In der vorliegenden Arbeit wurde Gewebe aus den Nasennebenhöhlen von Patienten mit Nasenpolypen untersucht. Außerdem wurden Zusammenhänge zwischen den Zellpopulationen und den Angaben zu allergischen Erkrankungen und wiederholtem Auftreten der Polypen analysiert. Es fand sich eine interindividuell unterschiedlich starke Infiltration mit eosinophilen Granulozyten. Es konnten keine Unterschiede in der prozentualen Verteilung von eosinophilen Granulozyten im Polypengewebe bei allergischen/ nichtallergischen Patienten oder Patienten mit/ ohne Rezidiv nachgewiesen werden. Die Untersuchungen erfolgten mit dem Laser Scanning Zytometer (LSC), das mit der Standardmethode, der Begutachtung mittels Lichtmikroskop, verglichen wurde. Mit der beschriebenen Methode erfolgte die Untersuchung von Polypengewebe nach einem speziell für diese Anwendung entwickelten Protokoll. Die Ergebnisse korrelierten gut mit den Ergebnissen der Lichtmikroskopie. Aufgrund der Weiterentwicklung des LSC und der ständig wachsenden Anzahl der Nachweismöglichkeiten der an der Polyposis nasi beteiligten Zytokine stellt das LSC eine ideale Methode für die Erforschung der Pathogenese von chronischen Entzündungen der Nasennebenhöhlen dar.

Objective. This study aimed to determine the predictors of olfactory improvement after endoscopic sinus surgery among patients with chronic rhinosinusitis with nasal polyps. Method. This prospective cohort study included patients admitted to a university hospital between 2006 and 2012. Assessment using odour identification testing, a sinonasal symptom questionnaire, the Rhinosinusitis Disability Index and mucus biomarker levels was performed at various time points. Correlation of variables with identification score differences at six postoperative time points and at baseline was performed, followed by multiple linear regression to determine significant predictors at each of the six post-operative time points. Results. Baseline absence of acute sinusitis, elevated serpin F2 and anterior rhinorrhoea predict early olfactory improvement, whereas baseline allergic rhinitis predicts late olfactory improvement. Baseline odour identification score was the strongest predictor across all time points. Conclusion. Patients with chronic rhinosinusitis and nasal polyps with worse disease or baseline olfactory function may benefit more from endoscopic sinus surgery in terms of olfactory improvement.

Introdução: O estudo dos fatores clínicos associados ao prognóstico da rinossinusite crônica (rsc), seja associada à polipose nasossinusal (RSCcPN) ou não (RSCsPN), ainda é pouco abordado a longo prazo. Objetivo: Avaliar pacientes submetidos à ESS (cirurgia endoscópica nasal, do inglês endoscopic sinus surgery) para o tratamento de RSC no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, entre 1996 e 2006, e correlacionar a recidiva em longo prazo com parâmetros como a extensão da doença, atopia, tabagismo, asma, eosinofilia e doença respiratória exacerbada pela aspirina (DREA). Métodos: Duzentos e um pacientes foram seguidos por um período médio de 12 anos. Os dados clínicos foram levantados, assim como exames de endoscopia nasal, Tomografia Computadorizada (TC), exames séricos, prick test e prova de função pulmonar. O tempo de seguimento pós-operatório foi analisado, sendo considerado fator de mau prognóstico a indicação de novo procedimento cirúrgico. Foi realizada comparação entre os fatores pela curva de Kaplan-Meyer, e pós-teste de Log-rank. Resultados e Discussão: Pacientes com RSCcPN tiveram chance de nova cirurgia três vezes maior do que aqueles sem pólipos nasais, no período seguido. Entre os pacientes com RSCsPN, apenas a asma foi um fator de pior prognóstico significativo, levando à chance de cirurgia 5,5 vezes maior do que os não-asmáticos. Já entre os pacientes com RSCcPN, aqueles com recidiva apresentaram maior extensão da doença à TC antes da primeira cirurgia. Foram ainda considerados fatores significativamente de pior prognóstico nos pacientes com RSCcPN: asma (odds ratio [OR] de 3,2); atopia a fungos (OR de 1,9); eosinofilia periférica (considerada como >500/µL, levando a OR de 1,9); e intolerância ao Ácido Acetil Salicílico (AAS) (DREA, apresentando OR de 2,5). Conclusões: Concluiu-se que a presença de pólipos per se é fator de pior prognóstico, aumentando em três vezes a chance de recorrência cirúrgica. Entre os pacientes com RSCsPN, apenas a asma influenciou o prognóstico. Já naqueles com RSCcPN, a asma, eosinofilia periférica, atopia a fungos e DREA aumentaram significativamente a probabilidade de nova intervenção cirúrgica. / Introduction: The analysis of prognostic factors associated with the recurrence of chronic rhinosinusitis (CRS), either with nasal polyps (CRSwNP) or without (CRSsNP), is still poorly discussed in the literature. Objective: To evaluate the patients that underwent endoscopic sinus surgery (ESS) due to CRS in Clinics Hospital of Ribeirão Preto Medical School, University of São Paulo, between 1996 and 2006, and to correlate the long-term recurrence to clinical factors, such as extensiveness of the disease, atopy, smoking habits, eosinophilia, and Aspirinexacerbated respiratory disease (AERD). Methods: We collected data of 201 patients, who were followed during an average period of 12 years. Clinical data collected were: extensiveness of the disease at endoscopy and at CT scans, prick test, blood exams, and pulmonary function. The follow-up period after surgery was assessed, and the indication of a new surgical procedure was considered as a poor prognostic factor. Comparison between factors was performed by Kaplan-Meyer curve, with Log-rank post-test. Results and discussion: CRSwNP patients were 3 times more likely to need a revisional surgery than CRSsNP during the follow-up period. Only asthma was a significant prognostic factor in patients with CRSsNP, leading to 5.5 times higher chance of recurrence than non-asthmatic patients. Among patients with CRSwNP, patients with recurrence presented, prior to surgery, higher CT scan extension of the disease. Other factors that influenced the prognosis on CRSwNP were: asthma (odds ratio [OR]: 3.2); atopy for fungi (OR: 1.9); peripheral eosinophilia (considered as >500/?L, leading to an OR: 1.9); and ASA intolerance (AERD; OR: 2.5). Conclusions: The presence of polyps were related to poor prognosis per se, leading to a higher chance of surgical recurrence. Among patients with CRSsNP, only asthma influenced the prognosis. Among the patients with CRSwNP, asthma, peripheral eosinophilia, fungi atopy, and AERD significantly increased the likelihood of further surgical intervention.

Para identificar, quantificar e correlacionar os eosinófilos, mastócitos, miofibroblastos e células TGF-beta positivas nos pólipos nasais de pacientes com e sem asma foi realizado a imunoistoquímica. A quantidade de eosinófilos, miofibroblastos e células TGF-beta positivas esteve aumentada no pólipo nasal de indivíduos asmáticos. O número de mastócitos não mostrou diferença entre os grupos. O miofibroblasto foi o denominador comum na correlação entre eosinófilos, mastócitos, células TGF-beta positivas e presença de asma / Introduction: Nasal polyposis is a chronic inflammatory disease of the nasal mucosa or paranasal sinuses characterized by the formation of benign polyps. The pathogenesis is not known, although nasal polyps are associated with several systemic diseases, with asthma being the most frequent. The aim of the present study was to identify, quantify, compare and correlate eosinophils, mast cells, myofibroblasts and TGF-ß-positive cells in nasal polyps of patients with and without asthma. Material and Methods: Seventy-eight subjects with nasal polyps undergoing endoscopic sinus surgery were selected. Control specimens were obtained from eight subjects with a normal sinus mucosa. One group consisted of polyps from 56 patients with asthma and the other of polyps from 22 patients without asthma. Immunohistochemistry was performed using monoclonal antibodies against eosinophil cationic protein to stain eosinophils, against tryptase to stain mast cells, against alpha-smooth muscle actin to stain myofibroblasts, and against TGF-ß to stain TGF-ß-positive cells. Results: The number of eosinophils, myofibroblasts and TGF-ß-positive cells was significantly higher in the asthma group than in the nonasthma group, whereas no significant difference in the number of mast cells was observed between the two groups. The number of eosinophils, mast cells, myofibroblasts and TGF-ß-positive cells was significantly higher in nasal polyps than in the control group. Myofibroblasts showed a significant correlation with eosinophils, mast cells, TGF-ß-positive cells, and asthma. Conclusion: Eosinophils, mast cells, myofibroblasts and TGF-ß-positive cells were identified in all nasal polyps, although the number of eosinophils, myofibroblasts and TGF-ß-positive cells was higher in the asthma group. The number of mast cells was similar regardless of the presence or absence of asthma. Myofibroblasts were a common denominator in the correlation between eosinophils, mast cells, TGF-ß-positive cells, and asthma

Para identificar, quantificar e correlacionar os eosinófilos, mastócitos, miofibroblastos e células TGF-beta positivas nos pólipos nasais de pacientes com e sem asma foi realizado a imunoistoquímica. A quantidade de eosinófilos, miofibroblastos e células TGF-beta positivas esteve aumentada no pólipo nasal de indivíduos asmáticos. O número de mastócitos não mostrou diferença entre os grupos. O miofibroblasto foi o denominador comum na correlação entre eosinófilos, mastócitos, células TGF-beta positivas e presença de asma / Introduction: Nasal polyposis is a chronic inflammatory disease of the nasal mucosa or paranasal sinuses characterized by the formation of benign polyps. The pathogenesis is not known, although nasal polyps are associated with several systemic diseases, with asthma being the most frequent. The aim of the present study was to identify, quantify, compare and correlate eosinophils, mast cells, myofibroblasts and TGF-ß-positive cells in nasal polyps of patients with and without asthma. Material and Methods: Seventy-eight subjects with nasal polyps undergoing endoscopic sinus surgery were selected. Control specimens were obtained from eight subjects with a normal sinus mucosa. One group consisted of polyps from 56 patients with asthma and the other of polyps from 22 patients without asthma. Immunohistochemistry was performed using monoclonal antibodies against eosinophil cationic protein to stain eosinophils, against tryptase to stain mast cells, against alpha-smooth muscle actin to stain myofibroblasts, and against TGF-ß to stain TGF-ß-positive cells. Results: The number of eosinophils, myofibroblasts and TGF-ß-positive cells was significantly higher in the asthma group than in the nonasthma group, whereas no significant difference in the number of mast cells was observed between the two groups. The number of eosinophils, mast cells, myofibroblasts and TGF-ß-positive cells was significantly higher in nasal polyps than in the control group. Myofibroblasts showed a significant correlation with eosinophils, mast cells, TGF-ß-positive cells, and asthma. Conclusion: Eosinophils, mast cells, myofibroblasts and TGF-ß-positive cells were identified in all nasal polyps, although the number of eosinophils, myofibroblasts and TGF-ß-positive cells was higher in the asthma group. The number of mast cells was similar regardless of the presence or absence of asthma. Myofibroblasts were a common denominator in the correlation between eosinophils, mast cells, TGF-ß-positive cells, and asthma

Ο ρινικός πολύποδας (ΡΠ) είναι μια χρόνια φλεγμονώδης νόσος του ρινικού βλεννογόνου, η οποία χαρακτηρίζεται από διήθηση φλεγμονωδών κυττάρων, όπως ηωσινόφιλα, λεμφοκύτταρα και πλασμοκύτταρα, τροποποιήσεις στη διαφοροποίηση του επιθηλίου και ανάπλαση ιστού, που περιλαμβάνει υπερπλασία της βασικής μεμβράνης, συσσώρευση εξωκυττάριου υλικού και οίδημα. Ο παράγοντας αναστολής της μετανάστευσης μακροφάγων (MIF) είναι μία μοναδική κυτταροκίνη με σημαντικό ρόλο στο σηπτικό σόκ και στις χρόνιες φλεγμονώδεις και αυτοάνοσες ασθένειες.Παράγεται από ενεργοποιημένα Τ-κύτταρα, μακροφάγα αλλά και από ποικιλία άλλων κυττάρων. Εκτός των άλλων, έχει βρεθεί ότι επάγει την έκφραση της IL-6 από διάφορα κύτταρα και ανταγωνίζεται την κατασταλτική επίδραση των γλυκοκορτικοειδών στην έκφρασή της. Απαντάται σε αυξημένα επίπεδα στο ρινικό πολύποδα. Ο αυξητικός παράγοντας μετασχηματισμού-β1 (TGF-β1) θεωρείται ένας αντιφλεγμονώδης παράγοντες, ο οποίος ανταγωνίζεται τη δράση της IL-1β και του TNF-α, στην έκφραση της ΜΜΡ-1 και ΜΜΡ-3. Διεγείρει επίσης την έκφραση του ΤΙΜΡ-1, του κολλαγόνου τύπου Ι και της IL-6 και λόγω των δράσεών του αυτών εμπλέκεται ισχυρά στις διαδικασίες ίνωσης. Απαντάται σε σημαντικά επίπεδα στο ρινικό πολύποδα. Η IL-6 είναι μία Th2 πολυλειτουργική κυτταροκίνη η οποία εμπλέκεται σε ποικίλες φλεγμονώδεις καταστάσεις. Διεγείρει την ανάπτυξη των ινοβλαστών, αυξάνει τη σύνθεση και εναπόθεση του κολλαγόνου και μειώνει την αποικοδόμησή του. Απαντάται σε αυξημένα επίπεδα στο ρινικό πολύποδα και θεωρείται σημαντικός παθαγενετικός παράγοντας μέσω της επαγωγής του σχηματισμού των πλασμοκυττάρων και της σύνθεσης συστατικών του στρώματος, και της προαγωγής της σύνθεσης και εναπόθεσης κολλαγόνου και της ανάπλασης ιστού. Σκοπός της παρούσης εργασίας είναι η μελέτη της συμβολής του MIF και του TGF-β1 στη παραγωγή της IL-6 από ινοβλάστες ρινικού πολύποδα, των σηματοδοτικών μονοπατιών που εμπλέκονται, και η διερεύνηση της πιθανής συνεργειακής δράσης τους στην έκφραση της κυτταροκίνης. Τόσο ο TGF-β1 (0,01-1 ng/ml) όσο και ο MIF (1-100 ng/ml) προκάλεσαν διέγερση της έκφραση της IL-6 σε ινοβλάστες ρινικού πολύποδα κατά δοσοεξαρτώμενο τρόπο, η οποία κατεστάλλει σημαντικά από αναστολέις των ΜΑΡ κινασών και της ΡΙ-3 κινάσης. Ο TGF-β1 (1 ng/ml) προκάλεσε επίσης χρονοεξαρτώμενη αύξηση στα επίπεδα της IL-6 γιά χρόνο επώασης μέχρι 2 ώρες, τα οποιά έμεινα σταθερά στη συνέχεια μέχρι τις 72 ώρες επώασης, επαγωγή της παραγωγής ενδοκυτταρικών ενεργών ειδών οξυγόνου (ROS) με μέγιστο σε δύο χρόνους επώασης 20 και 180 λεπτά, και ενεργοποίηση των ERK κινασών από 15-60 λεπτά επώασης, με μέγιστη ενεργοποίηση στα 30 λεπτά, και στη συνέχεια πτώση στα επίπεδα του μάρτυρα. Ενώ ο MIF σε συγκέντρωση 1-100 ng/ml προκάλεσε μικρή μείωση στην έκφραση της φωσφατάσης-1 των ΜΑΡΚ (ΜΚΡ-1), ο TGF-β1 αντίθετα, σε συγκέντρωση 1 ng/ml προκάλεσε αύξηση στην έκφραση της ΜΚΡ-1 σε δύο χρόνους επώασης 0,5 και 24 ώρες. Μετά από επώαση των ινοβλαστών ρινικού πολύποδα παρουσία TGF-β1 (1 ng/ml) και MIF (100 ng/ml) μαζί, δεν παρατηρήθηκε συνεργειακή επίδραση στην έκφραση της IL-6. Ενώ τόσο ο TGF-β1 όσο και ο MIF προκάλεσαν διέγερση στην έκφραση της IL-6 από ινοβλάστες πνεύμονα, δεν παρατηρήθηκε και πάλι συνεργειακή επίδρασή τους στην έκφραση της κυτταροκίνης αυτής. Συμπερασματικά, φαίνεται ότι ο MIF, ενώ ανταγωνίζεται την κατασταλτική επίδραση των γλυκοκορτικοειδών στην έκφραση της IL-6 μέσω της ρύθμισης των επιπέδων της ΜΚΡ-1, δεν έχει την ίδια επίδραση στην έκφραση της IL-6 από τον TGF-β1, μέσω ρύθμισης της έκφρασης της φωσφατάσης αυτής. Από την άλλη μεριά η επαγωγή της έκφρασης της ΜΚΡ-1 από τον TGF-β1 φαίνεται να μην επηρεάζει την παραγωγή της IL-6 για μικρούς χρόνους επώασης, μέχρι 2 ώρες, πιθανόν λόγω της ανασταλτικής επίδρασης των ROS, που επάγονται από τον TGF-β1, στη δράση της ΜΚΡ-1, ενώ την επηρεάζει για μεγάλους χρόνους επώασης , εξ ού και τα σταθερά επίπεδα της IL-6 μέχρι και 72 ώρες επώασης. / Nasal polyp (NP) is a chronic inflammatory condition of nasal mucosa, characterized by infiltration of inflammatory cells such as eosinophils, lymphocytes and plasma cells, alterations in epithelial differentiation and tissue reconstruction, involving hyperplasia of basal membrane, accumulation of extracellular material and edema. Macrophage migration inhibitory factor (MIF) is a unique cytokine, the role of which in chronic inflammatory and autoimmune diseases and septic shock pathogenesis is very important. MIF is produced by activated T-lymphocytes, macrophages and a plethora of other cells. MIF appears to antagonize the suppressive effect of glucocorticoids as well as induce the expression of IL-6 in multiple cells. High levels of MIF are detected in nasal polyps. Transforming growth factor- β1 (TGF-β1) is an anti-inflammatory factor antagonizing the positive effect of IL-1β and TNF-α on the expression of MMP-1 and MMP-3, TGF-β1 also stimulates the expression of TIMP-1, collagen type I and IL-6; because of these effects, TGF-β1 is involved in the process of fibrosis. TGF-β1 levels in nasal polyps are significantly elevated. IL-6 is a cytokine participating in Th2 response and consequently is involved in a subset of inflammatory reactions. IL-6 stimulates the growth of fibroblasts, increases the production and deposition of collagen and it decreases its degradation. IL-6 is found in nasal polyps at elevated levels and it is thought to be an important pathogenic factor acting mainly in tissue reconstruction, stimulation of plasma cell differentiation, production of stromal material, promotion of collagen synthesis and deposition. The purpose of this paper is to study the effect of MIF and TGF-β1 in IL-6 production by fibroblasts isolated from nasal polyps, dissect the signaling pathways involved, and investigate their synergistic effect on the production of IL-6. Both TGF-β1 (0, 01-1 ng/ml) and MIF (1-100 ng/ml) induced IL-6 expression in nasal polyp fibroblasts in a dose-dependent manner. This effect was significantly suppressed by inhibitors of MAP and PI-3 kinase pathways. TGF-β1 (1 ng/ml) also induced IL-6 expression within 2 hours of administration. Elevated IL-6 levels remained unchanged for 72h further. TGF-β1 also promoted the production of intracellular reactive oxygen species (ROS), which peaked in 20 and 180 minutes and the activation of ERK kinase, peaked in 30 minutes. While MIF, at a concentration of 1-100 ng/ml, caused a slight decrease in the expression of phospatase-1 of MAPK (MKP-1), TGF-β1, at a concentration of 1 ng/ml, increased the expression of MKP-1. No synergistic effect on IL-6 expression was detected after incubating nasal polyp and lung fibroblasts together with TGF-β1 (1 ng/ml) and MIF (100 ng/ml). In conclusion, while MIF antagonizes the suppressive effect of glucocorticoids on the expression of IL-6 by regulating the levels of MKP-1, it fails to antagonize the TGF-β1 inducing effect on IL-6 via MKP-1. The induction of MKP-1expression by TGF-β1 is not affecting the production of IL-6 after short incubation periods; this effect can be explained by the inhibitory effect of TGF-β1 induced ROS on MKP-1. After prolong incubation with TGF-β1 (up to 72 hours), IL-6 levels remain elevated.

<p>Uvod: Infertilitet pogađa 10-15% parova reproduktivnog doba. Vanetesna oplodnja (VTO) je najefikasniji vid tret-mana infertiliteta, ali uprkos značajnom napretku stopa uspeha VTO u proseku iznosi oko 30% po ciklusu. Glavnim razlogom neuspeha smatra se neadekvatan kvalitet embriona, dok se pretpostavlja da u 10-20% slučajeva razlog neuspeha leži u neadekvatnoj receptivnosti uterusa. Na osnovu inicijalnih istraživanja histeroskopija, koja predstvalja zlatni standard u dijagnostici i tretmanu patologije kavuma uterusa, se često izvodi u svakodnevnoj kliničkoj praksi kako bi se povećala uspe&scaron;nost VTO. Uprkos &scaron;irokoj primeni i dalje ne postoji dovoljno kvalitetnih dokaza o realnoj ulozi histeroskopije na ishod VTO kako kod patolo&scaron;kih stanja kavuma tako i rutinski, pre prvog ili rekurentnog poku&scaron;aja VTO. Cilj disertacije bio je da se utvrdi uticaj sprovođenja histeroskopije na ishod VTO, ustanovi učestalost prethodno neprepoznate patologije kavuma uterusa, kao i da se ispitaju stavovi pacijenata o primeni rutinske histeroskopije pred VTO. Materijal i metode: Istraživanje je sprovedeno u Kliničkom centru Vojvodine, u formi prospektivne studije u dve sukcesivne etape od 01.01.2015. do 01.04.2017. U prvoj etapi poređen je ishod VTO kod pacijentkinja kojima pred postupak VTO nije sprovedena histeroskopija (Grupa A), pacijentkinja kod kojih je dobijen uredan nalaz histeroskopije pred postupak VTO (Grupa B) i pacijentkinja gde je pred postupak VTO dobijen patolo&scaron;ki nalaz kavuma na histeroskopiji koji je u istom aktu tertian (Grupa C). Druga etapa istraživanja predstavljala je randomiziranu kontrolisanu studiju (RCT &ndash; randomised controlled trial). Nakon verifikacije urednog ultrazvučnog nalaza pred prvi postupak VTO, pacijentkinje su randomizirane u Grupu A2 kojima pred postupak VTO nije sprovedena histeroskopija i Grupu B2 kojima je pred postupak VTO sprovedena rutinska histeroskopija. Statistička analiza sprovedena je upotrebom odgovarajućeg softvera (JMP Ver. 9). Poređeni su podaci o osnovnim karakteristikama pacijenata, toka i ishoda ciklusa VTO. Primarni parametar ishoda bila je stopa kliničke trudnoće po embriotransferu. Pored analize ishoda primarno konstruisanih grupa, urađena je analiza i naknadno konstruisanih subgrupa, kao i predikcioni model uspeha VTO baziran na logističkoj regresiji. Rezultati: Studija je uključila 253 pacijentkinje (52 pacijentkinja iz Grupe A, 50 iz Grupe B, 50 iz Grupe C, 51 iz Grupe A2 i 50 iz Grupe B2). Nije postojala statistički značajna razlika u karakteristikama pacijentkinja, parametrima ovarijalne rezerve, broju dobijenih jajnih ćelija ni drugim parametrima toka postupka VTO među posmatranim grupama. U prvoj etapi istraživanja dobijena je statistički značajno (p=0,013) veća stopa kliničkih trudnoća kod pacijentkinja kojima je pred postupak VTO sprovedena histeroskopija - 50 % za Grupu B i 42% za grupu C u odnosu na 30,77% kod pacijentkinja bez histeroskopije (Grupa A), bez statistički značajne razlike među histeroskopskim grupama. U drugoj etapi istraživanja stopa kliničkih trudnoća prilikom upotrebe rutinske histeroskopije pred prvu VTO (Grupa B2) iznosila je 46% naspram 31,37% kod pacijentkinja bez histeroskopije pred prvu VTO (Grupa A2), iako uočena razlika nije dostigla statističku značajnost (p =0,089), uz relativan rizik (RR) za ostvarivanje kliničke trudnoće nakon primene histeoskopije uiznosio od 1,47 (95% CI 0,88-2,43) (p=0,13). Analizon subgrupa kod 100 pacijentkinja sa rutinski sprovedenom histeroskopijom pred VTO i 103 pacijentkinje bez histeroskopije pred VTO, dobijena je statistički značajnao veća stopa kliničkih trudnoća (48% naspram 31,07%, istim redom), uz RR od 1,54 (95% CI 1,08-2,20) (p=0,013), kao i stopa tekućih trudnoća od RR 1,49 (CI 1,01-2,19) (p= 0,039). Analiza ukupnog uticaja izvođenja histeroskopije pred VTO dobila je statistički značanjno veću stopu kliničkih trudnoća po ET za grupu histeroskopije uz RR 1,48 (CI 1,06-2,07) (p=0,017). Histeroskopijom je nakon urednog ultrazvučnog nalaza ustanovljeno postojanje patolo&scaron;kog nalaza kod 34,65% pacijenata i to 22,7% major patologije i 11,88% minor patologije kavuma. Nije postojala statistički značajna razlika u uspehu VTO u odnosu na sam nalaz histeroskopije. 98,67% pacijenata podržalo je rutinsku upotrebu histeroskopije pred prvi postupak VTO, dok je 83% pacijenata podržavlo rutinsku upotrebu histeroskopije pred svaki postupak VTO. U finalnom predikcionom modelu se uz AUC od 0,748 jedino postojanje visokokvalitetnog embriona uz odnos &scaron;ansi (OR) 7,91 (95% CI 1,80-56,06; p=0,0047), transfer blastociste uz OR 3,80 (95% CI 1,90-7,98; p=0,0001) i izvođenje histeroskopije pred VTO uz OR 2,13 (95% CI 1,14-4,08, p=0,0169) pokazalo statistički značajnim prediktorima trudnoće. Diskusija: Studija je dobila pozitivan uticaj histeroskopije na ishod postupka VTO, iskazan pre svega povećanjem stope kliničkih trudnoća nakon sprovođenja histeroskopije (bilo da je na histeroskopiji nađen uredan ili patolo&scaron;ki nalaz). Dodatna prednost histeroskopije predstavljala je i i detekcija prethodno nepropoznate patologije kavuma. Umeren efekat na ukupno pobolj&scaron;anje stope kliničkih trudnoća prilikom rutinskog sprovođenja histeroskopije pred prvu VTO, koji je statističku značajnost dostigao tek analizom subgrupa u skladu je sa nalazima novijih dobro dizajniranih studija koji donekle limitiraju nekritičku upotrebu histeroskopije. Biolo&scaron;ko obja&scaron;njenje potencijalnog pozitivnog uticaja histeroskopije najverovatnije leži u detekciji i tretmanu prethodno nepropoznate patologije kavuma, olak&scaron;avanju procedure embriotransfera, kao i humoralnim i molekularnim promenama koje nastaju u endometrijumu kao posledica odgovarajuće histeroskopske traume a koji su u dosa&scaron;anjim istraživanjima apostrofirani kao faktori koji mogu povećati receptivnost uterusa. Zaključak: Histeroskopija je efikasna, bezbedna i visoko prihvatljiva procedura koja dovodi do povećanja uspeha VTO u standardnim kliničkim indikacijama (prethodnog neuspelog postupka VTO i sumnje na patolo&scaron;ki nalaz kavuma uterusa) bilo da se na samoj histeroskopiji nađe uredan ili patolo&scaron;ki nalaz. Rutinska primena histeroskopije pred prvi postupak VTO se na osnovu rezultata studije ne može smatrati apsolutno opravdanom usled statistički nedovoljno značajnog povećanja stope kliničke trudnoće. Uzev&scaron;i u obzir visoku prihvatljivost od strane pacijenata i najverovatniji pozitivan efekat na stopu trudnoće primena rutinske histeroskopije pred prvu VTO bila bi opravdana ukoliko se implementira koncept ambulantne histeroskopije.</p> / <p>Introduction: Infertility affects 10-15% of all couples. In vitro fertilisation (IVF) is the most effective method of infertility treatment, but despite a significant improvement, success rate of IVF is still around 30% per cycle. The main reason for the IVF failure is inadequate embryo quality, but in 10-20% of cases the cause of IVF failure lies in impaired uterine receptivity. Based on earlier studies hysteroscopy, gold standard in the diagnosis and treatment of uterine cavity pathology, is often performed to increase IVF success. Despite its wide use, there is lack of high quality evidence regarding real contribution of hysteroscopy on IVF outcome in situations of uterine cavity pathology or routinely prior to first IVF or after recurrent implantation failure. The aim of this dissertation was to determine the influence of performing hysteroscopy on IVF outcome, as well as the incidence of previously unrecognized uterine pathology, and to examine patient&#39;s attitudes about performing routine hysteroscopy prior to IVF. Material and methods: The research was conducted in a prospective manner in two successive stages at Clinical Center of Vojvodina from 01.01.2015. until 01.04.2017. During first stage of the study IVF outcome was compared between patients who did not have a hysteroscopy prior to IVF (group A), patients with normal hysteroscopic finding prior to the IVF (Group B) and patients with abnormal hysteroscopic findings prior to IVF which was treated at the same time (Group C). The second stage of the study was a randomized controlled trial (RCT). After verification of normal ultrasound findings prior to the first IVF, patients were randomized to group A2 in who me hysteroscopy was not performed and group B2 who had routine hysteroscopy prior to first IVF. Statistical analysis was carried out using the appropriate statistical software (JMP Ver. 9). Patient characteristics, course and outcome of IVF cycle were compared between groups. The primary outcome was clinical pregnancy rate (CPR) per embryotransfer. In addition to analyzing the IVF outcomes in primarily defined groups, subgroup analysis was also performed, as well as IVF success pre-diction model based on logistic regression. Results: The study included 253 patients (52 patients in Group A, 50 in Group B, 50 in Group C, 51 in Group A2 and 50 in Group B2). There was no statistically significant difference in patient characteristics, ovarian reserve parameters, number of retrieved oocytes, or other relevant parameters of IVF course between the observed groups. In the first stage of the study there was statistically significant (p = 0.013) higher clinical pregnancy rate in patients who had a hysteroscopy before IVF - 50% for Group B and 42% for group C versus 30,77 % in patients without hysteroscopy before IVF (Group A), without statistically significant difference between hysteroscopic groups. In the second stage of the study, routine hysteroscopy prior to first IVF (Group B2) led to clinical pregnancy rate 46% versus 31.37% in patients without hysteroscopy prior to first IVF (Group A2), although without statistical significance (p = 0.089. Relative risk (RR) for achieving clinical pregnancy after performing hysteroscopy was 1.47 (95% CI 0.88-2.43) (p = 0.13). Subgroup analysis of 100 patients with routinely performed hysteroscopy before IVF and 103 patients without hysteroscopy prior to the IVF showed statistically significant higher rates of clinical pregnancies (48% versus 31.07%, in the same order), with RR of 1.54 (95% CI 1.08-2.20), (p = 0.013), and for ongoing pregnancies RR was 1.49 (95% CI 1.01-2.19) (p = 0.039). Overall effect of performing hysteroscopy prior to IVF resulted in a statistically significant increase in the clinical pregnancy with RR 1.48 (95% CI 1.06-2.07) (p = 0.017). After normal ultrasound finding hysteroscopy revealed 34.65% of pathological finding, 22.7% of major and 11.88% of minor pathology of the cavity). There was no statistically significant difference in IVF outcome based on hysteroscopy findings. 98.67% of patients supported the routine use of hysteroscopy before the first IVF procedure, while 83% of patients supported the routine use of the hysteroscopy before every IVF procedure. In the final prediction model, with the AUC of 0.748, only the presence of high quality embryos with odds ratio (OR) 7,91 (95% CI 1,80-56,06; p=0,0047), blastocyst transfer with OR 3,80 (95% CI 1,90-7,98; p=0,0001) and performing hysteroscopy prior to IVF with OR 2,13 (95% CI 1,14-4,08, p=0,0169) proved to be statistically significant predictors of pregnancy. Discussion: The study shoved a positive influence of hysteroscopy on the IVF outcome by increasing clinical pregnancy rate after performing hysteroscopy (whether hysteroscopy revealed normal or pathological finding). Additional benefit of hysteroscopy was detection of previously unrecognized uterine pathology. A moderate effect on the overall improvement in clinical pregnancy rate with use of routine hysteroscopy, which reached statistical significance only by subgroup analysis, is in line with findings of recent well designed studies that somewhat limit the noncritical use of hysteroscopy. A biological explanation of the potential positive effect of hysteroscopy is most likely due to detection and treatment of the previously unrecognized uterine pathology, facilitating embryotransfer procedure, as well as the humoral and molecular changes that occur in the endometrium as a consequence of the hysteroscopic trauma. Those changes were hypothesized as factors that can increase uterine receptivity by numerous research. Conclusion: Hysteroscopy is an effective, safe and highly acceptable procedure that increases IVF success when performed for accepted clinical indications (previous IVF failures, pathological findings of uterine cavity), whether hysteroscopy reveals normal or pathological finding. The routine use of hysteroscopy prior to first IVF based on this study can not be considered justified since increase in clinical pregnancy rate did not reach statistical significance. Given the high acceptance of this concept by the patients and moderate but probable positive effect on IVF outcome, implementation of routine hysteroscopy prior to first VTO would be justified only in office hysteroscopy setting.</p>

Στην παρούσα διατριβή μελετήθηκε η έκφραση του παράγοντα αναστολής της μετανάστευσης των μακροφάγων (MIF) στον ιστό από ρινικό πολύποδα αλλά και στον φυσιολογικό ρινικό βλεννογόνο, καθώς και η ικανότητα αυτού να εξουδετερώνει την ανασταλτική δράση των γλυκοκορτικοειδών (ΓΚ) στην επαγόμενη από διάφορους αυξητικούς παράγοντες παραγωγή διαμεσολαβητών, όπως η IL-6 η MMP-1, η MMP-3 το κολλαγόνο τύπου-Ι και ο TIMP-1, που εμπλέκονται στη παθογένεια του ρινικού πολύποδα (ΡΠ). Ο MIF ανιχνεύθηκε στο μέσο καλλιέργειας όλων των ιστών και σε όλα τα εκχυλίσματα. Η έκφρασή του ήταν αυξημένη στον ρινικό πολύποδα σε σχέση με τον φυσιολογικό ρινικό βλεννογόνο. O TGF-β1 προκάλεσε δοσο- και χρονο-εξαρτώμενη αύξηση των επιπέδων της IL-6 του TIMP-1 και του κολλαγόνου τύπου-Ι, και παράλληλα ο TNF-α προκάλεσε δοσο- αλλά και χρονο-εξαρτώμενη διέγερση στην παραγωγή της IL-6 του TIMP-1 και των μεταλλοπρωτεασών MMP-1 και MMP-3. Η δεξαμεθαζόνη προκάλεσε στατιστικά σημαντική και δοσοεξαρτώμενη μείωση της επαγόμενης από τον TGF-β1 και TNF-α, παραγωγής της IL-6 του TIMP-1 του κολλαγόνου τύπου-Ι και των μεταλλοπρωτεασών MMP-1 και MMP-3. Διερευνώντας τον μηχανισμό μέσω του οποίου η δεξαμεθαζόνη ασκεί την κατασταλτική της δράση στην επαγόμενη τόσο από τον TGF-β1 όσο και από τον TNF-α, παραγωγή της IL-6, φάνηκε πως αυτή εκδηλώνεται κυρίως μέσω της επαγωγής αλλά και της προστασίας της ΜΚΡ-1 και κατά συνέπεια της καταστολής του μονοπατιού των ΜΑΡΚ και της ενεργοποίησης του ΑΡ-1, και λιγότερο μέσω της καταστολής της ενεργοποίησης του NF-κB. Ο ISO-1, ένας αναστολέας της δράσης του MIF, ενίσχυσε σημαντικά την κατασταλτική επίδραση της δεξαμεθαζόνης στα επίπεδα της IL-6 και του TIMP-1 στο μέσο καλλιέργειας ιστού από ΡΠ, ενώ αντίθετα προκάλεσε αναστροφή της κατασταλτικής δράσης της δεξαμεθαζόνης, η οποία ήταν στατιστικά σημαντική για την ΜΜΡ-1 όχι όμως και για την ΜΜΡ-3. Η ενίσχυση της κατασταλτικής δράσης της δεξαμεθαζόνης παρουσία του ISO-1, που κυμάνθηκε από 15.0% έως 20.5% θα πρέπει μάλλον να οφείλεται στην αναστολή του ενδογενούς MIF από τον ISO-1. Συμπερασματικά, η παρουσία του MIF στον ιστό του ρινικού πολύποδα, φαίνεται να εξασθενίζει το κατασταλτικό αποτέλεσμα της δεξαμεθαζόνης στην παραγωγή IL-6 και TIMP-1 από αυτόν τον ιστό, ενώ η ταυτόχρονη χρήση του αναστολέα του MIF, ISO-1 οδηγεί σε μια περαιτέρω ενίσχυση της κατασταλτικής δράσης της δεξαμεθαζόνης. Έτσι, είναι λογικό κατ΄αρχήν, να προταθεί πως η δημιουργία ενός φαρμακευτικού σχήματος που περιέχει κορτιζόλη και ένα αναστολέα του MIF, θα μπορούσε να είναι πιο αποτελεσματικό στην θεραπεία της ΡΠ. Απαιτούνται περαιτέρω πειράματα με συνδυασμό ΓΚ και αναστολέων του MIF για να μελετηθεί η επίδρασή τους στη παραγωγή και άλλων παραγόντων που εμπλέκονται στη παθογένεια της ΡΠ προκειμένου να εξαχθούν ασφαλέστερα συμπεράσματα. / In the present study we investigated the expression of macrophage migration inhibitory factor (MIF) in nasal polyp tissues and also in normal nasal mucosa. The ability of MIF to neutralize the inhibitory effect of glucocorticoids on various growth factors induced expression of IL-6, TIMP-1, collagen type-I and matrix metalloproteinases MMP-1 and MMP-3, involved in the pathogenesis of nasal polyps, was studied. MIF was detected in all polyp tissue extracts and tissue culture conditioned media and its expression was increased in nasal polyps compared with normal nasal mucosa. TGF-b1 caused a dose-and time-dependent increase in levels of IL-6 of TIMP-1 and collagen type-I, while the TNF-a induced a dose-and time-dependent stimulation in the production of IL-6 of TIMP-1 and metalloproteinases MMP-1 and MMP-3. Dexamethasone caused a statistically significant and dose-dependent reduction induced by TGF-b1 and TNF-a, production of IL-6 of TIMP-1 of collagen type-I and the metalloproteinases MMP-1 and MMP-3. Investigating the mechanism by which dexamethasone exercises the suppressive action on both induced by TGF-b1 and by TNF-a, production of IL-6, showed that this occurs mainly through the induction and protection of MKP-1 and hence the suppression of the MAPK pathway and activation of AP-1, and less through the suppression of the activation of NF-kB. The ISO-1, an inhibitor of the action of MIF, significantly enhanced the suppressive effect of dexamethasone on the levels of IL-6 and TIMP-1 in tissue culture medium from nasal polyps. In contrary, ISO-1 induced inversion of the suppresive action of dexamethasone, which was statistically significant for MMP-1 but not for MMP-3. Enhancing of the suppresive action of dexamethasone in the presence of ISO-1, which ranged from 15.0% to 20.5% would probably be due to inhibition of endogenous MIF by ISO-1. In conclusion, the presence of MIF in nasal polyp tissue, appears to attenuate the suppressor effect of dexamethasone on the production of IL-6 and TIMP-1by this tissue, while simultaneously using the inhibitor of MIF, ISO-1 leads to an enhancement of dexamethasone activity. Therefore, it is reasonable to propose that the creation of a pharmaceutical regimen containing cortisol and an inhibitor of MIF, might be more effective in the treatment of nasal polyposis. Of course, requires further experiments with a combination of glucocorticoids and MIF inhibitors to study their effect on production of other factors involved in the pathogenesis of nasal polyposis in order to draw safer conclusions.

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