Résumé : Aux soins intensifs (SI), une diminution du décompte plaquettaire peut avoir un impact important. Des études ont démontré une association entre la thrombopénie et la durée de séjour, les saignements, les transfusions et la mortalité. Les facteurs qui prédisent une thrombopénie varient selon les populations étudiées. Les médicaments sont souvent suspectés, mais peu ont été indépendamment associés à la thrombopénie aux SI. Les études publiées à ce jour souffrent de plusieurs limites. Les objectifs de cette thèse étaient de décrire l’épidémiologie, identifier les facteurs de risque associés, d’évaluer l’impact sur la morbidité et la mortalité et d’évaluer les causes indépendantes médicamenteuses de thrombopénie aux SI. Une cohorte rétrospective a été créée à partir de données administratives et cliniques afin de décrire l’épidémiologie, et d’évaluer les facteurs prédictifs et les conséquences de la thrombopénie aux SI. Par la suite, une étude cas-témoin a été entreprise en sélectionnant les patients qui ont souffert d’une thrombopénie de cause indéterminée afin de déterminer les associations entre les médicaments fréquemment utilisés aux SI et la thrombopénie. Un total de 20 711 patients a été inclus dans l’analyse. La prévalence et l’incidence de thrombopénie ont été de 13,3% et 7,8%, respectivement. La thrombopénie a été indépendamment associée à une augmentation des saignements majeurs (aRC 1,32 95% CI 1,20-1,46). Après des ajustements statistiques, la thrombopénie était associée à une augmentation de mortalité (aRC 1,25 IC95% 1,20-1,31). L’impact sur la mortalité a été le plus important dans les catégories d’admission suivantes: cancer, respiratoire, digestif, génito-urinaire et infectieuses. Les facteurs de risque indépendants suivants ont été identifiés: l’âge, le genre masculin, la ventilation mécanique, l’alcoolisme, la cirrhose hépatique, le décompte plaquettaire à l’admission, l’hypersplénisme, le ballon intra-aortique, le choc septique, l’hépatite aiguë, la chirurgie de pontage coronarien et les maladies thromboemboliques. Dans l’étude cas-témoin, 200 cas de thrombopénie ont été identifiés après l’exclusion des maladies fortement associées. Ces cas ont été appariés à 200 témoins admis dans la même année. Parmi les 15 classes de médicaments évalués, seules les quinolones 1,67 (IC95% 1,00-2,87) ont été indépendamment associées à la thrombopénie dans le modèle final. En conclusion, la thrombopénie est indépendamment associée à une hausse de la mortalité qui varie grandement selon la catégorie d’admission. Les facteurs de risque sont nombreux et incluent des facteurs modifiables. Bien que les médicaments soient fréquemment soupçonnés, seules les quinolones semblent être associées à la thrombopénie aux SI. // Abstract : In the intensive care unit, a reduction in platelet counts can have a major impact on patient outcomes. Studies have showed an association between thrombocytopenia and length of stay, bleeding, blood product administration and mortality. Predictors of thrombocytopenia in the intensive care setting vary according to studies. Although medications are often suspected as potential causes, few have been independently associated with thrombocytopenia. In addition, published studies have many limits including small sample sizes, probable residual confounding, and inclusion of invasive interventions. The objectives of the thesis are to describe the epidemiology of thrombocytopenia, identify its risk factors, evaluate its impact on morbidity and mortality, and evaluate the drug-induced causes of thrombocytopenia. A retrospective cohort was created using administrative and clinical data. In the first study, multivariate analysis was used to identify risk factors. In the second study, a case control strategy was used to determine the association between thrombocytopenia and drugs commonly used in the intensive care unit previously associated with thrombocytopenia. A total of 20 711 patients were included in the analysis. The prevalence and incidence of thrombocytopenia defined as a platelet count below 100 x 10[superscript 9]/L were 13.3% and 7.8%, respectively. Thrombocytopenia was independently associated with an increase in the risk of major bleeding (aOR 1.32 95% CI 1.20-1.46). After adjusting for confounders, thrombocytopenia was associated with an increased risk of hospital mortality (aOR 1.25 IC95% 1.20-1.31). The impact of thrombocytopenia on mortality was the most important in the following diagnostic categories: cancer, respiratory, digestive, genitourinary, and infectious. The following independent risk factors were identified: age, male gender, admission platelet counts, mechanical ventilation, alcoholism, liver cirrhosis, hypersplenism, intra aortic balloon pumps, septic shock, acute hepatitis, coronary bypass surgery and venous thromboembolism. In the case control study, 200 cases were identified after exclusion of patients with diseases strongly associated with thrombocytopenia and paired with 200 controls admitted in the same year. Among the 15 medication classes evaluated, only quinolones 1.67 (IC95% 1.00-2.87) were independently associated with thrombocytopenia. In conclusion, thrombocytopenia is independently associated with an increased risk of mortality, which varies according to diagnostic admission categories. Risk factors are numerous and some are modifiable. Although medications are often suspected, only quinolones were statistically associated with thrombocytopenia.

Introdução: O sangramento por queda de escara é uma complicação potencialmente letal da ligadura elástica (LE) de varizes de esôfago. Os fatores relacionados a esse evento são pouco explorados na literatura, porém a coagulopatia, principalmente a plaquetopenia, do paciente com cirrose poderia estar implicada. O número e a função plaquetária têm particular relevância na manutenção da hemostasia, uma vez que a geração de trombina depende fortemente desses parâmetros. Entretanto, dados demonstram a preservação da função plaquetária como consequência de mecanismos compensatórios representados, principalmente, pelo aumento dos níveis do fator de von Willebrand (FVW) e diminuição de ADAMTS13. Deste modo, os pontos de corte para contagem plaquetária utilizados na prática clínica não refletiriam o risco de sangramento após procedimentos. Objetivos: O objetivo desse estudo foi descrever a função plaquetária em pacientes com cirrose e a sua influência no sangramento após LE de varizes de esôfago. Pacientes e Métodos: 1) Casuística. Foram incluídos pacientes com diagnóstico de cirrose, de diferentes etiologias, encaminhados para realização de LE como profilaxia primária ou secundária de sangramento por varizes de esôfago. Os critérios de inclusão foram: a) idade acima de 18 anos; b) pacientes com cirrose e varizes de esôfago com indicação de ligadura elástica eletiva e c) concordância em participar do estudo. Os critérios de exclusão foram: a) doenças pulmonares e cardíacas graves; b) carcinoma hepatocelular; c) insuficiência renal com uremia ou dialítica; d) uso de qualquer droga que interfere na coagulação. 2) Métodos. Imediatamente antes da realização da endoscopia digestiva com LE, foi coletada amostra de sangue de cada paciente para a realização dos seguintes testes: contagem de plaquetas, testes relacionados à função plaquetária (adesão e agregação medida pela superfície coberta (SC) com valor de referência: > 7,5% e tamanho do agregado (AS) com valor de referência: > 25um² pela tecnologia Impact- R®), antigeno de FVW (referência: 40-157%), atividade de FVW (referência: 38- 176%), proteinase ADAMTS13 (referência: 40-130%), P-selectina por citometria (34,9±2,32%) e P-selectina solúvel (92-212ng/mL). Os pacientes foram estratificados de acordo com número de plaquetas. O grau de comprometimento da função hepática foi avaliado pelos estadiamentos de Child-Pugh e MELD. O desfecho primário do estudo foi a ocorrência do sangramento atribuído à queda da escara da LE. Resultados: Foram incluídos 111 pacientes, divididos em três grupos: A) plaquetas < 50x10³/mm³ (n = 38; 34,2%); B) plaquetas entre 50x10³/mm³ e 100x10³/mm³ (n = 47; 42,4%) e C) plaquetas > 100x10³/mm³ (n = 26; 23,4%). Os três grupos não diferiram significativamente em relação aos seguintes parâmetros: gênero, etiologia e grau de disfunção hepática. Na comparação entre os grupos, os parâmetros hemoglobina e bilirrubina foram significantemente maior no grupo B (p=0,04 e p=0,009, respectivamente). Nos testes relacionados à função plaquetária, encontramos no Impact-R®, SC de 7 ± 4% e AS de 52 ± 24?m2. Na avaliação do FVW o valor encontrado foi de 369 ± 157% para o antígeno e 336 ± 149% para atividade. ADAMTS13 apresentou resultado 73 ± 24%. Na comparação entre os grupos: o parâmetro Impact-R® SC foi no grupo A: 4,9 ± 3%, no grupo B: 7,7 ± 4,6% e 9,1 ± 3,6 no grupo C (p < 0,005). O AS foi de 49,9 ± 22,4% no grupo A, no grupo B foi 55,1 ± 26,6% e 51,3 ± 20 no grupo C (p=0,599). Os outros parâmetros específicos relacionados à função plaquetária não foram significantes: o antígeno do FVW com p=0,926, a atividade do FVW com p=0,870 e ADAMTS13 com p=0,080. O resultado da P-selectina por citometria de fluxo foi de 37,8 ± 23% e P-selectina solúvel foi 182,3 ± 86 ng/mL. A maioria dos pacientes (58,5%) realizaram LE como profilaxia primária. A presença de sinais vermelhos ocorreu em 74% e a gastropatia hipertensiva foi vista em 95% dos pacientes. Houve sangramento após LE em seis (5,4%) pacientes, sendo duas ocorrências no grupo A, uma no grupo B e três no grupo C (p=0,316). O valor médio do MELD foi 13 ± 3,6, sendo 12,6 ± 3,3 no grupo sem sangramento e 16 ± 5,9 no grupo sem sangramento (p=0,025). Quando comparados os pacientes sem e com sangramento não encontramos diferença estatisticamente significante em nenhum parâmetro de função plaquetária. Conclusões: Os resultados dos testes de adesão e agregação plaquetária: SC e AS; FVW e ADAMTS13 demonstraram compensação funcional a despeito da plaquetopenia e não se correlacionaram com o risco de sangramento após LE de varizes de esôfago. O MELD foi significantemente maior nos pacientes que sangraram / Introduction: Bleeding caused by ulceration after band ligation of esophageal varices is a potentially fatal complication. Contributing factors to this event are little explored in the literature, although coagulopathy, principally thrombocytopenia, in patients with cirrhosis could be implicated. The number and function of platelets has particular relevance to the maintenance of hemostasis, since thrombin generation depends heavily on these parameters. However, data show that the preservation of platelet function is a consequence of compensatory mechanisms represented principally by an increase in von Willebrand factor (VWF) levels and a reduction in ADAMTS13. Because of this, the cutoff points for platelet count used in routine clinical practice do not reflect the risk of bleeding following invasive procedures. Objective: The aim of this study was to describe platelet function in patients with cirrhosis and its influence on the bleeding following band ligation of esophageal varices. Methodology: 1) Inclusion. Patients with cirrhosis of different etiologies, referred for band ligation as primary or secondary prophylaxis of bleeding from esophageal varices were included. Inclusion criteria were: a) age > 18 years; b) patients with cirrhosis and esophageal varices elegible for elective band ligation; c) agreement to participate in the study. The exclusion criteria were: severe pulmonary or cardiovascular disease; b) hepatocellular carcinoma; c) renal dysfunction with uremia or requiring dialysis; d) use of any medication that could interfere with coagulation. 2) Methods. Immediately prior to digestive endoscopy with band ligation, a blood sample was taken from each patient to carry out the following coagulation tests: platelet count, platelet function test (adhesion and aggregation measured as surface coverage (SC) with normal range: > 7.5% and aggregate size (AS) with normal range: > 25um² by Impact-R® technology), antigen of VWF (normal range: 40- 157%), activity of VWF (normal range: 38-176%), protease ADAMTS13 (normal range: 40-130%), P-Selectin by cytometry (34.9±2.32%) and soluble P-Selectin (92- 212ng/mL). The degree of hepatic function was staged according to Child-Pugh and MELD. The principal clinical event assessed by the study was the occurrence of post-banding bleeding. Results: 111 patients were included in the study, divided into three groups: A) platelet count < 50x10³/mm³ (n=38; 34.2%); B) platelet count between 50x10³/mm³ and 100x10³/mm³ (n=47; 42.4%); and C) platelet count > 100x10³/mm³ (n=26; 23.4%). The three groups did not differ significantly in relation to the following parameters: gender, cirrhosis etiology and degree of hepatic dysfunction. The comparison among groups showed that the parameters hemoglobin and bilirubin were significantly higher in group B (p=0.04 and p=0.009, respectively). With regards to platelet function, in Impact-R® the mean SC was 7 ± 4%; in group A was 4.9 ± 3%, in group B was 7.7 ± 4.6% and 9,1 ± 3,6 in group C (p < 0.005). The AS was 52 ± 24?m2; in group A was 49.9 ± 22.4%, in group B was 55.1 ± 26.6% and 51.3 ± 20 in group C (p=0.599). The mean VWF value was 369 ± 157% for antigen and 336 ± 149% for activity. ADAMTS13 activity values were 73 ± 24%. The comparison among groups showed that the other specific parameters for platelet function were not significant: VWF antigen with p=0.926, VWF activity with p=0.870 and ADAMTS13 with p=0.080. The result of P-Selectin by flow cytometry was 37.8 ± 23% and soluble P-Selectin was 182.3 ± 86ng/mL. The majority of patients (58.5%) underwent band ligation as primary prophylaxis. Red signs appeared in 74%, and hypertensive gastropathy was seen in 95% of patients. There was bleeding following band ligation in 6 (5.4%) of patients, with 2 occurring in group A, 1 in group B, and 3 in group C (p=0.316). The mean MELD score was 13 ± 3.6, with 12.6 ± 3.3 in the group without bleeding, and 16 ± 5.9 in the group with bleeding (p=0.025). When patients with bleeding were compared with those without, there was no statistically significant difference in any parameter for platelet function. Conclusions: The results of the platelet function test SC and AS; VWF and ADAMTS13 tests showed functional compensation for thrombocytopenia, and did not correlate with the risk of bleeding following band ligation of esophageal varices. The MELD score was significantly higher in patients who suffered bleeding

O eritrovírus humano (parvovírus), gênero Erytrovírus, é o único representante da família Parvoviridae responsável por um amplo espectro de doenças. Estudos recentes têm demonstrado variações entre o eritrovírus e orientam a reclassificação destas variantes em três genótipos distintos: genótipos 1, 2 e 3. O papel do eritrovírus na etiopatogenia de doenças hematológicas em humanos permanece incerto. Este estudo teve como objetivo principal avaliar a relação etiopatogênica dos genótipos do eritrovírus e as citopenias de origem desconhecida. Materiais e Métodos: Participaram do estudo 285 indivíduos procedentes do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Destes, 120 apresentavam citopenias de origem desconhecida (grupo 1 Casos), 45 eram doadores de medula óssea (grupo 2 Controles Saudáveis) e 120 eram pacientes com doenças oncohematológicas crônicas (grupo 3 Controles com Neoplasias Hematológicas). A pesquisa do vírus foi realizada pelo método de semi-nested PCR (Reação em Cadeia da Polimerase) em amostras de medula óssea e de sangue periférico. As fitas complementares foram seqüenciadas diretamente do produto da PCR. Amostras de plasma de todos os indivíduos incluídos no estudo foram testadas para presença de anticorpos IgG e IgM específicos contra o eritrovírus por ensaio imunoenzimático. Resultados: Dos 40 indivíduos com resultado positivo na PCR em amostra da medula óssea, o genótipo 1 foi encontrado em 22 (55%), o genótipo 2 em 5 (12,5%), o genótipo 3 em 13 (32,5%). Quando comparadas as freqüências de positividade entre os casos e controles (Grupo 1 VS Grupos 2 e 3), não encontramos diferença significativa com relação ao genótipo 1 (p=0, 192) nem com relação aos genótipos 2 e 3 (p= 0.143). A soroprevalência encontrada na amostra foi de 71%. Conclusão: Concluímos que a infecção isolada pelo eritrovírus, independente do genótipo encontrado, não tem relação etiopatogênica com as citopenias de origem desconhecida, uma vez que o vírus foi encontrado com a mesma freqüência nos casos e nos controles estudados / The human erythrovirus (parvovirus), genus Erytrovirus, is the only representative of the family Parvoviridae responsible for a broad spectrum of diseases. Recent studies have shown variations within the erythrovirus and guide the classification of these variants in three distinct genotypes: genotypes 1, 2 and 3. The role of the erythrovirus in the etiopathogenesis of hematological diseases in humans remains uncertain. This studys main objective was to evaluate the etiopathogenic relationship between the genotypes of the erythrovirus and the cyptopenias of unknown origins. Methods and Materials: 285 individuals coming from the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo participated in the study. Of these, 120 represented cytopenias of unknown origins (group one Cases), 45 were bone marrow donors (group two - Healthy Controls), and 120 were patients with chronic oncohematological diseases (group three Controls with Hematological Disorder). The research of the virus was done through the semi-nested PCR method (polymerase chain reaction) in bone marrow and peripheral blood samples. The complementary strands were sequenced directly from the product of the PCR. Plasma samples from all of the individuals included in the study were tested through immunosorbent assay for the presence of lgG and IgM antibodies specific to the eritrovírus. Results: Of the 40 individuals that had positive PCR bone marrow results, the genotype 1 was found in 22 (55%), the genotype 2 in 5 (12.5%), and genotype 3 in 13 (32.5%). When the frequency of positivity was compared between the cases and the controls (Group 1 vs. Groups 2 and 3), we did not find a significant difference in relation to genotype 1 (p=0.192), nor did we find a significant difference in relation to genotypes 2 and 3 (p=0.143). The overall seroprevalence found in the samples was 71%. Conclusion: We conclude that the infection isolated by the erytrovirus, independent of the genotype found, does not have a etiopathogenic relationship with the cytopenias of unknown origins, hence the virus was found with the same frequency in the cases and the controls studied

O eritrovírus humano (parvovírus), gênero Erytrovírus, é o único representante da família Parvoviridae responsável por um amplo espectro de doenças. Estudos recentes têm demonstrado variações entre o eritrovírus e orientam a reclassificação destas variantes em três genótipos distintos: genótipos 1, 2 e 3. O papel do eritrovírus na etiopatogenia de doenças hematológicas em humanos permanece incerto. Este estudo teve como objetivo principal avaliar a relação etiopatogênica dos genótipos do eritrovírus e as citopenias de origem desconhecida. Materiais e Métodos: Participaram do estudo 285 indivíduos procedentes do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Destes, 120 apresentavam citopenias de origem desconhecida (grupo 1 Casos), 45 eram doadores de medula óssea (grupo 2 Controles Saudáveis) e 120 eram pacientes com doenças oncohematológicas crônicas (grupo 3 Controles com Neoplasias Hematológicas). A pesquisa do vírus foi realizada pelo método de semi-nested PCR (Reação em Cadeia da Polimerase) em amostras de medula óssea e de sangue periférico. As fitas complementares foram seqüenciadas diretamente do produto da PCR. Amostras de plasma de todos os indivíduos incluídos no estudo foram testadas para presença de anticorpos IgG e IgM específicos contra o eritrovírus por ensaio imunoenzimático. Resultados: Dos 40 indivíduos com resultado positivo na PCR em amostra da medula óssea, o genótipo 1 foi encontrado em 22 (55%), o genótipo 2 em 5 (12,5%), o genótipo 3 em 13 (32,5%). Quando comparadas as freqüências de positividade entre os casos e controles (Grupo 1 VS Grupos 2 e 3), não encontramos diferença significativa com relação ao genótipo 1 (p=0, 192) nem com relação aos genótipos 2 e 3 (p= 0.143). A soroprevalência encontrada na amostra foi de 71%. Conclusão: Concluímos que a infecção isolada pelo eritrovírus, independente do genótipo encontrado, não tem relação etiopatogênica com as citopenias de origem desconhecida, uma vez que o vírus foi encontrado com a mesma freqüência nos casos e nos controles estudados / The human erythrovirus (parvovirus), genus Erytrovirus, is the only representative of the family Parvoviridae responsible for a broad spectrum of diseases. Recent studies have shown variations within the erythrovirus and guide the classification of these variants in three distinct genotypes: genotypes 1, 2 and 3. The role of the erythrovirus in the etiopathogenesis of hematological diseases in humans remains uncertain. This studys main objective was to evaluate the etiopathogenic relationship between the genotypes of the erythrovirus and the cyptopenias of unknown origins. Methods and Materials: 285 individuals coming from the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo participated in the study. Of these, 120 represented cytopenias of unknown origins (group one Cases), 45 were bone marrow donors (group two - Healthy Controls), and 120 were patients with chronic oncohematological diseases (group three Controls with Hematological Disorder). The research of the virus was done through the semi-nested PCR method (polymerase chain reaction) in bone marrow and peripheral blood samples. The complementary strands were sequenced directly from the product of the PCR. Plasma samples from all of the individuals included in the study were tested through immunosorbent assay for the presence of lgG and IgM antibodies specific to the eritrovírus. Results: Of the 40 individuals that had positive PCR bone marrow results, the genotype 1 was found in 22 (55%), the genotype 2 in 5 (12.5%), and genotype 3 in 13 (32.5%). When the frequency of positivity was compared between the cases and the controls (Group 1 vs. Groups 2 and 3), we did not find a significant difference in relation to genotype 1 (p=0.192), nor did we find a significant difference in relation to genotypes 2 and 3 (p=0.143). The overall seroprevalence found in the samples was 71%. Conclusion: We conclude that the infection isolated by the erytrovirus, independent of the genotype found, does not have a etiopathogenic relationship with the cytopenias of unknown origins, hence the virus was found with the same frequency in the cases and the controls studied

Ehrlichia canis e Anaplasma platys são parasitas de células sanguíneas transmitidos por carrapatos de larga distribuição mundial. O objetivo deste trabalho foi detectar a presença de E. canis e A. platys em cães naturalmente infectados no município de Porto Alegre, RS, Brasil, através de técnicas sorológicas e moleculares; realizar análise molecular dos agentes através do sequenciamento de um fragmento do gene 16S rRNA e compará-lo com sequências disponíveis no Genbank. Adicionalmente, avaliamos os parâmetros hematológicos e possíveis fatores de risco associados à infecção. Amostras de sangue foram coletadas de 146 cães residentes no Bairro Arquipélago, região suburbana de Porto Alegre e 53 cães mantidos no Centro de Controle de Zoonoses (CCZ). Dentre os animais analisados, 27 (13,56%) apresentaram resultado positivo na nPCR e 20 (10,2%) apresentaram sorologia positiva para A. platys. Através da ferramenta BLASTn, as sequências obtidas neste estudo foram comparadas e mostraram similaridade de 99,75% a 100% em relação a outras sequências de A. platys disponíveis no Genbank. Neste estudo não foi observada a presença de E. canis. DNA do agente não foi amplificado em nenhuma das amostras analisadas através de técnicas moleculares, e tampouco foram detectados cães sororreagentes, indicando a baixa prevalência do agente no município. Ao comparar a prevalência de infecção/exposição entre as populações estudadas, não observamos diferença significativa entre elas. Não foram observadas diferenças significativas nos parâmetros hematológicos e fatores de risco analisados nos animais infectados ou expostos, exceto a contagem de basófilos, que foi associada positivamente com infecção por A. platys. / Erlichia canis and Anaplasma platys are tick borne disease which has a worldwide geographic distribution. The aim of this study was to detect the presence of E. canis and A. platys in naturally infected dogs in Porto Alegre/RS – Brazil by serological and molecular techniques, performing molecular analysis of the agents by sequencing of a fragment of the 16S rRNA and comparing it with sequences available in Genbank. Additionally, we evaluated the hematological parameters and potential risk factors associated with infection. Blood samples were collected from 146 dogs living in the Arquipelago neighborhood, a suburban area of Porto Alegre and 53 dogs from Control Centrer of Zoonosis (CCZ). Among the examined animals, 27 (13.56%) were positive by nPCR and 20 (10.2%) were seropositive for A. platys. Through the BLASTn, the sequences obtained in this study were compared and showed similarity of 99.75% to 100% as compared to other sequences of A. platys available in Genbank. None of the dogs showed antibodies or E. canis DNA, indicating the low occurrence of the agent in Porto Alegre. There were no significant differences between positive groups and hematological parameters, or among the risk factors evaluated, except basophils count was associated with A. platys infection.

Echinacea is an herbal supplement commonly used as an immune system stimulant to prevent infections, such as the common cold or flu. Echinacea has been documented as a cyctochrome P450 (CYP) 3A4 inhibitor in vitro, but no formal studies have been conducted in humans. Etoposide is a cytotoxic, topoisomerase II inhibitor, chemotherapeutic agent used in the treatment of lung cancer. Etoposide is primarily metabolized by CYP 3A4. We report the first possible drug–herbal interaction between Echinacea and etoposide. A 61-year-old gentleman newly diagnosed with nonsmall cell lung cancer began concurrent chemoradiation with cisplatin and etoposide. He was admitted to the hospital on day 8 of his first cycle and found to be thrombocytopenic. His platelet count eventually reached a nadir of 16 × 103/L, requiring platelet transfusion support. Upon admission, it was discovered he was taking Echinacea, which was discontinued. He received his next cycle of chemotherapy without taking Echinacea. His platelet count decreased to a nadir of 44 × 103/L, but he did not require platelet transfusions. Echinacea likely contributed to this patient's profound thrombocytopenia and should be avoided in patients receiving etoposide and possibly other chemotherapeutic drugs that are CYP 3A4 substrates.

Immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by autoantibody-mediated platelet destruction. To test the efficacy of novel sulfur compounds as alternative treatments for ITP, we used a mouse model of passive immune thrombocytopenia (PIT). Using this model, the platelet nadir could not be maintained, with platelet counts rising after day 4, despite daily anti-platelet antibody administration. We examined reticulated platelet counts by flow cytometry, and found increased thrombopoiesis in the bone marrow to be at least partially responsible for this platelet rebound. Consequentially, two improved mouse models of PIT were developed, where the platelet rebound is circumvented. The first model employs sublethal total body gamma-irradiation in combination with daily antibody administration, while the second model employs gradual escalation of the daily antibody dose. Finally, we show that none of the tested candidate compounds show efficacy in elevating platelet counts in vivo, likely due to their limited solubility.

Immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by autoantibody-mediated platelet destruction. To test the efficacy of novel sulfur compounds as alternative treatments for ITP, we used a mouse model of passive immune thrombocytopenia (PIT). Using this model, the platelet nadir could not be maintained, with platelet counts rising after day 4, despite daily anti-platelet antibody administration. We examined reticulated platelet counts by flow cytometry, and found increased thrombopoiesis in the bone marrow to be at least partially responsible for this platelet rebound. Consequentially, two improved mouse models of PIT were developed, where the platelet rebound is circumvented. The first model employs sublethal total body gamma-irradiation in combination with daily antibody administration, while the second model employs gradual escalation of the daily antibody dose. Finally, we show that none of the tested candidate compounds show efficacy in elevating platelet counts in vivo, likely due to their limited solubility.

Thematic Paper ((M.C.T.M. Clinical Tropical Medicine))--Mahidol University, 2006. / LICL has E-Thesis 0012 ; please contact computer services. LIRV has E-Thesis 0012 ; please contact circulation services.

Ehrlichia canis e Anaplasma platys são parasitas de células sanguíneas transmitidos por carrapatos de larga distribuição mundial. O objetivo deste trabalho foi detectar a presença de E. canis e A. platys em cães naturalmente infectados no município de Porto Alegre, RS, Brasil, através de técnicas sorológicas e moleculares; realizar análise molecular dos agentes através do sequenciamento de um fragmento do gene 16S rRNA e compará-lo com sequências disponíveis no Genbank. Adicionalmente, avaliamos os parâmetros hematológicos e possíveis fatores de risco associados à infecção. Amostras de sangue foram coletadas de 146 cães residentes no Bairro Arquipélago, região suburbana de Porto Alegre e 53 cães mantidos no Centro de Controle de Zoonoses (CCZ). Dentre os animais analisados, 27 (13,56%) apresentaram resultado positivo na nPCR e 20 (10,2%) apresentaram sorologia positiva para A. platys. Através da ferramenta BLASTn, as sequências obtidas neste estudo foram comparadas e mostraram similaridade de 99,75% a 100% em relação a outras sequências de A. platys disponíveis no Genbank. Neste estudo não foi observada a presença de E. canis. DNA do agente não foi amplificado em nenhuma das amostras analisadas através de técnicas moleculares, e tampouco foram detectados cães sororreagentes, indicando a baixa prevalência do agente no município. Ao comparar a prevalência de infecção/exposição entre as populações estudadas, não observamos diferença significativa entre elas. Não foram observadas diferenças significativas nos parâmetros hematológicos e fatores de risco analisados nos animais infectados ou expostos, exceto a contagem de basófilos, que foi associada positivamente com infecção por A. platys. / Erlichia canis and Anaplasma platys are tick borne disease which has a worldwide geographic distribution. The aim of this study was to detect the presence of E. canis and A. platys in naturally infected dogs in Porto Alegre/RS – Brazil by serological and molecular techniques, performing molecular analysis of the agents by sequencing of a fragment of the 16S rRNA and comparing it with sequences available in Genbank. Additionally, we evaluated the hematological parameters and potential risk factors associated with infection. Blood samples were collected from 146 dogs living in the Arquipelago neighborhood, a suburban area of Porto Alegre and 53 dogs from Control Centrer of Zoonosis (CCZ). Among the examined animals, 27 (13.56%) were positive by nPCR and 20 (10.2%) were seropositive for A. platys. Through the BLASTn, the sequences obtained in this study were compared and showed similarity of 99.75% to 100% as compared to other sequences of A. platys available in Genbank. None of the dogs showed antibodies or E. canis DNA, indicating the low occurrence of the agent in Porto Alegre. There were no significant differences between positive groups and hematological parameters, or among the risk factors evaluated, except basophils count was associated with A. platys infection.