Células-tronco hematopoéticas de cordão umbilical: uma nova alternativa terapêutica?

Na medicina, a importância das células-tronco hematopoéticas (CTH) é evidentepelo seu uso rotineiro no tratamento de doenças onco-hematológicas e imunológicas, atravésdo transplante de medula óssea. Entretanto, pelas difi culdades de se encontrar doadorescompatíveis de medula óssea, tem-se buscado outras opções, como a utilização de sanguede cordão umbilical (SCU) como fonte celular. O presente trabalho apresenta uma revisão daliteratura médica pertinente, analisando os prós e os contras dessa alternativa terapêutica.A despeito do baixo volume coletado e do maior tempo necessário para regenerar o tecidohematopoético, o SCU tem alta concentração de CTH, menor risco de causar doença enxertoversus hospedeiro e maior facilidade de obtenção, contribuindo para sua utilização crescenteno mundo. Os novos estudos sobre a utilização do SCU em diferentes formas de terapiascelular e gênica tenderão a agregar conhecimento a esse campo de pesquisas.In medicine, the importance of hematopoietic stem cells (HSC) is evident fromtheir routine use in the treatment of oncohematologic and immunologic disorders achievedthrough bone marrow transplantation. Nevertheless, due to the diffi culties encountered in fi ndingcompatible bone marrow donors, other options have been sought, for example, the use ofumbilical cord blood (UCB) as a cell source. This work presents a review of pertinent medicalliterature and it analyzes the pros and cons of this therapeutic alternative. Despite the smallvolume obtained and greater time necessary for regeneration of the hematopoietic tissue,UCB presents a high concentration of HSC, lower risk of causing graft versus host diseaseand is easier to obtain, what contributes to its increasing use in the world. New studies on theutlization of UCB in different types of cell and gene therapies will tend to add knowledge tothis fi eld of research

Characteristics of a hepatitis C patient cohort at a specialized tertiary care facility: Identifying criteria to improve the allocation of public health resources

OBJECTIVES: Our objective was to analyze, in a population treated for hepatitis C infection at a tertiary care treatment unit, the prevalence of comorbidities and extrahepatic manifestations, the range and degree of the clinical complexity and the associations between advanced liver disease and clinical variables. METHODS: Medical records from chronically infected hepatitis C patients seen at a dedicated treatment facility for complex cases in the Infectious Diseases Division of Hospital das Clı´nicas in Brazil were analyzed. Clinical complexity was defined as the presence of one or more of the following conditions: advanced liver disease (Metavir score F3 or F4 and/or clinical manifestations or ultrasound/endoscopy findings consistent with cirrhosis) or hepatocellular carcinoma and/or 3 or more extrahepatic manifestations and/or comorbidities concomitantly. RESULTS: Among the 1574 patients analyzed, only 41% met the definition of being clinically complex. Cirrhosis or hepatocarcinoma was identified in 22.2% and 1.8% of patients, respectively. According to multiple logistic regression analysis, male sex (p=0.007), age440 years (po0.001) and the presence of metabolic syndrome (p=0.008) were independently associated with advanced liver disease. CONCLUSION: The majority of patients did not meet the criteria for admittance to this specialized tertiary service, reinforcing the need to reevaluate public health policies. Enhanced utilization of existing basic and intermediate complexity units for the management of less complex hepatitis C cases could improve care and lower costs

A Brazilian university hospital position regarding transplantation criteria for HIV-positive patients according to the current literature

Human immunodeficiency virus (HIV) infection was considered a contraindication for solid organ transplantation (SOT) in the past. However, HIV management has improved since highly active antiretroviral therapy (HAART) became available in 1996, and the long-term survival of patients living with HIV has led many transplant programs to reevaluate their policies regarding the exclusion of patients with HIV infection. Based on the available data in the medical literature and the cumulative experience of transplantation in HIVpositive patients at our hospital, the aim of the present article is to outline the criteria for transplantation in HIVpositive patients as recommended by the Immunocompromised Host Committee of the Hospital das Clı´nicas of the University of Sa˜o Paulo

A randomised controlled open-label parallel group pilot study evaluating the immunogenicity and safety of three regimens of the trivalent inactivated influenza vaccine in kidney transplant recipients

Receptores de transplante de órgãos apresentam altas taxas de complicações associadas à influenza e a imunogenicidade vacinal é menor nestes indivíduos. Avaliamos a imunogenicidade e segurança de uma dose dobrada (DD-VIT) e uma dose de reforço (DR-VIT) da vacina influenza trivalente fragmentada e inativada, comparadas à dose padrão (DP-VIT) em receptores de transplante renal (RTR). Foram recrutados e randomizados 176 RTR para os grupos de vacinação (59 DP-VIT, 59 DD-VIT e 58 DR-VIT) e incluímos 15 adultos sadios como controles da DP-VIT. Foram vacinados 172 RTR (57 DP-VIT, 58 DD-VIT e 57 DR-VIT) e 14 adultos sadios. Conclusão de esquema de vacinação e todas as coletas de sangue conforme o protocolo foi confirmado para 120 RTR (44 DP-VIT, 44 DD-VIT e 32 DR-VIT) e 13 adultos sadios. As taxas de soroconversão foram abaixo das recomendações da Agência Europeia de Medicamentos em todos os grupos sugerindo baixa antigenecidade da vacina. O grupo de RTR que recebeu DR-VIT apresentou as maiores taxas de soroconversão e razão das médias geométricas de títulos de anticorpos do que os outros grupos, incluindo o grupo controle de adultos sadios. Entre os RTR, a DR-VIT induziu significativamente maiores taxas de soroconversão e razão das médias geométricas de títulos de anticorpos para as cepas de Influenza A do que a DP-VIT tanto na análise por intenção de tratar (A/H1N1 - 34,5% versus 8,5%, p=0,002 e 2,6 versus 1,4; A/H3N2 - 37,9% versus 18,6%, p=0,051 e 3,0 versus 1,8, p=0,046) como na análise por protocolo (A/H1N1 - 37,5% versus 9,1%, p=0,024 e 2,4 versus 1,3, p=0,013; A/H3N2 - 37,9% versus 18,6%, p=0,051 e 3,1 versus 1,7, p=0,132). As taxas de soroproteção foram adequados em todos os grupos, mas o grupo de RTR que recebeu a DP-VIT apresentou as menores taxas em relação aos adultos sadios que receberam a mesma dose da vacina e os outros grupos de RTR. Entre os RTR, as taxas de soroproteção foram maiores para as três cepas vacinais após DR-VIT do que DP-VIT, com significância estatística para A/H3N2 (96,9% versus 70,5% p=0,003). Não houve nenhuma diferença estatisticamente significativa dos desfechos avaliados para a cepa B. A DD-VIT promoveu maiores taxas de soroconversão e razão das médias geométricas de títulos para as cepas de Influenza A, e maiores taxas de soroproteção para todas as três cepas vacinais, em relação à DP-VIT, embora sem significância estatística. Na análise multivariada por protocolo, a DR-VIT obteve uma associação independente com a soroconversão para A/H3N2 (RP=2,99; IC95%=1,42-6,26; p=0,03). Não foi observada maior incidência de eventos adversos ou rejeição aguda do enxerto renal com a DD-VIT ou DR-VIT. Em conclusão, DR-VIT foi superior a DD-VIT em nosso estudo. Ambas as estratégias de vacinação foram seguros e necessitam de estudos multicêntricos visando comparação direta de sua imunogenicidade e eficácia em indivíduos imunodeprimidosSolid organ transplant recipients present high burdens of influenza-associated complications and vaccine immunogenicity is lower in these individuals. We evaluated the immunogenicity and safety of a double-dose (DD-TIV) and a booster dose (BD-TIV) of the trivalent inactivated split-virus influenza vaccine compared to the standard dose (SD-TIV) in kidney transplant recipients (KTR). We enrolled and randomized 176 KTR to each vaccination group (59 SD-TIV, 59 DD-TIV and 58 BD-TIV) and we enrolled 15 healthy controls as SD-TIV control group. Vaccination was confirmed for 172 KTR (57 SD-TIV, 58 DD-TIV and 57 BD-TIV) and 14 healthy adults. Conclusion of vaccination schedule and provision of blood samples according to the study protocol was confirmed for 120 KTR (44 SD-TIV, 44 DD-TIV and 32 BD-TIV) and 13 healthy adults. Seroconversion rates were below the European Medicines Agency in all treatment groups suggesting low vaccine antigenicity. The KTR group that received BD-TIV presented the highest seroconversion rates than the rest, including the healthy control group. Among KTR, BD-TIV induced significantly higher seroconversion and mean geometric ratios for Influenza A antigens compared to SD-TIV both in the modified intention to treat (A/H1N1 - 34.5% versus 8.5%, p=0.002 and 2.6 versus 1.4; A/H3N2 - 37.9% versus 18.6%, p=0.051 and 3.0 versus 1.8, p=0.046) and per protocol analyses (A/H1N1 - 37.5% versus 9.1%, p=0.024 and 2.4 versus 1.3, p=0.013; A/H3N2 - 37.9% versus 18.6%, p=0.051 and 3.1 versus 1.7, p=0.132). Seroprotection rates were adequate in all groups, with the KTR group that received SD-TIV presenting the lowest rates compared to the healthy control group that received the same vaccine dose and the other KTR groups. Among the KTR treatment groups, seroprotection rates were higher after BD-TIV than SD-TIV for the three vaccine antigens, with statistical significance for A/H3N2 (96.9% versus 70.5% p=0.003). No statistically significant differences were observed for the Influenza B antigen. DD-TIV resulted in higher seroconversion and mean geometric ratios for Influenza A antigens, as well as higher seroprotection rates for all three vaccine antigens, compared to SD-TIV, albeit without statistical significance. In the per protocol multivariate analysis, BD-TIV was independently associated with seroconversion to A/H3N2 (RP=2.99; IC95%=1.42-6.26; p=0.03). We did not observe a higher incidence of adverse events or acute graft rejection with DD-TIV or BD-TIV. In conclusion, BD-TIV was superior to DD-TIV in our study. Both vaccination strategies require head-to-head multicentre comparisons of their immunogenicity and efficacy in immunosuppressed individual

Fatal Disseminated Kaposi's Sarcoma due to Immune Reconstitution Inflammatory Syndrome following HAART Initiation

This is a case report of disseminated Kaposi's sarcoma in the context of immune reconstitution inflammatory syndrome in an HIV-infected patient on HAART regimen for 2 months. The patient rapidly progressed to death in 5 days after worsening pulmonary infiltrates and multiple organ failure

Rothia aeria endocarditis in a patient with a bicuspid aortic valve: case report

Rothia aeria is an uncommon pathogen mainly associated with endocarditis in case reports. In previous reports, endocarditis by R. aeria was complicated by central nervous system embolization. In the case we report herein, endocarditis by R. aeria was diagnosed after acute self-limited diarrhea. In addition to the common translocation of R. aeria from the oral cavity, we hypothesize the possibility of intestinal translocation. Matrix-assisted laser desorption ionization-time of flight mass spectrometry and genetic sequencing are important tools that can contribute to early and more accurate etiologic diagnosis of severe infections caused by Gram-positive rods

A Brazilian university hospital position regarding transplantation criteria for HIV-positive patients according to the current literature

Human immunodeficiency virus (HIV) infection was considered a contraindication for solid organ transplantation (SOT) in the past. However, HIV management has improved since highly active antiretroviral therapy (HAART) became available in 1996, and the long-term survival of patients living with HIV has led many transplant programs to reevaluate their policies regarding the exclusion of patients with HIV infection. Based on the available data in the medical literature and the cumulative experience of transplantation in HIV-positive patients at our hospital, the aim of the present article is to outline the criteria for transplantation in HIV-positive patients as recommended by the Immunocompromised Host Committee of the Hospital das Clínicas of the University of São Paulo