronostic de patients sélectionnés, les résultats restent insatisfaisants. Par exemple les patients atteints de carcinose d’origine colorectale présentent un taux de survie globale à 5 ans de 40% lorsqu’ils sont éligibles à la CRS-CHIP et une médiane de survie de l’ordre de 16 mois quand le traitement se cantonne à de la chimiothérapie systémique.Une meilleure compréhension des mécanismes cellulaires impliqués dans cette chimiorésistance est donc nécessaire pour déterminer de nouvelles cibles thérapeutiques. Les protéines de choc thermique jouent un rôle fondamental dans l’homéostasie protéique intracellulaire en agissant comme protéines chaperonnes et en régulant l’architecture du cytosquelette. L’Hsp27 (ou HspB1) en particulier est impliquée dans la réponse à différents stress cellulaires comme le choc thermique, le stress oxydatif et l’exposition aux drogues de chimiothérapie. Via des mécanismes finement régulés, Hsp27 exerce une protection garantissant la survie cellulaire, en adaptant ses niveaux d’expression, d’oligomérisation et de phosphorylation. Le taux d’Hsp27 est dès lors augmenté dans la plupart des cancers et apparaît comme marqueur fort de mauvais pronostic. Cela en fait un acteur clé de la chimiorésistance et une cible thérapeutique potentielle.Parmi les thérapeutiques ciblées basées sur l’ARN, les oligonucléotides antisens (ASO) sont des molécules issues du génie génétique capables de bloquer spécifiquement la traduction d’un ARN messager cible en protéine. L’apatorsen, un ASO anti-Hsp27 de deuxième génération, a été développé pour bloquer la synthèse d’Hsp27 au sein de la cellule cancéreuse et ainsi rétablir la chimiosensibilité. Après avoir mis en place un modèle de carcinose péritonéale colorectale traitée par CRS et CHIP chez le rat, nous avons étudié in vitro et in vivo, l’effet de l’adjonction de l’apatorsen au traitement standard de cette maladie. Nos résultats ne montrent pas de gain significatif de survie et donnent lieu à une discussion sur cette stratégie de traitement / Peritoneal carcinomatosis is a neoplasic metastatic process of the peritoneal serous lining characterized by the spread of multiple tumoral nodules. The prognosis of such attempt is very poor, characterized by a global chemoresistance. Intraperitoneal treatments were developed to improve drug’s cytoxicity by delivering them directly on nodules. The principle is to take advantage of the peritoneal-plasma barrier that allows to deliver higher drug’s concentration directly onto nodules and so to improve cytotoxicity. In curative intent strategy intraperitoneal chemotherapy is combined to a complete surgical cytoreduction (CRS) and to hyperthermia to enhance efficiency (Hyperthermic Intraperitoneal Chemotherapy - HIPEC). Thanks to this strategy overall survival improved in selected patients but still be flawed. For example, patients with colorectale peritoneal carcinomatosis present a 40% five-year overall survival, whereas those not eligible to that aggressive treatment present a 16 months median survival. So a better understanding of cellular molecular mechanisms responsible for this chemoresistance that will allow identifying new therapeutic targets is needed. Heat shock proteins play a fundamental role in intracellular protein homeostasis by acting as chaperone and regulating cytoskeleton architecture. In particular, Hsp27 acts as a regulator of the cellular response to various stress, such as thermic choc, oxidative stress, exposition to antineoplasic drugs. Through finely regulated process, Hsp27 exerts a cytoprotective role to guaranty cell survival, by adapting its level of expression, oligomerization and phosphorylation. As so Hsp27 is a key actor of chemoresistance and a designated therapeutic target.Antisens oligonucleotides are a new class of molecular targeted treatment able to specifically block the traduction into protein of a messenger RNA. Apatorsen, a second generation anti-Hsp27 ASO, has been developed to decrease Hsp27 levels in neoplastic cells and so restore chemosensitivity.After establishing a colorectal peritoneal carcinomatosis rat model with CRS and HIPEC, we studied in vitro and in vivo the effect of the apatorsen adjunction to this standard treatment. Our results did not show a significant survival improvement and give rise to a discussion upon this treatment strategy

Objectif : La carcinose péritonéale (CP) d’origine appendiculaire est une pathologie rare avec un pauvre pronostic à long terme. Le but de cette étude fut d’évaluer une approche agressive utilisée dans notre institution au cours des cinq dernières années. Méthodes : Les données de tous les patients avec CP d’origine appendiculaire ont été recueillies et analysées de façon prospective. Le traitement consista en une cytoréduction chirurgicale complète de la CP suivie d’une chimiohyperthermie intrapéritonéale (CHIP) à l’oxaliplatine (460 mg/m2) dans 2 L/m2 de D5% à 43°C pendant 30 minutes. Résultats : De février 2003 à mars 2007, 38 patients eurent une laparotomie à visée curative. Vingt-trois patients reçurent la CHIP. Par contre, chez 10 patients, une cytoréduction complète fut impossible et pour 5 autres patients, la chirurgie de « second-look » s’est révélée négative ; ils ne reçurent donc pas de CHIP. Le suivi moyen fut de 23 mois. La survie globale à 3 ans fut de 100% pour le groupe « second-look » négatif, 86% pour le groupe CHIP et 29% pour les patients avec maladie non-résécable (p=0.0098). La survie sans maladie (SSM) à 3 ans fut de 49% pour les patients du groupe CHIP. Le grade histologique fut identifié comme facteur pronostique en regard de la SSM dans le groupe CHIP (p=0.011). Il y eut un décès post-opératoire. Le taux de complications chez les patients traités fut de 39%, incluant les abcès intra-abdominaux (22%), les hémorragies (18%) et les fuites anastomotiques (9%). Conclusion : Bien que ces résultats soient préliminaires, cette approche thérapeutique semble à la fois faisable et sécuritaire chez des patients sélectionnés. / Background: Peritoneal carcinomatosis (PC) arising from the appendix is a rare disease with a poor long-term prognosis. The aim of this study was to evaluate the results of an aggressive approach used at our institution over the last five years. Methods: Data from all patients with a PC arising from the appendix were prospectively collected and analyzed. Treatment consisted of complete surgical cytoreduction of the tumor followed by hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin (460 mg/m2) in 2 L/m2 of D5W at 43˚C during 30 minutes. Results: From February 2003 to March 2007, 38 patients with PC arising from the appendix underwent laparotomy with curative intent. Mean follow-up was 23 months. Twenty-three patients received HIPEC but 10 patients could not have complete cytoreductive surgery and received no HIPEC. Five patients with a negative second-look surgery also received no HIPEC. The 3-year overall survival (OS) was 100% for the negative second-look patients, 86% for the HIPEC patients, and 29% for the unresectable patients (p=0.0098). The 3-year disease-free survival (DFS) was 49% for the HIPEC patients. Histologic grade was a prognostic factor with regard to DFS for the HIPEC patients (p = 0.011). There was one postoperative mortality. The overall complication rate for treated patients was 39%, including intra-abdominal abscess (22%), hemorrhage (18%), and anastomotic leak (9%). Conclusions: Although these results are preliminary, this therapeutic approach seems both feasible and safe in selected patients.

Darbe atlikta teorinė gyvenimo kokybės sampratos ir lėtiniu inkstų nepakankamumu sergančių pacientų gyvenimo bruožų analizė.Iškelta hipotezė, kad dialize gydomi pacientai blogai vertina visas pagrindines gyvenimo kokybės sritis. Gyvenimo kokybės klausimynu ir interviu pokalbio metodais buvo atliktas tyrimas, kurio tikslas - ištirti dialize gydomų pacientų gyvenimo kokybę. Tyrimo duomenys apdoroti statistinių programų paketu SPSS Statistics 17.0, Microsoft Excel ir turinio (angl. content) analizės metodu. Tyrime dalyvavo 100 dialize gydomų pacientų, iš kurių 5 pacientai dalyvavo interviu pokalbyje. Empirinėje dalyje nagrinėjamas dialize gydomų pacientų pagrindinių gyvenimo sričių (fizinės sveikatos, psichologinės, socialinių santykių, aplinkos sričių) vertinimas ir gyvenimo kokybės ypatumai. / The work carried out in the theoretical concept of quality of life and chronic renal failure patients living traits analyzed.The hypothesis that dialysis patients bad the quality of life of all the key areas.The quality of life questionnaire and interview techniques interview was conducted with the aim - to investigate dialysis patients quality of life. The data processing of the statistical software package SPSS 17.0, Microsoft Excel, and text content analysis.The study included 100 dialysis patients, of which five patients participated in the interview conversation.In the empirical part of dialysis patients major life domains (physical health, psychological, social relationships, environment areas) Assessment of quality of life features.

The number of patients with kidney disease is increasing worldwide. Such diseases include chronic kidney failure that needs dialysis treatment. Problems associated with providing nursing care to patients in a dialysis program are extensive and specific. Starting the treatment with a peritoneal dialysis or a haemodialysis causes a great psychological burden to patients. It noticeably affects not only patients' lives but also lives of their family and friends. Patients in the regular dialysis program are facing many health and social problems. Mutual trust between a nurse and a patient on dialysis to a certain extent influences the course of the treatment. Balanced and satisfied patient can live a better and more valuable life. The goals of the thesis: 1) To determine whether a comparably high quality nursing care is provided to patients with haemodialysis and peritoneal dialysis 2) To determine whether the approach to the provision of nursing care to the patients with haemodialysis and peritoneal dialysis is comparable. 3) To determine whether comparable forms of education and communication are used in providing nursing care for the patients with haemodialysis and peritoneal dialysis. Research questions: 1) Is the nursing care provided to the patients with haemodialysis and peritoneal dialysis of comparable quality? 2) A the approach to the provision of nursing care for patients with haemodialysis and peritoneal dialysis comparable? 3) Are comparable forms of education and communication used in providing nursing care for the patients with haemodialysis and peritoneal dialysis? Methods used: In the empirical part of the thesis a qualitative research was used to process data. The research was conducted through a non-standardized interview. Three sets of questions were created for the three groups of respondents, i.e. the respondents with peritoneal dialysis, respondents with haemodialysis and nurses who take care of patients with haemodialysis and peritoneal dialysis. The criterion for the selection of respondents was their willingness to cooperate. The nature and purpose of the research was explained to the addressed respondents. From the interviews with patients it was determined how they perceive the provided nursing care, the nurses' approach, and the way of interaction during haemodialysis and peritoneal dialysis. Interviews with nurses were focused on comparability and demands of nursing care for patients with haemodialysis and peritoneal dialysis, as well as on the used forms of communication and the way how to approach these patients. Results: The results of the research show that the care provided to patients with peritoneal dialysis as well as with haemodialysis is perceived by the responding patients with peritoneal dialysis, with haemodialysis and nurses as of the same quality. Peritoneal dialysis and haemodialysis each have their specificities and a different way of execution. Both are provided in differing environments. Peritoneal dialysis is done by the patient himself in their own social environment. During haemodialysis, nursing care is provided to the patient by nurses in a haemodialysis centre. As comparable is perceived by all respondents the nurses' approach to the patients, i.e. to each patient individually. In conclusion, the results imply that nurses during the contact with the patients with peritoneal dialysis and with haemodialysis use comparable forms of communication and education. Conclusion: At the present time there is an attempt to perform dialysis treatment to benefit the patient as much as possible. Peritoneal dialysis and haemodialysis are considered as equivalent substitute for renal function. They differ only in the principle and the method of executing. Nursing care provided to patients with peritoneal dialysis and with haemodialysis is perceived by the respondents as of comparable quality. The results of this thesis can be the basis for further research.

The literature indicates that treatment by means of elimination methods is extremely challenging for patients, bringing a fundamental change to their lives. The aim of the thesis was to identify and describe the challenges of treatment in patients with renal failure and how a given method of treatment affects the patient's quality of life and needs, as well as to understand the subjective difficulties and problems. A data collection method in the form of non-standardized semi-structured interviews was selected for qualitative research. The surveyed sample consisted of six patients of a dialysis centre. The respondents taking part in the qualitative research were informed in advance of the course, circumstances and ethical aspects of the research. The obtained data was analyzed, colour-coded and then sorted into subcategories. The results were interpreted using the "showdown" technique. The interviewed sample of respondents was subjected to multiple elimination methods in the treatment of their disease. Kidney transplant patients subjectively evaluated the quality of their lives as very high, talking about "a life of a normal man". Peritoneal dialysis patients also evaluated their quality of life as relatively high, highlighting a certain feeling of independence. Haemodialysis patients describe...

Submitted by Cláudia Bueno (claudiamoura18@gmail.com) on 2016-06-09T21:26:35Z No. of bitstreams: 2 Dissertação - Kelly de Souza Fernandes - 2016: 2715711 bytes, checksum: a2c065301e1443bb424fa23c738e43d2 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2016-06-10T13:24:18Z (GMT) No. of bitstreams: 2 Dissertação - Kelly de Souza Fernandes - 2016: 2715711 bytes, checksum: a2c065301e1443bb424fa23c738e43d2 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2016-06-10T13:24:18Z (GMT). No. of bitstreams: 2 Dissertação - Kelly de Souza Fernandes - 2016: 2715711 bytes, checksum: a2c065301e1443bb424fa23c738e43d2 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2016-02-15 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Miltefosine (MT) is a alkylphospholipid originally developed for treatment of breast cancer and other solid tumors. It is currently used in the treatment of leishmaniasis, an infectious parasitic disease caused by protozoa of the genus Leishmania, being the first oral drug adopted for this purpose. However, its mechanism of action remains unclear. Electron paramagnetic resonance (EPR) spectroscopy of a spin-labeled lipid (5-DOXIL stearate) and a thiol-specific spin label (4-maleimido-TEMPO) in the membrane of axenic amastigotes of L.(Leishmania) amazonensis and peritoneal macrophages from Balb/c mice showed that MT causes significant increase in membrane dynamics at similar concentrations that inhibit parasite growth or are cytotoxic to macrophage. Although these alterations can be detected using a spin-labeled lipid, our experimental results indicated that MT interacts predominantly with the protein component of the membrane. Using a method for the rapid incorporation of MT into the membrane, these effects were measured immediately after treatment. Cytotoxicity, estimated via microscopic counting of living and dead cells, indicated ~80% parasites and macrophages death at the concentration of MT at which EPR spectroscopy detected a significant change in membrane dynamics. Cell viability, analyzed using the MTT (3-(4,5-dimethylthiazol-2-yl)-2,5- diphenyltetrazolium bromide tetrazolium) reduction assay, showed that 50% inhibitory concentration (IC50) of MT depends on the cell concentration used in the assay. This dependence was analyzed using a theoretical equation involving biophysical parameters such as the partition coefficient of watermembrane and MT concentrations on the membrane and in the aqueous medium. The data showed that cells more sensitive to MT are respectively: erythrocytes, Leishmania promastigotes and Leishmania amastigotes and macrophage. The IC50 value of MT for 4 x 107 parasites/mL was 24,35 M. For the same cell concentration, a significant alteration was detected in the membrane lipid fluidity of parasites to 15 M of MT. The EPR spectra of spinlabeled membrane-bound proteins were consistent with more expanded and solvent exposed protein conformations, suggesting a detergent-like action, with a possible formation of micelle-like structures around polypeptide chains. / A Miltefosina (MT) é um alquilfosfolipídio originalmente desenvolvido para o tratamento de câncer de mama e outros tumores sólidos. Atualmente é utilizada no tratamento da leishmaniose, uma doença infecto-parasitária causada pelo protozoário do gênero Leishmania, sendo o primeiro fármaco de uso oral aprovado para tal fim. No entanto, seu mecanismo de ação ainda é pouco conhecido. A espectroscopia de Ressonância Paramagnética Eletrônica (RPE) de um marcador de spin lipídico (5-DOXIL estearato) e outro específico de grupo tiol (4-maleimido-TEMPO) na membrana de amastigotas axênicas de L. (Leishmania) amazonensis e de macrófagos extraídos de peritônio de camundongos BALB/c, mostrou que a MT causa um aumento significativo na dinâmica destas membranas para concentrações similares àquelas que inibem o crescimento do parasito ou que são citotóxicas ao macrófago. Embora essas alterações possam ser detectadas usando um marcador de spin lipídico, nossos resultados experimentais indicaram que a MT interage predominantemente com a componente proteica da membrana. Utilizando um método para incorporação rápida da MT na membrana, esses efeitos foram medidos imediatamente após o tratamento. Ensaios de citotoxicidade, estimada via contagem microscópica de células vivas e mortas, indicaram que ~80% dos parasitos e dos macrófagos estão mortos na concentração de MT no qual a espectroscopia de RPE detectou uma mudança significativa na dinâmica da membrana. A viabilidade celular, quantificada pela redução do sal MTT ((3-4,5- Dimetiltiazol-2yl)-2,5 difenil brometo de tetrazolina), mostrou que a concentração de MT que inibe 50% da proliferação celular (IC50) depende da concentração celular usada no ensaio. Esta dependência foi analisada utilizando uma equação teórica envolvendo parâmetros biofísicos tais como o coeficiente de partição membrana-água e concentrações de MT na membrana e no meio aquoso. Os dados mostraram que as células mais sensíveis à MT são respectivamente: eritrócitos, formas promastigotas e amastigotas da Leishmania e macrófagos. O valor do IC50 da MT para 4 x 107 parasitos/mL foi de 24,35 M. Para esta mesma concentração de células, foi detectada uma alteração significativa na fluidez lipídica da membrana dos parasitos com 15 M de MT. Os espectros de RPE do marcador de spin ligados a proteínas da membrana foram consistentes com as conformações mais expandidas e dinâmicas das proteínas expostas no solvente, sugerindo uma ação semelhante à de detergente, com uma possível formação de estruturas tipo micelas em volta das cadeias polipeptídicas.