Paulo Roberto Slud Brofman

Hospital gowns as a vehicle for bacterial dissemination in an intensive care unit

The microbiota from the uniforms of 31 professionals from the general intensive care unit was analyzed. The samples were collected in duplicate at the beginning and at the end of the work period. Total viable counts of microorganisms were determined; there was a significant increase in the counts at the end of the period, when compared with those obtained at the beginning. No significant difference was observed between the first and second counts obtained from the cuffs. However, differences were observed for the samples from the abdominal region. Among the isolated pathogens 11/18 were Staphylococcus aureus, 2/18 were Acinetobacter baumannii, 2/18 were Klebsiela pneumoniae and 1/18 were Serratia rubidae. Some of these isolates were multi-resistant to antibiotics. Emphasis should be placed on reducing the spread of these pathogens in the hospital, making sure that biosafety protocols are followed by the staff.

Double skeletonized internal thoracic artery vs. double conventional internal thoracic artery in diabetic patients submitted to OPCAB

OBJECTIVE To evaluate the influence of the technique used in the dissection of thoracic arteries in the evolution of diabetic patients submitted to OPCAB. METHODS Seventy diabetic patients submitted to OPCAB using bilateral thoracic arteries were evaluated. In Group A, thoracic arteries were dissected as a pedicle, while in Group B they were skeletonized. RESULTS The mean age of patients in Group A was 52.14 +/- 7.35 years old versus 55.71 +/- 8.1 years for Group B (p=0.057). In Group A, six patients (17.1%) were insulin dependent against nine (25.7%) in Group B (p = 0.561). The EUROSCORE was 3.97 +/- 2.49 for Group A opposed to 4.14 +/- 3.06 for Group B (p = 0.879). The number of distal anastomoses in Group A was 3 +/- 0.77 versus 3.03 +/- 0.89 in Group B (p = 0.981). Three patients (8.57%) from Group A presented with mediastinitis. Insulin dependence was the only significant risk factor (p=0.008) for mediastinitis. In this group the use of skeletonized internal thoracic arteries significantly decreased the incidence of mediastinitis (p = 0.044). CONCLUSION The incidence of mediastinitis was lower in the group for which mammary arteries were dissected using skeletonization. Among insulin-dependent diabetics, 50% of the patients from the group in which the pedicled internal thoracic artery was utilized presented with mediastinitis; the utilization of skeletonized internal thoracic arteries significantly decreases the incidence of mediastinitis.

Are purified or expanded cord blood-derived CD133+ cells better at improving cardiac function?

Endothelial progenitor cells (EPCs), which express the CD133 marker, can differentiate into mature endothelial cells (ECs) and create new blood vessels. Normal angiogenesis is unable to repair the injured tissues that result from myocardial infarction (MI). Patients who have high cardiovascular risks have fewer EPCs and their EPCs exhibit greater in vitro senescence. Human umbilical cord blood (HUCB)-derived EPCs could be an alternative to rescue impaired stem cell function in the sick and elderly. The aim of this study was to purify HUCB-derived CD133+ cells, expand them in vitro and evaluate the efficacy of the purified and expanded cells in treating MI in rats. CD133+ cells were selected for using CD133-coupled magnetic microbeads. Purified cells stained positive for EPC markers. The cells were expanded and differentiated in media supplemented with fetal calf serum and basic fibroblast growth factor, insulin-like growth factor-I and vascular endothelial growth factor (VEGF). Differentiation was confirmed by lack of staining for EPC markers. These expanded cells exhibited increased expression of mature EC markers and formed tubule-like structures in vitro. Only the expanded cells expressed VEGF mRNA. Cells were expanded up to 70-fold during 60 days of culture, and they retained their functional activity. Finally, we evaluated the therapeutic potential of purified and expanded CD133+ cells in treating MI by intramyocardially injecting them into a rat model of MI. Rats were divided into three groups: A (purified CD133+ cells-injected); B (expanded CD133+ cells-injected) and C (saline buffer-injected). We observed a significant improvement in left ventricular ejection fraction for groups A and B. In summary, CD133+ cells can be purified from HUCB, expanded in vitro without loosing their biological activity, and both purified and expanded cells show promising results for use in cellular cardiomyoplasty. However, further pre-clinical testing should be performed to determine whether expanded CD133+ cells have any clinical advantages over purified CD133+ cells.

Multicentre, randomized, double-blind trial of intracoronary autologous mononuclear bone marrow cell injection in non-ischaemic dilated cardiomyopathy (the dilated cardiomyopathy arm of the MiHeart study).

AIMS Pre-clinical and few clinical studies suggest that transplantation of autologous bone marrow mononuclear cells (BMNC) improves heart function in dilated cardiomyopathies. Our objective was to determine if intracoronary injection of autologous BMNC improves the left ventricular ejection fraction (LVEF) of patients with non-ischaemic dilated cardiomyopathy (NIDCM). METHODS AND RESULTS This study was a multicentre, randomized, double-blind, placebo controlled trial with a follow-up of 12 months. Patients with NIDCM and LVEF <35% were recruited at heart failure ambulatories in specialized hospitals around Brazil. One hundred and sixty subjects were randomized to intracoronary injection of BMNC or placebo (1:1). The primary endpoint was the difference in change of LVEF between BMNC and placebo groups as determined by echocardiography. One hundred and fifteen patients completed the study. Left ventricular ejection fraction decreased from 24.0% (21.6-26.3) to 19.9% (15.4-24.4) in the BMNC group and from 24.3% (22.1-26.5) to 22.1% (17.4-26.8) in the placebo group. There were no significant differences in changes between cell and placebo groups for left ventricular systolic and diastolic volumes and ejection fraction. Mortality rate was 20.37% in placebo and 21.31% in BMNC. CONCLUSION Intracoronary injection of autologous BMNC does not improve left ventricular function in patients with NIDCM. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00333827.

Comparison of mononuclear and mesenchymal stem cell transplantation in myocardium infarction

Background: Bone marrow stem cell (SC) transplantation into failing myocardium has emerged as a novel therapeutic option for the treatment of ventricular dysfunction. Both mononuclear (MoSC) and mesenchymal (MeSC) stem cells have been proposed as ideal cell types to this goal. The objective of this study is to compare the efficacy of these cells in improving ventricular function in a rat model of postinfarct ventricular dysfunction. Method: Myocardial infarction was induced in Wistar rats by left coronary occlusion. After 1 week, 42 animals with resulting ejection fractions (EF) lower than 30% were included in the study. MoSC and MeSC were obtained from bone marrow aspirates and separated by the Ficoll-Hypaque method. MeSC were cultured for 14 days before injection. Nine days after infarction, rats received intramyocardial injections of MoSC (n=8), MeSC (n=13) or culture medium as a control (n=21). Echocardiographic evaluation was performed at baseline and after one month. Results: There were no significant differences in the baseline ejection fractions or the left ventricular end diastolic volumes (LVEDV) between all groups. After 1 month, ejection fraction decreased in the Control Group and remained unchanged in MoSC and MeSC Groups. In all three groups ventricular dilation was observed. Histopathology of the infarcted area where injections were performed identified new smooth muscle cells and endothelial cells in the MeSC Group and only new endothelial cells in MoSC Group Conclusions: Both MoSC and MeSC provided stabilization in the ejection fraction in this post-infarction ventricular dysfunction model however, no therapy prevented ventricular dilation.

Qualidade de vida e indicadores clínicos na insuficiência cardíaca: análise multivariada

FUNDAMENTO: En la insuficiencia cardiaca (IC), la atencion especial es necesaria no solamente en cuanto a aspectos objetivos o aislados, sino tambien a las percepciones de la salud del paciente. Los aspectos subjetivos pueden ayudar a los profesionales de la salud a comprender a tratar mejor la IC. OBJETIVO: El objetivo de ese estudio fue evaluar simultaneamente los efectos de los indicadores clinicos de la IC en la calidad de vida (CDV). METODOS: Investigamos, por medio de analisis multivariado, la CDV de 101 pacientes ambulatorios brasilenos, con la utilizacion del cuestionario de Minnesota (Minnesota Living with Heart Failure Questionnaire), incluyendo sus subescalas y su correlacion con las variables clinicas y psicologicas, tales como edad, etnia, genero, parametros ecocardiograficos, indice de masa corporal, presion arterial promedio de reposo, tiempo de diagnostico, Clasificacion Funcional de acuerdo con la NYHA, capacidad funcional a traves de una Escala de Actividad Especifica, comorbilidades, Score de Riesgo de Framingham (ERF), prueba de funcion pulmonar (espirometria) y composicion corporal. RESULTADOS: La CDV presento correlaciones univariadas significantes con el ecocardiograma: fraccion de eyeccion (p=0,0415), diametro diastolico del ventriculo izquierdo (DDVI) (p=0,004), diametro sistolico del ventriculo izquierdo (DSVI) (p=0,0001); comorbilidades (p=0,002) y prueba de funcion pulmonar: Capacidad Vital Forzada (CVF) (p<0,0001), Volumen Espiratorio Forzado en el 1er segundo (FEV1) (p<0,0001) y Ventilacion Voluntaria Maxima (VVM) (p=0,001). En el analisis multivariado, el protocolo Backward Stepwise detecto importantes variables influyentes simultaneas (r2=0.60): genero (0,000178), etnia (p<0,00001), DSVI (P<0.00001), ERF (p=0,000002), CVF (p=0,002027), FEV1 (p<0,00001) y VVM (p=0,00001). CONCLUSION: Genero, etnia, DSVI, ERF, CVF, FEV1 y VVM son predictores independientes de CDV en pacientes con IC. Simultaneamente, ellos son responsables por cerca del 60% de la variancia de la CDV. Los aspectos biopsicosociales pueden contribuir a las expectativas de los pacientes y profesionales de salud y resultado del tratamiento.

O transplante em conjunto de células mioblásticas esqueléticas e mesenquimais (cocultivadas) na disfunção ventricular pós-infarto do miocárdio

OBJECTIVE: Cell therapy in the myocardium has been mainly performed with satisfactory results using 2 cell types: skeletal myoblasts (myogenic) and mesenchymal cells (angiogenic). This study assessed the combined transplantation of those 2 cell types (SMM) into infarcted rats. METHODS: Myocardial infarction was induced by ligature of the left coronary artery in 26 Wistar rats. After one week, the animals underwent echocardiography for assessing ejection fraction (EF%) and left ventricular end-diastolic and systolic volumes (EDV, ESV, mL). After 2 days, the animals were reoperated on and divided into 2 groups: 1) control (n=10), which received 0.15 mL of culture medium; and 2) SMM (n=16), which received 7.5x106 heterologous skeletal myoblasts and mesenchymal cells in the infarcted region. The cells were obtained from puncture of the iliac crest and biopsy of skeletal muscle, and were cultured in vitro. After one month, the animals underwent a new echocardiography. RESULTS: No significant difference in EF, EDV, and ESV was observed between the 2 groups on baseline echocardiographic values. One month after transplantation, the following was observed: a reduction in EF in the control group (29.31 ± 5.6% to 23.54 ± 6.51%; P=0.048); and an increase in EF in the SMM group (24.03 ± 8.68% to 31.77 ± 9.06%; P=0.011). The presence of neovascularization and muscle fibers was identified in the regions of myocardial fibrosis in the SMM group. CONCLUSION: Cocultivation of skeletal myoblasts and mesenchymal cells is functionally effective.

Genetic evaluation of mesenchymal stem cells by G-banded karyotyping in a Cell Technology Center

Objective To present the initial results of first three years of implementation of a genetic evaluation test for bone marrow-derived mesenchymal stem cells in a Cell Technology Center. Methods A retrospective study was carried out of 21 candidates for cell therapy. After the isolation of bone marrow mononuclear cells by density gradient, mesenchymal stem cells were cultivated and expanded at least until the second passage. Cytogenetic analyses were performed before and after cell expansion (62 samples) using G-banded karyotyping. Results All the samples analyzed, before and after cell expansion, had normal karyotypes, showing no clonal chromosomal changes. Signs of chromosomal instability were observed in 11 out of 21 patients (52%). From a total of 910 analyzed metaphases, five chromatid gaps, six chromatid breaks and 14 tetraploid cells were detected giving as total of 25 metaphases with chromosome damage (2.75%). Conclusion The absence of clonal chromosomal aberrations in our results for G-banded karyotyping shows the maintenance of chromosomal stability of bone marrow-derived mesenchymal stem cells until the second passage; however, signs of chromosomal instability such as chromatid gaps, chromosome breaks and tetraploidy indicate that the long-term cultivation of these cells can provide an intermediate step for tumorigenesis.

Quality of life and clinical indicators in heart failure: a multivariate analysis.

FUNDAMENTO: En la insuficiencia cardiaca (IC), la atencion especial es necesaria no solamente en cuanto a aspectos objetivos o aislados, sino tambien a las percepciones de la salud del paciente. Los aspectos subjetivos pueden ayudar a los profesionales de la salud a comprender a tratar mejor la IC. OBJETIVO: El objetivo de ese estudio fue evaluar simultaneamente los efectos de los indicadores clinicos de la IC en la calidad de vida (CDV). METODOS: Investigamos, por medio de analisis multivariado, la CDV de 101 pacientes ambulatorios brasilenos, con la utilizacion del cuestionario de Minnesota (Minnesota Living with Heart Failure Questionnaire), incluyendo sus subescalas y su correlacion con las variables clinicas y psicologicas, tales como edad, etnia, genero, parametros ecocardiograficos, indice de masa corporal, presion arterial promedio de reposo, tiempo de diagnostico, Clasificacion Funcional de acuerdo con la NYHA, capacidad funcional a traves de una Escala de Actividad Especifica, comorbilidades, Score de Riesgo de Framingham (ERF), prueba de funcion pulmonar (espirometria) y composicion corporal. RESULTADOS: La CDV presento correlaciones univariadas significantes con el ecocardiograma: fraccion de eyeccion (p=0,0415), diametro diastolico del ventriculo izquierdo (DDVI) (p=0,004), diametro sistolico del ventriculo izquierdo (DSVI) (p=0,0001); comorbilidades (p=0,002) y prueba de funcion pulmonar: Capacidad Vital Forzada (CVF) (p<0,0001), Volumen Espiratorio Forzado en el 1er segundo (FEV1) (p<0,0001) y Ventilacion Voluntaria Maxima (VVM) (p=0,001). En el analisis multivariado, el protocolo Backward Stepwise detecto importantes variables influyentes simultaneas (r2=0.60): genero (0,000178), etnia (p<0,00001), DSVI (P<0.00001), ERF (p=0,000002), CVF (p=0,002027), FEV1 (p<0,00001) y VVM (p=0,00001). CONCLUSION: Genero, etnia, DSVI, ERF, CVF, FEV1 y VVM son predictores independientes de CDV en pacientes con IC. Simultaneamente, ellos son responsables por cerca del 60% de la variancia de la CDV. Los aspectos biopsicosociales pueden contribuir a las expectativas de los pacientes y profesionales de salud y resultado del tratamiento.

Metabolic switches during the first steps of adipogenic stem cells differentiation.

The understanding of metabolism during cell proliferation and commitment provides a greater insight into the basic biology of cells, allowing future applications. Here we evaluated the energy and oxidative changes during the early adipogenic differentiation of human adipose tissue-derived stromal cells (hASCs). hASCs were maintained under differentiation conditions during 3 and 7days. Oxygen consumption, mitochondrial mass and membrane potential, reactive oxygen species (ROS) generation, superoxide dismutase (SOD) and catalase activities, non-protein thiols (NPT) concentration and lipid peroxidation were analyzed. We observed that 7days of adipogenic induction are required to stimulate cells to consume more oxygen and increase mitochondrial activity, indicating organelle maturation and a transition from glycolytic to oxidative energy metabolism. ROS production was only increased after 3days and may be involved in the differentiation commitment. ROS source was not only the mitochondria and we suggest that NOX proteins are related to ROS generation and therefore adipogenic commitment. ROS production did not change after 7days, but an increased activity of catalase and NPT concentration as well as a decreased lipid peroxidation were observed. Thus, a short period of differentiation induction is able to change the energetic and oxidative metabolic profile of hASCs and stimulate cytoprotection processes.