Contexte : La littérature suggère que le virus du papillome humain (VPH) puisse être transmis verticalement. Or, le mécanisme exact de transmission verticale demeure inconnu et les données ne permettent pas de savoir dans quelle mesure la transmission verticale est affectée par le mode d’accouchement. L’objectif de l’étude était de mesurer l’association entre le mode d’accouchement et la détection d’ADN du VPH chez les bébés. Méthode : Nous avons utilisé les données de 1052 femmes enceintes de la cohorte HERITAGE. Des échantillons vaginaux auto-collectés ont été obtenus chez les mères durant la grossesse, et des échantillons des muqueuses de la bouche, la gorge, les yeux et de la région anogénitale ont été collectés chez les bébés à la naissance et à 3 mois. Nous avons inclus les 282 femmes ayant eu un test VPH positif au premier et troisième trimestre de grossesse. Tous les échantillons ont été analysés pour la détection d’ADN du VPH par la méthode de réaction de polymérase en chaîne (PCR) avec le test Linear ArrayMC. Les informations sur l’accouchement ont été collectées dans les dossiers médicaux. L’association entre le mode d’accouchement et la transmission verticale du VPH a été mesurée par régressions logistiques. Résultats : La probabilité de transmission verticale du VPH a été de 8,9% (25/282), soit 3,7% (3/81) pour les césariennes et 10,9% (22/201) pour les accouchements vaginaux. Chez 21 des 25 enfants positifs au VPH (84%), il y avait au moins un génotype concordant avec leur mère, et tous sont nés par accouchement vaginal. Une augmentation significative du risque de transmission verticale du VPH a été observée pour l’accouchement vaginal, en comparaison avec la césarienne (OR ajusté: 3,63, intervalles de confiance à 95% (IC 95%): 1,03-12,82). Nous n’avons pas observé d’association significative entre la césarienne suivant la rupture des membranes et le risque de transmission, lorsque comparé avec la césarienne avec membranes intactes (OR ajusté : 1,31, IC 95% : 0,10-17,76). Il n’y a pas eu d’association entre la durée écoulée entre la rupture des membranes et la naissance (en heures continues) et le risque de transmission verticale (OR : 1,00, IC 95% : 0,97-1,02). Conclusion : L’accouchement par césarienne a été associé à un risque significativement plus faible de transmission du VPH chez les bébés. La transmission verticale du VPH surviendrait principalement lors du passage dans le canal vaginal car très peu d’enfants nés par césarienne ont été infectés au VPH. Puisque la rupture des membranes avant la césarienne et la durée entre la rupture des membranes et la naissance n’ont pas été associées à un risque de transmission du VPH plus élevé, nos résultats suggèrent que la transmission par infection ascendante après rupture des membranes est probablement rare. / Background: The literature suggests that human papillomavirus (HPV) can be transmitted vertically. However, the exact mechanism of vertical transmission remains unknown and the data do not allow us to know to what extent vertical transmission is affected by the mode of delivery. The aim of the study was to measure the association between mode of delivery and the detection of HPV DNA in infants. Method: We used data from 1052 pregnant women from the HERITAGE cohort. Self-collected vaginal samples were obtained from mothers during pregnancy, and specimens from the mucous membranes of the mouth, throat, eyes and anogenital region were collected from infants at birth and at 3 months. We included 282 women who had both positive HPV tests in the first and third trimester of pregnancy. All samples were analyzed for detection of HPV DNA by the polymerase chain reaction (PCR) method with the Linear ArrayTM assay. Information about the delivery was collected from medical records. The association between the mode of delivery and HPV detection in infants was measured using logistic regressions. Results: The probability of transmission of HPV was 8.9% (25/282); 3.7% (3/81) for caesarean sections and 10.9% (22/201) for vaginal deliveries. In 21 of 25 HPV positive infants (84%), there was at least one genotype concordant with their mother, and all were born vaginally. A significant increase in the risk of transmission of HPV was observed for vaginal delivery, compared to caesarean section (adjusted OR: 3.63, 95% confidence intervals (95% CI): 1.03-12.82). We found no significant increase in the risk of HPV transmission for caesarean section following rupture of membranes, compared to caesarean section with intact membranes (adjusted OR: 1.31, 95% CI: 0.10-17.76). There was no association between the time between rupture of membranes and birth (in continuous hours) and the risk of vertical transmission (OR: 1.00, 95% CI: 0.97-1.02). Conclusion: Caesarean delivery is associated with a significantly lower risk of HPV vertical transmission. Vertical transmission is thought to occur mainly during passage through the vaginal canal, because very few infants born by caesarean section have been infected with HPV. Since rupture of membranes before caesarean section and the time between ruptured membranes and birth have not been associated with a higher risk of HPV transmission, our results suggest that transmission by ascending infection after rupture of membranes is unlikely.

Thesis (MScPhysio (Interdisciplinary Health Sciences. Physiotherapy))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: The pelvic floor muscles (PFM) contribute to urinary continence and overactive PFM seem to be associated with pelvic pain syndrome (PPS). The literature indicates that ethnic differences regarding symptoms of urinary incontinence may exist. Research is needed to establish relationships between PFM function and symptoms reported by women of different ethnic groups. Objectives: To compare the PFM strength and endurance in black, white and coloured women. To investigate relationships between PFM strength, vaginal resting pressures, risk factors and symptoms associated with PFM dysfunction and PPS. Method: A cross-sectional study assessed the PFM strength and vaginal resting pressures of 122 nulliparous black (n=44), white (n=44) and coloured (n=34) university students. A self-developed questionnaire determined inclusion, demographic variables, factors affecting/factors associated with PFM strength and symptoms related to PPS. Maximum voluntary contraction pressure (cmH2O) and vaginal resting pressure (cmH2O) were measured with the Peritron TM 9300 (Cardio Design, Australia) used with the Camtech AS vaginal balloon sensor (Sandvika, Norway). Two sets of 3 maximum voluntary contractions of the PFM were recorded. Results: The mean age of the group was 22 ± 3.54 years and mean BMI of 23± 4.16 kg/m2. Black women (25 cmH2O ± 13.5) had significantly stronger PFM than white (p=0.02) or coloured (p<0.01) women, but no significant difference (p=0.78) in PFM strength existed between white (18.4 cmH2O ± 9.8) and coloured (15.6 cmH2O ± 8) women. In black women, PFM strength decreased significantly (p=0.02) between the sets, whereas no significant difference between sets was noted in the other ethnic groups. Increased PFM strength was associated with SUI (p=0.03) and amenorrhoea (p=0.01) and decreased PFM strength was associated with decreased frequency of bowel motion (p=0.01). In this sample, increased vaginal resting pressure was associated with menorrhagia (p=0.04). Conclusion: Black nulliparous women had stronger PFM than white and coloured women. There was no difference in PFM strength between white and coloured women. Endurance, as measured in this study, indicates that black women have decreased endurance of the PFM compared to white and coloured women. These findings inform the current research on ethnic differences in the prevalence of urinary incontinence. Preliminary data suggest that there was no relationship between vaginal resting pressures and symptoms of PPS and risk factors for PFM dysfunction, except for menorrhagia. / AFRIKAANSE OPSOMMING: Die bekkenvloer spiere (BVS) dra by tot urinêre kontinensie en ooraktiewe BVS kan moontlik geassosieer wees met pelviese pyn sindroom (PPS). Uit die literatuur blyk dit of daar etniese verskille bestaan in die simptome van urinere inkontinensie gerapporteer deur vroue. Navorsing is nodig om die verwantskap tussen BVS funksie en simptome wat deur pasiënte van verskillende etniese groepe gerapporteer word vas te stel. Doel: Om „n vergelyking te tref tussen BVS sterkte in swart, wit en kleurling vroue. Om vas te stel of daar assosiasies bestaan tussen BVS sterkte, rustende vaginale druklesings en risiko faktore en simptome geassosieer met bekkenvloer disfunksie en PPS. Metodologie: „n Dwarssnit studie het die BVS sterkte en rustende vaginale drukke van 122 nullipareuse swart (n=44), wit (n=44) en kleurling (n=34) universiteit studente geëvalueer. Insluiting, uitsluiting, demografiese veranderlikes, faktore wat kan affekteer/faktore geassosieer met BVS sterkte en simptome geassosier met PPS is deur „n self ontwikkelde vraelys geëvalueer. Maksimale willekeurige spiersametrekking drukke (cmH2O) en rustende vaginale drukke (cmH2O) was gemeet met „n Peritron™9300 perineometer (Cardio Design, Australië) wat saam „n vaginale ballon sensor (Camtech AS, Sandvika, Noorweë) gebruik is. Twee stelle van 3 maksimale willekeurige sametrekkings van die BVS was gemeet. Resultate: Die groep se gemiddelde ouderdom was 22±3.54 jaar en die gemiddelde liggaamsgewig indeks was 23±4.16kg/m2. Swart vroue (25 cmH2O ±13.5) het beduidend sterker BVS gehad as wit (p=0.02) en kleurling (p<0.01) vroue, maar daar was geen beduidende verskil (p=0.78) in BVS sterkte tussen wit (18.4 cmH2O ± 9.8) en kleurling (15.6 cmH2O ± 8) vroue nie. Die BVS sterkte in swart vroue het beduidend (p=0.02) verminder tussen die stelle, maar geen beduidende verskille was waargeneem in die ander etniese groepe tussen stelle. Verhoogde BVS sterkte was geassosieer met druklek (p=0.03), amenorrhoea (p=0.01) en verminderde BVS sterkte was geassosieer met verminderde frekwensie van opelyf (p=0.01). Verhoogde rustende vaginale drukke was geassosieer met menoragie in hierdie steekproef. Gevolgtrekking: Swart nullipareuse vroue het sterker BVS gehad as wit en kleurling vroue, Daar was geen verskil in BVS sterkte tussen wit en kleurling vroue nie. Uithouvermoë soos in hierdie studie getoets toon dat swart vroue verminderde uithouvermoë het i.v.m. wit en kleurling vroue. Hierdie bevindings dra by tot die huidige navorsing oor etniese verskille in die prevalensie van urinêre inkontinensie. Daar was geen verwantskap tussen vaginale rustende drukke en simptome van PPS en risiko faktore vir die ontwikkeling van bekkenvloer disfunksie, behalwe vir menoragie.

The gonococcal transferrin binding proteins (Tbps) are two surface-exposed outer membrane proteins, TbpA and TbpB, which together function to remove and internalized iron from human transferrin. Iron is an essential nutrient to the gonococcus, without which it cannot survive. The Tbps have been established as virulence factors, demonstrating their importance in establishing infection. Both TbpA and TbpB are well conserved among gonococcal isolates, and have been considered potential vaccine targets. Vaccine studies with the closely related species Neisseria meningitidis, have demonstrated these proteins to be protective in murine challenge studies. Though the meningococcal Tbps have demonstrated promise, no similar gonococcal vaccine experiments have been conducted prior to the current studies. Here we demonstrate purification of recombinant TbpA and TbpB. These recombinant proteins were utilized to evaluate the human immune response to these proteins during natural infections, and their immunogenicity in murine vaccine studies. Our results demonstrate a paucity of antibodies elicited to these proteins during natural infections in serum and mucosal secretions from infected individuals. From this study we hypothesized the induction of both serum and genital antibodies to these proteins could serve to protect an individual from infection. To begin testing this hypothesis, we immunized mice both intranasally (IN) and subcutaneously (s.c.) with full-length Tbps in conjunction with the B subunit of cholera toxin (Ctb) as an adjuvant. We also performed another vaccine study using domains from both proteins in genetic fusions with Ctb and E. coli heat labile toxin IIb (LtbIIb). Both studies demonstrated that these antigens were immunogenic, as Tbp-specific antibodies were elicited in the serum and vaginal washes of female Balb/C mice. Intranasal immunization however was the only route with which we were able to elicit vaginal Tbp-specific IgA, and IgG, whereas subcutaneous immunization only elicited vaginal IgG. Furthermore, we found the full-length Tbps and the Ctb/LtbIIb chimeras were able to elicit bactericidal antibodies, which were also effective in killing heterologous gonococcal strains. This body of work comprises the first published study using the gonococcal transferrin binding proteins as vaccine antigens, and highlights their potential as vaccine antigens in the development of an efficacious gonococcal vaccine.

Foram estudados, prospectivamente, por um período médio de 4,9 anos, os resultados do tratamento de 31 mulheres com incontinência urinária e afecção benigna do útero que foram submetidas à cirurgia de sling fascial associada à histerectomia vaginal, atendidas na Clínica Ginecológica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no período de fevereiro de 2000 a outubro de 2006. O objetivo foi avaliar os resultados do tratamento comparando-se os diagnósticos urodinâmicos pré- e pós-tratamento. As mulheres foram submetidas à cirurgia de histerectomia vaginal, para tratamento da afecção benigna do útero e sling fascial para correção da incontinência urinária. Realizou-se estudo urodinâmico no pré- e pós-tratamento, para avaliação da taxa de cura da incontinência urinária e do comportamento vesical nas fases de enchimento e esvaziamento, os quais foram avaliados por meio dos parâmetros urodinâmicos de fluxometria e cistometria. Na fluxometria avaliou-se o fluxo urinário máximo, fluxo urinário médio e volume de urina residual e na cistometria, determinou-se a capacidade vesical no 1° desejo miccional, capacidade vesical máxima e a pressão vesical necessária para ocorrer ou não a perda de urina. Os resultados mostraram, em relação á fluxometria diminuição significante do fluxo máximo, tendência à diminuição do fluxo médio e redução significante do volume de urina residual. Em relação à cistometria, houve aumento estatisticamente significante da capacidade vesical no 1° desejo miccional, da capacidade vesical máxima e valor da pressão vesical necessária para avaliar a presença ou não de perda urinária. Com relação ao diagnóstico urodinâmico, foi demonstrada a cura da incontinência urinária em 96,8% dos casos. Avaliando-se os parâmetros de cura objetiva da incontinência urinária, em seguimento de 4,9 anos, podemos inferir que o tratamento da incontinência urinária de esforço pode ser realizado simultaneamente, quando houver também, a indicação de histerectomia vaginal / We studied, prospectively, for a 4.9 years period the results of the treatment of 31 women with urinary incontinence and benign uterine disease that were submitted the surgery fascial sling associated to vaginal hysterectomy, the patients were all treated in the Gynecology Department of the Clinic Hospital of the University of Sao Paulo, in the period between February 2000 to October 2006. The objective was evaluate the results of the treatment comparing the urodinamic diagnosis pre and post treatment. All women were submitted to vaginal hysterectomy for treatment of benign uterine disorders and to facial sling to treat the urinary incontinence. An urodinamic study was performed pre and post treatment to define the rate of cure of the urinary incontinence and vesical behaviour in the filling and emptying fases, witch will evaluate through urodinamic parameters of flowmetry and cystometry, In the flowmetry were evaluated maximum urinary flow, medium urinary flow and residual urinary volume; and in the cystometry were determinated the bowel capacity in the first urinary desire, maximum bowel capacity in the first urinary desire, maximum bowel capacity and the needed bowel pressure to occur or not the urinary loss. The results showed in relation to the flowmetry significant reduction of the maximum flow, medium flow and urinary residual volume. In relation to cystometry we demonstrated an increase statistically significant in the vesical capacity in the first miccional desire, in the maximum bowel capacity and the value of the bowel pressure to evaluate the presence or not of urinary lost. In relation to the urodimanic diagnosis we could demonstrate the cure of urinary incontinence in 96.8% of cases. Evaluating the parameters of objective cure of urinary incontinence, in a follow up of 4.9 years, we can affirm that the treatment of urinary incontinence should be always be together with the vaginal hysterectomy when it is needed

Made available in DSpace on 2016-08-10T10:38:52Z (GMT). No. of bitstreams: 1 Tatiane Ribeiro da Fonseca.pdf: 3044117 bytes, checksum: d604b5b291d33d0e053ad75336e7a264 (MD5) Previous issue date: 2014-06-26 / This study evaluated the sociodemographic and clinicopathological aspects of patients with cancer of the vulva and the vagina diagnosed in Araújo Jorge Hospital, Goiânia - GO as well as the prevalence of HPV and HPV16 and 18 genotypes in these tumors. The sample consisted of paraffin embedded samples from 57 patients with primary invasive vulvar cancer and 20 patients with primary invasive cancer of the vagina. The HPV detection was made by polymerase chain reaction (PCR) with SPF (short PCR fragment) 1-2 primers and the HPV 16 and 18 genotyping was performed with primers designed to detect these two genotypes. The results were analyzed by Fisher s exact test. The prevalence of HPV in vulvar cancer samples was 89%. The HPV16 genotype was detected in 42% of positive cases and HPV18 in 24%. The HPV prevalence in vaginal cancer samples was 90%. Among these, 56% were infections by HPV16 and HPV18 by 18%. Over 70% of patients with vulvar and vaginal cancer and positive for HPV detection were over 50 years. Statistical analyzes of the data showed significance of smoking for cancer of the vulva (p = 0.0110). A relationship between lymph node metastasis and cancer of the vulva was also observed (p = 0.0304). A better prognosis for patients with vaginal cancer HPV positive was found (p = 0.0158). A relationship between the degree of tumor differentiation and the presence of HPV in patients with cancer of the vulva was suggested (p = 0.0541). Based on the results presented, it is estimated that the HPV vaccine could have prevented 58% of cases of vulvar cancer and 65% of cases of vaginal cancer of the sample investigated. / O presente estudo avaliou os aspectos sociodemográficos e clinicopatológicos de pacientes com câncer de vulva e vagina diagnosticadas no Hospital Araújo Jorge, Goiânia-GO, bem como a prevalência do HPV e dos genótipos do HPV16 e 18 nesses tumores. A casuística consistiu de amostras parafinizadas de 57 pacientes com câncer invasor primário de vulva e 20 pacientes com câncer invasor primário de vagina. A detecção do HPV foi feita por meio de reação em cadeia da polimerase (PCR) com oligonucleotídeos iniciadores SPF (do inglês short PCR fragment) 1-2 e a genotipagem do HPV16 e 18 foi realizada com oligonucleotídeos iniciadores projetados para a detecção desses dois genótipos. Os resultados foram analisados por Teste Exato de Fisher. A prevalência do HPV nas amostras de câncer de vulva foi de 89%. O genótipo HPV16 foi detectado em 42% dos casos positivos e o HPV18 em 24%. A prevalência do HPV nas amostras de câncer de vagina foi de 90%. Dentre estas, 56% eram infecções pelo HPV16 e 18% pelo HPV18. Mais de 70% das pacientes com câncer de vulva e de vagina positivas para a detecção do HPV tinham mais de 50 anos. As análises estatísticas dos dados demonstraram significância do tabagismo para o câncer de vulva (p=0,0110). Uma relação entre metástase linfonodal e câncer de vulva também foi observada (p=0,0304). Um melhor prognóstico para pacientes com câncer de vagina HPV positivas foi constatado (p= 0,0158). Uma relação entre o grau de diferenciação tumoral e a presença do HPV em pacientes com câncer de vulva foi sugerida (p= 0,0541). Com base nos resultados apresentados, estima-se que a vacina contra o HPV poderia ter prevenido 58% dos casos de câncer de vulva e 65% dos casos de câncer de vagina da casuística investigada.

A via de administração vaginal pode ser considerada uma alternativa para diversos tratamentos, tanto de ação farmacológica local como sistêmica. No entanto, o tempo de permanência do fármaco no local da aplicação e a eficácia esperada representam um desafio para o desenvolvimento de formulações. O objetivo deste trabalho foi desenvolver nanocápsulas de superfície catiônica (EUDRAGIT® RS 100) ou aniônica (EUDRAGIT® S 100), contendo ou não o marcador de fluorescência Vermelho do Nilo como um modelo de fármaco lipofílico, e incorporar essas partículas em hidrogéis de quitosana, a fim de aumentar o tempo de residência da formulação na mucosa vaginal, devido às propriedades mucoadesivas desse polímero. Diversas formulações foram preparadas com concentrações crescentes de quitosana e analisadas em termos de pH e comportamento reológico, a fim de selecionar a mais adequada para aplicação vaginal. Os hidrogéis foram produzidos com quitosana 2,5% p/p, com ou sem nanocápsulas. Foi avaliada a aderência (mucoadesividade e perfil lavabilidade) e a capacidade de penetração (microscopia confocal e extração seguido de quantificação do vermelho do nilo) das formulações quando aplicadas em mucosa vaginal de porcas. As suspensões de nanocápsulas apresentaram diâmetro em torno de 200 nm e potencial zeta entre +13 mV (NC-RS) e -13 mV( NC-S) e valores de pH entre 5,1 e 6,2. A formulação de quitosana apresentou viscosidade característica e pH ácido (em torno de 4,5), ideal para aplicação vaginal. Os testes de mucoadesão mostraram que as formulações propostas contendo nanocápsulas poliméricas apresentaram maior adesividade em mucosa vaginal em comparação com a formulação composta somente de quitosana. Através do experimento de lavabilidade não foram encontradas diferenças significativas entre as formulações. No entanto, as técnicas de microscopia confocal e a quantificação após a extração de fluorescência a partir da mucosa demonstraram uma maior penetração de vermelho do nilo quando nanoencapsulado, especialmente em nanocápsulas catiônicas. As formulações desenvolvidas com base no veículo do hidrogel de quitosana e nanocápsulas poliméricas, especialmente as nanocápsulas catiônicas, demonstraram aplicabilidade para a entrega de substâncias hidrofóbicas pela via vaginal. Palavras-chave: quitosana, nanocápsuas, via vaginal, EUDRAGIT® RS100, EUDRAGIT® S100. / The vaginal route of administration might be an alternative for several treatments, either for local or systemic pharmacological effect. However, the permanence of the drug at the site of application and its expected effectiveness represent a challenge in the development of formulations. Thus, the objective of this work was to develop nanocapsules with cationic or anionic surface charge, containing or not nile red as a model of lipophilic substance, and to incorporate such particles into chitosan vehicle in order to increase the residence time of the formulation due to chitosan mucoadhesive properties. Several formulations prepared with increasing chitosan concentrations were analyzed in terms of pH and rheological behaviour in order to select the most suitable one for vaginal application. Gel formulations were produced with chitosan at 2.5% w/w, with or without nanocapsules. The adhesion (tensile stress test and washability profile) and penetration enhancement properties (confocal microscopy- CLSM and extraction followed by quantification) of the formuations, when applied on porcine vaginal mucosa, were evaluated. The nanocapsule suspensions presented adequate properties and pH values around 5.1 and 6.2. The chitosan formulation presented a characteristic viscosity and an acid pH (around 4.5), which is suitable for vaginal application. Mucoadhesion tests showed that the proposed formulations containing polymeric nanocapsules had higher adhesion to the vaginal mucosa in comparison with the formulation containing only chitosan. The washability evaluation showed no significant differences between the formulations. However, the confocal microscopy and the fluorescence quantification after extraction from the mucosa showed higher penetration of nile red when nanoencapsulated, especially into cationic-charged nanocapsules. The formulations developed, based on chitosan gel vehicle and polymeric nanocapsules, especially the cationic nanocapsules, demonstrated applicability for the vaginal delivery of hydrophobic substances.

Trichomonas vaginalis é o agente etiológico da doença sexualmente transmissível não viral mais comum no mundo, sendo registrados aproximadamente 276 milhões de novos casos de tricomonose a cada ano. O estabelecimento da infecção se deve principalmente à capacidade de adesão do parasito às células epiteliais vaginais, cervicais ou de próstata, seguida pela intensa reação inflamatória, resultado da infiltração de neutrófilos no sítio da infecção. Nucleotídeos e nucleosídeos, especialmente ATP e adenosina, são liberados para o espaço extracelular por células em situações de estresse ou injúria tecidual e desenvolvem seus efeitos sinalizadores através da ativação de purinoceptores. Ainda, as ectonucleotidases, NTPDase e ecto-5’-nucleotidase, são capazes de hidrolisar os nucleotídeos gerando adenosina e finalmente, a enzima adenosina deaminase (ADA) é responsável pela conversão de adenosina em inosina. A expressão gênica de cinco NTPDases putativas presentes no genoma de T. vaginalis foram investigadas, assim como o envolvimento da sinalização purinérgica na relação parasito-hospedeiro. Nossos resultados mostraram que diferentes isolados de T. vaginalis expressam os genes TvNTPDase1, 2, 3, 4 e 5, sendo observado o maior número de transcritos para TvNTPDase1, 2 e 4. A sequência preditiva de aminoácidos revelou a presença das cinco regiões conservadas da apirase, domínios transmembrana, sítios de fosforilação, peptídeos sinais e os prováveis sítios ativos da enzima. A análise filogenética demonstrou maior similaridade das TvNTPDases com as formas intracelulares da enzima, como as NTPDases 4 e 7 humanas e a de Saccharomyces cerevisiae. Além disso, a restrição de soro promoveu aumento significativo da atividade da NTPDase de T. vaginalis, no entanto sem corresponder com o aumento de expressão gênica de determinada(s) sequência(s). Quanto à participação da sinalização purinérgica na resposta inflamatória de células do hospedeiro frente ao parasito, foram utilizados como modelos celulares as células epiteliais vaginais (HMVII), cervicais (HeLa) e neutrófilos humanos. As linhagens HMVII e HeLa mostraram expressar todos os subtipos de receptores P1, P2X e P2Y e XI os diferentes isolados de T. vaginalis, que foram cocultivados com as células, mostraram hidrolisar eficientemente os nucleotídeos ATP, ADP e AMP. Ainda, o isolado clínico fresco TV-LACM6 foi o único a apresentar elevada citotoxicidade frente às células epiteliais vaginais e cervicais, no entanto não foi detectado aumento da liberação de ATP pelas células após o cocultivo, provavelmente devido à alta atividade da enzima NTPDase observada nesse isolado. Os trofozoítos de T. vaginalis não foram capazes de aumentar a produção de IL-8 e IL-6 pelas linhagens HMVII e HeLa, e apenas os isolados ATCC30236 e TV-LACM6 causaram aumento na secreção da citocina MIP-3α pelas células epiteliais cervicais. Finalmente, o nucleotídeo ATP e o nucleosídeo adenosina não modularam a produção dos mediadores inflamatórios investigados. Em relação aos neutrófilos, estes mostraram aumentar a produção de espécies reativas de oxigênio (ERO) e IL-8 após incubação com os trofozoítos de T. vaginalis. Os nucleotídeos e nucleosídeos da adenina e guanina não produziram efeito na produção de ERO e IL-8; no entanto, quando o nucleosídeo adenosina foi incubado junto com o inibidor da enzima ADA (EHNA) observou-se uma redução significativa da produção de ERO e IL-8 pelos neutrófilos, devido à inibição da ADA e consequentemente, ao aumento da concentração de adenosina disponível no meio extracelular. Os nossos resultados indicaram a ativação do receptor A1 dos neutrófilos nessa condição. O conjunto de dados aqui obtidos contribuiu para uma melhor caracterização da família de enzimas NTPDases de T. vaginalis assim como para um maior conhecimento acerca da influência da sinalização purinérgica na relação parasito-hospedeiro. / Trichomonas vaginalis is the agent of the most common non-viral sexually transmitted disease worldwide, causing 276.4 million new cases a year. The establishment of the infection is closely related to the parasite ability to adhere to vaginal, cervical and prostate epithelial cells, followed by an intense inflammatory response as result of neutrophil infiltration. Nucleotides and nucleosides, mainly ATP and adenosine, are released into the extracellular space by cells under stress or injury and they exert their signaling effects through activation of the purinoceptors. Moreover, the ectonucleotidases, NTPDase and ecto-5'-nucleotidase, are capable of hydrolyzing the nucleotides producing adenosine and finally, the adenosine deaminase (ADA) is responsible for the conversion of adenosine to inosine. We investigated the gene expression of five putative NTPDases found in T. vaginalis genome as well as the involvement of purinergic signaling on the host-parasite relationship. Our results showed that different T. vaginalis isolates are able to express TvNTPDase1, 2, 3, 4 and 5 and that TvNTPDase1, 2 and 4 are the most expressed genes. Predictive amino acid sequence revealed the presence of the five apyrase conserved regions, transmembrane domains, phosphorylation sites, signal peptides and the active sites. Phylogenetic analysis showed that TvNTPDases share more similarity with the intracellular enzymes, such as human NTPDase 4 and 7 and Saccharomyces cerevisiae NTPDase. In addition, the serum limitation caused a significant increase in NTPDase activity, but without association with the gene expression of a specific TvNTPDase sequence. Regarding the participation of purinergic signaling on the inflammatory responses against the parasite, the vaginal (HMVII) and cervical (HeLa) epithelial cells and the human neutrophils were used as cellular models. HMVII and HeLa cell lines showed to express all subtypes of P1, P2X and P2Y receptors and the different T. vaginalis isolates, which were co-cultured with the cells, showed to hydrolyze efficiently ATP, ADP and AMP. Furthermore, only the fresh clinical isolate, TV-LACM6, caused a profound cytotoxicity against the vaginal and cervical epithelial cells. Interestingly, it was not detected an increase in ATP release by the cells after cocultivation, probably due to the high NTPDase activity dislplayed by TV-LACM6 isolate. The T. vaginalis trophozoites were not able to increase the production of IL-8 and IL-6 by HMVII and HeLa cells and only ATCC30236 and TV-LACM6 isolates enhanced MIP-3α secretion by the cervical epithelial cells. Finally, neither ATP nor adenosine has modulated the production of the inflammatory mediators here investigated. Considering the neutrophils, T. vaginalis stimulated the production of reactive oxygen species (ROS) and IL-8 by these immune cells and both adenine as guanine nucleotides and nucleosides did not cause any effect on ROS and IL-8 levels. However, when adenosine was incubated with an ADA inhibitor (EHNA) we observed a significant reduction of ROS and IL-8 production by neutrophils, due to inhibition of ADA with a subsequent increase of adenosine concentration in the extracellular milieu. . Our results suggested the participation of A1 receptor in this condition. The data set obtained in this study contributed to the characterization of T. vaginalis NTPDases family as well as to a better understanding of the influence of purinergic signaling on host-parasite relationship.

Antimicrobial peptides (AMPs) are small proteins produced by epithelial surfaces, which have broad-spectrum antimicrobial and immunomodulatory activities. In the lung, skin and alimentary tract AMPs are known to be important in infectious and inflammatory conditions. Far less is known regarding the role of AMPs within the female reproductive tract, but as infection and inflammation are causes of preterm labour, AMPs may have a key function in maintain and protecting pregnancy. The major groups of human AMPs include the human beta defensins (HBDs), two antileukoproteinases (secretory leukocyte protease inhibitor (SLPI) and Trappin-2/Elafin), and the human cathelicidin hCAP18/LL-37, with several studies identifying their presence at sites throughout the reproductive tract. The cervix in pregnancy is positioned between the upper genital tract containing the developing fetus and the lower tract where infections usually arise. I hypothesise that AMPs are fundamental to mucosal immune defence of the cervix in pregnancy, preventing ascending infection and excessive inflammation that can cause preterm labour. This thesis focused on the human cathelicidin hCAP18/LL-37 and its role within the cervix and vagina. The aims of this thesis were to; investigate the inflammatory effects of LL-37 from cervical and vaginal derived epithelial cells and determine the pathways and receptors in which LL-37 may elicit its effects and how production may be regulated; investigate the role of CRAMP in a mouse model of preterm birth; and determine the production of AMPs by the pregnant cervix whilst investigating the relationship between AMP concentrations in cervicovaginal secretions and preterm labour. The inflammatory effect of LL-37 was investigated using cell lines derived from endocervical, ectocervical and vaginal epithelium. The study of these cell lines suggests divergent responses of cervical and vaginal epithelial cells. LL-37 mediated induction of IL-8 and IL-6 production from endocervical epithelial cells was observed in a dose-dependent and time-dependent manner, whilst ectocervical and vaginal cells also respond to treatment with LL-37 through IL-8 and IL-6 production. To determine a possible mechanism of action of LL-37 on IL-8 and IL-6 in the three cell lines, inhibitors against MAPK cascades, ERK, p38 MAPK and JNK, and known LL-37 receptors were investigated. In endocervical cells LL-37 mediated IL-8 occurs via activation of unidentified GPCRs, whilst in ectocervical cells this effect on IL‐8 and IL-6 is via the activation of ERK and p38 MAPK cascades. The mechanism by which LL-37 induces IL-8 secretion in vaginal epithelial cells remains unknown. Expression of LL-37 was shown to be mediated by vitamin D3 in vitro in cervical and vaginal epithelial cells. However when this relationship was investigated in vivo, using matched serum and cervicovaginal secretions from woman at early pregnancy, no correlation was observed between circulating vitamin D and cervicovaginal or circulating hCAP18/LL-37. However, the majority of women in this study reported with insufficient levels of vitamin D, which may effect the relationship observed with hCAP18/LL-37. Using a mouse model of LPS-induced preterm labour, to mimic the presence of intrauterine infection bacterial infection, I aimed to characterise the role of CRAMP, the mouse orthologue of hCAP18/LL-37, in the lower inflammatory and immune response that results in preterm labour. Wild type C57Bl/6J mice receiving an intrauterine injection of LPS deliver prematurely, within 24 hours of injection. However mice deficient in CRAMP (Camp -/-) receiving an intrauterine injection of LPS deliver significantly later and have a non-significant increase in pup survival compared to wild type C57Bl/6J mice. Cervical tissue collected post partum showed no difference in inflammatory markers between wild type C57Bl/6J and Camp -/- mice, however there was increased expression of the neutrophil chemoattractant marker, Cxcl5, and the neutrophil marker, Ngp in Camp -/- mice. In the lower genital tract, levels of antimicrobial peptides were determined in samples of cervicovaginal secretions collected from pregnant women. AMPs, hCAP18/LL-37, HBD-2 and SLPI were found in cervicovaginal secretions, and levels of hCAP18/LL-37 were increased in women with the common vaginal infection bacterial vaginosis. However no relationship was identified between the concentration of AMPs and preterm birth in this study. This work has shown that the lower genital tract, where infections that are associated with preterm labour originate, expresses the human cathelicidin hCAP18/LL-37. It may play an important role in modulating the immune response to invading infection associated with preterm labour. Further investigation of these responses may increase understanding of the physiology and pathophysiology of labour, and lead to strategies for the prevention of premature delivery.

Foram estudados, prospectivamente, por um período médio de 4,9 anos, os resultados do tratamento de 31 mulheres com incontinência urinária e afecção benigna do útero que foram submetidas à cirurgia de sling fascial associada à histerectomia vaginal, atendidas na Clínica Ginecológica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no período de fevereiro de 2000 a outubro de 2006. O objetivo foi avaliar os resultados do tratamento comparando-se os diagnósticos urodinâmicos pré- e pós-tratamento. As mulheres foram submetidas à cirurgia de histerectomia vaginal, para tratamento da afecção benigna do útero e sling fascial para correção da incontinência urinária. Realizou-se estudo urodinâmico no pré- e pós-tratamento, para avaliação da taxa de cura da incontinência urinária e do comportamento vesical nas fases de enchimento e esvaziamento, os quais foram avaliados por meio dos parâmetros urodinâmicos de fluxometria e cistometria. Na fluxometria avaliou-se o fluxo urinário máximo, fluxo urinário médio e volume de urina residual e na cistometria, determinou-se a capacidade vesical no 1° desejo miccional, capacidade vesical máxima e a pressão vesical necessária para ocorrer ou não a perda de urina. Os resultados mostraram, em relação á fluxometria diminuição significante do fluxo máximo, tendência à diminuição do fluxo médio e redução significante do volume de urina residual. Em relação à cistometria, houve aumento estatisticamente significante da capacidade vesical no 1° desejo miccional, da capacidade vesical máxima e valor da pressão vesical necessária para avaliar a presença ou não de perda urinária. Com relação ao diagnóstico urodinâmico, foi demonstrada a cura da incontinência urinária em 96,8% dos casos. Avaliando-se os parâmetros de cura objetiva da incontinência urinária, em seguimento de 4,9 anos, podemos inferir que o tratamento da incontinência urinária de esforço pode ser realizado simultaneamente, quando houver também, a indicação de histerectomia vaginal / We studied, prospectively, for a 4.9 years period the results of the treatment of 31 women with urinary incontinence and benign uterine disease that were submitted the surgery fascial sling associated to vaginal hysterectomy, the patients were all treated in the Gynecology Department of the Clinic Hospital of the University of Sao Paulo, in the period between February 2000 to October 2006. The objective was evaluate the results of the treatment comparing the urodinamic diagnosis pre and post treatment. All women were submitted to vaginal hysterectomy for treatment of benign uterine disorders and to facial sling to treat the urinary incontinence. An urodinamic study was performed pre and post treatment to define the rate of cure of the urinary incontinence and vesical behaviour in the filling and emptying fases, witch will evaluate through urodinamic parameters of flowmetry and cystometry, In the flowmetry were evaluated maximum urinary flow, medium urinary flow and residual urinary volume; and in the cystometry were determinated the bowel capacity in the first urinary desire, maximum bowel capacity in the first urinary desire, maximum bowel capacity and the needed bowel pressure to occur or not the urinary loss. The results showed in relation to the flowmetry significant reduction of the maximum flow, medium flow and urinary residual volume. In relation to cystometry we demonstrated an increase statistically significant in the vesical capacity in the first miccional desire, in the maximum bowel capacity and the value of the bowel pressure to evaluate the presence or not of urinary lost. In relation to the urodimanic diagnosis we could demonstrate the cure of urinary incontinence in 96.8% of cases. Evaluating the parameters of objective cure of urinary incontinence, in a follow up of 4.9 years, we can affirm that the treatment of urinary incontinence should be always be together with the vaginal hysterectomy when it is needed

Background: Persistent infection with high risk HPV is a necessary but insufficient cause of cervical cancer. Behavioural, viral and host factors modulate the risk of HPV persistence. In this thesis, I explore the role of the vaginal microbiota, a host factor and the presence of multiple HPV infections, a viral factor in HPV persistence. Considering the limited data on the epidemiology of HPV related diseases in low and middle-countries (LMIC), and the limited success of cervical cancer screening strategies in many LMIC, I provide data on the distribution of HPV related diseases in Nigeria and evaluate the acceptability of innovative strategies to increase cervical cancer screening uptake. Methods/Results: To achieve my aims, I implemented a longitudinal cohort study of 1,020 women in Nigeria. I begin my results chapters with two methodological papers. Attrition is an important consideration for every longitudinal cohort, particularly in LMIC, therefore, I present my findings on attrition, determinants of attrition and practical strategies to ensure low attrition in studies conducted in LMIC. Considering that sexual behaviour is an important potential confounder in all HPV studies, and the reliability of self-reported history is often questioned, I present findings on the test-retest reliability of self-reported sexual behaviour history collected in my study. Having found that attrition levels were low and that self-reported sexual behaviour history was generally reliable within my cohort, I present my findings on the association between the vaginal microbiota and persistent hrHPV; and the role of multiple HPV infections in viral persistence. I found that the vaginal microbiota was associated with persistent hrHPV in HIV negative women, but not in HIV positive women; and that multiple HPV infections did not increase the risk of viral persistence when compared to single HPV infections. Next, I present my findings on the prevalence and incidence of anogenital warts in Nigeria, with additional reports on the prevalence of cervical cancer and other HPV associated cancers using data from two population based cancer registries. Finally, I present my findings on the acceptability of innovative strategies to improve cervical cancer screening uptake in Nigeria. I found that Nigerian women had a favorable attitude to the use of HPV DNA based screening as part of routine antenatal care, however attitudes towards the use of self-sampling techniques for HPV based cervical cancer screening varied by religious affiliations. Conclusion: In my thesis, I was able to systematically investigate the epidemiology of HPV infections in a LMIC. I considered the distribution of HPV related diseases, host and viral determinants of HPV persistence and investigated control strategies to reduce the burden of cervical cancer in a LMIC. My results provide useful data for surveillance, monitoring and evaluation of control programs on HPV and cervical cancer in Nigeria and may be useful to cervical cancer control programs in other LMIC.