Compare CPM-RMI trial: intramyocardial transplantation of autologous bone marrow-derived cd133+ cells and mononuclear cells during coronary artery bypass grafting in patients with recent myocardial infarction: a phase II/III, multicenter, placebo-controlled, randomized, double-blind clinical trial

Objective: The regenerative potential of bone marrow-derived mononuclear cells [MNCs] and CD133+ stem cells in the heart varies in terms of their pro-angiogenic effects. This phase II/III, multicenter and double-blind trial is designed to compare the functional effects of intramyocardial autologous transplantation of both cell types and placebo in patients with recent myocardial infarction [RMI] post-coronary artery bypass graft

Materials and Methods: This was a phase II/III, randomized, double-blind, placebo-controlled trial COMPARE CPM-RMI [CD133, Placebo, MNCs - recent myocardial infarction] conducted in accordance with the Declaration of Helsinki that assessed the safety and efficacy of CD133 and MNCs compared to placebo in patients with RMI. We randomly assigned 77 eligible RMI patients selected from 5 hospitals to receive CD133+ cells, MNC, or a placebo. Patients underwent gated single photon emission computed tomography assessments at 6 and 18 months post-intramyocardial transplantation. We tested the normally distributed efficacy outcomes with a mixed analysis of variance model that used the entire data set of baseline and between-group comparisons as well as within subject [time] and group×time interaction terms

Results: There were no related serious adverse events reported. The intramyocardial transplantation of both cell types increased left ventricular ejection fraction by 9% [95% confidence intervals [CI]: 2.14% to 15.78%, P=0.01] and improved decreased systolic wall thickening by -3.7 [95% CI: -7.07 to -0.42, P=0.03]. The CD133 group showed significantly decreased non-viable segments by 75% [P=0.001] compared to the placebo and 60% [P=0.01] compared to the MNC group. We observed this improvement at both the 6- and 18-month time points

Conclusion: Intramyocardial injections of CD133+ cells or MNCs appeared to be safe and efficient with superiority of CD133+ cells for patients with RMI. Although the sample size precluded a definitive statement about clinical outcomes, these results have provided the basis for larger studies to confirm definitive evidence about the efficacy of these cell types

Optimisation of polymerase chain reaction conditions for detection of mineralization markers in isolated odontoblasts from human teeth

The present study aimed to determine the best polymerase chain reaction (PCR) conditions for amplification of odontoblast markers; alkaline phosphatase (ALP), dentin matrix protein 1 (DMP1), dentin sialophosphoprotein (DSPP) and osteopontin (OPN). Informed consent was obtained from the individuals prior to tooth extraction. RNA was extracted from odontoblasts obtained from extracted teeth using innuPREP RNA Mini kit (Analytik Jena, Germany). Five selected target factors in enhancing PCR: primer concentration, extension time, number of cycles, annealing time, and annealing temperature were manipulated to yield the correct size of amplicons. One step reverse transcriptase PCR reactions were performed using MyTaq One-Step RT-PCR kit (Bioline, USA) with a C1000 Thermal Cycler (Bio-Rad, USA) in a 25 µL reaction, keeping the amount of 2 ng/µL RNA, 0.25 µL reverse transcriptase, 0.5 µL RiboSafe Rnase inhibitor and 1X MyTaq One-Step Mix, constant. The optimal conditions were determined to be 400nM of primers for DMP1 and DSPP, 200 nM for ALP and OPN; 30 seconds of extension time and 35 PCR cycles for all genes; 10 seconds of annealing time for ALP, DMP1 and DSPP, 7 seconds for OPN. The annealing temperature were 56.4°C for ALP, 58.6°C for DMP1, 52.7°C for DSPP, and 56.3°C for OPN, respectively. The optimized PCR protocols produced the correct size of odontoblast markers.

Angiogenic Potential of Extracellular Matrix of Human Amniotic Membrane

Combination between tissue engineering and other fields has brought an innovation in the area of regenerative medicine which ultimate aims are to repair, improve, and produce a good tissue construct. The availability of many types of scaffold, both synthetically and naturally have developed into many outstanding end products that have achieved the general objective in tissue engineering. Interestingly, most of this scaffold emulates extracellular matrix (ECM) characteristics. Therefore, ECM component sparks an interest to be explored and manipulated. The ECM featured in human amniotic membrane (HAM) provides a suitable niche for the cells to adhere, grow, proliferate, migrate and differentiate, and could possibly contribute to the production of angiogenic micro-environment indirectly. Previously, HAM scaffold has been widely used to accelerate wound healing, treat bone related and ocular diseases, and involved in cardiovascular repair. Also, it has been used in the angiogenicity study, but with a different technical approach. In addition, both side of HAM could be used in cellularised and decellularised conditions depending on the objectives of a particular research. Therefore, it is of paramount importance to investigate the behavior of ECM components especially on the stromal side of HAM and further explore the angiogenic potential exhibited by this scaffold.

Percutaneous mitral valve repair with the edge-to-edge technique: case series of first Iranian experience

Mitral regurgitation [MR] is a common valvular lesion in the general population with considerable impact on mortality and morbidity. The MitraClip System [Abbot Laboratories, Abbot Park, IL, USA] is a novel percutaneous approach for treating MR which involves mechanical edge-to-edge coaptation of the mitral leaflets. We present our initial experience with the MitraClip System in 5 patients. In our series, the cause of MR was both degenerative and functional. Two patients received two MitraClips due to unsatisfactory results after the implantation of the first clip. Acute procedural success was seen in 4 patients. Blood transfusion was required for 2 patients. All the patients, except one, reported improvement in functional status during a 2-month follow-up period. Our initial experience with MitraClip implantation indicates that the technique seems feasible and promising with acceptable results and that it could be offered to a broader group of patients in the near future

Development and validation of the first Iranian questionnaire to assess quality of life in patients with heart failure: IHF-QoL

In its Constitution of 1948, WHO defined health as "a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity". In 1994, the Agency for Health Care Policy and Research published clinical practice guidelines recommending providers to routinely evaluate patients' HRQoL [Health Related Quality of Life] and use their assessment to modify and guide patient care. To create a valid, sensitive, disease-specific Persian health status quality of life questionnaire for patients with chronic heart failure in Iran. Considering the existing relevant inventories and scientific literature, the authors designed the first draft of questionnaire which was modified and validated, using expert opinions and finalized in a session of expert panel. The questionnaire was processed among 130 patients with heart failure. Construct validity evaluated by principle component factor analysis, and promax method was used for factor rotation. MacNew quality of life questionnaire was selected to assess convergence validity, and the agreements were measured in 60 patients. Discriminant validity was also assessed. Thirty patients were followed for 3 months and responsiveness of questionnaire was measured. Cronbach's alpha, item analysis, and Intra-class correlation coefficients [ICCs] were used to investigate reliability of questionnaire. SPSS 15 for Windows was applied for statistical analysis. Principle component factor analysis revealed 4 main components. Sub-group analysis suggested that IHF-QoL questionnaire demonstrated an acceptable discriminant validity. High conformity between this inventory and MacNew questionnaire revealed an appropriate convergence validity. Cronbach's alpha [alpha] for the overall questionnaire was equal to 0.922. Intra-class correlation coeffcients [ICCs] for all components were significant [from. 708 to. 883; all P values < 0.001]. Patients fallow-up revealed an acceptable responsiveness of our questionnaire. IHF-QoL questionnaire is a valid and reliable inventory. It can be applied in daily clinical practice and in the clinical research context

Liver function tests and uric acid serum levels in relation to hemodynamic profile: a comparison between heart failure and pulmonary arterial hypertension patients

Systemic venous congestion has been considered the main cause of liver dysfunction in heart failure patients. In this study, we assessed the relation of liver function tests to hemodynamic profile in patients with systolic heart failure [SHF] and primary pulmonary arterial hypertension [PAH]. Fifty patients with left ventricular ejection fraction < 35% and 27 patients with mean PAH> 25 mmHg were enrolled. Hemodynamic indices, including PAP, right atrial and ventricular pressures [RAP and RVP], pulmonary capillary wedge pressure [PCWP], and cardiac simultaneously. Fifty age- and sex-matched normal controls were also studied. CO was significantly lower in the HF group [P= 0.006]. Multivariate analysis showed a significant correlation between total bilirubin level and mean PAP [R=0.04, P=0.004], RAP [R=0.33, P<0.03], RVP [R=0.43, P<0.004], PCWP [R=0.36,P<0.01], and direct bilirubin with mean PAP [R=0.01, P=0.02], RVP[R=0.33, P<0.03], PCWP[R=0.32, P<0.03], and CI [R=0.33, P<0.01]. In the PAH group, such correlations were mostly absent. Systemic venous congestion, more prominent in PAH, might not play the main role in deteriorating liver function. Further studies are needed to determine whether hepatic blood flow, which is significantly decreased in SHF, is a more important factor

Comparison of transthoracic echocardiography and right heart catheterization for assessing pulmonary arterial pressure in patients with congenital or valvular heart defects

Although right heart catheterization [RHC] has acceptable accuracy for the measurement of pulmonary arterial pressure [PAP], significant risks and cost issues are worrisome. Thus, a non-invasive technique such as echocardiography for assessing PAP would clearly be of great clinical value. We aimed to compare estimated systolic PAP [SPAP] by echocardiogram with the actual RHC measurements in the two groups of congenital and valvular heart diseases [CHD and VHD, respectively], in whom pulmonary hypertension [PHT] was clinically suspected. A total of 103 consecutive patients with confirmed CHD or VHD referred to our center between January and December 2009 were studied. Participants underwent transthoracic echocardiogaphy and RHC within 4 hours of each other. The mean SPAP in the CHD group was no different measured by RHC or echo [46.49 +/- 29.04 vs. 46.45 +/- 23 mmHg, p = 0.541]. The mean SPAP in the VHD group measured by RHC was significantly higher than that measured by echo [48.70 +/- 14.50 vs. 44.90 +/- 11.0 mmHg, p = 0.041]. Fifty-one [49.5%] patients were found to have PHT at RHC. Echocardiography correctly identified 48 of these patients [sensitivity=94.1%]. Nineteen of the 52 patients without PHT on RHC were correctly identified by echocardiography [specificity= 36.5%]. The positive and negative predictive values for echocardiography in assessing the presence or absence of PHT were 59.3% and 86.4%, respectively. Integration of hemodynamic data with the eho examination can appropriately provide comprehensive assessment of PHT with high sensitivity in individual patients with congenital or valvular heart defects

Long sheaths for endomyocardial biopsy via femoral approach

Endomyocardial biopsy has long been a useful tool to evaluate myocardial diseases. It is a gold standard in diagnosing cardiac rejection and certain types of myocarditis, but there is always a risk for related complications. We have assessed the safety and feasibility of applying long sheaths in endomyocardial biopsy via the femoral approach. We performed endomyocardial biopsy in 63 patients via the femoral approach and used a long sheath to guide bioptome from the venous access to the interventricular septum and evaluate the procedure success and complications. Success rate [acceptable endomyocardial specimen] was 96%, and there were no complications [death, no death, urgent cardiac surgery, advanced cardiac life support, hemothorax, and pneumothorax]. Using long sheaths for the femoral approach seems to be safe and feasible; it confers an acceptable room to grab the endomyocardial samples while obviating the possibility of complications

Right ventricular strain predicts functional capacity in patients with repaired tetralogy of Fallot

Echocardiography-derived strain rate and strain may provide new insights into right ventricular [RV] function in repaired tetralogy of Fallot [rTOF] patients in whom evaluation of RV function and functional capacity has an important role in further management. In 45 rTOF patients with severe pulmonary regurgitation. the routine echocardiography-derived indices for evaluation of RV function [TAPSE. RVOT Excursion and eyeball method] and longitudinal strain rate and strain were acquired from basal, mid and apical segments of RV free wall [RVFW] and interventricular septum; functional capacity was measured by standard Bruce protocol exercise testing. All patients had some degrees of RV dysfunction with no correlations between results of routine indices and functional capacity. Reduced RVFW average systolic strain was correlated directly with reduced functional capacity [r = 0.86[P <0.001], this was also true for peak systolic strain of basal and mid segments of RVFW. Derivation of ROC curves showed that a cut-off value of 15.8% for average RVFW systolic strain predicts good exercise capacity [>/= 10 METs] with a sensitivity of 91.2% and a specificity of 100%. Although routine echocardiography indices are not accurate tools in rTOF patients, systolic strain of RVFW seems to be reliable in estimation of RV function and functional capacity

18-year-old man with cardiomegaly and pericardial effusion

We present an 18-year-old male who sought medical attention due to exertional dyspnea of a few weeks' duration. His physical exam revealed an elevated jugular venous pressure, facial puffiness, muffled heart sounds, and mild lower extremity pitting edema. Chest X-ray showed cardiomegaly; and in echocardiography, huge intrapericardial masses with massive pericardial effusion were noted. The oinly noteworthy finding on abdominal ultrasonography and CT scan was the presene of ascites. The only abnormal laboratory results consisted of a hemoglobin level of 10.8 g/dl, a 1-hr ESR 77, CRP 34 mg/dl and LDH 771. Some 1500cc pericardial fluid was aspirated, and tow multilobated creamy-brown masses with foci of necrosis and hemorrhage were excised. Microscopically, hypercellular sheets of malignant round cells were seen. Based on morphology, a diagnosis of high-grade round cell sarcoma was made. Immunohistochemical markers were negative for cytokeratin, CD 34, desmin, and smooth muscle actin, while positive reactivity was noted only for vimentin. Therefore, the cells were mesenchymal in origin with no vascular, skeletal, or smooth muscle differentiation and the final diagnosis was undifferentiated sarcoma. The patient was discharged in good clinical condition and underwent chemoradiation therapy

Vascular endothelial growth factor [VEGF-C] signaling through KDR [VEGFR-2] and FLT-4 [VEGFR-3] mediates leukemic cell proliferation and survival

VEGF, a key angiogenic molecule, is a multifunctional cytokine that acts both as a potent inducer of vascular permeability and as a specific endothelial cell mitogen. Because of its effects on endothelial cell growth and microvascular permeability, VEGF is believed to be an important mediator of tumor angiogenesis. Leukemic cells not only release VEGF but also express its receptors, resulting in the establishment of an autocrine loop that supports their migration and survival. VEGF-C may play an important role in the pathophysiology of hematopoietic malignancies by not only regulation of lymphangiogenesis, in vivo, but also by promotion of angiogenesis invasion of neoplastic cells into lymphatic vessels and enhancing lymphatic metastasis during tumor progression. although it is well established that growth in solid tumors is dependent on the formation of neovasculature, the role of angiogenesis in hematopoietic neoplasms has not been determined. The present study was undertaken to identify whether VEGF-C and its receptors VEGFR-2 [KDR] and VEGFR-3 [FLT-4] were expressed in patients with denovo acute leukemia by RT-PCR and to evaluate the relationship between their expression and clinical, laboratory findings and prognosis. Using reverse transcription polymerase chain reaction analysis [RT-PCR], 30 de novo acute leukemia patients [20 ALL patients and 10 AML patients] as well as 10 controls were tested for the expressions of VEGF-C, VEGFR-3 [FLT 4] and VEGFR-2 [KDR] genes. In the current study, VEGF-C, FLT-4 and KDR were detected in 10% of control samples. In ALL patients VEGF C was expressed in 65% of cases, FLT-4 in 70% of cases and KDR in 30% of cases. The expressions of VEGF-C, FLT-4 and KDR in ALL patients were associated with increased risk of leukemia [with OR 16.7 and 95% CI 1.7-160.4, OR 21.0 and 95% CI 2.2-204.6 and with OR 3.9 and 95% CI 0.4-37.6 respectively]. In AML patients, VEGF-C was expressed in 60% of cases, FLT-4 in 70% of cases and KDR in 40% of cases. The expression of VEGF-C, FLT-4 and KDR in AML patients was associated with increased risk of leukemia [with OR 13.5 and 95% CI 1.2-152.2, OR 21.0 and 95% CI 1.8-248.1 and OR 6.0 and 95% CI 0.5-67.7 respectively]. In the 6 followed-up ALL patients, 3 [50%] were in remission, three of them were VEGF-C negative, 2 were FLT4 positive and 1 was KDR positive. 2 of the 6 ALL patients [33.3%] were resistant to treatment, both were VEGF-C positive, FLT-4 positive and 1 was KDR positive. One of the 6 ALL patients [16.6% died during induction, this patient was VEGF-C positive and FLT-4 and KDR negative. In the 4 followed-up AML patients, 3 of them [75%] were in remission, 1 of the 3 was VEGF-C positive and 2 were FLT-4 positive. One of the four AML patients [25%] was resistant to treatment, this patient was VEGF-C, FLT-4 and KDR positive. The number of VEGF-C positive patients with no treatment failure was lower than the number of VEGF-C positive patients with treatment failure. Also, the risk of failed induction was found to be greater in VEGF-C positive patients than in VEGF-C negative patients, thus, the expression of VEGF-C and its receptors [FLT-4 and KDR] in ALL and AML patients was associated with increased risk of leukemia and unfavorable treatment outcome. VEGF-C and its receptors KDR [VEGFR-2] and FLT-4 [VEGFR-3] may play an important role in the pathophysiology of hematopoietic malignancies and may actually contribute to the development of leukemia. Also, owing to the importance of angiogenesis in tumor progression and the effects of VEGF-C, KDR and FLT-4 in chemotherapy-treated leukemias, inhibition of VEGF-C signaling represents an attractive cancer treatment

Evaluation of the serum levels of immunoglobulin and complement factors in beta thalassemia major patients in Southern Iran

Beta-thalassemia major is one of the major health problems in our country. Many studies have confirmed the fact that, these patients have an increased susceptibility to bacterial infections. In this study, we have assessed the humoral immune system in 68 thalassemic patients by measuring their serum concentration of Immunoglobulin G [IgG], IgM, IgA, C3 and C4 in order to find out a responsible immune defect. Sixty eight beta-thalassemia major patients were enrolled randomly from referrals to Dastgheib clinic of thalassemia. The same number of case controls with matched age and sex were selected from healthy people without any history of recent or recurrent infections. Serum IgG, IgM, IgA, C3 and C4 levels were assessed using Single Radial Immunodiffusion [SRID]. Serum levels of IgG, IgM and IgA were significantly higher [P<0.01] and those of C3 and C4 were significantly lower [P<0.01] in thalassemic patients than the controls. Considering the result of analytic tests, it was revealed that, thalassemia patients show much more increase in serum immunoglobulin levels as they get older. Splenectomized patients had higher serum IgG and IgA levels than non-splenectomized patients but had no difference in serum IgM, C3 and C4. Serum ferritin level had no correlation with the changes of humoral immunity; however, patients with serum ferritin level >2500ng/ml had higher serum IgM level. These results can be due to continuous exposure to antigens, repeated infections, chronic liver disease and splenectomy but not iron overload. The only probable cause of humoral immune deficiency found in these patients is a defect in serum complement levels