Os pacientes submetidos ao transplante de células-tronco hematopoéticas (TCTH) necessitam da inserção do cateter venoso central (CVC) de longa permanência e semi-implantado. No entanto, a obstrução trombótica do CVC é uma complicação que pode ocasionar o funcionamento inadequado do dispositivo intravascular e levar sua remoção precoce. Este estudo trata-se de uma revisão integrativa da literatura, com o objetivo de sintetizar as medidas relacionadas à prevenção e tratamento da obstrução trombótica relacionada ao CVC de longa permanência e semi-implantado, nos pacientes submetidos ao TCTH. A amostra constituiu-se de sete estudos primários, sendo dois ensaios clínicos randomizados, três estudos de coorte e duas séries de casos. Quanto as categorias temáticas, quatro estudos abordaram medidas de prevenção da obstrução trombótica relacionada ao CVC, dois estudos abordaram as medidas de tratamento e um abordou as medidas de prevenção e tratamento. Dentre os estudos que abordaram medidas de prevenção, obteve-se um único que se mostrou efetivo na prevenção da obstrução, trata-se de um coorte sobre o uso da varfarina oral, iniciado no dia da inserção do dispositivo venoso central. Os demais estudos não evidenciaram diferenças estatisticamente significantes entre o tratamento padrão e a intervenção testada. Quanto às medidas de tratamento, três estudos evidenciaram sucesso, sendo que um apontou a eficácia do uso de estreptoquinase ou uroquinase, outro estudo mostrou benefício no uso de heparina de baixo peso molecular e outro tratou a obstrução com heparina e uroquinase com sucesso. Nota-se que a evolução da pesquisa referente a perviedade do CVC foi restrita, não acompanhando a evolução da terapia com CTH, principalmente, no que tange os cuidados de enfermagem, visto que todos tratam de intervenções medicamentosas, sem abordar os aspectos não medicamentosos, como, por exemplo, volume e freqüência do flush com solução fisiológica, descrição da técnica com pressão positiva, tamanho ideal da seringa, pressão exercida durante a infusão de medicamentos e dispositivos para vedação dos lumens do cateter com pressão positiva. Tais resultados mostram a necessidade da realização de novos estudos controlados, para testar as intervenções de enfermagem na prevenção da obstrução trombótica relacionada ao cateter. / Patients submitted to hematopoietic stem cell transplantation (HSCT) need indwelling and semi-implanted central venous catheterization. Thrombotic obstruction of CVC, however, is a complication that can lead to the inadequate functioning of the intravascular device and its early removal. This integrative literature review aimed to summarize measures for the prevention and treatment of thrombotic obstruction related to indwelling and semi-implanted CVC, in patients submitted to HSCT. The sample included seven primary studies, with two randomized clinical trials, three cohorts and two case series. As for the theme categories, four studies discussed CVC-related thrombotic obstruction prevention measures, two addressed treatment measures and one prevention and treatment measures. Among the studies that discussed prevention measures, one single research showed effective obstruction prevention, which was a cohort on the use of oral warfarin, started on the day the central venous device was inserted. The other studies showed no statistically significant differences between standard treatment and the tested intervention. Regarding treatment measures, three studies showed to be successful: one appointed the efficacy of streptokinase or urokinase use, another showed the benefits of using low molecular weight heparin and the third successfully treated the obstruction with heparin and urokinase. The restricted evolution of research regarding CVC patency was observed, which did not accompany the evolution of HSC therapy, mainly regarding nursing care, as all addressed discuss medication interventions, without discussing non-medication aspects, such as the flush volume and frequency with physiological salt solution, description of positive pressure technique, ideal syringe size, pressure exerted during medication infusion and catheter lumen sealing devices with positive pressure. These results show the need for further controlled studies to test nursing interventions in the prevention of catheter-related thrombotic obstruction.

Contexte :Le conditionnement précédant la greffe de cellules souches hématopoïétiques (CSH) a été associé avec des taux élevés de malnutrition meme à 100 jours après la greffe. Objectif: Cette étude évalua l'impact du conseil nutritionel fournie à la sortie de l'hôpital sur l'état nutritionnel,100 jours après la greffe de CSH (dit T4).Conception: Il s'agissait d'un essai contrôlé randomisé monocentrique. Les patients adultes étaient randomisés à un groupe témoin (GT) recevant des soins habituels et un groupe d'intervention (GI) recevant des conseils nutritionnels mensuels après la sortie de l’hôpital. Le résultat principal était le score de l'évaluation globale subjective générée par le patient (PGSGA) à T4. La malnutrition était évalué aussi par le score de la société américaine de nutrition parentérale et entérale/Académie de nutrition et diététique (AND-ASPEN).Résultats: 52 participants ont été randomisés (août 2016 jusqu'en août 2017) et 46 ont été analysés [65% d'hommes, 63% de greffes autologues, GI (n = 22), GT (n = 24)]. Les deux groupes etaient comparable au moment de randomization.A T4, le pourcentage de patients bien nourris n'était pas significativement différent entre les groupes selon le PGSGA (72% GI vs 43% GT, p = 0,063). Le pourcentage de patients bien nourris selon AND-ASPEN s'est améliorré à T4 dans le GI (50% vs 14%, p = 0,02) et non pas dans le GT par rapport aux valeurs d'admission. A T4, le GI avait un apport de protéines et de calories plus élevé que le GT(p<0.05).Conclusion:Le conseil nutritionnel après la greffe de CSH a amélioré l’apport en protéines et calories ainsi que le score AND-ASPEN mais non pas le score PGSGA. / Background: Conditioning preceding Hematopoietic Stem Cell Transplantation (HSCT) has been associated with elevated rates of malnutrition until 100 days post HSCT.Objective: This study aimed to assess the impact of nutritional counseling provided at hospital discharge on nutritional status 100 days post HSCT (defined as T4). Design: This was a single center randomized controlled trial among adult HSCT patients. Around discharge from the hospital, recruited patients were randomized to a Control Group (CG) receiving usual care and to an Intervention Group (IG) receiving nutritional counseling on a monthly basis post discharge.The primary outcome was the Patient Generated Subjective Global Assessment (PGSGA) scores at T4. Malnutrition was also assessed though the American Society for Parenteral and Enteral Nutrition/ Academy of Nutrition and Dietetics malnutrition score.Results: 52 participants were randomized (August 2016 until August 2017) and 46 were analyzed [65% males, 63% autologous HSCT, IG (n=22), CG (n=24)]. Groups were comparable at randomization. At T4, the percent of well-nourished patients was not significantly different between groups when assessed via PGSGA (72% IG vs. 43% CG, p=0.063).The percent of wellnourished patients as per AND-ASPEN criteria improved in IG at T4 (14% vs. 50%, p=0.02) and remained the same in CG (48% vs. 50%, p=1) compared to admission values. IG had higher protein and caloric intake (p<0.05). Conclusion:Nutritional counseling post HSCT improved patients’ protein and caloric intake and AND-ASPEN score but did not significantly improve PGSGA score.

O transplante de células-tronco hematopoéticas tem surgido como alternativa ao tratamento de doenças autoimunes como artrite reumatóide, lúpus eritematoso sistêmico, esclerose múltipla e diabetes mellitus tipo 1. No diabetes mellitus tipo 1, uma síndrome de etiologia múltipla, o transplante de células-tronco hematopoéticas, na sua modalidade autóloga, tem sido utilizado como alternativa ao tratamento convencional (insulinoterapia), já que este retarda, mas não elimina as consequências da doença como disfunção e falência de vários órgãos, especialmente rins, olhos, nervos, coração e vasos sanguíneos. Apesar disso, o transplante é um procedimento altamente invasivo que acarreta repercussões intensas na qualidade de vida desses pacientes exigindo dos mesmos uma readaptação à essas repercussões. O presente estudo teve por objetivo avaliar a qualidade de vida e o ajustamento psicossocial de participantes com diabetes mellitus tipo 1. Participaram do estudo 22 pacientes que foram submetidos consecutivamente ao transplante de células-tronco hematopoéticas na Unidade de Transplante de Medula Óssea do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, no período de 2006 a 2008. Os instrumentos aplicados para a coleta de dados: Questionário Genérico de Avaliação de Qualidade de Vida Medical Outcomes Study 36 Item Short-Form Health Survey (SF-36), Escala de Ansiedade e Depressão Hospitalar - Hospital Anxiety and Depression Scale (HAD) e Inventário de Sintomas de Stress para Adultos de Lipp (ISSL). As avaliações ocorreram em três momentos distintos: na admissão do paciente, um ano após a realização do procedimento e dois anos após o transplante no retorno ambulatorial. A análise dos instrumentos aconteceu de acordo com as recomendações específicas preconizadas pela literatura. Os resultados obtidos mostraram, que para a maioria dos participantes deste estudo, após um ano do procedimento, os índices de qualidade de vida melhoraram significativamente principalmente os domínios Aspectos Físicos (p=0,0003), Estado Geral de Saúde (p=0,0142), Aspectos Sociais (p=0,0018) e Aspectos Emocionais (p=0,0316). Decorrido dois anos, o transplante teve um impacto também positivo sobre a qualidade de vida principalmente nos domínios Aspectos Físicos (p<0,0001), Aspectos Sociais (p=0,0235) e Aspectos Emocionais (p=0,0270). Em relação ao ajustamento psicossocial os resultados mostraram redução dos sintomas de ansiedade após o primeiro ano de transplante (p<0,01) e depressão nos dois momentos após o transplante (p<0,01). Observou-se ainda a diminuição dos sintomas de estresse nos momentos avaliados (p<0,01). Tais resultados podem representar uma possibilidade de retomada da vida e dos planos futuros que foram interrompidos por uma doença crônica que impunha inevitáveis dificuldades e limitações para esses participantes. Os resultados deste estudo oferecem subsídios para a equipe multidisciplinar de saúde refletir sobre as implicações dessa terapêutica inovadora em aspectos essenciais da vida do participante que vão além da dimensão biomédica, considerando as repercussões sobre sua qualidade de vida e ajustamento psicossocial. / Transplantation of hematopoietic stem cells has emerged as an alternative to the treatment of autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, multiple sclerosis and type 1 diabetes mellitus. In the latter, a syndrome of multiple etiology, the hematopoietic stem cell transplantation, in its autologous method, has been used as an alternative to conventional treatment (therapy with insulin), once it slows, but does not eliminate the consequences of the disease such as dysfunction and failure of various organs, especially kidneys, eyes, nerves, heart and blood vessels. Nevertheless, transplantation is a highly invasive procedure that carries severe repercussions on the quality of life of these patients, requiring from them a readjustment to these repercussions. The present study aimed to evaluate the quality of life and psychosocial adjustment of participants with type 1 diabetes mellitus. The study included 22 patients who underwent consecutive hematopoietic stem cell transplantation in the Bone Marrow Transplantation Ward of the Hospital das Clinicas of the University of Sao Paulo at Ribeirao Preto Medical School, between 2006 and 2008. The following instruments were used for data collection: Medical Outcomes Study 36 Item Short-Form Health Survey (SF-36), Hospital Anxiety and Depression Scale (HAD) and Lipp Stress Symptoms Inventory for Adults (LSSI). Assessments were performed at three different moments: at patient admission, one year after the performance of the procedure and two years after transplantation at the post-transplant outpatient clinic. Analysis of the instruments was done according to specific recommendations proposed in the literature. Results showed that, for most participants of the study, one year after the procedure, the indices of quality of life improved significantly, mainly the domains Physical Functioning (p=0.0003), General Health (p=0.0142), Social Functioning (p=0.0018) and Role-Emotional (p=0.0316). After two years, the transplant also had a positive impact on the quality of life, especially in the domains Physical Functioning (p<0.0001), Social Functioning (p=0.0235) and Role-Emotional (p=0.0270). In relation to psychosocial adjustment, results showed a reduction in symptoms of anxiety after the first year of transplantation (p<0.01) and depression at the two moments after transplantation (p<0.01). A decrease in symptoms of stress at the studied moments (p <0.01) was also observed. These results may represent a possibility of renewed life and future plans that were interrupted by a chronic illness that imposed inevitable difficulties and limitations to these participants. Results of this study provide support to the multidisciplinary health team reflect on the implications of this innovative therapy in essential aspects of participants life that go beyond the biomedical dimension, considering the repercussions on their quality of life and psychosocial adjustment.

幹細胞療法是近年的研究熱點之一，然而幹細胞在組織修復中的實際應用受到移植後幹細胞存活率低的制約，約80% 的幹細胞在移植至組織後不能存活。 人類臍帶血管周皮 (HUCPV) 幹細胞為多功能間充質幹細胞移植提供豐富的細胞來源。 在合適的誘導環境下，它們具有向多種間充質細胞系分化的能力。 與從骨髓或臍帶血中提取的間充質幹細胞比較，人類臍帶血管周皮幹細胞的體外增殖更為容易。 在本研究中，我們從人類臍帶血管周圍組織中分離人類臍帶血管周皮幹細胞，並採用流式細胞技術分選細胞表面標記物CD34、CD45呈陰性同時CD44 、CD90、 CD105、 CD146呈陽性的HUCPV細胞。HUCPV細胞在體外培養以及三維支架的環境下具有分化為骨和軟骨的能力。 / 在本研究中，我們主要研究腦和生殖器官表達基因（BRE）在HUCPV細胞中的功能。 BRE蛋白與其他已知蛋白的同源性均不高，目前尚未鑑定出任何功能性的結構域。 至今為止，BRE基因的已知功能大多數是通過對腫瘤模型的研究發現的。 據報導，BRE能夠提高DNA損傷的腫瘤細胞的存活率，但BRE在幹細胞中的作用仍不清楚。 我們發現，當HUCPV細胞分化後，其BRE的表達水平降低。 此外，利用BRE-siRNA降低HUCPV細胞中BRE基因的表達，能夠促進HUCPV細胞向骨和軟骨分化的進程。 因此，我們假設BRE對維持HUCPV細胞的幹細胞功能具有重要的作用。 由於經過BRE基因沉默處理的HUCPV細胞與對照組相比並無顯著的表型差別，我們採用微陣列（microarray）以及比較蛋白組學的方法研究兩者間的區別，從而找出BRE基因的功能以及可能涉及BRE的信號通路。 / 通過微陣列技術，我們深入地分析了BRE基因表達沉默後HUCPV細胞的轉錄組。 在經過BRE基因沉默處理的HUCPV細胞中，我們發現與維持幹細胞多向分化潛能有關的OCT4、 FGF5和FOXO1A等基因的表達顯著下調。 另外，BRE基因的沉默能夠影響表觀遺傳調控基因以及TGF-β 信號通路組成部件的表達，而TGF -β 信號通路是維持幹細胞自我更新的重要通路。 這些結果提示，BRE作為一個重要的調控因子，在維持HUCPV細胞的多向分化潛能的同時能夠防止細胞分化。 / 在比較蛋白組學的研究中，我們發現BRE基因的沉默能夠降低細胞骨架結合蛋白的表達，例如actin, annexin II 及 tropomyosin。 此外，我們利用免疫共沉澱的方法證明了BRE蛋白與actin及 annexin II蛋白直接結合。 細胞骨架的改變可能為HUCPV細胞的分化提供了一個有利的環境，因而BRE基因的沉默能夠促進HUCPV細胞向骨和軟骨分化。 支持這一推論的其中一個依據是Lim et al., 2000; Solursh, 1989; Zhang et al., 2006，文獻報導肌動蛋白多聚化抑製劑能夠促進軟骨形成的過程。 綜上所述，本研究為進一步研究BRE基因在HUCPV細胞中的功能以及與BRE直接作用的蛋白打下了基礎。 / Stem cells therapy has gained considerable attention in recent years. However, the practical use of stem cells for tissue repair has been hindered due to their low survival rate after grafting into tissues, for approximately 80% of the stem cells died after implantation. Human umbilical cord perivascular (HUCPV) stem cells offer a new and rich resource of multipotent mesenchymal stem cells. These cells possess the ability to differentiate into various mesenchymal cell lineages when induced. HUCPV cells can be more easily amplified in culture than mesenchymal stem cells extracted from bone marrow or umbilical cord blood. In this study, HUCPV cells were isolated from the perivascular regions of human umbilical cords. The HUCPV cells were sorted using flow cytometer for CD34⁻, CD44⁺, CD45⁻, CD90⁺, CD105⁺ and CD146⁺ surface markers. These HUCPV cells were found to be capable of differentiating into osteogenic lineage in monolayer culture and chondrogenic lineage in pellet culture. These cells were also found to be capable of differentiating into osteogenic and chondrogenic lineage in silk fibroin which acted as three-dimensional scaffolds for the cells to grow on. / The function of the Brain and Reproductive Organ-Expressed (BRE) gene in the context of HUCPV cells was investigated. The BRE protein shares no homology with any other known gene products and contains no known functional domain. To date, most of what we know about the function of this gene has been conducted in the tumor model. It has been reported that BRE can enhance the cellular survival of cancer cells following DNA damage. The role of BRE in stem cells has never been examined. We have established that BRE expression was down-regulated when HUCPV cells started to differentiate. In addition, silencing BRE expression, using BRE-siRNA, in HUCPV cells could accelerate osteogenic and chondrogenic differentiation. Hence, we hypothesized that BRE played an important role in maintaining the stemness of HUCPV cells. Because there was a lack of phenotypic difference between the BRE-silenced HUCPV cells and cells transfected with the control-siRNA, we decided to profile these cells using microarray and proteomic analyses. The aim was to elucidate the function of the BRE gene and establish whether BRE was involved in any signaling pathways. / In the microarray analysis, we examined the transcriptome of HUCPV cells in response to BRE-silencing in depth. Amongst the genes that we identified were significantly down-regulated by BRE-silencing and involved in the maintenance of pluripotency in ES cells were OCT4, FGF5 and FOXO1A. BRE-silencing also altered the expression of epigenetic genes and also components of the TGF-β signaling pathway. This pathway is crucially involved in maintaining stem cell self-renewal. Therefore, we propose that BRE acts like a modulator that promotes stemness and at the same time inhibits the differentiation of HUCPV cells. / In the comparative proteomic study, BRE-silencing resulted in decreased expression patterns of cytoskeletal binding proteins such as actin, annexin II and tropomyosin. In addition, co-immunoprecipitation experiments revealed that the BRE protein can bind directly with actin and annexin II. It is possible that altering the cytoskeleton may provide a favorable environment for HUCPV cells to differentiate. This may explain why we were able to accelerate osteogenic and chondrogenic differentiation following BRE-silencing. In support of the view, it has been reported that chondrogenesis could be enhanced after cells have been treated with actin polymerization inhibitors (Lim et al., 2000; Solursh, 1989; Zhang et al., 2006). In sum, our studies provide an insight into the function of the BRE gene in HUCPV cells and the proteins that BRE can directly act on. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Chen, Elve. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references (leaves 135-159). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese. / Thesis/Assessment Committee --- p.i / Abstract --- p.ii / 摘要 --- p.v / Acknowledgements --- p.viii / List of Figures --- p.ix / List of Tables --- p.xiii / Table of Abbreviations --- p.xiv / Contents --- p.xviii / Chapter 1 --- p.1 / Literature Review --- p.1 / Chapter 1.1 --- Stem cells --- p.1 / Chapter 1.2 --- Embryonic stem cells (ESCs) --- p.2 / Chapter 1.3 --- Epiblast-derived stem (EpiS) cells --- p.2 / Chapter 1.4 --- Somatic stem cells (SSCs) --- p.3 / Chapter 1.5 --- Induced pluripotent stem (iPS) cells --- p.5 / Chapter 1.6 --- Human umbilical cord perivascular (HUCPV) cells --- p.7 / Chapter 1.7 --- CD146 --- p.8 / Chapter 1.8 --- Stem cell senescence --- p.9 / Chapter 1.9 --- Brain and reproductive organ-expressed (BRE) protein --- p.12 / Chapter 1.10 --- Stem cell self-renewal --- p.14 / Chapter 1.11 --- Apoptosis --- p.16 / Chapter 1.12 --- Stem cell niche --- p.21 / Chapter 1.13 --- Stem cell homing --- p.22 / Chapter 1.14 --- Objective --- p.22 / Chapter 2 --- p.24 / Accelerated osteogenic and chondrogenic differentiation of HUCPV cells by modulating the expression of BRE --- p.24 / Chapter 2.1 --- Introduction --- p.24 / Chapter 2.2 --- Rationale --- p.27 / Chapter 2.3 --- Materials and Methods --- p.27 / Chapter 2.3.1 --- Extraction of HUCPV cells from umbilical cord --- p.27 / Chapter 2.3.2 --- Cell culture condition --- p.28 / Chapter 2.3.3 --- Flow cytometry analysis and cell sorting --- p.28 / Chapter 2.3.4 --- In vitro osteogenic differentiation --- p.29 / Chapter 2.3.5 --- In vitro chondrogenic differentiation --- p.29 / Chapter 2.3.6 --- Alcian blue staining --- p.29 / Chapter 2.3.7 --- Alizarin red S staining --- p.30 / Chapter 2.3.8 --- Immunofluorescence analysis --- p.30 / Chapter 2.3.9 --- Quantitative real-time reverse transcription-polymerase chain reaction (qRT-PCR) --- p.31 / Chapter 2.3.10 --- Transfection with siRNA --- p.35 / Chapter 2.3.11 --- Microarray --- p.35 / Chapter 2.3.12 --- Cell lysis and immunoprecipitation --- p.36 / Chapter 2.3.13 --- SDS-PAGE and Western blot --- p.36 / Chapter 2.3.14 --- Isoelectric focusing and 2-dimensional gel electrophoresis --- p.37 / Chapter 2.3.15 --- Migration (wound healing) assay --- p.38 / Chapter 2.4 --- Results --- p.38 / Chapter 2.4.1 --- HUCPV cells were capable to differentiate into osteoblasts and chondrocytes --- p.38 / Chapter 2.4.2 --- BRE expression is down-regulated when HUCPV cells begins to differentiate --- p.40 / Chapter 2.4.3 --- Silencing of BRE expression accelerates induction of osteogenesis and chondrogenesis --- p.40 / Chapter 2.4.4 --- Microarray analysis of BRE-silenced HUCPV cells --- p.42 / Chapter 2.4.4.1 --- Stemness factors --- p.43 / Chapter 2.4.4.2 --- Epigenetic regulation --- p.43 / Chapter 2.4.4.3 --- Signaling pathways crucial for stemness maintenance --- p.44 / Chapter 2.4.4.4 --- TGF-β signaling --- p.44 / Chapter 2.4.4.5 --- FGF signaling --- p.44 / Chapter 2.4.4.6 --- NOTCH signaling --- p.45 / Chapter 2.4.4.7 --- WNT signaling --- p.46 / Chapter 2.4.4.8 --- Homeobox transcription factors (HOX) --- p.46 / Chapter 2.4.4.9 --- Cell cycle regulation --- p.47 / Chapter 2.4.4.10 --- Chemokines and cytokines regulation --- p.48 / Chapter 2.4.4.11 --- Apoptosis --- p.49 / Chapter 2.4.5 --- BRE-silencing alters the cellular proteome of HUCPV cells --- p.50 / Chapter 2.4.5.1 --- BRE-silencing alters the cytoskeletal binding proteins of HUCPV cells --- p.51 / Chapter 2.4.5.2 --- BRE-silencing alters the expressions of stemness-related proteins in HUCPV cells --- p.52 / Chapter 2.4.5.3 --- BRE-silencing alters the expressions of apoptosis-related proteins in HUCPV cells --- p.53 / Chapter 2.5 --- Discussion --- p.86 / Chapter 2.5.1 --- Microarray study discussion --- p.87 / Chapter 2.5.2 --- Proteomic study discussion --- p.89 / Chapter 3 --- p.93 / Replicative senescence alters the transcriptome and proteome of HUCPV cells --- p.93 / Chapter 3.1 --- Introduction --- p.93 / Chapter 3.2 --- Materials and methods --- p.93 / Chapter 3.3 --- Results --- p.93 / Chapter 3.3.1 --- Microarray analysis of aged HUCPV cells --- p.94 / Chapter 3.3.1.1 --- Stemness factors --- p.95 / Chapter 3.3.1.2 --- Epigenetic regulation --- p.96 / Chapter 3.3.1.3 --- Senescence associated markers --- p.96 / Chapter 3.3.1.4 --- Chemokines and cytokines regulation --- p.97 / Chapter 3.3.1.5 --- Matrix metalloproteinases regulation --- p.97 / Chapter 3.3.1.6 --- WNT signaling --- p.98 / Chapter 3.3.1.7 --- Toll-like receptor signaling pathway --- p.98 / Chapter 3.3.2 --- Proteomic profiling of aged HUCPV cells --- p.98 / Chapter 3.4 --- Discussion --- p.117 / Chapter 3.4.1 --- Aging alters the transcriptome of HUCPV cells --- p.117 / Chapter 3.4.2 --- Aging alters the proteome of HUCPV cells --- p.118 / Chapter 4 --- p.121 / Osteogenic and chondrogenic differentiation capacities of HUCPV cells in silk fibroin scaffold --- p.121 / Chapter 4.1 --- Introduction --- p.121 / Chapter 4.2 --- Materials and methods --- p.121 / Chapter 4.2.1 --- Extraction of silk fibroin --- p.121 / Chapter 4.2.2 --- Fabrication of porous silk fibroin scaffold --- p.122 / Chapter 4.2.3 --- Scanning electron microscopy --- p.123 / Chapter 4.2.4 --- Cell culture --- p.123 / Chapter 4.3 --- Results --- p.124 / Chapter 4.4 --- Discussion --- p.132 / Chapter 5 --- p.133 / Conclusions --- p.133 / References --- p.135

Background e objetivo. A reconstituição celular hematopoiética com o transplante de células tronco hematopoiéticas (TCTH) alogênicas é um método de tratamento estabelecido para uma variedade de doenças hematológicas, oncológicas e imunológicas. Entretanto, TCTH está associado a considerável morbimortalidade devido a fatores como recidiva da doença de base, grau de compatibilidade HLA, tipo de regime de condicionamento e infecções durante o período de neutropenia. Este estudo investigou a associação entre o aloantígenoneutrofílico humano (HNA) e o dia de pega, a ocorrência de DECH aguda e TRM em pacientes que foram submetidos a transplante de células tronco hematopoiéticas alogênico. Tipo de estudo e local. Estudo de coorte prospectivo realizado no Hospital de Clínicas de Porto Alegre. Métodos. Avaliamos 27 pacientes transplantados entre maio de 2013 e abril de 2014 e seus respectivos doadores. A tipagem HNA foi realizada, nas amostras dos doadores, por PCR-SSP e os anticorpos anti-HNA foram detectados nos pacientes utilizando o kit LABSCREEN MULTI (LSMUTR – One Lambda). Resultados. A idade variou entre 1 a 63 anos, com uma média de 20,4 ± 17,5 anos. Dezenove pacientes eram pediátricos (<21 anos) com média de idade de 10,05 ± 6,4 anos e entre os pacientes adultos a média foi 42,2 ± 12,6 anos. Houve um discreto predomínio do sexo masculino 16 (59,3%). As leucemias agudas foram frequentes em 19 (70,4%) dos pacientes, outras doenças oncohematológicas malignas (Linfoma Hodgkin e Linfoma não Hodgkin) estiveram em 3 (11,1%) e as não malignas (síndrome mielodisplásica, osteopetrose, hemoglobinúria paroxicística noturna, aplasia e doença granulomatosa) estiveram em 6 (22,2%) dos casos. A maioria dos pacientes 19 (70,4%), apresentavam a doença há menos de 12 meses na época do transplante e 24 (88,9%) deles foram totalmente compatível com seus doadores quanto ao sistema HLA. O regime de condicionamento mieloablativo foi utilizado em 16 (59,2%) dos pacientes e a profilaxia padrão para DECH (ciclosporina e metotrexate) foi utilizada em 15 (55,5%) dos pacientes. O dia de pega teve uma mediana de 19 e mínimo e máximo de 15 e 30, respectivamente. Quatro pacientes (14,8%) tiveram óbito antes da pega. Aproximadamente 63% (17 pacientes) apresentaram DECH aguda (em todos os estágios) e a taxa de mortalidade (TRM) foi de aproximadamente 44% dos casos (12 pacientes). Os pacientes que receberam TCTH de um doador aparentado tiveram TRM de aproximadamente 41% (7 pacientes) e os que receberam de um doador não aparentado foi de aproximadamente 45% (5 pacientes). A frequência dos antígenos HNA detectados nos doadores foi de 46,4% HNA-1a, 89,3% HNA-1b, 3,6% HNA-1c, 96,4% HNA-3a, 32,1% HNA-3b, 96,4% HNA-4a, 21,4% HNA-4b, 85,7% HNA-5a e 71,4% HNA-5b. A frequência dos anticorpos anti-HNA1a, anti-HNA1b, anti-HNA1c e anti-HNA2 no D0 foram respectivamente 46,4%, 42,9%, 42,9% e 53,6%. A associação entre a tipagem HNA dos doadores e anticorpos anti-HNAdos receptores com dia da pega, DECH aguda e TRM não mostrou correlação estatisticamente significativa. Conclusão. A frequência de HNA encontradanos doadores está de acordo com o descrito pela literatura. Contudo, a frequência dos anticorpos anti-HNAs foi bastante alta na população do estudo, embora a maioria apresentasse doença há menos de 12 meses até o transplante. Apesar de não encontrarmos uma correlação, novos estudos são necessários para melhor avaliar o papel do HNA no desfecho do TCTH. / Background and purpose. Hematopoietic cellular reconstruction with allogeneic hematopoietic stem cell transplantation (HSCT) is an established method of treatment for a variety of hematological, oncologic and immunologic diseases. However, HSCT is associated with considerable morbidity and mortality due to recurrence of underlying disease, incomplete HLA compatibility, type of conditioning regimen and infection during the unavoidable period of neutropenia. This study investigates a surrogate cause of morbidity: compatibility of Human Neutrophil Antigens (HNA) between donors and receivers and its association with day of engraftment, incidence of acute graft versus host disease (GVHD) and total rate of mortality (TRM) in patients who underwent allogeneic HSCT. Type of study and location. Prospective cohort study carried out at the Hospital de Clínicas de Porto Alegre (HCPA), Brazil. Methods. We have studied 27 patients who underwent HSCT between May, 2013 and April, 2014, and their respective donors. HNA typing in the donors was performed by PCR-SSP (One Lambda) and anti-HNA antibodies in receivers were detected using the LABSCREEN MULTI kit (LSMUTR-One Lambda). Results. The age ranged from 1 to 63 years, with an average of 20.4 ± 17.5 years. Nineteen were pediatric patients (<21 years) with an average age of 10.05 ± 6.4 years, and among adult patients the average was 42.2 ± 12.6 years. There was a discreet male prevalence, 16 (59,3%). The acute leukemias were frequent in 19 (70,3%) of patients, other malignant onco-hematological diseases (Hodgkin Lymphoma and non-Hodgkin's Lymphoma) in 3 (11,1%) and non-malignant (myelodysplastic syndrome, osteopetrosis, paroxysmal nocturnal hemoglobinuria, aplasia and granulomatous disease) in 6 (22,2%). Nineteen (70,3%) of the patients, had the disease for less than 12 months at the time of the transplant and 24 (88,9%) were fully HLA compatible with their donors. Myeloablative conditioning regimen was used in 16 (59,3%) of the patients and the standard prophylaxis for GVHD (cyclosporine and methotrexate) was used in 15 (55,5%) of the patients. The day of engraftment had a median of 19 and minimum and maximum of 15 and 30, respectively. Four patients (14,8%) died before the engraftment. Approximately 17 patients (63%) showed acute GVHD (in all stages) and the total rate of mortality (TRM) was approximately 44% of the cases (12 patients). Patients who received HSCT from a related donor had TRM of approximately 41% (7 patients) and those who have received an unrelated donor was approximately 45% (5 patients). The frequency of HNA antigens detected in donors was 46,4% HNA-1a, 89,3% HNA-1b, 3,6% HNA-1c, 96,4% HNA-3a, 32,1% HNA-3b, 96,4% HNA-4a, 21,4% HNA-4b, 85,7% HNA-5a and 71,4% HNA-5b. The frequency of antibodies anti-HNA1a, anti-HNA1b, anti-HNA1c and anti-HNA2 at D0 were respectively 46,4%, 42,9%, 42,9% and 53,6%. The association between the HNA donor typing and anti-HNA antibodies of receivers with day of the engraftment, acute GVHD and TRM showed no statistically significant correlation. Conclusion. The HNA frequency found in our donors was close to the described in the literature. The frequency of anti-HNAs antibodies, however, was quite high in our study population; although the majority presented the disease for less than 12 months before the transplant. The association between HNA donor typing and anti-HNA antibodies of patients with day of engraftment, acute GVHD incidence and TRM showed no statistically significant correlation. As the number of cases was small, further studies with higher numbers and with antigen/antibodies assayed in both sides of transplantation pairs, are needed to better assess the role of the HNAs on the outcome of HSCT.

Introdução: O Transplante Alogênico de Célula Tronco Hematopoiética (TCTH alogênico) é um procedimento de alto potencial curativo para a Leucemia Mielóide Aguda (LMA), principalmente pelo efeito “graft versus leukemia” (GVL), que leva a redução do risco de recaída. Atualmente, os pacientes com LMA de risco intermediário são submetidos ao procedimento caso possuam doador aparentado. Pacientes sem doador aparentado disponível são submetidos a tratamento de consolidação com quimioterapia, com maior chance de recaída da doença. Acredita-se que os pacientes submetidos ao TCTH tenham maiores sobrevida global e livre de doença, a despeito das altas taxas de morbimortalidade. A classificação de risco é extremamente importante para escolha terapêutica pós remissão. Assim, a realização da pesquisa de marcadores moleculares, para refinar a estratificação prognóstica, tem importância especial no grupo de risco intermediário, complementando a avaliação citogenética, e auxiliando na decisão terapêutica, sendo cada vez mais necessária, apesar de não disponível em todos os centros. Material e métodos: Foram avaliados os pacientes com LMA de risco intermediário em primeira Remissão Completa (1RC) do Serviço de Hematologia e TCTH do Hospital de Clínicas de Porto Alegre do período de 01 de abril de 1999 a 01 de outubro de 2014, com pelo menos 1 ano de seguimento após o tratamento, através de revisão de prontuários. Os dados foram dispostos no programa Excel e posteriormente exportados para o programa SPSS v. 18.0 para análise estatística. Resultados: Foram avaliados 69 pacientes, sendo 45 pacientes submetidos a consolidação com quimioterapia (“QT”) e 24 submetidos a TCTH Alogênico (“TCTH Alogênico”). A média de idade do grupo “QT” foi de 47,8 anos e do grupo “TCTH Alogênico” foi de 35,5 anos, com diferença estatisticamente significativa (P<0,001). Não houve diferença na distribuição entre o sexo. A mediana de tempo de seguimento do grupo “QT” foi de 1,1 anos (intervalo interquartil de 0,4 a 2,5 ) e no grupo “TCTH Alogênico” foi de 2,7 anos (intervalo interquartil de 0,4 a 5,5), sem diferença estatisticamente significativa na distribuição dos tempos de seguimento entre os grupos (P=0,236). A sobrevida do grupo “QT” em 12 meses foi de 52,3% e no grupo “TCTH Alogênico” foi de 62,5%. Aos 24 meses, a sobrevida do grupo “QT” foi de 31,7% e no grupo “TCTH Alogênico” foi de 58,3% e em 5 anos de 21,1% e 53,8%, respectivamente. O teste do Long-Rank aponta uma diferença estatisticamente significativa nas sobrevidas entre os grupos após 5 anos, com Hazard Ratio (HR) para óbito de 2,2 (IC 95%: 1,1-4,2), P=0,027, porém ao ajustarmos a relação pela idade esta associação perde significância estatística (HR:1,6 IC95%:1 - 1,1; P=0,246) Discussão: Os dados evidenciaram melhor sobrevida no grupo submetido à TCTH alogênico, porém o grupo submetido ao procedimento apresentava média de idade menor. No entanto, apesar da perda da significância estatística, o HR corrigido para idade permanece maior para o grupo sem TCTH, o que pode dever-se ao “n” pequeno da amostra. Identificar quais pacientes terão benefício com TCTH torna-se cada vez mais um desafio. O uso de marcadores moleculares são importantes no refinamento da estratificação de risco do grupo de risco intermediário, podendo auxiliar nessa decisão. Além disso, com o advento da possibilidade de condicionamentos não mieloablativos como alternativa aos pacientes mais velhos e com escore de comorbidades pior e a melhor terapia de suporte, talvez possamos ser menos conservadores na indicação desse procedimento, identificando assim aqueles que poderão obter melhores resultados no tratamento de uma doença tão agressiva e grave. / Background: Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) is a high potentially curative procedure to Acute Myeloid Leukemia (AML), mainly by the “graft-versus-leukemia” (GVL) effect, which leads to reduced risk of relapse. Nowadays, intermediate risk AML patients are submitted to this procedure if a matched sibling donor is available. Patients without a sibling donor are submitted to consolidation with chemotherapy, with a greater chance of relapse. It is believed that patients submitted to allo-HSCT have a greater overall survival and disease-free survival, even though it presents high morbidity and mortality rates. Risk stratification is extremely important to post-remission treatment choice. Molecular markers research is especially important in intermediate risk group, complementing cytogenetic evaluation to a better prognostic stratification and, although it is still not available in all health centers, it is more and more necessary. Materials and Methods: We evaluated intermediate risk AML patients in first Complete Remission (CR1) at the Hematology Service and Bone Marrow Transplantation from Hospital de Clínicas de Porto Alegre from April 1st 1999 to October 1st 2014, and which had, at least, a one year follow-up after treatment, by conducting a medical record review. Data was inserted in Microsoft Excel 2010 spreadsheets and after exported to SPSS v. 18.0 to statistical analysis. Results: Among the 69 patients analyzed, 45 were submitted to consolidation with chemotherapy (Intermediate risk AML – non allo-HSCT) and 24 of then submitted to allo-HSCT (Intermediate risk AML – allo-HSCT). The average age of Intermediate risk AML – non allo-HSCT was 47.8 years old and Intermediate risk AML – allo-HSCT was 35.5 years old, with statistically significance difference (P<0,001). There was no difference regard sex of patients. The median follow-up in the Intermediate risk AML – non allo-HSCT was 1.1 years (interquartile rage of 0.4 to 2.5) and in the Intermediate risk AML – allo-HSCT was 2.7 years (interquartile rage of 0.4 to 5.5), with no statistically significance difference in follow-up time distribution between groups (P=0.236). Intermediate risk AML – non allo-HSCT survival in 12 months was 52.3% and in the Intermediate risk AML – allo-HSCT was 62.5%. In 24 months, Intermediate risk AML – non allo-HSCT survival was 31.7% and in Intermediate risk AML – allo HSCT survival was 58.3% and in 5 years it was 21.1% and 53.8% respectively. Long- Rank test indicates a statistically significant difference in survival between groups after 5 years, with hazard ratio (HR) for death of 2.2 (IC95% 1.1 – 4.2), P=0.027, but when we adjust the relation to age, this association loses statistical significance (HR:1.6 95%CI: 1 – 1.1; P=0.246). Discussion: Data showed a better survival rate to the group submitted to allo-HSCT, but the group presented a lower average age. However, despite de loss of statistical significance, Hazard Ratio (HR), adjusted to age remains higher to the non allo-HSCT group. It can be explained by the small number of the sample. Identifying which patients will benefit from allo-HSCT becomes increasingly challenging. The use of molecular markers are important in the refinement of risk stratification in intermediate risk group, assisting in the decision. Moreover, with the advent of the possibility of nonmyeloablative conditioning as an alternative to older patients and with worst rates of comorbidity, and the better supporting therapy, we may be less conservative in indicating this procedure, identifying the patients who may obtain better results during treatment of such aggressive and serious disease.

Introdução: O transplante de células tronco hematopoiéticas é reconhecidamente uma opção terapêutica para doenças neoplásicas hematológicas, tumores sólidos, deficiências imunológicas e doenças metabólicas. É um procedimento associado a uma alta freqüência de complicações agudas e crônicas, causadas pela toxicidade do regime de condicionamento, dentre elas a mucosite, Doença do Enxerto versus Hospedeiro - DECH e infecções. Essas complicações podem causar grandes mudanças na composição corporal através de mudanças no metabolismo, piorando o estado nutricional. Um adequado consumo de alguns micronutrientes como zinco, vitamina D e ferro, tem sido investigado como forma de evitar ou minimizar essas complicações. Objetivo: Avaliar em pacientes submetidos a transplante de células tronco hematopoiéticas os níveis séricos de zinco, vitamina D e ferritina e o seu impacto nos desfechos do TCTH alogênico e os níveis de ingestão de zinco, vitamina D e ferro. Métodos: Foram avaliadas as dosagens séricas de zinco, vitamina D e ferritina, e os níveis de ingestão de zinco, vitamina D e ferro, os tipos de condicionamento, o grau de DECH e mucosite, a presença de infecções e o estado nutricional. Resultado: Foram incluídos na análise 32 pacientes. Não foi encontrado associação significativa entre a deficiência sérica de Zinco e mucosite e os níveis elevados de ferritina sérica com a ocorrência de infecções. Deficiência sérica de vitamina D aos 45 dias pós transplante foi associado com o desenvolvimento de DECH. Conclusão: Os nossos resultados reforçam a importância dos pacientes manterem os níveis adequados de micronutrientes e reforçam o papel da vitamina D na prevenção de DECH durante o TCTH. / Introduction: The transplantation of hematopoietic stem cells is recognized as a treatment option for hematological neoplastic diseases, solid tumors, immune deficiencies and metabolic diseases. It is a procedure associated with a high frequency of acute and chronic complications caused by the toxicity of the conditioning regimen, among them mucositis, Graft-versus-Host Disease - GVHD and infections. These complications can cause major changes in body composition through changes in metabolism, worsening the nutritional status. An adequate intake of some micronutrients such as zinc, vitamin D and iron, has been investigated as a way to avoid or minimize these complications. Objective: To evaluate in patients undergoing hematopoietic stem cell transplantation serum levels of zinc, vitamin D and ferritin and its impact on the outcomes of allogeneic HSCT and zinc intake levels of vitamin D and iron. Method: The following aspects were evaluated: serum levels of zinc, vitamin D and ferritin, and zinc intake levels of vitamin D and iron, the conditioning types, the degree of GVHD and mucositis, the presence of infections, the nutritional status. Result: The analysis included 32 patients. No significant association has been found between zinc serum deficiency and mucositis and elevated levels of serum ferritin with the occurrence of infections. The serum deficiency of vitamin D at 45 days post-transplantation has been associated with the development of GVHD. Conclusion: Our results reinforce that it is important for the patients to maintain adequate levels of micronutrients and reinforce the role of vitamin D in the prevention of GVHD during the HSCT. Keywords: hematopoietic stem cell transplantation, GVHD, mucositis, infections, Vitamin D, ferritin, zinc, nutritional status.

O transplante autólogo de células-tronco hematopoéticas (TACTH) tem se mostrado mais eficaz como tratamento das formas graves da esclerose sistêmica (ES) do que a imunossupressão convencional (IS), porém os mecanismos imunológicos envolvidos com a resposta terapêutica não estão completamente elucidados. Células mononucleares do sangue periférico e soro/plasma foram coletados de 31 pacientes com ES antes e semestralmente, até 36 meses pós-transplante, e de 16 pacientes com ES não-transplantados tratados com IS. A função tímica foi avaliada por RT-qPCR dos valores de b- e signal joint (sj)-T-cell receptor excision circles (TREC), sendo a taxa de proliferação intratímica (n) calculada pela fórmula: n=LOG(sjTREC/bTREC)/LOG2. A história replicativa das células B e a função medular foram quantificadas pelos valores de coding-joint (Cj) e sj-kappa-deleting recombination excision circles (sjKREC) e a taxa de proliferação das células B no sangue periférico (N) foi calculada pela fórmula: N=LOG(Cj/sjKREC)/LOG2. O comprimento telomérico foi avaliado por RT-qPCR e estimado pela razão T/S (Telomere repeat copy number/Single-copy gene copy number). As células recém-emigradas do timo (RET) CD3+CD4+CD31+CD45RA+, T reguladoras (Tregs) CD4+CD25hiFoxP3+(GITR+/CTLA-4+), naïve CD19+CD27-IgD+, Bm2 CD19+CD38lowIgD+, B reguladoras (Bregs) CD19+CD24hiCD38hi, senescentes CD8+CD28- CD57+ e exaustas PD1+ foram quantificadas por citometria de fluxo. O TCR foi sequenciado por sequenciamento de nova geração e o perfil de citocinas séricas inflamatórias e pró- fibróticas foi avaliado por CBA-Flex e ELISA. Observamos que os valores de sjTREC e bTREC diminuíram aos 6 meses pós-TACTH, retornando a valores basais aos 12 meses, correlacionando com o número de RET e promovendo maior diversidade do TCR. Não houve mudança na taxa de divisão de timócitos. A contagem de Tregs aumentou aos 12 meses pósTACTH, correlacionando com valores de sjTREC e apresentando maior expressão de GITR e CTLA-4. A partir dos 12 meses, até o final do acompanhamento, os valores de sjKREC aumentaram, enquanto que os de Cj permaneceram estáveis, correlacionando com aumento da contagem de células B naïve e Bm2, e resultando em uma menor taxa de divisão de células B. Houve aumento de Bregs de 6 meses a um ano após o TACTH, cujos níveis correlacionaramse com aqueles de sjKREC, e apresentando maior produção de IL-10 mediante estímulo com CPG±CD40L do que antes do transplante. O comprimento telomérico diminuiu aos 6 meses pós-TACTH e correlacionou-se com níveis elevados de células senescentes que expressavam FoxP3, aliado a um aumento de expressão de PD1 pelas células T e redução dos níveis séricos de IL-6, IL-1b e proteína C reativa. Seis pacientes recaíram após o transplante, apresentando menor expressão de FoxP3, GITR e CTLA-4 pelas Tregs, diminuição da contagem de Breg e da diversidade do TCR. Adicionalmente, a remissão clínica foi associada a maior expressão de PD1 por células T e B e baixos níveis séricos de TGF-b, IL-6, IL-1b, IL-17A, MIP-1a, GCSF e IL-12. Portanto, o aumento de células T e B reguladoras geradas de novo pós-TACTH, associado à renovação do repertório de células T, alta expressão de PD1 e baixos níveis séricos de mediadores inflamatórios e prófibróticos, estão relacionadas com a resposta clínica dos pacientes com ES ao transplante. / Autologous hematopoietic stem cell transplantation (AHSCT) is more effective for patients with severe systemic sclerosis (SSc) than conventional immunosuppression (IS). However, the immunological mechanisms associated with the therapeutic efficacy of AHSCT are not fully elucidated. Peripheral blood mononuclear cells and serum/plasma were collected from 31 SSc patients before and semiannually, until 36 months post-transplant, and from 16 nontransplanted SSc patients treated with IS. Thymic function was measured by RT-qPCR quantification of ?- and signal joint (sj)-T-cell receptor excision circles (sjTREC) and intrathymic T-cell division (n) was calculated by the formula: n=LOG(sjTREC/?TREC)/LOG2. Bcell replication history and bone marrow function were assessed by coding-joint (Cj) and sjkappa-deleting recombination excision circles (sjKREC). B-cell divisions in the peripheral blood (N) were calculated by the formula: N=LOG(Cj/sjKREC)/LOG2. CD3+CD4+CD31+CD45RA+ recent thymic emigrants (RTE), CD4+CD25hiFoxP3+ (GITR+/CTLA-4+) regulatory T-cells (Tregs), CD19+CD27-IgD+ naïve B-cells, CD19+CD38lowIgD+ Bm2 B-cells, CD19+CD24hiCD38hi regulatory B-cells (Bregs), CD8+CD28-CD57+ senescent cells and PD1+ exhausted cells were quantified by FACS (fluorescence-activated cell sorting). The T-cell receptor (TCR) was sequenced by New Generation Sequencing and the profile of inflammatory and pro-fibrotic serum cytokines was evaluated by CBA-Flex (cytometric bead-array) and ELISA (enzyme-linked immunosorbent assay). sjTREC and ?TREC values decreased at 6 months post-AHSCT, returning to pretransplant values at 12 months, correlating with RTE counts and associated with higher diversity of the TCR. There was no change in thymocyte division rates. At 12 months postAHSCT, Treg counts increased and correlated with sjTREC values, presenting increased expression of GITR and CTLA-4 when compared to pre-transplant levels. From 12 months until the end of follow-up, sjKREC values increased, while those of Cj remained stable, correlating with increased counts of naïve and Bm2 B-cells, resulting in reduced rate of B-cell division. There was an increase of Breg frequency from 6-months until one-year after AHSCT, correlating with sjKREC values and presenting higher IL-10 production after stimulation with CPG±CD40L than before transplantation. Telomere length decreased at 6 months post-transplant and correlated with elevated levels of FoxP3-expressing senescent cells, together with increased expression of PD1 by T-cells and reduced serum IL-6, IL-1b and C-reactive protein levels. Six patients relapsed after transplantation, presenting lower expression of FoxP3, GITR, CTLA-4 by Tregs, decreased Breg counts and reduced TCR diversity. In addition, clinical remission was associated with increased PD1 expression by T and B cells and low serum levels of TGF-?, IL-6, IL-1, IL-17A, MIP-1, G-CSF and IL-12. Therefore, newly-generated regulatory T and B cells after AHSCT, associated with T-cell repertoire renewal, high PD1 expression and low serum levels of inflammatory and profibrotic mediators associate with clinical outcomes of SSc patients after AHSCT.

A esclerose múltipla (EM) é uma doença autoimune desmielinizante progressiva imunomediada por linfócitos T auto-reativos, que provocam uma cascata imunológica, amplificando a inflamação local. No Diabetes mellitus tipo 1 (DM1), existem linfócitos T auto reativos destroem as células beta do pâncreas, causando deficiência na produção de insulina. O desenvolvimento de terapêuticas específicas fica limitado pela etiologia indefinida destas doenças, apesar de avanços na terapêutica antiinflamatória e imunossupressora. Uma alternativa de tratamento atual para tais doenças é o transplante autólogo de células tronco hematopoéticas (TACTH). O presente estudo, observacional do tipo transversal, com a coleta de dados de caráter retrospectivo, tem como objetivo identificar as reações adversas manifestadas pelos pacientes diabéticos ou de esclerose múltipla, submetidos ao TACTH no período de 2004 a dezembro de 2010. Para a coleta de dados elaborou-se dois instrumentos que foram submetidos à validação aparente e de conteúdo por três juízes. A amostra final do estudo foi constituída pela obtenção dos dados de 72 prontuários, sendo 23 de pacientes diabéticos e 49 de pacientes com EM. Em relação aos pacientes diabéticos 16 pertenciam ao sexo masculino e a idade média foi 18,26 anos. Todos possuíam positividade para o anticorpo anti-carboxilase do ácido glutâmico (antiGAD65). Quanto aos pacientes com EM, trinta e três pertenciam ao sexo feminino e idade média foi de 37,2 anos. O subtipo da doença mais frequente foi o surto-remissivo em 21 (42,9%) pacientes. A escala expandida do estado de incapacidade (EDSS) variou entre 3,0 e 6,5. Em relação às reações adversas manifestadas pelos pacientes diabéticos foram mais frequentes os calafrios, febre, cefaléia, náusea e vômito e nos pacientes com esclerose múltipla foram retenção hídrica e cefaléia. As principais intervenções de enfermagem identificadas para os pacientes diabéticos e com EM foram monitorização dos sinais vitais, coleta de hemocultura, otimização da administração de medicamentos antieméticos, controle da infusão da globulina antitimocitária, orientações sobre alimentação e para reduzir o risco de queda. Os pacientes com DM1 apresentam reações mais agudas e necessitam de monitorização contínua. Já os pacientes com EM são mais dependentes dos cuidados de enfermagem, exigindo maior tempo de cuidados prestados pelo profissional. Embora o DM1 e a EM sejam doenças distintas, percebe-se que na prática clínica, exigem do enfermeiro uma excelência no cuidado, quer pelas particularidades do tratamento realizado ou pelas singularidades de cada uma delas. / Multiple sclerosis (MS) is a progressive demyelinating autoimmune disease, immune- mediated by auto-reactive T lymphocytes, which provoke an immunological cascade, enhancing the local inflammation. In type 1 diabetes mellitus (DM1), self-reactive T lymphocytes exist that destroy ? cells in the pancreas, causing insulin production deficiency. The development of specific therapeutics is limited by these diseases\' undefined etiology, despite advances in anti-inflammatory and immunosuppressive therapy. A current treatment alternative for these diseases is autologous hematopoietic stem cell transplantations (AHSCT). The aim of this observational and cross-sectional study with retrospective data collection is to identify the adverse reactions manifested by diabetic or MS patients who were submitted to AHSCT between 2004 and December 2010. For data collection, two instruments were elaborated, submitted to face and content validation with the help of three experts. The final study sample comprised data from 72 patient files, 23 from diabetic and 49 from MS patients. As for the diabetic patients, 16 were male and the mean age was 18.26 years. All were positive for the anti-glutamic acid decarboxylase (antiGAD65) antibody. Concerning MS patients, 33 were female and the mean age was 37.2 years. The most frequent disease subtype was relapsing-remitting in 21 (42.9%) patients. The expanded disability status scale (EDSS) score ranged between 3.0 and 6.5. As for the adverse reactions the diabetic patients manifested, shivers, fever, migraine, nausea and vomiting were the most frequent, while fluid retention and migraine were the most frequent among multiple sclerosis patients. The main nursing interventions identified for the diabetic and MS patients were vital sign monitoring, blood culture collection, optimization of anti-emetic drug administration, control of anti- thymocyte globulin infusion, dietary orientations and advice to reduce the risk of falls. DM1 patients present more acute reactions and need continuous monitoring. MS patients are more dependent on nursing care, demanding lower professional care time. Although DM1 and MS are distinct conditions, in clinical practice, they demand excellent care from nurses, whether due to the particularities of the treatment or the singularities of each disease.

O transplante de células-tronco hematopoéticas é uma modalidade de tratamento baseada na infusão de células-tronco hematopoéticas. Para tanto, o paciente necessita de um cateter venoso central de longa permanência. Espera-se que este cateter permaneça in situ durante o tratamento, porém uma complicação frequente que leva a sua retirada é a ocorrência da infecção relacionada ao cateter. Neste contexto, a técnica de bloqueio/lock terapia pode ser usada na prevenção e controle da infecção relacionada ao cateter intravascular e consiste em manter o cateter sem uso durante um período de tempo com sua via preenchida por algum tipo de solução. No entanto, é uma técnica pouco estudada e com escassos resultados de sua efetividade. O presente estudo teve o objetivo de identificar a forma de utilização da técnica de bloqueio/lock terapia pela equipe de enfermagem nos centros de transplante de células-tronco hematopoéticas brasileiros cadastrados na Sociedade Brasileira de Transplante de Medula Óssea. Trata-se de um estudo descritivo de corte transversal. As variáveis foram analisadas por meio de estatística descritiva. A casuística compôs de 46 centros de transplante de células-tronco hematopoéticas, na qual foi enviado um questionário on-line composto de oito questões de múltipla escolha realizado no período de Junho a Novembro de 2014. A população respondente foi de vinte e dois centros (47,8%), com predomínio de dezoito (82%) centros da região sudeste. Observou-se que dezesseis (73%) dos centros conhecem a técnica de bloqueio e, desses, quatorze (87%) utilizam a mesma. Tal técnica é utilizada há mais de cinco anos por seis (43%) dos centros. A maioria dos centros respondentes utilizam a técnica para prevenção da infecção relacionada ao cateter venoso central e apenas cinco (36%) para o tratamento. Em relação à redução da taxa de infecção relacionada ao cateter, oito (57%) responderam que há redução, no entanto, na avaliação da eficácia na redução da infecção relacionada ao cateter, seis (43%) dos enfermeiros declararam-se parcialmente favorável ao uso da técnica de bloqueio. Independente do tipo de antibiótico utilizado seis (43%) utilizam antibiótico mais heparina e seis (43%) usam apenas vancomicina. Os resultados oferecem aos profissionais dos centros de transplantes de células-tronco hematopoéticas um panorama geral sobre o uso da técnica de bloqueio/lock terapia para os serviços, a fim de que conheçam uma estratégia que pode evitar a retirada precoce do cateter venoso central / Hematopoietic stem cell transplantation is a modality of treatment based on the infusion of hematopoietic stem cells, and for such procedure, the patient needs an indwelling long-term central venous catheter. This catheter is expected to remain in situ during treatment, however a frequent complication that leads to its removal is the occurrence of catheter-related infection. The therapy lock technique consists in keeping the catheter unused for some time with its route filled in by some type of solution, and it may be used to prevent and control intravascular catheter-related infection. Nonetheless, this technique is poorly studied and has few results as for its effectiveness. The aim of the present study was to identify the way the therapy lock technique has been used by the nursing staff of Brazilian hematopoietic stem cell transplantation centers registered in the Brazilian Society of Bone Marrow Transplantation. A descriptive cross-sectional study was conducted, and variables were analyzed by means of descriptive statistics. The sample of cases comprised forty six hematopoietic stem cell transplantation centers, which received an on-line questionnaire with eight multiple-choice questions, between June and November 2014. The respondent population was twenty two centers (47.8%), with prevalence of eighteen (82%) centers in the southeast region. The staff of sixteen (73%) centers knew the lock technique and, of these, the staff of fourteen (87%) used it. This technique has been used for over five years in six (43%) centers. Most of the centers used the technique to prevent catheter-related infection and only five (36%) used it for treatment. Regarding catheter-related infection rates, eight (57%) stated they were reduced, however, in the assessment of efficacy in the reduction of catheter- related infection, six (43%) nurses claimed to be partially favorable to the use of the lock technique. Regardless of the type of antibiotic used, six (43%) used antibiotic and heparin, and six (43%) used only vancomycin. Results provide professionals from the hematopoietic stem cell transplantation centers with a general panorama on the use of the therapy lock technique for the services, so they can learn a strategy that can prevent the early removal of the central venous catheter