Family informed consent to organ donation--who performs better: organ procurement organizations, in-hospital coordinators, or intensive care unit professionals?

Successful organ donation in countries adopting informed consent legislation depends on adequate interviewing of potential donors' families. As the number of both referral and effective donors in Brazil increases, health care managers argue whether educational efforts should be directed toward training in-hospital coordinators (IHC)--based on the "Spanish model"--or on the creation of extra-hospital-based professionals (Organ Procurement Organizations [OPOs], the "American model"). Meanwhile, many potential donor families are still approached by intensive care unit (ICU) professionals not trained in donation interviews. The aim of our study was to compare performances in obtaining informed consent from potential donors' families, according to the type of health care professional conducting the interviews: OPO, IHC, or ICU staff. In this retrospective 2-year study performed in Rio de Janeiro, Brazil, we observed an increase in referrals (285 to 411) and consent rates (48.1% to 55.7%). Each year, OPO professionals conducted most family interviews (58.6% and 60.4%, respectively) and obtained better consent rates (63.5% and 64.5%, respectively), when compared to IHC (41.8% and 53.7%, respectively) or untrained ICU professionals (22.1% and 13.4%, respectively). Our results show that adequate professional training is necessary for obtaining family consent for organ donation. Both established international policies for organ procurement and donation, namely the "Spanish model" with its IHCs or the "American model" of extra-hospital OPOs, may equally achieve this task. However, family interviews performed by untrained ICU professionals result in low donation rates and should be discouraged.

Collagen arrangement in hepatic granuloma in mice infected with Schistosoma mansoni: dependence on fiber radiation centers.

The collagen structure of isolated and in situ liver granuloma from Swiss Webster mice infected with Schistosoma mansoni was sequentially and three-dimensionally analyzed during different times of infection (early acute, acute, transitional acute-chronic, and chronic phases) by laser scanning confocal microscopy and electron scanning variable vacuum microscopy. The initial granuloma structure is characterized by vascular collagen residues and by anchorage points (or fiber radiation centers), from where collagenous fibers are angularly shed and self-assembled. During the exudative-productive stage, the self-assembly of these fibers minimizes energy and mass through continuous tension and focal compression. The curvature or angles between collagen fibers probably depends on the fibroblastic or myofibroblastic organization of stress fibers. Gradually, the loose unstable lattice of the exudative-productive stage transforms into a highly packed and stable architecture as a result of progressive compactness. The three-dimensional architecture of granulomas provides increased tissue integrity, efficient distribution of soluble compounds and a haptotactic background to the cells.

Collagen arrangement in hepatic granuloma in mice infected with Schistosoma mansoni: dependence on fiber radiation centers

The collagen structure of isolated and in situ liver granuloma from Swiss Webster mice infected with Schistosoma mansoni was sequentially and three-dimensionally analyzed during different times of infection (early acute, acute, transitional acute-chronic, and chronic phases) by laser scanning confocal microscopy and electron scanning variable vacuum microscopy. The initial granuloma structure is characterized by vascular collagen residues and by anchorage points (or fiber radiation centers), from where collagenous fibers are angularly shed and self-assembled. During the exudative-productive stage, the self-assembly of these fibers minimizes energy and mass through continuous tension and focal compression. The curvature or angles between collagen fibers probably depends on the fibroblastic or myofibroblastic organization of stress fibers. Gradually, the loose unstable lattice of the exudative-productive stage transforms into a highly packed and stable architecture as a result of progressive compactness. The three-dimensional architecture of granulomas provides increased tissue integrity, efficient distribution of soluble compounds and a haptotactic background to the cells

Effects of schistosomal mansoni infection on Calomys callosus coelom-associated lymphomyeloid tissue (milky spots).

Calomys callosus Rengger, 1830 (Rodentia: Cricetidae) is a mouse-like South American wild rodent, which is permissive to Schistosoma mansoni infection. In this paper we studied the effect of schistosomal infection in C. callosus mesenteric and omental milky spots (MS), subsidiary foci of coelom-associated lymphomyeloid tissue (CALT), during the acute, transitional (acute to chronic), and chronic phases of the infection. MS were morphologically analyzed by histological methods, using brightfield and confocal laser scanning microscopies. The MS of infected animals were mainly of lymphomyelocytic (42 to 90 days) and lymphoplasmacytic (160 days of infection) types and showed frequent presence of lymphoid follicles with germinal centers, plasmacytogenesis and plasmacytosis, mastocytosis, megakaryopoiesis, erythropoiesis and less pronounced eosinopoiesis. These results indicate that MS are a preferential site of germinal-center-dependent and independent plasmacytogenesis, and a bone marrow-like organ, committed with various cellular lineages. The consequence of C. callosus MS reactivity for schistosomal infection is still unknown and is under investigation.

Histoarchitecture of schistosomal granuloma development and involution: morphogenetic and biomechanical approaches.

The authors present morphogenetic and biomechanical approaches on the concept of the Schistosoma mansoni granulomas, considering them as organoid structures that depend on cellular adhesion and sorting, forming rearrangement into hierarchical concentric layers, creating tension-dependent structures, aiming to acquire round form, since this is the minimal energy form, in which opposing forces pull in equally from all directions and are in balance. From the morphogenetic point of view, the granulomas function as little organs, presenting maturative and involutional stages in their development with final disappearance (pre-granulomatous stages, subdivided in: weakly and/or initial reactive and exudative; granulomatous stages: exudative-productive, productive and involutional). A model for the development of granulomas was suggested, according to the following stages: encapsulating, focal histolysis, fiber production, orientation and compacting and involution and disintegration. The authors concluded that schistosomal granuloma is not a tangled web of individual cells and fibers, but an organized structure composed by host and parasite components, which is not formed to attack the miracidia, but functions as an hybrid interface between two different phylogenetic beings.

Immunological system and Schistosoma mansoni: co-evolutionary immunobiology. What is the eosinophil role in parasite-host relationship?

Schistosomes, ancestors and recent species, have pervaded many hosts and several phylogenetic levels of immunity, causing an evolutionary pressure to eosinophil lineage expression and response. Schistosoma mansoni adult worms have capitalized on the apparent adversity of living within the mesenteric veins, using the dispersion of eggs and antigens to other tissues besides intestines to set a systemic activation of several haematopoietic lineages, specially eosinophils and monocytes/macrophages. This activation occurs in bone marrow, spleen, liver, lymph nodes, omental and mesenteric milky spots (activation of the old or primordial and recent or new lymphomyeloid tissue), increasing and making easy the migration of eosinophils, monocytes and other cells to the intestinal periovular granulomas. The exudative perigranulomatous stage of the periovular reaction, which present hystolitic characteristics, is then exploited by the parasites, to release the eggs into the intestinal lumen. The authors hypothesize here that eosinophils, which have a long phylogenic story, could participate in the parasite-host co-evolution, specially with S. mansoni, operating together with monocytes/macrophages, upon parasite transmission.

Coelom-associated lymphomyeloid tissue (milky spots): site of lymphoid and myelomonocytic cell generation.

Pleural and peritoneal milky spots (MS) are small morphofunctional structures representing subsidiary foci of coelom-associated lymphomyeloid tissue (CALT). In this paper we studied the cellular composition of CALT in normal and Schistosoma mansoni-infected mice. In the healthy mouse, CALT is mainly composed of IgM (+) B cells and presents lower numbers of CD23 and CD45R (B220) B2 lymphocytes. When activated by the infection, it may show pronounced lymphocytosis, plasmocytogenesis (IgM > IgG > IgA > IgG2a > IgG1) and myelomonocytosis. The lymphocytes were mainly of the B1 type (double positive CD5/IgM), with smaller number of T cells (TCR alpha beta (+), TCR gamma delta (+), CD3 (+) and CD5 (+)) and conventional B2 cells (B220 (+), CD23 (+)). The myeloid compartment was composed of immature and mature cells of monocyte/macrophage, eosinophil, neutrophil and megakaryocytic lineages, especially in the omental milky spots. CALT is also a favorable microenvironment for LFA-1 (+) mast cells. Thus, CALT appears to be a mixed lymphoid organ, with secondary and/or primary lymphoid organ functions, being an important site of B1 cell generation, plasma cell maturation and extramedullar hematopoiesis. CALT operates as an interface between blood and lymphatic circulation and coelomic cavities, because locally or externally produced cells have easy and ready access to the pleural and peritoneal cavities. Furthermore, MS cells can escape into blood and lymphatic vessels, providing lymphocytes to other lymphoid organs and to the mucosa-associated lymphoid tissue.

Coelom-associated lymphomyeloid tissue (milky spots): site of lymphoid and myelomonocytic cell generation

Pleural and peritoneal milky spots (MS) are small morphofunctional structures representing subsidiary foci of coelom-associated lymphomyeloid tissue (CALT). In this paper we studied the cellular composition of CALT in normal and Schistosoma mansoni-infected mice. In the healthy mouse, CALT is mainly composed of IgM (+) B cells and presents lower numbers of CD23 and CD45R (B220) B2 lymphocytes. When activated by the infection, it may show pronounced lymphocytosis, plasmocytogenesis (IgM >IgG>IgA>IgG2a>IgG1) and myelomonocytosis. The lymphocytes were mainly of the B1 type (double positive CD5/IgM), with smaller number of T cells (TCR alpha beta (+), TCR gamma delta (+), CD3 (+) and CD5 (+)) and conventional B2 cells (B220 (+), CD23 (+)). The myeloid compartment was composed of immature and mature cells of monocyte/macrophage, eosinophil, neutrophil and megakaryocytic lineages, especially in the omental milky spots. CALT is also a favorable microenvironment for LFA-1 (+) mast cells. Thus, CALT appears to be a mixed lymphoid organ, with secondary and/or primary lymphoid organ functions, being an important site of B1 cell generation, plasma cell maturation and extramedullar hematopoiesis. CALT operates as an interface between blood and lymphatic circulation and coelomic cavities, because locally or externally produced cells have easy and ready access to the pleural and peritoneal cavities. Furthermore, MS cells can escape into blood and lymphatic vessels, providing lymphocytes to other lymphoid organs and to the mucosa-associated lymphoid tissue.

Calomys callosus: an alternative model to study fibrosis in schistosomiasis mansoni. The pathology of the acute phase

Twenty Calomys callosus, Rengger, 1830 (Rodentia-Cricetidae) were studied in the early stage of the acute schistosomal mansoni infection (42nd day). The same number of Swiss Webster mice were used as a comparative standard. Liver and intestinal sections, fixed in formalin-Millonig and embedded in paraffin, were stained with hematoxilin and eosin, PAS-Alcian Blue, pH = 1.0 and 2.5, Lennert's Giemsa, Picrosirius plus polarization microscopy, Periodic acid methanamine silver, Gomori's silver reticulin and resorcin-fuchsin. Immunohistological study (indirect immunofluorescence and peroxidase labeled extravidin-biotin methods) was done with antibodies specific to pro-collagen III, fibronectin, elastin, condroitin-sulfate, tenascin, alpha smooth muscle actin, vimentin and desmin. The hepatic granulomas were small, reaching only 27 of the volume of the hepatic Swiss Webster granuloma. They were composed mainly by large immature macrophages, often filled by schistosomal pigment, characterizing an exsudative-macrophage granuloma type. The granulomas were situated in the parenchyma and in the portal space. They were often intravascular, poor of extracellular matrix components, except fibronectin and presented, sometimes alpha smooth muscle actin and vimentin positive cells. The C. callosus intestinal granulomas were similar to Swiss Webster, showing predominance of macrophages. Therefore, the C. callosus acquire very well the Schistosoma mansoni infection, without developing strong hepatic acute granulomatous reaction, suggesting lack of histopathological signs of hypersensitivity.

Extramedullary hematopoiesis in murine schistosomiasis mansoni

During Schistosoma mansoni infection, there is morphological evidence of involvement of various hematopoietic growth factors, which cause eosinophil, neutrophil, megakaryocytic and erythroid extramedullary foci in the liver, lymph nodes and omental and mesenteric milky spots. While the eosinophil metaplasia in the periphery of hepatic granulomas roughly reproduced the intensity of the medullary eosinopoiesis, the neutrophil metaplasia, on the contrary, was more intense during the period of neutrophil depression in the bone marrow. This fact suggests that extramedullary hematopoietic foci are locally regulated, and amplify and/or compensate the systemic hematopoietic response during the infection.

Extramedullary hematopoiesis in murine schistosomiasis mansoni.

During Schistosoma mansoni infection, there is morphological evidence of involvement of various hematopoietic growth factors, which cause eosinophil, neutrophil, megakaryocytic and erythroid extramedullary foci in the liver, lymph nodes and omental and mesenteric milky spots. While the eosinophil metaplasia in the periphery of hepatic granulomas roughly reproduced the intensity of the medullary eosinopoiesis, the neutrophil metaplasia, on the contrary, was more intense during the period of neutrophil depression in the bone marrow. This fact suggests that extramedullary hematopoietic foci are locally regulated, and amplify and/or compensate the systemic hematopoietic response during the infection.

Calomys callosus: an alternative model to study fibrosis in schistosomiasis mansoni. The pathology of the acute phase.

Twenty Calomys callosus, Rengger, 1830 (Rodentia-Cricetidae) were studied in the early stage of the acute schistosomal mansoni infection (42nd day). The same number of Swiss Webster mice were used as a comparative standard. Liver and intestinal sections, fixed in formalin-Millonig and embedded in paraffin, were stained with hematoxilin and eosin, PAS-Alcian Blue, pH = 1.0 and 2.5, Lennert's Giemsa, Picrosirius plus polarization microscopy, Periodic acid methanamine silver, Gomori's silver reticulin and resorcin-fuchsin. Immunohistological study (indirect immunofluorescence and peroxidase labeled extravidin-biotin methods) was done with antibodies specific to pro-collagen III, fibronectin, elastin, condroitin-sulfate, tenascin, alpha smooth muscle actin, vimentin and desmin. The hepatic granulomas were small, reaching only 27% of the volume of the hepatic Swiss Webster granuloma. They were composed mainly by large immature macrophages, often filled by schistosomal pigment, characterizing an exsudative-macrophage granuloma type. The granulomas were situated in the parenchyma and in the portal space. They were often intravascular, poor of extracellular matrix components, except fibronectin and presented, sometimes alpha smooth muscle actin and vimentin positive cells. The C. callosus intestinal granulomas were similar to Swiss Webster, showing predominance of macrophages. Therefore, the C. callosus acquire very well the Schistosoma mansoni infection, without developing strong hepatic acute granulomatous reaction, suggesting lack of histopathological signs of hypersensitivity.

Milky spots reaction to schistosomal mansoni infection.

Milky spots (MS), considered by the authors as a Coelomatic Lympho-myelopoietic Organ (CLMO), present a strong reactivity during experimental schistosomal mansoni infection, characterized by an increase of lymphocytes, macrophages, plasmocytes, mast cells, neutrophils and expression of eosinophil metaplasia. Intraperitoneal injection of purified Schistosoma mansoni (Sm) eggs provoked a rise in the number and size of MS, which developed the sessile marginal and pedunculated types. The authors conclude that egg antigens are, at least partially, responsible for MS reactivity during Sm infection.

Milky spots reactions to schistosomal mansoni infection

Milky spots (MS), considered by the authors as a Coelomatic Lympho-myelopoietic Organ (CLMO), present a strong reactivity during experimental schistosomal mansoni infection, characterized by an increase of lymphocytes, macrophages, plasmocytes, mast cells, neutrophils and expression of eosinophil metaplasia. Intraperitoneal injection of purified Schistosoma mansoni (Sm) eggs provoked a rise in the number and size of MS, which developed the sessile marginal and pedunculated types. The authors conclude that egg antigens are, at least partially, responsible for MS reactivity during Sm infection

Comparative distribution of eosinophils in bone marrow, blood and peritoneal cavity in murine schistosomiasis.

Eosinophilia in murine schistosomiasis is very intense and extensive, involving distinct compartments such as bone marrow, blood, peritoneal cavity and tissues. Comparison of the shapes of eosinophil concentration or distribution curves showed a synchronization of the tendencies around 50% between blood and bone marrow, 33 to 64% between blood and peritoneal cavity, and 33 to 43% between peritoneal cavity and bone marrow. The hepatic eosinophil granulocytopoiesis or metaplasia follows the same pattern as observed in bone marrow. Schistosoma infection can be divided into three distinct phases based on the eosinophilic response: 1) non- or low-productive phase (before 35-40 days of infection), 2) acute productive phase (from 35-40 to 70-90 days), and 3) chronic productive phase (after 70-90 days of infection).

Comparative distribution of eosinophils in bone marrow, blood and peritoneal cavity in murine schistosomiasis

Eosinophilia in murine schistosomiasis is very intense and extensive, involving distinct compartments such as bone marrow, blood, peritoneal cavity and tissues. Comparison of the shapes of eosinophil concentration or distribution curves showed a synchronization of the tendencies around 50% between blood and bone marrow, 33 to 64% between bloode and peritoneal cavity, and 33 to 43% between peritoneal cavity and bone marrow. The hepatic eosinophil granulocytopoiesis or metaplasia follows the same pattern as observed in bone marrow. Schistosoma infection can be divided into three distinct phases based on the eosinophilic response: 1) non- or low-productive phase (before 35-40 days of infection), 2) acute productive phase (from 35-40 to 70-90 days), and 3) chronic productive phase (after 70-90 days of infection)