[Edicto Perpetuo de Adriano]

Sign.: []6, 3*4, 2*4, a4-r4, s6

A multidisciplinary reference framework to support innovative design, implementation and assessment of chronic care models

Hoy en día, por primera vez en la historia, la mayor parte de la población podrá vivir hasta los sesenta años y más (United Nations, 2015). Sin embargo, todavía existe poca evidencia que demuestre que las personas mayores, estén viviendo con mejor salud que sus padres, a la misma edad, ya que la mayoría de los problemas de salud en edades avanzadas están asociados a las enfermedades crónicas (WHO, 2015). Los sistemas sanitarios de los países desarrollados funcionan adecuadamente cuando se trata del cuidado de enfermedades agudas, pero no son lo suficientemente eficaces en la gestión de las enfermedades crónicas. Durante la última década, se han realizado esfuerzos para mejorar esta gestión, por medio de la utilización de estrategias de prevención y de reenfoque de la provisión de los servicios de atención para la salud (Kane et al. 2005). Según una revisión sistemática de modelos de cuidado de salud, comisionada por el sistema nacional de salud Británico, pocos modelos han conceptualizado cuáles son los componentes que hay que utilizar para proporcionar un cuidado crónico efectivo, y estos componentes no han sido suficientemente estructurados y articulados. Por lo tanto, no hay suficiente evidencia sobre el impacto real de cualquier modelo existente en la actualidad (Ham, 2006). Las innovaciones podrían ayudar a conseguir mejores diagnósticos, tratamientos y gestión de pacientes crónicos, así como a dar soporte a los profesionales y a los pacientes en el cuidado. Sin embargo, la forma en las que estas innovaciones se proporcionan no es lo suficientemente eficiente, efectiva y amigable para el usuario. Para mejorar esto, hace falta crear equipos de trabajo y estrategias multidisciplinares. En conclusión, hacen falta actividades que permitan conseguir que las innovaciones sean utilizadas en los sistemas de salud que quieren mejorar la gestión del cuidado crónico, para que sea posible: 1) traducir la “atención sanitaria basada en la evidencia” en “conocimiento factible”; 2) hacer frente a la complejidad de la atención sanitaria a través de una investigación multidisciplinaria; 3) identificar una aproximación sistemática para que se establezcan intervenciones innovadoras en el cuidado de salud. El marco de referencia desarrollado en este trabajo de investigación es un intento de aportar estas mejoras. Las siguientes hipótesis han sido propuestas: Hipótesis 1: es posible definir un proceso de traducción que convierta un modelo de cuidado crónico en una descripción estructurada de objetivos, requisitos e indicadores clave de rendimiento. Hipótesis 2: el proceso de traducción, si se ejecuta a través de elementos basados en la evidencia, multidisciplinares y de orientación económica, puede convertir un modelo de cuidado crónico en un marco descriptivo, que define el ciclo de vida de soluciones innovadoras para el cuidado de enfermedades crónicas. Hipótesis 3: es posible definir un método para evaluar procesos, resultados y capacidad de desarrollar habilidades, y asistir equipos multidisciplinares en la creación de soluciones innovadoras para el cuidado crónico. Hipótesis 4: es posible dar soporte al desarrollo de soluciones innovadoras para el cuidado crónico a través de un marco de referencia y conseguir efectos positivos, medidos en indicadores clave de rendimiento. Para verificar las hipótesis, se ha definido una aproximación metodológica compuesta de cuatro Fases, cada una asociada a una hipótesis. Antes de esto, se ha llevado a cabo una “Fase 0”, donde se han analizado los antecedentes sobre el problema (i.e. adopción sistemática de la innovación en el cuidado crónico) desde una perspectiva multi-dominio y multi-disciplinar. Durante la fase 1, se ha desarrollado un Proceso de Traducción del Conocimiento, elaborado a partir del JBI Joanna Briggs Institute (JBI) model of evidence-based healthcare (Pearson, 2005), y sobre el cual se han definido cuatro Bloques de Innovación. Estos bloques consisten en una descripción de elementos innovadores, definidos en la fase 0, que han sido añadidos a los cuatros elementos que componen el modelo JBI. El trabajo llevado a cabo en esta fase ha servido también para definir los materiales que el proceso de traducción tiene que ejecutar. La traducción que se ha llevado a cabo en la fase 2, y que traduce la mejor evidencia disponible de cuidado crónico en acción: resultado de este proceso de traducción es la parte descriptiva del marco de referencia, que consiste en una descripción de un modelo de cuidado crónico (se ha elegido el Chronic Care Model, Wagner, 1996) en términos de objetivos, especificaciones e indicadores clave de rendimiento y organizada en tres ciclos de innovación (diseño, implementación y evaluación). Este resultado ha permitido verificar la segunda hipótesis. Durante la fase 3, para demostrar la tercera hipótesis, se ha desarrollado un método-mixto de evaluación de equipos multidisciplinares que trabajan en innovaciones para el cuidado crónico. Este método se ha creado a partir del método mixto usado para la evaluación de equipo multidisciplinares translacionales (Wooden, 2013). El método creado añade una dimensión procedural al marco. El resultado de esta fase consiste, por lo tanto, en una primera versión del marco de referencia, lista para ser experimentada. En la fase 4, se ha validado el marco a través de un caso de estudio multinivel y con técnicas de observación-participante como método de recolección de datos. Como caso de estudio se han elegido las actividades de investigación que el grupo de investigación LifeStech ha desarrollado desde el 2008 para mejorar la gestión de la diabetes, actividades realizadas en un contexto internacional. Los resultados demuestran que el marco ha permitido mejorar las actividades de trabajo en distintos niveles: 1) la calidad y cantidad de las publicaciones; 2) se han conseguido dos contratos de investigación sobre diabetes: el primero es un proyecto de investigación aplicada, el segundo es un proyecto financiado para acelerar las innovaciones en el mercado; 3) a través de los indicadores claves de rendimiento propuestos en el marco, una prueba de concepto de un prototipo desarrollado en un proyecto de investigación ha sido transformada en una evaluación temprana de una intervención eHealth para el manejo de la diabetes, que ha sido recientemente incluida en Repositorio de prácticas innovadoras del Partenariado de Innovación Europeo en Envejecimiento saludable y activo. La verificación de las 4 hipótesis ha permitido demonstrar la hipótesis principal de este trabajo de investigación: es posible contribuir a crear un puente entre la atención sanitaria y la innovación y, por lo tanto, mejorar la manera en que el cuidado crónico sea procurado en los sistemas sanitarios. ABSTRACT Nowadays, for the first time in history, most people can expect to live into their sixties and beyond (United Nations, 2015). However, little evidence suggests that older people are experiencing better health than their parents, and most of the health problems of older age are linked to Chronic Diseases (WHO, 2015). The established health care systems in developed countries are well suited to the treatment of acute diseases but are mostly inadequate for dealing with CDs. Healthcare systems are challenging the burden of chronic diseases by putting more emphasis on the prevention of disease and by looking for new ways to reorient the provision of care (Kane et al., 2005). According to an evidence-based review commissioned by the British NHS Institute, few models have conceptualized effective components of care for CDs and these components have been not structured and articulated. “Consequently, there is limited evidence about the real impact of any of the existing models” (Ham, 2006). Innovations could support to achieve better diagnosis, treatment and management for patients across the continuum of care, by supporting health professionals and empowering patients to take responsibility. However, the way they are delivered is not sufficiently efficient, effective and consumer friendly. The improvement of innovation delivery, involves the creation of multidisciplinary research teams and taskforces, rather than just working teams. There are several actions to improve the adoption of innovations from healthcare systems that are tackling the epidemics of CDs: 1) Translate Evidence-Based Healthcare (EBH) into actionable knowledge; 2) Face the complexity of healthcare through multidisciplinary research; 3) Identify a systematic approach to support effective implementation of healthcare interventions through innovation. The framework proposed in this research work is an attempt to provide these improvements. The following hypotheses have been drafted: Hypothesis 1: it is possible to define a translation process to convert a model of chronic care into a structured description of goals, requirements and key performance indicators. Hypothesis 2: a translation process, if executed through evidence-based, multidisciplinary, holistic and business-oriented elements, can convert a model of chronic care in a descriptive framework, which defines the whole development cycle of innovative solutions for chronic disease management. Hypothesis 3: it is possible to design a method to evaluate processes, outcomes and skill acquisition capacities, and assist multidisciplinary research teams in the creation of innovative solutions for chronic disease management. Hypothesis 4: it is possible to assist the development of innovative solutions for chronic disease management through a reference framework and produce positive effects, measured through key performance indicators. In order to verify the hypotheses, a methodological approach, composed of four Phases that correspond to each one of the stated hypothesis, was defined. Prior to this, a “Phase 0”, consisting in a multi-domain and multi-disciplinary background analysis of the problem (i.e.: systematic adoption of innovation to chronic care), was carried out. During phase 1, in order to verify the first hypothesis, a Knowledge Translation Process (KTP) was developed, starting from the JBI Joanna Briggs Institute (JBI) model of evidence-based healthcare was used (Pearson, 2005) and adding Four Innovation Blocks. These blocks represent an enriched description, added to the JBI model, to accelerate the transformation of evidence-healthcare through innovation; the innovation blocks are built on top of the conclusions drawn after Phase 0. The background analysis gave also indication on the materials and methods to be used for the execution of the KTP, carried out during phase 2, that translates the actual best available evidence for chronic care into action: this resulted in a descriptive Framework, which is a description of a model of chronic care (the Chronic Care Model was chosen, Wagner, 1996) in terms of goals, specified requirements and Key Performance Indicators, and articulated in the three development cycles of innovation (i.e. design, implementation and evaluation). Thanks to this result the second hypothesis was verified. During phase 3, in order to verify the third hypothesis, a mixed-method to evaluate multidisciplinary teams working on innovations for chronic care, was created, based on a mixed-method used for the evaluation of Multidisciplinary Translational Teams (Wooden, 2013). This method adds a procedural dimension to the descriptive component of the Framework, The result of this phase consisted in a draft version of the framework, ready to be tested in a real scenario. During phase 4, a single and multilevel case study, with participant-observation data collection, was carried out, in order to have a complete but at the same time multi-sectorial evaluation of the framework. The activities that the LifeStech research group carried out since 2008 to improve the management of diabetes have been selected as case study. The results achieved showed that the framework allowed to improve the research activities in different directions: the quality and quantity of the research publications that LifeStech has issued, have increased substantially; 2 project grants to improve the management of diabetes, have been assigned: the first is a grant funding applied research while the second is about accelerating innovations into the market; by using the assessment KPIs of the framework, the proof of concept validation of a prototype developed in a research project was transformed into an early stage assessment of innovative eHealth intervention for Diabetes Management, which has been recently included in the repository of innovative practice of the European Innovation Partnership on Active and Health Ageing initiative. The verification of the 4 hypotheses lead to verify the main hypothesis of this research work: it is possible to contribute to bridge the gap between healthcare and innovation and, in turn, improve the way chronic care is delivered by healthcare systems.

Efecto sobre el rendimiento productivo y calidad de la canal de la inclusión de guisantes (Pisum sativum) y alberjón (Vicia narbonensis) en el pienso de lechones y cerdos de cebo

Las leguminosas grano presentan un perfil nutricional de gran interés para alimentación de ganado porcino, debido principalmente a su elevado contenido proteico. Sin embargo, la presencia de factores antinutritivos (FAN), que según el género difieren en calidad y cantidad, condiciona la absorción de la proteína, el nutriente más valorado. El objetivo de esta Tesis Doctoral ha sido el estudio del efecto de los principales FAN de guisante y alberjón sobre el rendimiento productivo, de canal y de piezas nobles, cuando sustituyen a la soja, parcial o totalmente, durante la fase estárter y el periodo de engorde de cerdos grasos. Con este motivo se llevaron a cabo 4 ensayos con machos castrados y la misma línea genética: híbrido Duroc x (Landrace x Large white). En el ensayo 1, se estudió la influencia de distintos niveles de inhibidores de proteasas (IP) en el pienso sobre la productividad de lechones durante la fase estárter (40 a 61 días de edad). Para ello, se utilizaron tres variedades de guisantes de invierno que contenían diferentes cantidades de IP, tanto de tripsina (IT) como de quimotripsina (IQ) [unidades de tripsina inhibida/mg (UTI), unidades de quimotripsina inhibida/mg (UQI): 9,87- 10,16, 5,75-8,62 y 12,55-15,75, para guisantes Cartouche, Iceberg y Luna, respectivamente] más elevadas que en la harina de soja 47 (HnaS) y en la soja extrusionada (SE) (UTI/mg - UQI/mg: 0,61-3,56 y 2,36-4,65, para HnaS y SE, respectivamente). El diseño experimental fue al azar, con cuatro tratamientos dietéticos que diferían en las fuentes proteicas y en la cantidad de IP, enfrentando un pienso control de soja a otros tres piensos con guisantes de invierno de las variedades indicadas, que sustituían parcialmente a la soja. Cada tratamiento se replicó cuatro veces, siendo la celda con 6 lechones la unidad experimental. Los animales que consumieron el pienso con guisante Cartouche tuvieron más ganancia media diaria (GMD) que el resto (P < 0,001) con el mismo consumo medio diario (CMD) e índice de conversión (IC). No hubo diferencias significativas entre los animales del pienso control y los que consumieron piensos con guisantes Iceberg y Luna. En el ensayo 2 la leguminosa objeto de estudio fue el alberjón y su FAN el dipéptido _Glutamyl-S-Ethenyl-Cysteine (GEC). El diseño y el periodo experimental fueron los mismos que en el ensayo 1, con cuatro dietas que variaban en el porcentaje de alberjones: 0%, 5%, 15% y 25%, y de GEC (1,54% del grano). Los lechones que consumieron el pienso con 5% tuvieron un CMD y GMD más elevado (P < 0,001), con el mismo IC que los animales pertenecientes al tratamiento 0%. Los índices productivos empeoraron significativamente y de manera progresiva al aumentar el porcentaje de alberjones (15 y 25%). Se obtuvieron ecuaciones de regresión con estructura polinomial que fueron significativas tanto para el nivel de alberjón como para la cantidad de GEC presente en el pienso. El ensayo 3 se efectuó durante el periodo de engorde, sustituyendo por completo la soja a partir de los 84 días de edad con las tres variedades de guisantes de invierno, observando el efecto sobre el rendimiento productivo, de canal y piezas nobles. El diseño, en bloques completos al azar, tuvo cuatro tratamientos según el guisante presente en el pienso y, por lo tanto, los niveles de IP: Control-soja, Cartouche, Iceberg y Luna, con 12 réplicas de 4 cerdos por tratamiento. De 84 a 108 días de edad los animales que consumieron los piensos Control-soja e Iceberg, tuvieron el mismo CMD y GMD, empeorando en los cerdos alimentados con Luna y Cartouche (P < 0,05). El IC fue igual en los tratamientos Control-soja e Iceberg, ocupando una posición intermedia en Cartouche y peor en los cerdos del pienso Luna (P < 0,001). De 109 a 127 días de edad la GMD y el IC fueron iguales, con un CMD más elevado en Control-soja e Iceberg que en los cerdos que consumieron Cartouche y Luna (P < 0,05). No hubo diferencias significativas durante el acabado (128 a 167 días de edad). Globalmente el CMD y GMD fueron más elevados en los cerdos que comieron los piensos Iceberg y Control-soja, empeorando por igual en los que comieron Cartouche y Luna (P < 0,05); el IC fue el mismo en todos los tratamientos. No se observaron diferencias en los datos relacionados con peso y rendimiento de canal y piezas nobles (jamón, paleta y chuletero), ni del contenido de grasa intramuscular en el lomo y proporción de ácidos grasos principales (C16:0, C18:0, C18:1n-9) en la grasa subcutánea. En el ensayo 4, realizado durante el periodo de engorde (60 a 171 días de edad), se valoró el efecto de dietas con distintos niveles de alberjones, y en consecuencia de su factor antinutritivo el dipéptido GEC, sobre el rendimiento productivo y la calidad de la canal y piezas nobles. El diseño fue en cuatro bloques completos al azar, con cuatro tratamientos según el porcentaje de inclusión de alberjón en el pienso: 0%, 5%, 15% y 25%, con 12 réplicas por tratamiento y cuatro cerdos en cada una de ellas. El tratamiento con 5% mejoró la GMD al final de la fase de cebo (152 días de vida) y, junto con el 0%, presentaron los resultados más favorables de peso e IC al final del ensayo (171 días de vida). Del mismo modo, el peso y rendimiento de canal fueron más elevados en los cerdos alimentados con los tratamientos 0% y 5% (P < 0,001). Piensos con el 15 y 25% de alberjones empeoraron los resultados productivos, así como el rendimiento y peso de canal. Sucedió lo mismo con el peso de las piezas nobles (jamón, paleta y chuletero), significativamente superior en 0% y 5% frente a 15% y 25%, siendo los cerdos que consumieron este último pienso los peores. Por el contrario el rendimiento de jamón y chuletero fue más elevado en los cerdos de los tratamientos 25% y 15% que en los que consumieron los piensos con 5% y 0% (P < 0,001); en el rendimiento de paletas se invirtieron los resultados, siendo mayores en los animales de los tratamientos 0% y 5% (P < 0,001). Se obtuvieron ecuaciones de regresión polinomial, para estimar las cantidades de inclusión de alberjones y de GEC más favorables desde el punto de vista productivo, así como los contrastes ortogonales entre los distintos tratamientos. ABSTRACT The grain legumes have a nutritional profile of great interest to feed pigs, mainly due to high protein content. However, the presence of antinutritional factors (ANF), which differ in quality and quantity according to gender, hinder the absorption of the protein, the most valuable nutrient. The aim of this thesis was to study the effect of the main ANF of pea and narbon vetch (NV) on productive performance, of the carcass and main lean cuts, when replacing soybean, partially or totally, during the starter phase and the fattening period of heavy pigs. For this reason were carried four trials with barrows and the same genetic line: Duroc hybrid x (Landrace x Large white). In trial 1, was studied the influence of different levels of protease inhibitors (PI) in the diet over productivity of piglets during the starter phase (40-61 days of age). For this, were used three varieties of winter peas containing different amounts of PI, both trypsin (TI) and chymotrypsin (CI) [inhibited units/mg trypsin (TIU), inhibited units/mg chymotrypsin (CIU): 9.87 - 10.16, 5.75 - 8.62 and 12.55 - 15.75, for peas Cartouche, Iceberg and Luna, respectively] higher than in soybean meal 47 (SBM) and soybeans extruded (SBE) (TIU/mg - CIU/mg: 0.61 - 3.56 and 2.36 - 4.65 for SBM and SBE, respectively). The design was randomized with four dietary treatments differing in protein sources and the amount of PI, with a control diet of soybean and three with different varieties of winter peas: Cartouche, Iceberg and Luna, which partially replace soybean. Each treatment was replicated four times, being the pen with 6 piglets the experimental unit. Pigs that ate the feed with pea Cartouche had better growth (ADG) than the rest (P < 0.001), with the same average daily feed intake (ADFI) and feed conversion ratio (FCR). There were no significant differences between piglets fed with control diet and those fed Iceberg and Luna diets. In trial 2 the legume under study was the NV and your ANF the dipeptide _Glutamyl FAN-S-Ethenyl-Cysteine (GEC). The experimental period and the design were the same as in trial 1, with four diets with different percentage of NV: 0%, 5%, 15% and 25%, and from GEC (1.52% of the grain). The piglets that consumed the feed containing 5% had higher ADG and ADFI (P < 0.05), with the same FCR that pigs belonging to the 0% treatment. Production rates worsened progressively with increasing percentage of NV (15 and 25%). Were obtained regression equations with polynomial structure that were significant for NV percentage and amount of GEC present in the feed. The test 3 was carried out during the fattening period, completely replace soy from 84 days of age with three varieties of winter peas, observing the effect on the yield, carcass and main lean cuts. The design, randomized complete blocks, had four treatments with different levels of PI: Control-soy, Cartouche, Iceberg and Luna, with 12 replicates of 4 pigs per treatment. From 84 to 108 days of age the pigs fed with Control-soy and Iceberg feed, had the same ADFI and ADG, worsening in pigs fed with Luna and Cartouche (P < 0.05). The FCR was similar in diets Control-soy and Iceberg, occupying an intermediate position in Cartouche and worse in pigs fed with Luna (P < 0.001). From 109-127 days of age the ADG and FCR were equal, with higher ADFI in pigs fed with Control-soy and Iceberg, regarding pigs fed with Cartouche and Luna (P < 0.05). There was no difference in the finishing phase (128-167 days of age). In global period, the ADFI and ADG were higher in pigs that ate Control-soy and Iceberg, and worse in those who ate Cartouche and Luna. The FCR was the same in all treatments. No significant differences were observed in the data related to weight and carcass yield, main lean cuts (ham, shoulder and loin chop) and intramuscular fat loin content and major fatty acids proportion (C16:0, C18:0, C18:1n-9) of subcutaneous fat. In experiment 4, made during the fattening period (60-171 days of age), was assessed the effect of diets with different levels of NV, and consequently of GEC, in the performance and quality of carcass and main lean cuts. There was a completely randomized design with four dietary treatments differing in percentage of NV: 0%, 5%, 15% and 25%, with 12 replicates per treatment and four pigs each. Treatment with 5% improved the ADG at the end of the fattening phase (152 days of age) and, together with 0%, showed the most favorable body weight and FCR at the end of the trial (171 days of age). Similarly, the weight and performance of carcass were higher for pigs fed with diets 0% and 5% (P < 0.05). Diets with 15 and 25% worsened the productive and carcass results. The weight of the main lean cuts (ham, shoulder and loin chop) was significantly higher in 0% and 5% vs 15% and 25%.The diet 25% was the worst of all. By contrast the performance of ham and loin chop was higher in pigs fed with diets 25% and 15%, that those who ate diets with 5% and 0% (P < 0.001); the results of shoulder performance were reversed, being greater in pigs feed with diets 0% and 5% (P < 0.001). Polynomial regression equations were obtained to estimate the percentage of NV and GEC more favorable from the point of view of production, and orthogonal contrasts between treatments.

A “REVOLTA” DE JEÚ E A ESTELA DE DÃ: Um Estudo Em 2 Reis 10,28-36

A pesquisa tem por objetivo trabalhar o evento da Revolta de Jeú, em conjunto com a Estela de Dã, tendo como ponto de partida para tal, a exegese da perícope de 2 Reis 10-28,36. A história Deuteronomista apresenta o ato da Revolta de Jeú como sendo um feito demasiadamente importante, na restauração do culto a Javé em Israel, a partir de um contexto onde o culto a outras divindades, em Israel Norte, estava em pleno curso. No entanto, a partir da análise conjunta da Estela de Dã, que tem como provável autor o rei Hazael de Damasco, somos desafiados a ler esta história pelas entrelinhas não contempladas pelo texto, que apontam para uma participação ativa de Hazael, nos desfechos referentes a Revolta de Jeú, como sendo o responsável direto que proporcionou a subida de Jeú ao trono em Israel, clarificando desta forma este importante período na história Bíblica. Para tal análise, observar-se-á três distintos tópicos, ligados diretamente ao tema proposto: (1) A Revolta de Jeú e a Redação Deuteronomista, a partir do estudo exegético da perícope de 2 Reis 10,28-36, onde estão descritas informações pontuais sobre período em que Jeú reinou em Israel; (2) Jeú e a Estela de Dã, a partir da apresentação e análise do conteúdo da Estela de Dã, tratando diretamente dos desdobramentos da guerra em Ramote de Gileade, de onde se dá o ponto de partida à Revolta de Jeú; e por fim (3) O Império da Síria, onde a partir da continuidade da análise do conteúdo da Estela de Dã, demonstraremos a significância deste reino, além de apontamentos diretamente ligados ao reinado de Hazael, personagem mui relevante no evento da Revolta de Jeú.

HLA alleles determine human T-lymphotropic virus-I (HTLV-I) proviral load and the risk of HTLV-I-associated myelopathy

The risk of disease associated with persistent virus infections such as HIV-I, hepatitis B and C, and human T-lymphotropic virus-I (HTLV-I) is strongly determined by the virus load. However, it is not known whether a persistent class I HLA-restricted antiviral cytotoxic T lymphocyte (CTL) response reduces viral load and is therefore beneficial or causes tissue damage and contributes to disease pathogenesis. HTLV-I-associated myelopathy (HAM/TSP) patients have a high virus load compared with asymptomatic HTLV-I carriers. We hypothesized that HLA alleles control HTLV-I provirus load and thus influence susceptibility to HAM/TSP. Here we show that, after infection with HTLV-I, the class I allele HLA-A*02 halves the odds of HAM/TSP (P < 0.0001), preventing 28% of potential cases of HAM/TSP. Furthermore, HLA-A*02+ healthy HTLV-I carriers have a proviral load one-third that (P = 0.014) of HLA-A*02− HTLV-I carriers. An association of HLA-DRB1*0101 with disease susceptibility also was identified, which doubled the odds of HAM/TSP in the absence of the protective effect of HLA-A*02. These data have implications for other persistent virus infections in which virus load is associated with prognosis and imply that an efficient antiviral CTL response can reduce virus load and so prevent disease in persistent virus infections.

Interaction between HLA-DM and HLA-DR involves regions that undergo conformational changes at lysosomal pH

Antigenic peptide loading of major histocompatibility complex class II molecules is enhanced by lysosomal pH and catalyzed by the HLA-DM molecule. The physical mechanism behind the catalytic activity of DM was investigated by using time-resolved fluorescence anisotropy (TRFA) and fluorescence binding studies with the dye 8-anilino-1-naphthalenesulfonic acid (ANS). We demonstrate that the conformations of both HLA-DM and HLA-DR3, irrespective of the composition of bound peptide, are pH sensitive. Both complexes reversibly expose more nonpolar regions upon protonation. Interaction of DM with DR shields these hydrophobic domains from the aqueous environment, leading to stabilization of the DM and DR conformations. At lysosomal pH, the uncovering of additional hydrophobic patches leads to a more extensive DM–DR association. We propose that DM catalyzes class II peptide loading by stabilizing the low-pH conformation of DR, favoring peptide exchange. The DM–DR association involves a larger hydrophobic surface area with DR/class II-associated invariant chain peptides (CLIP) than with stable DR/peptide complexes, explaining the preferred association of DM with the former. The data support a release mechanism of DM from the DM–DR complex through reduction of the interactive surface, upon binding of class II molecules with antigenic peptide or upon neutralization of the DM–DR complex at the cell surface.

Postsymbiotic plasmid acquisition and evolution of the repA1-replicon in Buchnera aphidicola

Buchnera aphidicola is an obligate, strictly vertically transmitted, bacterial symbiont of aphids. It supplies its host with essential amino acids, nutrients required by aphids but deficient in their diet of plant phloem sap. Several lineages of Buchnera show adaptation to their nutritional role in the form of plasmid-mediated amplification of key-genes involved in the biosynthesis of tryptophan (trpEG) and leucine (leuABCD). Phylogenetic analyses of these plasmid-encoded functions have thus far suggested the absence of horizontal plasmid exchange among lineages of Buchnera. Here, we describe three new Buchnera plasmids, obtained from species of the aphid host families Lachnidae and Pemphigidae. All three plasmids belong to the repA1 family of Buchnera plasmids, which is characterized by the presence of a repA1-replicon responsible for replication initiation. A comprehensive analysis of this family of plasmids unexpectedly revealed significantly incongruent phylogenies for different plasmid and chromosomally encoded loci. We infer from these incongruencies a case of horizontal plasmid transfer in Buchnera. This process may have been mediated by secondary endosymbionts, which occasionally undergo horizontal transmission in aphids.

Identification of the vitamin K-dependent carboxylase active site: Cys-99 and Cys-450 are required for both epoxidation and carboxylation

The vitamin K-dependent carboxylase modifies and renders active vitamin K-dependent proteins involved in hemostasis, cell growth control, and calcium homeostasis. Using a novel mechanism, the carboxylase transduces the free energy of vitamin K hydroquinone (KH2) oxygenation to convert glutamate into a carbanion intermediate, which subsequently attacks CO2, generating the γ-carboxylated glutamate product. How the carboxylase effects this conversion is poorly understood because the active site has not been identified. Dowd and colleagues [Dowd, P., Hershline, R., Ham, S. W. & Naganathan, S. (1995) Science 269, 1684–1691] have proposed that a weak base (cysteine) produces a strong base (oxygenated KH2) capable of generating the carbanion. To define the active site and test this model, we identified the amino acids that participate in these reactions. N-ethyl maleimide inhibited epoxidation and carboxylation, and both activities were equally protected by KH2 preincubation. Amino acid analysis of 14C- N-ethyl maleimide-modified human carboxylase revealed 1.8–2.3 reactive residues and a specific activity of 7 × 108 cpm/hr per mg. Tryptic digestion and liquid chromatography electrospray mass spectrometry identified Cys-99 and Cys-450 as active site residues. Mutation to serine reduced both epoxidation and carboxylation, to 0.2% (Cys-99) or 1% (Cys-450), and increased the Kms for a glutamyl substrate 6- to 8-fold. Retention of some activity indicates a mechanism for enhancing cysteine/serine nucleophilicity, a property shared by many active site thiol enzymes. These studies, which represent a breakthrough in defining the carboxylase active site, suggest a revised model in which the glutamyl substrate indirectly coordinates at least one thiol, forming a catalytic complex that ionizes a thiol to initiate KH2 oxygenation.

Calcium-dependent oligonucleotide antagonists specific for L-selectin.

The selectins are calcium-dependent C-type lectins that recognize complex anionic carbohydrate ligands, initiating many cell-cell interactions in the vascular system. Selectin blockade shows therapeutic promise in a variety of inflammatory and postischemic pathologies. However, the available oligosaccharide ligand mimetics have low affinities and show cross-reaction among the three selectins, precluding efficient and specific blockade. The SELEX (systematic evolution of ligands by exponential enrichment) process uses combinatorial chemistry and in vitro selection to yield high affinity oligonucleotides with unexpected binding specificities. Nuclease-stabilized randomized oligonucleotides subjected to SELEX against recombinant L-selectin yielded calcium-dependent antagonists with approximately 10(5) higher affinity than the conventional oligosaccharide ligand sialyl LewisX. Most of the isolated ligands shared a common consensus sequence. Unlike sialyl LewisX, these antagonists show little binding to E- or P-selectin. Moreover, they show calcium-dependent binding to native L-selectin on peripheral blood lymphocytes and block L-selectin-dependent interactions with the natural ligands on high endothelial venules.

Differential activation of proliferation and cytotoxicity in human T-cell lymphotropic virus type I Tax-specific CD8 T cells by an altered peptide ligand.

Human T-cell leukemia virus type I (HTLV-I) gives rise to a neurologic disease known as HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP). Although the pathogenesis of the disease is unknown, the presence of a remarkably high frequency of Tax-specific, cytotoxic CD8 T cells may suggest a role of these cells in the development of HAM/TSP. Antigen-mediated signaling in a CD8 T-cell clone specific for the Tax(11-19) peptide of HTLV-I was studied using analog peptides substituted in their T-cell receptor contact residues defined by x-ray crystallographic data of the Tax(11-19) peptide in the groove of HLA-A2. CD8 T-cell stimulation with the wild-type peptide antigen led to activation of p56lck kinase activity, interleukin 2 secretion, cytotoxicity, and clonal expansion. A Tax analog peptide with an alanine substitution of the T-cell receptor contact residue tyrosine-15 induced T-cell-mediated cytolysis without activation of interleukin 2 secretion or proliferation. Induction of p56lck kinase activity correlated with T-cell-mediated cytotoxicity, whereas interleukin 2 secretion correlated with [3H]thymidine incorporation and proliferation. Moreover, Tax peptide analogs that activated the tyrosine kinase activity of p56lck could induce unresponsiveness to secondary stimulation with the wild-type peptide. These observations show that a single amino acid substitution in a T-cell receptor contact residue of Tax can differentially signal CD8 T cells and further demonstrate that primary activation has functional consequences for the secondary response of at least some Tax-specific CD8 T cells to HTLV-I-infected target cells.

Parkinson's disease and gastrointestinal dysfunctions: morphological, neurochemical and functional modifications of the enteric nervous system associated with central dopaminergic impairment

Parkinson’s disease (PD) is frequently associated with gastrointestinal (GI) symptoms, mostly represented by abdominal distension, constipation and defecatory dysfunctions. Despite GI dysfunctions have a major impact on the clinical picture of PD, there is currently a lack of information on the neurochemical, pathological and functional correlates of GI dysmotility associated with PD. Moreover, there is a need of effective and safe pharmacological therapies for managing GI disturbances in PD patients. The present research project has been undertaken to investigate the relationships between PD and related GI dysfunctions by means of investigations in an animal model of PD induced by intranigral injection of 6-hydroxydopamine (6-OHDA). The use of the 6-OHDA experimental model of PD in the present program has allowed to pursue the following goals: 1) to examine the impact of central dopaminergic denervation on colonic excitatory cholinergic and tachykininergic neuromotility by means of molecular, histomorphologic and functional approaches; 2) to elucidate the role of gut inflammation in the onset and progression of colonic dysmotility associated with PD, characterizing the degree of inflammation and oxidative damage in colonic tissues, as well as identifying the immune cells involved in the production of pro-inflammatory cytokines in the gut; 3) to evaluate the impact of chronic treatment with L-DOPA plus benserazide on colonic neuromuscular activity both in control and PD animals. The results suggest that central nigrostriatal dopaminergic denervation is associated with an impaired excitatory cholinergic neurotransmission and an enhanced tachykininergic control, resulting in a dysregulated smooth muscle motor activity, which likely contributes to the concomitant decrease in colonic transit rate. These motor alterations might result from the occurrence of a condition of gut inflammation associated with central intranigral denervation. The treatment with L-DOPA/BE following central dopaminergic neurodegeneration can restore colonic motility, likely through a normalization of the cholinergic enteric neurotransmission, and it can also improve the colonic inflammation associated with central dopaminergic denervation.

An idea from Donnellan: deferential and non-deferential uses of proper names

When we use a proper name, by virtue of what do we succeed in saying something about an individual? In other words, how are we supposed to explain the seemingly trivial fact that by uttering “Aristotle was wise” we actually predicate something of the famous philosopher? Questions like these have animated a fervent debate among philosophers of language; however, nowadays the standard answer is that by using “Aristotle” we say something about that famous philosopher because the name we have used in our utterance refers to him. Even though no general consensus has been reached on how to characterize the relation of reference – there are still different and competing accounts of the latter on the philosophical market – almost everybody believes, especially after the publication of Saul Kripke’s "Naming and necessity", that reference is the only semantic relation that connects our uses of proper names to individuals in the world. Contrary to this widespread assumption, in this dissertation I shall claim that our uses of proper names are not always referential.

Alterazione della proteostasi a livello del reticolo endoplasmatico: un potenziale target terapeutico nel carcinoma prostatico

Nel sesso maschile il carcinoma della prostata (CaP) è la neoplasia più frequente ed è tra le prime cause di morte per tumore. Ad oggi, sono disponibili diverse strategie terapeutiche per il trattamento del CaP, ma, come comprovato dall’ancora alta mortalità, spesso queste sono inefficaci, a causa soprattutto dello sviluppo di fenomeni di resistenza da parte delle cellule tumorali. La ricerca si sta quindi focalizzando sulla caratterizzazione di tali meccanismi di resistenza e, allo stesso tempo, sull’individuazione di combinazioni terapeutiche che siano più efficaci e capaci di superare queste resistenze. Le cellule tumorali sono fortemente dipendenti dai meccanismi connessi con l’omeostasi proteica (proteostasi), in quanto sono sottoposte a numerosi stress ambientali (ipossia, carenza di nutrienti, esposizione a chemioterapici, ecc.) e ad un’aumentata attività trascrizionale, entrambi fattori che causano un accumulo intracellulare di proteine anomale e/o mal ripiegate, le quali possono risultare dannose per la cellula e vanno quindi riparate o eliminate efficientemente. La cellula ha sviluppato diversi sistemi di controllo di qualità delle proteine, tra cui gli chaperon molecolari, il sistema di degradazione associato al reticolo endoplasmatico (ERAD), il sistema di risposta alle proteine non ripiegate (UPR) e i sistemi di degradazione come il proteasoma e l’autofagia. Uno dei possibili bersagli in cellule tumorali secretorie, come quelle del CaP, è rappresentato dal reticolo endoplasmatico (RE), organello intracellulare deputato alla sintesi, al ripiegamento e alle modificazioni post-traduzionali delle proteine di membrana e secrete. Alterazioni della protestasi a livello del RE inducono l’UPR, che svolge una duplice funzione nella cellula: primariamente funge da meccanismo omeostatico e di sopravvivenza, ma, quando l’omeostasi non è più ripristinabile e lo stimolo di attivazione dell’UPR cronicizza, può attivare vie di segnalazione che conducono alla morte cellulare programmata. La bivalenza, tipica dell’UPR, lo rende un bersaglio particolarmente interessante per promuovere la morte delle cellule tumorali: si può, infatti, sfruttare da una parte l’inibizione di componenti dell’UPR per abrogare i meccanismi adattativi e di sopravvivenza e dall’altra si può favorire il sovraccarico dell’UPR con conseguente induzione della via pro-apoptotica. Le catechine del tè verde sono composti polifenolici estratti dalle foglie di Camellia sinesis che possiedono comprovati effetti antitumorali: inibiscono la proliferazione, inducono la morte di cellule neoplastiche e riducono l’angiogenesi, l’invasione e la metastatizzazione di diversi tipi tumorali, tra cui il CaP. Diversi studi hanno osservato come il RE sia uno dei bersagli molecolari delle catechine del tè verde. In particolare, recenti studi del nostro gruppo di ricerca hanno messo in evidenza come il Polyphenon E (estratto standardizzato di catechine del tè verde) sia in grado, in modelli animali di CaP, di causare un’alterazione strutturale del RE e del Golgi, un deficit del processamento delle proteine secretorie e la conseguente induzione di uno stato di stress del RE, il quale causa a sua volta l’attivazione delle vie di segnalazione dell’UPR. Nel presente studio su due diverse linee cellulari di CaP (LNCaP e DU145) e in un nostro precedente studio su altre due linee cellulari (PNT1a e PC3) è stato confermato che il Polyphenon E è capace di indurre lo stress del RE e di determinare l’attivazione delle vie di segnalazione dell’UPR, le quali possono fungere da meccanismo di sopravvivenza, ma anche contribuire a favorire la morte cellulare indotta dalle catechine del tè verde (come nel caso delle PC3). Considerati questi effetti delle catechine del tè verde in qualità di induttori dell’UPR, abbiamo ipotizzato che la combinazione di questi polifenoli bioattivi e degli inibitori del proteasoma, anch’essi noti attivatori dell’UPR, potesse comportare un aggravamento dell’UPR stesso tale da innescare meccanismi molecolari di morte cellulare programmata. Abbiamo quindi studiato l’effetto di tale combinazione in cellule PC3 trattate con epigallocatechina-3-gallato (EGCG, la principale tra le catechine del tè verde) e due diversi inibitori del proteasoma, il bortezomib (BZM) e l’MG132. I risultati hanno dimostrato, diversamente da quanto ipotizzato, che l’EGCG quando associato agli inibitori del proteasoma non produce effetti sinergici, ma che anzi, quando viene addizionato al BZM, causa una risposta simil-antagonistica: si osserva infatti una riduzione della citotossicità e dell’effetto inibitorio sul proteasoma (accumulo di proteine poliubiquitinate) indotti dal BZM, inoltre anche l’induzione dell’UPR (aumento di GRP78, p-eIF2α, CHOP) risulta ridotta nelle cellule trattate con la combinazione di EGCG e BZM rispetto alle cellule trattate col solo BZM. Gli stessi effetti non si osservano invece nelle cellule PC3 trattate con l’EGCG in associazione con l’MG132, dove non si registra alcuna variazione dei parametri di vitalità cellulare e dei marcatori di inibizione del proteasoma e di UPR (rispetto a quelli osservati nel singolo trattamento con MG132). Essendo l’autofagia un meccanismo compensativo che si attiva in seguito all’inibizione del proteasoma o allo stress del RE, abbiamo valutato che ruolo potesse avere tale meccanismo nella risposta simil-antagonistica osservata in seguito al co-trattamento con EGCG e BZM. I nostri risultati hanno evidenziato, in cellule trattate con BZM, l’attivazione di un flusso autofagico che si intensifica quando viene addizionato l’EGCG. Tramite l’inibizione dell’autofagia mediante co-somministrazione di clorochina, è stato possibile stabilire che l’autofagia indotta dall’EGCG favorisce la sopravvivenza delle cellule sottoposte al trattamento combinato tramite la riduzione dell’UPR. Queste evidenze ci portano a concludere che per il trattamento del CaP è sconsigliabile associare le catechine del tè verde con il BZM e che in futuri studi di combinazione di questi polifenoli con composti antitumorali sarà importante valutare il ruolo dell’autofagia come possibile meccanismo di resistenza.

Electro-mechanical coupling in the aging heart: role of the Late Na+ current

The aging myopathy manifests itself with diastolic dysfunction and preserved ejection fraction. However, the difficulty in defining myocardial aging and the mechanisms involved complicates the recognition of the cellular processes underlying impaired diastolic relaxation. We raised the possibility that, in a mouse model of physiological aging, defects in the electromechanical properties of cardiomyocytes are important determinants of the diastolic properties of the myocardium, independently from changes in the structural composition of the muscle and collagen framework. Here we show that an increase in the late Na+ current (INaL) in aging cardiomyocytes prolongs the action potential (AP) and influences the temporal kinetics of Ca2+ cycling and cell shortening. These alterations increase force development and passive tension. Inhibition of INaL shortens the AP and corrects the dynamics of Ca2+ transient, cell contraction and relaxation. Similarly, repolarization and diastolic tension of the senescent myocardium are partly restored. INaL offers inotropic support, but negatively interferes with cellular and ventricular compliance, providing a new perspective of the biology of myocardial aging and the etiology of the defective cardiac performance in the elderly.

Habitat e genoma: possibili adattamenti di H. pylori allo stomaco umano

Helicobacter pylori è un batterio patogeno che infetta e abita lo stomaco umano. La sua diffusione è ubiquitaria nel mondo ed esso è responsabile di varie patologie, sia gastriche che extra-gastriche. Vista l’estrema ostilità del suo habitat, H. pylori necessita di specifici adattamenti che lo rendono unico nella sua capacità di tollerare l’estrema acidità dello stomaco umano, oltre ad evitare la risposta immunitaria dell’ospite. In questa tesi verranno adottati degli approcci bioinformatici per cercare di individuare quali possano essere gli adattamenti e le caratteristiche del genoma di questo batterio correlati con la sopravvivenza nell’ambiente gastrico e l’adattamento all’ospite umano.