Introdução - Os custos para o tratamento da doença arterial coronariana (DAC) são altos em todo o mundo. Foi realizada uma análise post hoc de custo-efetividade de três estratégias terapêuticas para DAC multiarterial. Métodos - De maio de 1995 a maio de 2000, um total de 611 pacientes foram aleatoriamente designados para CRM (n = 203), ICP (n = 205) ou TM (n = 203). Este estudo de análise de custos baseou-se na perspectiva do Sistema Público de Saúde. Os custos iniciais de procedimentos e acompanhamento de medicamentos, exames cardiológicos e hospitalizações por complicações foram calculados após a randomização. Anos de vida e anos de vida ajustados pela qualidade (QALY) foram usados como medidas de eficácia. As razões de custo-efetividade incremental (RCEI) foram obtidas usando métodos de bootstrap não paramétricos com 5.000 replicações. Resultados - Os custos iniciais do procedimento foram menores para o TM. No entanto, os custos acumulados de 5 anos foram menores para a CRM. Em comparação com a linha de base, as 3 opções de tratamento produziram melhorias significativas no QALY. Após 5 anos, a ICP e a CRM tiveram melhores resultados de QALY em comparação com o TM. Os resultados da RCEI favoreceram a CRM e a ICP quando comparadas ao TM, já a ICP em relação à CRM foi mais custo-efetiva em 61% para limiares até 3 PIB per capita por QALY. Por outro lado, a análise de sensibilidade mostrou o TM como a terapia preferida em comparação com a CRM e ICP, na análise considerando custos mais elevados. Conclusão - No seguimento de 5 anos, a ICP e CRM mostraram ser os tratamentos com QALYs cumulativos mais altos entre pacientes com DAC multiarterial quando comparados com TM. Além disso, apesar dos custos iniciais serem mais elevados, a comparação de custo-efetividade após 5 anos de acompanhamento entre os 3 tratamentos mostrou que ambas as intervenções (CRM e ICP) são estratégias custo-efetivas em comparação com a TM / Background. The costs for treating coronary artery disease (CAD) are high worldwide. We performed a post hoc analysis of cost-effectiveness of 3 therapeutic strategies for multivessel CAD. Methods. From May 1995 to May 2000, a total of 611 patients were randomly assigned to CABG (n=203), PCI (n=205), or MT (n=203). This cost analysis study was based on the perspective of the Public Health Care System. Initial procedural and follow-up costs for medications, cardiology examinations, and hospitalizations for complications were calculated after randomization. Life-years and quality-adjusted life years (QALY) were used as effectiveness measures. Incremental cost-effectiveness ratios (ICER) were obtained by using nonparametric bootstrapping methods with 5000 resamples. Results. Initial procedural costs were lower for MT. However, the subsequent 5-year cumulative costs were lower for CABG. Compared with baseline, the 3 treatment options produced significant improvements in QALY. After 5 years, PCI and CABG had better QALY results compared with MT. The ICER results favored CRM and PCI when compared to the TM, since the PCI in relation to the CRM was more costeffective in 61% for the thresholds up to 3 GDP per capita per QALY. On the other hand, sensitivity analysis showed MT as the preferred therapy compared with CABG and PCI, in the analysis considering higher costs. Conclusion. At 5-year follow-up, the 3 treatment options yielded improvements in quality of life, with comparable and acceptable costs. However, despite higher initial costs, the comparison of costeffectiveness after 5 years of follow-up among the 3 treatments showed both interventions (CABG and PCI) to be cost-effective strategies compared with MT

Introdução - Os custos para o tratamento da doença arterial coronariana (DAC) são altos em todo o mundo. Foi realizada uma análise post hoc de custo-efetividade de três estratégias terapêuticas para DAC multiarterial. Métodos - De maio de 1995 a maio de 2000, um total de 611 pacientes foram aleatoriamente designados para CRM (n = 203), ICP (n = 205) ou TM (n = 203). Este estudo de análise de custos baseou-se na perspectiva do Sistema Público de Saúde. Os custos iniciais de procedimentos e acompanhamento de medicamentos, exames cardiológicos e hospitalizações por complicações foram calculados após a randomização. Anos de vida e anos de vida ajustados pela qualidade (QALY) foram usados como medidas de eficácia. As razões de custo-efetividade incremental (RCEI) foram obtidas usando métodos de bootstrap não paramétricos com 5.000 replicações. Resultados - Os custos iniciais do procedimento foram menores para o TM. No entanto, os custos acumulados de 5 anos foram menores para a CRM. Em comparação com a linha de base, as 3 opções de tratamento produziram melhorias significativas no QALY. Após 5 anos, a ICP e a CRM tiveram melhores resultados de QALY em comparação com o TM. Os resultados da RCEI favoreceram a CRM e a ICP quando comparadas ao TM, já a ICP em relação à CRM foi mais custo-efetiva em 61% para limiares até 3 PIB per capita por QALY. Por outro lado, a análise de sensibilidade mostrou o TM como a terapia preferida em comparação com a CRM e ICP, na análise considerando custos mais elevados. Conclusão - No seguimento de 5 anos, a ICP e CRM mostraram ser os tratamentos com QALYs cumulativos mais altos entre pacientes com DAC multiarterial quando comparados com TM. Além disso, apesar dos custos iniciais serem mais elevados, a comparação de custo-efetividade após 5 anos de acompanhamento entre os 3 tratamentos mostrou que ambas as intervenções (CRM e ICP) são estratégias custo-efetivas em comparação com a TM / Background. The costs for treating coronary artery disease (CAD) are high worldwide. We performed a post hoc analysis of cost-effectiveness of 3 therapeutic strategies for multivessel CAD. Methods. From May 1995 to May 2000, a total of 611 patients were randomly assigned to CABG (n=203), PCI (n=205), or MT (n=203). This cost analysis study was based on the perspective of the Public Health Care System. Initial procedural and follow-up costs for medications, cardiology examinations, and hospitalizations for complications were calculated after randomization. Life-years and quality-adjusted life years (QALY) were used as effectiveness measures. Incremental cost-effectiveness ratios (ICER) were obtained by using nonparametric bootstrapping methods with 5000 resamples. Results. Initial procedural costs were lower for MT. However, the subsequent 5-year cumulative costs were lower for CABG. Compared with baseline, the 3 treatment options produced significant improvements in QALY. After 5 years, PCI and CABG had better QALY results compared with MT. The ICER results favored CRM and PCI when compared to the TM, since the PCI in relation to the CRM was more costeffective in 61% for the thresholds up to 3 GDP per capita per QALY. On the other hand, sensitivity analysis showed MT as the preferred therapy compared with CABG and PCI, in the analysis considering higher costs. Conclusion. At 5-year follow-up, the 3 treatment options yielded improvements in quality of life, with comparable and acceptable costs. However, despite higher initial costs, the comparison of costeffectiveness after 5 years of follow-up among the 3 treatments showed both interventions (CABG and PCI) to be cost-effective strategies compared with MT

Hypertension is a chronic non-communicable disease and a major risk factor for cardiovascular diseases, renal malfunction, disability, and premature death. One of the public health recommendations for the management of hypertension is the reduction of sodium/salt intake. There is need to develop and implement new evidence-based theoretical interventions to initiate and sustain behavior change in health education and promotion. Therefore, the quantitative cross-sectional method and design was used to investigate the adequacy of multi-theory model (MTM) constructs for the initiation and the sustenance of low sodium/salt intake behavior in hypertensive Nigerian adults. In addition, the impact of the MTM (initiation) constructs on actual salt/sodium intake was evaluated to validate self-reported behavior. A convenience sample of 149 consenting Nigerian adults with hypertension and of ages 20 to 60 years, self -administered the valid and reliable 39-item MTM instrument. The findings of confirmatory factor analysis showed construct validity of subscales for the initiation and sustenance model. All items loading for the two models were significant, p < 0.001. Multivariate regression analysis revealed 40.6% of the variance in initiating the consumption of low salt diets explained by advantages outweighing disadvantages, behavioral confidence, and changes in physical environment. About 41.8 % of the variance to sustain the intake of low salt diet was explained by emotional transformation, practice for change, and changes in social environment. The results justified the predictive role of MTM and adequacy of its utility to build evidence-based health education programs and interventions to address the health need of people with hypertension and contribute to social change in the country.

El TDAH és un trastorn neuroevolutiu de l’atenció i la impulsivitat de naturalesa crònica que afecta un 4% de la població i que freqüentment s’associa amb altres trastorns, com els problemes de conducta i les dificultats en l’aprenentatge. Actualment hi ha base empírica sobre el seu origen genètic i biològic, encara que el seu curs evolutiu i el seu pronòstic estan molt influenciats per factors ambientals. És per això que un abordatge adequat del procés d’avaluació i d’intervenció d’aquest trastorn ha de contemplar de forma primerenca els contextos en què el nen es desenvolupa (escola, família i comunitat) i ha de comptar amb un equip multidisciplinari. En aquesta línia, las modalitats d’intervenció que han evidenciat ser més efectives són les medicacions psicoestimulants, les intervencions psicosocials i els tractaments que combinen ambdues modalitats terapèutiques. L’estimulant més utilitzat per al TDAH, el metilfenidat, és el fàrmac més prescrit en psiquiatria infantil i s’ha constatat la seva efectivitat de forma reiterada. No obstant això, s’ha d’administrar amb cautela perquè presenta limitacions que a vegades no en compensen l’administració, com el efectes no desitjats, el desconeixement sobre els efectes a llarg termini o els escassos estudis sobre eficàcia i seguretat en nens preescolars. Aquests troballes ens fan considerar les intervencions psicosocials, que també són una bona opció terapèutica. Les intervencions psicosocials validades empíricament serveixen d’entrenament a pares i mestres per manejar el trastorn, com també al mateix nen, tot i que en menor mesura, per exercitar les seves habilitats socioemocionals. La finalitat d’aquestes teràpies és que paral•lelament o tres la formació, s’implementen intervencions conductuals, cognitiu-conductuals, escolars i sòcio-emocionals en els contexts naturals del nen. Encara que està provada la eficàcia d’aquestes modalitat d’intervenció de forma aïllada, s’han trobat millores superiors amb els tractaments combinats o multimodals, que cobren un ampli ventall de dificultats i plànols de funcionament, permetent en ocasions reduir la dosi de medicació amb un manteniment dels efectes positius. Però, malauradament, encara s’observa una relativa carència d’estudis que incloguin tractaments combinats per al TDAH infantil, si més no a España. En el millor del casos, les intervencions han estat breus i intensives. Tanmateix, no s’han publicat estudis sobre l’eficàcia d’aquestes intervencions per millorar variables com el clima escolar i familiar d’aquests nens. L’objectiu, doncs, d’aquest projecte és analitzar l’eficàcia relativa i diferencial d’un tractament combinat (medicació estimulant + entrenament a pares i mestres) versus un de farmacològic, durant un curs escolar, per millorar diverses variables relacionades amb el nen hiperactiu, com també amb els seus mestres i pares (símptomes, rendiment acadèmic, clima escolar i familiar, autoeficàcia percebuda i coneixements sobre TDAH). / El TDAH es un trastorno neuro-evolutivo de la atención, la actividad y la impulsividad de naturaleza crónica, que afecta a un 4% de la población, asociándose frecuentemente con otros trastornos, como los problemas de conducta y las dificultades de aprendizaje. En la actualidad, hay evidencia empírica sobre su origen genético y biológico, aunque su curso evolutivo y pronóstico están enormemente influidos por factores ambientales. De ahí que un adecuado abordaje del proceso de evaluación e intervención de este trastorno deba contemplar de forma temprana los contextos donde el niño se desenvuelve (escuela, familia y comunidad), contando con un equipo multidisciplinar. En esta línea, las modalidades de intervención que han mostrado ser más efectivas son las medicaciones estimulantes, las intervenciones psicosociales y los tratamientos que combinan ambas opciones terapéuticas. El estimulante más utilizado para el TDAH, el metilfenidato, es el fármaco más prescrito en psiquiatría infantil y se ha constatado reiteradamente su efectividad. Pero se debe administrar con cautela porque presenta limitaciones que en ocasiones no compensan su administración, como sus efectos indeseados; el desconocimiento sobre sus efectos a largo plazo; y los escasos estudios sobre su eficacia y seguridad en niños preescolares. Estos hallazgos nos instan a considerar las intervenciones psicosociales, que son también una buena opción terapéutica. Las intervenciones psicosociales validadas empíricamente son el entrenamiento a padres y a maestros en el manejo del trastorno, y en menor medida el entrenamiento en habilidades socio-emocionales al propio niño. La finalidad de estas terapias es que paralelamente o tras la formación, se implementen intervenciones conductuales, cognitivo-conductuales, escolares y socio-emocionales en los contextos naturales del niño. Sin embargo, a pesar de la eficacia de estas modalidades de intervención de forma aislada, se han mostrado mejoras superiores con los tratamientos combinados o multimodales, que cubren un amplio abanico de dificultades y planos de funcionamiento, permitiendo en ocasiones reducir la dosis de medicación con un mantenimiento de los efectos positivos. Pero desafortunadamente, aún se observa una relativa carencia de estudios que incluyan tratamientos combinados para el TDAH infantil, al menos en España. Y en el mejor de los casos, las intervenciones han sido muy breves e intensivas. Asimismo, no se han publicado estudios sobre la eficacia de estas intervenciones para mejorar variables como el clima escolar y familiar de estos niños. Precisamente, el objetivo de este proyecto es analizar la eficacia relativa y diferencial de un tratamiento combinado (medicación estimulante+entrenamiento a padres y maestros) versus farmacológico, durante un curso escolar, para mejorar diversas variables relacionadas con el niño hiperactivo, sus maestros y sus padres (síntomas, rendimiento académico, clima escolar y familiar, autoeficacia percibida y conocimientos sobre TDAH). / ADHD is a neuro-developmental disorder of attention, impulsivity and activity of a chronic nature, affecting 4% of the population, frequently associated with other disorders such as behavioral problems and learning disabilities. Today, there is empirical evidence on genetic and biological origin, although its clinical course and prognosis are greatly influenced by environmental factors. Hence, an adequate management of the process of assessment and intervention for this disorder should contemplate early contexts where the child develops (school, family and community), with a multidisciplinary team. In this stratum, the interventions that have proven most effective are stimulant medications, psychosocial interventions and treatments that combine both options. The stimulant used for ADHD, methylphenidate, is the most prescribed drug in child psychiatry and has been found repeatedly to be effective. But it should be administered with caution, because it has limitations, like its side effects, the lack of long-term effects, and the few studies on efficacy and safety in preschool children. These findings urge us to consider psychosocial interventions, which are also a good option. Empirically valid psychosocial interventions are parent training and teachers in the management of the disorder, and less training in socio-emotional skills the child itself. The purpose of these therapies is that, - parallel or after the training -, behavioral, cognitive-behavioral, and socio-emotional interventions would be implemented in the child's natural settings. However, despite the effectiveness of these modalities of intervention in isolation, greater improvement has been shown with combined or multimodal treatments covering a wide range of problems, allowing sometimes to reduce the dose of medication, with a maintenance of positive effects. But unfortunately there is still a relative lack of studies involving combined treatments for childhood ADHD, at least in Spain. And in most cases, interventions have been very brief and intensive. Also, there are no published studies on the effectiveness of these interventions to improve variables such as school and family environment of these children. The precise purpose of this project is to analyze the relative and differential efficacy of combined treatment (stimulant medication + training for parents and teachers) versus drug, during a school year, in order to improve various variables related to the hyperactive child, their teachers and their parents (symptoms, academic performance, school and family evironment, self-efficacy and knowledge about ADHD).

No description available.

Abstract The β1-adrenergic receptor (β1AR) belongs to the large family of G protein-coupled receptors. It is activated by epinephrine and norepinephrine and thus has a central role in mediating the effects of the sympathetic nervous system. β1AR is the predominant adrenergic receptor in the heart, where it mediates positive inotropy and chronotropy. Thus, it is the most important target receptor for β-adrenergic antagonists, which are widely used in the treatment of cardiovascular diseases. Furthermore, β1AR is also expressed in the brain, where it has a crucial role in regulating memory formation and synaptic plasticity. Human β1AR (hβ1AR) has two polymorphisms, one at each terminus. The carboxyl-terminal (C-terminal) Arg389Gly8.56 polymorphism has previously been shown to have functional significance. Despite the clinical importance of hβ1AR, its biosynthetic profile and post-translational processing have not been well characterized to date. The aims of the present study were to shed light on these events, focusing on the limited proteolysis of hβ1AR and the impact of β-adrenergic ligands on receptor processing. In addition, the C-terminal polymorphism and its associations with certain parameters were investigated in a population consisting of survivors of acute myocardial infarction (AMI). By using a heterologous expression system, hβ1AR biosynthesis was revealed to be efficient and rapid. The N-terminus of the mature receptor was modified with O-glycans and one N-glycan, but despite these modifications it was subject to cleavage at the cell surface that resulted in two C-terminal fragments. The cleavage was mediated by a metalloproteinase, and importantly, it also occurred in vivo. Moreover, receptor activation enhanced the cleavage, which suggests that it represents a novel regulatory mechanism of hβ1AR. Interestingly, those ligands that enhanced the cleavage stabilized intracellular hβ1AR precursors, possibly via a pharmacological chaperone activity. Thus, the present study demonstrates that β-adrenergic ligands can have different regulatory effects on distinct hβ1AR forms. Among the AMI survivors, the Arg3898.56 homozygotes had significantly increased left ventricular mass indexes, when compared to the Gly3898.56 carriers, which suggests an association between Arg3898.56 and left ventricular hypertrophy (LVH). When euglycemic and diabetic patients were analyzed separately, the association existed among the euglycemic patients but was not present in diabetic patients. Diabetes is one of several risk factors that have previously been shown to influence the progression of LVH. Here, diabetes was shown to have a stronger effect on the development of LVH, when compared with the Arg3898.56 variant of hβ1AR. / Tiivistelmä β1-adrenerginen reseptori (β1AR) kuuluu laajaan G-proteiineihin kytkettyjen reseptorien perheeseen. β1AR on tärkeässä asemassa sympaattisen hermoston toiminnassa. Sydämessä β1AR on vallitseva adrenerginen reseptori, ja sydänlihaksen supistusvireys sekä -taajuus voimistuvat β1AR:n aktivaation kautta. Siten se edustaa sydän- ja verisuonisairauksissa käytettävien β-salpaajien tärkeintä kohdereseptoria. β1AR:n luontaisia agonisteja ovat lisämunuaisytimestä ja hermopäätteistä vapautuvat adrenaliini ja noradrenaliini. Sydänlihaksen lisäksi β1AR:a ilmennetään myös aivoissa, jossa reseptorilla on keskeinen asema muistin ja synaptisen muovautuvuuden kannalta. Ihmisen β1AR (hβ1AR) sisältää kaksi polymorfismia, joista toinen (Arg389Gly8.56) sijaitsee reseptorin karboksyyli- (C-) terminaalissa solulimassa. Tällä polymorfismilla on havaittu olevan toiminnallista merkitystä. Vaikka hβ1AR:n kliininen merkitys on huomattava, sen biosynteesistä ja translaationjälkeisestä muokkauksesta ei ole tähän mennessä ollut juurikaan tutkimustietoa. Tämän väitöskirjatyön tavoite oli kuvata näitä tapahtumia ja erityisesti keskittyä hβ1AR:n solunulkoisen amino- (N-) terminaalin rajoitettuun proteolyysiin. Lisäksi haluttiin tutkia, onko β-adrenergisillä ligandeilla vaikutusta reseptorin prosessointiin. Tutkimuksen kliinisessä osiossa kartoitettiin C-terminaalisen polymorfian yhteyttä valikoituihin muuttujiin aineistossa, joka koostui akuutin sydäninfarktin (AMI) sairastaneista potilaista. hβ1AR:n biosynteesin havaittiin olevan tehokas ja nopea heterologisessa systeemissä. Kypsän reseptorin N-terminaalissa havaittiin useita O-kytkennäisiä ja yksi N-kytkennäinen glykaani. Glykosyloinnista huolimatta N-terminaali pilkkoutui solun pinnalla, mikä tuotti kaksi solukalvolla sijaitsevaa, C-terminaalista reseptoripalasta. Pilkkoutumista, joka havaittiin myös in vivo, katalysoi metalloproteinaasi. Reseptorin aktivaatio kiihdytti pilkkoutumista, joka siten todennäköisesti edustaa uudenlaista hβ1AR:n säätelymekanismia. Ligandit, jotka kiihdyttivät pilkkoutumista, toisaalta stabiloivat solunsisäisiä hβ1AR:n epäkypsiä muotoja toimien luultavasti ns. farmakologisina kaperoneina. Näin ollen väitöskirjatyö osoittaa, että β-adrenergisillä ligandeilla voi olla erilaisia säätelyvaikutuksia eri hβ1AR-muotoihin. Kliinisessä tutkimuksessa Arg3898.56-homotsygooteilla potilailla havaittiin merkittävästi suurentunut vasemman kammion massaindeksi Gly3898.56-kantajiin verrattuina, mikä puoltaa Arg3898.56-polymorfismin ja vasemman kammion hypertrofian (LVH) välistä yhteyttä. Kun euglykeemisiä potilaita ja diabeetikkoja tutkittiin erikseen, yhteys ilmeni vain euglykeemisessä ryhmässä. Diabetes on riskitekijä, joka vaikuttaa LVH:n kehittymiseen. Tässä tutkimuksessa diabeteksellä havaittiin olevan voimakkaampi vaikutus LVH:n kehittymiseen Arg3898.56 -polymorfismiin verrattuna.

G protein-coupled receptors (GPCRs) form the biggest family of membrane receptors and are involved in numerous physiological processes. Collectively, these receptors are also prominently targeted by the pharmaceutical industry due to their implications in multiple diseases and disorders. GPCR signaling is tightly regulated. Several kinases, activated downstream of the receptor, initiate negative feedback loops; and arrestins play a crucial role in these regulatory processes by desensitizing the ligand–activated receptor and promoting its endocytosis. By doing so, arrestins control the duration and the amplitude of signal transduction at the cell surface. In the last few years, several non-canonical roles have also been attributed to arrestins, such as the post-endocytic activation of several signalling pathways, or the regulation of crosstalks between GPCRs and various other signalling events. My thesis project was aimed at providing a better understanding of the non-canonical functions of arrestins. The first objective of my research work was to investigate a possible reciprocal effect of the activation of the extracellular signal-regulated kinases 1 and 2 (ERK1/2) on GPCR signaling. We demonstrated that stimulation of ERK1/2, either by a cell surface receptor or a constitutively active mutant, leads to a reduction in steady-state expression levels of many GPCRs at the cell surface. This receptor redistribution mechanism is dependent on beta-arrestins phosphorylation. In vitro kinase assays combined with complementation experiments in mouse embryonic fibroblasts (MEFs) lacking beta-arrestins, revealed that beta-arrestin-2 phosphorylation on Ser14 and Thr276 is essential for the ERK1/2-promoted GPCR sequestration. This ERK1/2- and arrestins mediated regulatory process was found to result in a global dampening of cell responsiveness. The second objective of my research work was to identify and develop a small organic compound that inhibits the interaction between arrestins and the adaptor protein AP-2, without interfering with the recruitment of arrestin to the receptor. This inhibitor, named Barbadin, was found to specifically block endocytic processes that are dependent on the interaction between arrestins and the appendage domain of the b-subunit of AP-2. We demonstrated its value as an analytical tool in studying the role of the arrestins in GPCR signaling, such as cAMP production and ERK1/2 activation. These results support the concept that beta-arrestin/AP-2-dependent signaling is important to both G protein-dependent and -independent pathways. The third objective of my research work was to develop a BRET-based biosensor able to detect signal-dependent PTEN conformational changes. This biosensor was validated by monitoring PTEN activation induced by targeted mutations affecting key intramolecular interactions or by modulating signalling pathways that impact PTEN function. We also demonstrated the value of this biosensor in studying PTEN/protein interactions using two known interactors that activate PTEN, beta-arrestin-2 and RhoA. Finally, we uncovered PTEN activation by several GPCRs, previously unknown as PTEN regulators. Given the central role of the tumor suppressor PTEN in oncogenesis, this biosensor could also provide a precious tool for anti-cancer drug research. To conclude, my research work highlighted non-canonical mechanisms for arrestins to activate GPCR-dependent signaling pathways, such as cAMP, ERK1/2 and PTEN, as well as negatively regulate GPCR signaling upon phosphorylation by ERK1/2. This work was made possible by the development of new tools: a beta-arrestin inhibitor named Barbadin and a PTEN BRET-based biosensor that have both shown their usefulness in studying beta-arrestin noncanonical signaling. / Les récepteurs couplés aux protéines G (RCPG) représentent la plus grande famille de récepteurs membranaires et sont impliqués dans un grand nombre de processus physiologiques. Cette famille de récepteurs constitue aussi une cible majeure dans la recherche pharmaceutique au vu de son importance dans de nombreuses pathologies. La signalisation des RCPG est étroitement régulée. Plusieurs kinases activées en aval du récepteur initient des boucles de régulation négative. Les arrestines jouent un rôle clé dans ces processus de régulation en favorisant la désensibilisation du récepteur activé par le ligand, suivie de son endocytose. Ainsi, les arrestines contrôlent la durée et l’amplitude de la transmission du signal à la surface de la cellule. Ces dernières années, plusieurs rôles non-canoniques ont été attribués aux arrestines comme l’activation de voies de signalisation post-endocytiques, ou la modulation de la régulation croisée entre les RCPG et d’autres acteurs de la signalisation cellulaire. Le premier objectif de mon travail de recherche est d’examiner l’effet réciproque de l’activation des kinases ERK1/2 (extracellular signal-regulated kinases 1/2) sur la signalisation des RCPG. Nous avons démontré que la stimulation de ERK1/2, soit par un récepteur de surface soit par l’utilisation d’un mutant constitutivement actif, conduit à la baisse de l’expression de surface basale de nombreux RCPG. Des essais kinases in vitro, combinés à des expériences de complémentation dans des fibroblastes embryonnaires de souris (MEF), où les gènes beta-arrestine-1/2 ont été supprimés, démontrent l’importance de la phosphorylation par ERK1/2 des résidus Ser14 et Thr276 dans ce mécanisme de séquestration des RCPG. Cette régulation, contrôlée par ERK1/2 et arrestine, conduit à une baisse globale de la capacité de réponse de la cellule aux stimuli extracellulaires. Le deuxième objectif de mon travail de recherche est d’identifier et de développer une petite molécule organique qui inhibe l’interaction entre l’arrestine et la protéine adaptatrice du complexe d’endocytose AP-2, sans toutefois empêcher la formation du complexe arrestine/récepteur. Cet inhibiteur, nommé Barbadin, bloque sélectivement les processus d’internalisation dépendants de l’interaction entre arrestine- et la sous-unité beta2 de la protéine adaptatrice AP-2. Barbadin représente le premier inhibiteur des fonctions d’arrestine, et nous avons démontré son utilité comme outil analytique pour déterminer la contribution des arrestines dans l’activation de plusieurs voies de signalisation en aval des RCPG, telles que la production d’AMP cyclique (AMPc) ou l’activation des kinases ERK1/2. Nos résultats démontrent l’importance du complexe arrestine/AP-2 dans la signalisation dépendante et indépendante des protéines G. Le troisième objectif de mon travail de recherche est de développer un biosenseur BRET capable de mesurer les changements de conformation du suppresseur de tumeur PTEN. Nous avons validé ce biosenseur en mesurant l’activation de PTEN suite à des mutations ciblées déstabilisant les interactions intramoléculaires au sein de cette protéine ou en modulant différentes voies de signalisation qui affectent sa fonction. Nous avons démontré l’intérêt de ce nouvel outil dans l’étude des interactions entre PTEN et des partenaires protéiques, en utilisant deux interacteurs connus pour activer PTEN : b-arrestine-2 et RhoA. Finalement, en utilisant ce biosenseur, nous avons démontré pour la première fois la capacité de plusieurs RCPG à induire l’activation de PTEN. Étant donné le rôle central de PTEN dans le développement tumoral, ce biosenseur constitue aussi un outil précieux pour la recherche de nouveaux médicaments anticancer. Ainsi, au travers de ces trois lignes directrices, nous avons pu mettre en lumière de nouveaux rôles non-canoniques des arrestines, soit dans l’activation de voies de signalisation, (comme la production d’AMPc, l’activation de ERK1/2 ou de PTEN), soit comme régulateur négatif de la signalisation des RCPG après phosphorylation par ERK1/2. Ce travail a été rendu possible par le développement de nouveaux outils pour l’étude des RCPG : un inhibiteur de beta-arrestine, Barbadin, et un biosenseur BRET de PTEN ; tous deux ayant démontré leur utilité dans l’étude des voies de signalisation non-canoniques des arrestines.

[ES] Las enfermedades cardiovasculares siguen siendo la principal causa de muerte en Europa. Las arritmias cardíacas son una causa importante de muerte súbita, pero sus mecanismos son complejos. Esto denota la importancia de su estudio y prevención. La investigación sobre electrofisiología cardíaca ha demostrado que las anomalías eléctricas causadas por mutaciones que afectan a canales cardíacos pueden desencadenar arritmias. Sorprendentemente, se ha descubierto una gran variedad de fármacos proarrítmicos, incluidos aquellos que usamos para prevenirlas. Las indicaciones de uso de fármacos actuales intentaron solucionar este problema diseñando una prueba para identificar aquellos fármacos que podían ser peligrosos basado en el bloqueo de un solo canal iónico. El estudio de las interacciones fármaco-canal ha revelado la existencia no sólo de compuestos que bloquean múltiples canales, sino también una gran complejidad en esas interacciones. Esto podría explicar por qué algunos medicamentos pueden mostrar efectos muy diferentes en la misma enfermedad. Existen dos desafíos importantes con respecto a los efectos de los fármacos en la electrofisiología cardíaca. Por un lado, las empresas y entidades reguladoras están buscando una herramienta de alto rendimiento que mejore la detección del potencial proarrítmico durante el desarrollo de fármacos. Por otro lado, los pacientes con anomalías eléctricas a menudo requieren tratamientos personalizados más seguros. Las simulaciones computacionales contienen un poder sin precedentes para abordar fenómenos biofísicos complejos. Deberían ser de utilidad a la hora de determinar las características que definen tanto los efectos beneficiosos como no deseados de los fármacos mediante la reproducción de datos experimentales y clínicos. En esta tesis doctoral, se han utilizado modelos computacionales y simulaciones para dar respuesta a estos dos desafíos. El estudio de los efectos de los fármacos sobre la actividad cardíaca se dividió en el estudio de su seguridad y de su eficacia, respectivamente. Para dar respuesta al primer desafío, se adoptó un enfoque más amplio y se generó un nuevo biomarcador fácil de usar para la clasificación del potencial proarrítmico de los fármacos utilizando modelos del potencial de acción de células y tejidos cardíacos humanos. Se integró el bloqueo de múltiples canales a través de IC50 y el uso de concentraciones terapéuticas con el fin de mejorar el poder predictivo. Luego, se entrenó el biomarcador cuantificando el potencial proarrítmico de 84 fármacos. Los resultados obtenidos sugieren que el biomarcador podría usarse para probar el potencial proarrítmico de nuevos fármacos. Respecto al segundo desafío, se adoptó un enfoque más específico y se buscó mejorar la terapia de pacientes con anomalías eléctricas cardíacas. Por lo tanto, se creó un modelo detallado de la mutación V411M del canal de sodio, causante del síndrome de QT largo, reproduciendo datos clínicos y experimentales. Se evaluaron los posibles efectos beneficiosos de ranolazina, a la par que se aportó información sobre los mecanismos que impulsan la efectividad de la flecainida. Los resultados obtenidos sugieren que, si bien ambos fármacos mostraron diferentes mecanismos de bloqueo de los canales de sodio, un tratamiento con ranolazina podría ser beneficioso en estos pacientes. / [CA] Les malalties cardiovasculars continuen sent la principal causa de mort a Europa. Les arrítmies cardíaques són una causa important de mort sobtada, però els seus mecanismes són complexos. Això denota la importància del seu estudi i prevenció. La investigació sobre electrofisiologia cardíaca ha demostrat que les anomalies elèctriques que afecten a canals cardiacs poden desencadenar arrítmies. Sorprenentment, s'ha descobert una gran varietat de fàrmacs proarrítmics, inclosos aquells que utilitzem per a previndre-les. Les indicacions d'ús de fàrmacs actuals van intentar solucionar aquest problema dissenyant una prova per a identificar aquells fàrmacs que podien ser perillosos basada en el bloqueig d'un sol canal iònic. L'estudi de les interaccions fàrmac-canal ha revelat l'existència no sols de compostos que bloquegen múltiples canals, sinó també una gran complexitat en aquestes interaccions. Això podria explicar per què alguns medicaments poden mostrar efectes molt diferents en la mateixa malaltia. Existeixen dos desafiaments importants respecte als efectes dels fàrmacs en la electrofisiologia cardíaca. D'una banda, les empreses i entitats reguladores estan buscant una eina d'alt rendiment que millore la detecció del potencial proarrítmic durant el desenvolupament de fàrmacs. D'altra banda, els pacients amb anomalies elèctriques sovint requereixen tractaments personalitzats més segurs. Les simulacions computacionals contenen un poder sense precedents per a abordar fenòmens biofísics complexos. Haurien de ser d'utilitat a l'hora de determinar les característiques que defineixen tant els efectes beneficiosos com no desitjats dels fàrmacs mitjançant la reproducció de dades experimentals i clíniques. En aquesta tesi doctoral, s'han utilitzat models computacionals i simulacions per a donar resposta a aquests dos desafiaments. L'estudi dels efectes dels fàrmacs sobre l'activitat cardíaca es va dividir en l'estudi de la seva seguretat i la seva eficacia. Per a donar resposta al primer desafiament, es va adoptar un enfocament més ampli i es va generar un nou biomarcador fàcil d'usar per a la classificació del potencial proarrítmic dels fàrmacs utilitzant models del potencial d'acció de cèl·lules i teixits cardíacs humans. Es va integrar el bloqueig de múltiples canals a través d'IC50 i l'ús de concentracions terapèutiques amb la finalitat de millorar el poder predictiu. Després, es va entrenar el biomarcador quantificant el potencial proarrítmic de 84 fàrmacs. Els resultats obtinguts suggereixen que el biomarcador podria usar-se per a provar el potencial proarrítmic de nous fàrmacs. Respecte al segon desafiament, es va adoptar un enfocament més específic i es va buscar millorar la teràpia de pacients amb anomalies elèctriques cardíaques. Per tant, es va crear un model detallat de la mutació V411M del canal de sodi, causant de la síndrome de QT llarg, reproduint dades clíniques i experimentals. Es van avaluar els possibles efectes beneficiosos de ranolazina, a l'una que es va aportar informació sobre els mecanismes que impulsen l'efectivitat de la flecainida. Els resultats obtinguts suggereixen que, si bé tots dos fàrmacs van mostrar diferents mecanismes de bloqueig dels canals de sodi, un tractament amb ranolazina podria ser beneficiós en aquests pacients. / [EN] Cardiovascular disease remains the main cause of death in Europe. Cardiac arrhythmias are an important cause of sudden death, but their mechanisms are complex. This denotes the importance of their study and prevention. Research on cardiac electrophysiology has shown that electrical abnormalities caused by mutations in cardiac channels can trigger arrhythmias. Surprisingly, a wide variety of drugs have also shown proarrhythmic potential, including those that we use to prevent arrhythmia. Current guidelines designed a test to identify dangerous drugs by assessing their blocking power on a single ion channel to address this situation. Study of drug-channel interactions has revealed not only compounds that block multiple channels but also a great complexity in those interactions. This could explain why similar drugs can show vastly different effects in some diseases. There are two important challenges regarding the effects of drugs on cardiac electrophysiology. On the one hand, companies and regulators are in search of a high throughput tool that improves proarrhythmic potential detection during drug development. On the other hand, patients with electrical abnormalities often require safer personalized treatments owing to their condition. Computer simulations provide an unprecedented power to tackle complex biophysical phenomena. They should prove useful determining the characteristics that define the drugs' beneficial and unwanted effects by reproducing experimental and clinical observations. In this PhD thesis, we used computational models and simulations to address the two abovementioned challenges. We split the study of drug effects on the cardiac activity into the study of their safety and efficacy, respectively. For the former, we took a wider approach and generated a new easy-to-use biomarker for proarrhythmic potential classification using cardiac cell and tissue human action potential models. We integrated multiple channel block through IC50s and therapeutic concentrations to improve its predictive power. Then, we quantified the proarrhythmic potential of 84 drugs to train the biomarker. Our results suggest that it could be used to test the proarrhythmic potential of new drugs. For the second challenge, we took a more specific approach and sought to improve the therapy of patients with cardiac electrical abnormalities. Therefore, we created a detailed model for the long QT syndrome-causing V411M mutation of the sodium channel reproducing clinical and experimental data. We tested the potential benefits of ranolazine, while giving insights into the mechanisms that drive flecainide's effectiveness. Our results suggest that while both drugs showed different mechanisms of sodium channel block, ranolazine could prove beneficial in these patients. / This PhD thesis was developed within the following projects: Ministerio de Economía y Competitividad and Fondo Europeo de Desarrollo Regional (FEDER) DPI2015-69125-R (MINECO/FEDER, UE): Simulación computacional para la predicción personalizada de los efectos de los fármacos sobre la actividad cardiaca. Dirección General de Política Científica de la Generalitat Valenciana (PROMETEU2016/088): “Modelos computacionales personalizados multiescala para la optimización del diagnóstico y tratamiento de arritmias cardiacas (personalised digital heart). Vicerrectorado de Investigación, Innovación y Transferencia de la Universitat Politècnica de València, Ayuda a Primeros Proyectos de Investigación (PAID-06-18), and by Memorial Nacho Barberá. Instituto de Salud Carlos III (La Fe Biobank PT17/0015/0043). / Cano García, J. (2021). Prediction of the effects of drugs on cardiac activity using computer simulations [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/164094 / TESIS

<p> Exposure to chronic low oxygen (hypoxia) leads to a series of adaptive responses involving changes in gene expression that are critical for cell, tissue, and organismal survival. These changes are mediated by an important set of regulators belonging to the hypoxia inducible factor (HIF) family of transcription factors (e.g. HIF-lα, HIF-2α, HIF3α) which undergo rapid degradation during normal oxygen (normoxia) but are rapidly stabilized during hypoxia. While the role of HIF-1α has been extensively studied in many cell types, there have been relatively few studies on the role of HIF-2α, though recent evidence suggests its function maybe tissue specific. This thesis examined the hypothesis that HIF-2α plays a central role in the development and function of catecholaminergic cells of the sympathoadrenal (SA) lineage. The study was aided by use of an immortalized line of rat adrenomedullary chromaffin cells (i.e. MAH cells), derived from fetal SA progenitors, which express several hypoxia-sensitive properties characteristic of native cells in the adrenal gland. In Chapter 2, I investigated the potential contributions of mitochondrial reactive oxygen species (ROS) and 0 2 consumption to HIF-2α induction in MAH cells exposed to chronic hypoxia (2% O(2); 24 hr). In MAH cells, chronic hypoxia caused an increase in HIF-2α induction which was blocked by inhibition of any of the mitochondrial complexes using pharmacological agents, or by specific inhibition of complexes III and IV using RNAi techniques. It was found that in this 0 2-sensitive chromaffin cell line mitochondrial O(2) consumption, rather than changes in ROS, regulated HIF-2α induction during hypoxia. In Chapter 3, I investigated the hypothesized role of HIF-2α in the development of the catecholaminergic phenotype in cells of the SA lineage using the MAH cell line as a model. Mutant MAH cells, with depleted HIF-2α due to siRNA knock-down, showed dramatically lower levels of dopamine and noradrenaline compared to untransfected and scrambled control cells, regardless of whether the cells were cultured under normoxia or chronic hypoxia. This was correlated with a marked reduction in the expression of DOPA decarboxylase (DDC) and dopamine B hydroxylase (DBH), though the expression of tyrosine hydroxylase (TH) was unaffected. Moreover, HIF-2α was able to bind to a region of the DDC gene promoter which contains two putative hypoxia response elements (HREs). These data suggest that a basal level of HIF-2α function is required for the normal developmental expression of DDC and DBH in SA progenitor cells, and that loss of this function leads to impaired catecholamine (CA) biosynthesis. In Chapter 4, I investigated genes regulated by chronic hypoxia in MAH cells, with a focus on those involved in CA metabolism, storage, and secretion. Using microarray analysis combined with QPCR and RNAi knock-down methodology I uncovered several genes, involved in amine vesicular packaging, trafficking and secretion, which were upregulated during chronic hypoxia. One gene specifically, the adenosine A(2A) receptor (A(2A)R) gene, which appears to modulate CA secretion via autocrine or paracrine actions of extracellular adenosine, was dramatically upregulated in chronic hypoxia. Interestingly, this effect was completely abolished in HIF-2α knockdown MAH cells, suggesting a critical involvement of HIF-2α. Chromatin immunoprecipitation (ChIP) assays revealed that HIF-2α bound to the promoter region of the A(2A)R gene which contains a putative hypoxia response element (HRE) immediately upstream of exon 1. Ratiometric fluorescence measurements of intracellular Ca(2+) revealed that adenosine (50 μM) potentiated the high K(+)-evoked rise in [Ca(2+)]i in MAH cells. This effect of adenosine was further enhanced after chronic hypoxia, but was abolished in HIF-2α knock-down cells. In conclusion, these data suggest that HIF-2α is a key regulator of several genes involved in CA biosynthesis, and of others that mediate the facilitatory effects of chronic hypoxia on CA secretion in sympathoadrenal derivatives. / Thesis / Doctor of Philosophy (PhD)

Ceramid, ein zentrales Signalmolekül des Sphingolipidstoffwechsels, ist neben der de novo Synthese über die enzymatische Spaltung von Sphingomyelin und Glucosylceramid zugänglich. Genetische Mutationen, die eine Fehlfaltung der verantwortlichen Enzyme saure Sphingomyelinase (aSMase) und Glucocerebrosidase (GCase) begünstigen, könnten somit zu einer Dysregulation des gesamten Sphingolipidstoffwechsels und den damit verbundenen Signaltransduktionsprozessen führen. Niedermolekulare Inhibitoren können in Zellstudien einen Einblick in diese Prozesse geben und den Defekt eines Enzyms simulieren oder eine etwaige Überaktivität derselben Enzyme verhindern. Für derartige Studien ist die Möglichkeit einer zeitaufgelösten Inhibition von Vorteil. Für diese Methode müssten photolabile Schutzgruppen in eine bereits bekannte Inhibitorstruktur integriert werden. Im Fall der aSMase würden sich hierfür myo-Inosit-bisphosphat-Derivate anbieten, die starke, kompetitive Inhibitoren des Enzyms darstellen. Auf dieser Grundlage werden in der vorliegenden Arbeit die Synthese sowie die in vitro und in cellulo Wirkung des ersten zellpermeablen, photoaktivierbaren Inhibitors für die aSMase präsentiert. Kompetitive Inhibitoren können ebenso als sogenannte pharmakologische Chaperone fungieren, welche Proteine durch Herabsetzung der freien Energie des jeweiligen Faltungszustandes stabilisieren. Dies ist besonders bei von Mutationen betroffenen lysosomalen Enzymen von Interesse, um diese vor einem proteasomalen Abbau zu bewahren und einen geregelten Transport in die Lysosomen zu gewährleisten. So wurden in der vorliegenden Arbeit verschiedene myo-Inositderivate als potenzielle pharmakologische Chaperone für die aSMase und GCase synthetisiert. Um eine Verdrängung der Verbindungen vom aktiven Zentrum des Enzyms durch das natürliche Substrat zu beschleunigen, wurde eine Orthoesterfunktion in die Seitenkette der Inhibitorstruktur integriert, die im sauren Milieu der Lysosomen gespalten werden kann. / Ceramide, a central signaling molecule in sphingolipid metabolism, is in addition to the novo synthesis accessible via the enzymatic cleavage of sphingomyelin and glucosylceramide. Genetic mutations that promote misfolding of the responsible enzymes acid sphingomyelinase (aSMase) and glucocerebrosidase (GCase) could thus lead to a dysregulation of the entire sphingolipid metabolism and the associated signal transduction processes. Small molecule inhibitors can provide insight into these processes in cell studies and simulate the defect of an enzyme or prevent eventual overactivity of the same enzyme. For such studies, the possibility of a time-resolved inhibition would be advantageous. For this method, photolabile protecting groups would have to be integrated into the structure of a known inhibitor. In the case of aSMase, myo-inositol-diphosphate derivatives, which represent strong, competitive inhibitors of the enzyme, would be suitable for this purpose. On this basis, the synthesis as well as the in vitro and in cellulo effects of the first cell-permeable photocaged inhibitor for acid sphingomyelinase are presented in this work. Competitive inhibitors can also act as so-called pharmacological chaperones, which stabilize proteins by reducing the free energy of the respective folding state. This is of particular interest in the case of lysosomal enzymes affected by mutations, in order to protect them from proteasomal degradation and to ensure regulated transport into the lysosomes. In the present work, various myo-inositol derivatives were synthesized as potential pharmacological chaperones for aSMase and GCase. To accelerate displacement of the compounds from the enzyme's active site by the natural substrate, an orthoester function was integrated into the side chain of the inhibitor structure, which can be cleaved in the acidic environment of the lysosome.