[Chronic pain after cesarean: Impact and risk factors associated]. / Douleurs chroniques après césarienne: impact et facteurs de risque associés.

BACKGROUND: Chronic postoperative pain is a well-recognized problem after amputation, thoracotomy, mastectomy and inguinal hernia repair but has not been well evaluated after obstetric surgery. STUDY DESIGN: Retrospective cohort. OBJECTIVES: To determine the rate of chronic pain after cesarean, their impact on quality of life of patients and risk factors associated with this complication. METHODS: A questionnaire was sent to 220 consecutive patients who underwent caesarean delivery in a 6-month period. The questions focused on the duration of incisional pain after caesarean, severity and impact on daily activities. Meanwhile, a retrospective collection of clinical data (history, details of surgery and anaesthesia) was performed. After a descriptive analysis of the study population, a comparison of patients with and without DCPC was conducted to highlight potential risk factors. RESULTS: One hundred and sixty-seven patients (76%) completed the survey. The average response time was 10months (range 8-12) after caesarean section. The postoperative pain was resoluted in most patients within three months but persisted in 25 patients (15%). Seven patients (4%) showed a deterioration of their quality of life because of daily moderate to severe incisional pain. Risk factors associated with chronic pain were the presence of acute pain in postoperative, pre-existing pain (headaches, back pain), a young age and the achievement of general anaesthesia without locoregional associated at caesarean section. CONCLUSION: The occurrence of chronic pain after cesarean section may be frequent and can be responsible for an impaired quality of life.

Role of autologous mesenchymal stem cells associated with platelet-rich plasma on healing of cutaneous wounds in diabetic mice.

BACKGROUND: Chronic cutaneous lesions affect 15% of human patients with diabetes, and the associated risk of limb amputations is 15-46 times greater than that of people with normal glycaemia. It is estimated that half of these limb amputations could be avoided by opportune treatment with somatic stem cells or platelet-rich plasma (PRP). METHODS: We evaluated the effects of autologous transplant of mesenchymal stem cells (MSCs) with or without combination with autologous PRP in the re-epithelialization of cutaneous lesions induced in diabetic mice. RESULTS: Animals treated with MSCs alone showed a similar level of re-epithelialization of cutaneous lesions to those treated with MSC plus PRP, and no significant difference was found between the two treatments. CONCLUSION: Both treatments gave better results than daily cleaning of the cutaneous lesions with saline or covering of the lesions with semipermeable adherent bandage.

Multicentric experience on double dartos flap protection in tubularized incised plate urethroplasty for distal and midpenile hypospadias.

PURPOSE: We report a multicenter experience using double dartos flap to protect the neourethra in TIP urethroplasty for distal and midpenile hypospadias. METHODS: A total of 394 patients underwent tubularized incised plate urethroplasty for primary distal and midpenile hypospadias using double dartos flap protection by ten pediatric surgeons and urologists at five different institutions. RESULTS: Tubularized incised plate urethroplasty protected by a double dartos flap was simple to perform and flaps were easy to obtain. Complications occurred in 23 patients (5.83%): fistulas 1.01% (4 cases), stenosis 0.25% (1 case), mild stenosis 2.53% (10 cases), dehiscence of ventral cutis 0.50% (2 cases) and penile torsion 1.26% (5 cases). All fistulae had a spontaneous resolution. CONCLUSION: Double dartos flap to protect tubularized incised plate urethroplasty is safe with a low complication rate. The neourethra is covered entirely with a double layer of vascularized tissue and the double coverage appears a good choice for preventing urethrocutaneous fistula formation.

Co-transplantation of mesenchymal stem cells maintains islet organisation and morphology in mice.

AIMS/HYPOTHESIS: Recent studies have shown that mesenchymal stem cells (MSCs) secrete several factors that improve survival and function of transplanted islets. Implantation of islets beneath the kidney capsule results in morphological changes, due to interactions of the graft with the host, thus impairing islet function. We co-transplanted MSCs with islets to determine their effects on the remodelling process and studied graft function in a mouse model of minimal islet mass. METHODS: Islets were syngeneically transplanted, either alone or with kidney-derived MSCs, underneath the kidney capsule of streptozotocin-induced diabetic C57Bl/6 mice. Blood glucose levels were monitored and intraperitoneal glucose tolerance tests carried out. Hormone contents of grafts and pancreas were assessed by radioimmunoassay. Graft morphology and vascularisation were evaluated by immunohistochemistry. RESULTS: MSCs improved the capacity of islet grafts to reverse hyperglycaemia, with 92% of mice co-transplanted with MSCs reverting to normoglycaemia, compared with 42% of those transplanted with islets alone. Average blood glucose concentrations were lower throughout the 1 month monitoring period in MSC co-transplanted mice. MSCs did not alter graft hormone content. Islets co-transplanted with MSCs maintained a morphology that more closely resembled that of islets in the endogenous pancreas, both in terms of size, and of endocrine and endothelial cell distribution. Vascular engraftment was superior in MSC co-transplanted mice, as shown by increased endothelial cell numbers within the endocrine tissue. CONCLUSIONS/INTERPRETATION: Co-transplantation of islets with MSCs had a profound impact on the remodelling process, maintaining islet organisation and improving islet revascularisation. MSCs also improved the capacity of islets to reverse hyperglycaemia.

An unusual case of asymptomatic appendicular cutting foreign body.

Foreign body ingestion is a common problem in pediatric age. Foreign bodies in the lumen of appendix is a well known event. In this condition perforation or appendicitis may occur even for blunt or sharp objects. For these reasons, in case of stasis of foreign body in the lumen of appendix a prophylactic appendectomy is recommended. A case of asymptomatic ingested cutting foreign body in the appendix is presented and the approach is discussed according to the literature data.

Association between the 1858T allele of the protein tyrosine phosphatase nonreceptor type 22 and type 1 diabetes in a Brazilian population.

The 1858T allele of the protein tyrosine phosphatase nonreceptor 22 (PTPN22) gene has been associated to diabetes in different populations. We investigated a possible relationship between this polymorphism and type 1 diabetes in a cohort of Brazilian patients. A significantly higher frequency of the 1858T allele was observed in diabetic patients (n = 211) than in control individuals (n = 241). Additionally, the heterozygote genotype was also increased in the diabetic group. No association was observed between the PTPN22 T allele and gender, or between T carriers and age of onset of T1D. This work describes for the first time a strong association of the 1858T allele with type 1 diabetes in a Brazilian population, reinforcing the role of this variant as an important susceptibility factor for this disease.

Scrotal dog bite: unusual case and review of pediatric literature.

Animal bites to human external genitalia are rare. Only a few cases of scrotal dog bite in children have been reported. We present an additional specific case of a scrotal dog bite in a child because the lesion and its repair have not been previously reported in published pediatric studies. A traumatic resection of the right testicular vas deferens was repaired by microsurgical vasoepididymal anastomosis. A review of the published data was also performed to analyze the management of scrotal dog bite lesions.

Mannose-binding lectin-low genotypes are associated with milder systemic and immunological disease expression in primary Sjögren's syndrome.

OBJECTIVE: To investigate the association of mannose-binding lectin (MBL)-low genotypes with the clinical and immunological expression of primary SS. METHODS: Eighty-one patients with primary SS who fulfilled the 2002 classification criteria were included in the study. MBL2 polymorphisms were investigated by sequence-based DNA typing of the promoter and exon 1. Genotypes 0/0, 0/XA or XA/XA were considered as MBL-low and XA/A, A/0 and A/A as MBL-sufficient. Control groups included 46 patients who exclusively fulfilled the 1993 SS criteria, 114 SLE patients and 104 healthy individuals. RESULTS: Twelve (15%) SS patients had MBL-low genotypes, of whom six (7%) had genotype 0/XA, five (6%) had genotype 0/0 and one (1%) had genotype XA/XA. A higher prevalence of the XA/A genotype (32 vs 17%, P = 0.01) was found in primary SS patients in comparison with SLE patients. No patient with primary SS carrying MBL-low genotypes had purpura, glomerulonephritis or neurological involvement (0 vs 29%, P = 0.025). Immunologically, patients carrying MBL-low genotypes had a lower frequency of anti-Ro/SS-A antibodies (17 vs 55%, P = 0.014), anti-La/SS-B antibodies (8 vs 48%, P = 0.009) and low C4/C3 levels (0 vs 32%, P = 0.016). No patient with primary SS carrying the homozygous MBL-deficient genotype 0/0 had anti-Ro/SS-A or anti-La/SS-B antibodies, low C3/C4 levels or circulating cryoglobulins. CONCLUSION: SS patients with MBL-low genotypes have a less pronounced systemic and immunological disease expression in comparison with those carrying MBL-sufficient genotypes. In primary SS, MBL deficiency may represent a protective factor against the development of more aggressive autoimmune damage.

Topical application of isosorbide dinitrate in patients with persistent constipation after pull-through surgery for Hirschsprung's disease.

AIMS: The aim of this study was to evaluate the anal manometric changes and the clinical effects after topical application of isosorbide dinitrate (ISDN) in patients with persistent constipation after pull-through surgery for Hirschsprung's disease (HD). METHODS: We studied 3 children (2 males and 1 female), aged 2, 3 and 5 years respectively, who had undergone the Soave-Boley surgical procedure for HD and who suffered from persistent constipation after operation. We performed a pre- and postoperative anorectal manometry study and we applied ISDN paste (1 mg/kg two times daily) in the anal region for three weeks. All patients were followed-up and re-evaluated at 1, 3, and 6 months. RESULTS: All patients showed an improvement of symptoms, with an average of 4 spontaneous evacuations per week. Prior to the topical treatment, the medium pressure was 115.6 mmHg (range 102 - 130 mmHg), the maximum pressure was 160 mmHg (range 145 - 175 mmHg), and the medium length of the high pressure zone was 1.8 cm (range 1.5 - 2.0 cm). At the 6 month follow-up, the medium pressure was 57.3 mmHg (range 52 - 61 mmHg, a decrease of 54.4 %), the maximum pressure was 98 mmHg (range 88 - 107 mmHg; a decrease of 38.7 %), and the medium length of the high pressure zone was 1.6 cm (range 1.4 - 1.8 cm; a decrease of 11.1 %). CONCLUSIONS: Topical treatment with ISDN is a valid therapeutic alternative to an anal myotomy in patients with persistent constipation after pull-through surgery for HD. However, a greater number of cases and a longer follow-up are necessary to confirm the validity of our experience.

Association of mannose-binding lectin gene polymorphisms with antiphospholipid syndrome, cardiovascular disease and chronic damage in patients with systemic lupus erythematosus.

OBJECTIVE: To investigate the association of mannose-binding lectin (MBL)-deficient genotypes with cardiovascular disease in a large series of patients with systemic lupus erythematosus (SLE). METHODS: A total of 114 patients diagnosed with SLE were included in the study. MBL polymorphisms were investigated by sequencing-based DNA typing of the promoter and exon 1 of the MBL2 gene. The genotypes 0/0, 0/XA and XA/XA were considered as MBL-low genotypes. RESULTS: A higher prevalence of cardiovascular disease was observed in patients carrying MBL-low genotypes compared with those carrying MBL-high genotypes [30 vs 9%, P = 0.012, odds ratio (OR) 4.54, 95% confidence interval (CI) 1.20-16.46]. Patients with MBL-low genotypes also presented higher mean values for total cholesterol (228.6 vs 202.3 mg/dl, P = 0.017) and low-density lipoprotein (LDL) cholesterol (139.9 vs 121.9 mg/dl, P = 0.045), a higher frequency of chronic renal failure (30 vs 4%, P = 0.001), vasculitis (30 vs 11%, P = 0.043), heart valve lesions (71 vs 32%, P = 0.026), cardiac valve dysfunction (57 vs 7%, P = 0.0004) and associated APS (39 vs 12%, P = 0.005), a higher mean Systemic Lupus International Collaborating Clinics score (2.09 vs 1.26, P = 0.029) and a lower prevalence of low C4 levels (43 vs 71%, P = 0.015). Multivariate analysis of genetic, clinical and immunological variables showed that only antiphospholipid syndrome (APS) was independently associated with cardiovascular events (P = 0.001). CONCLUSION: Although the prevalence of cardiovascular disease in our SLE patients carrying MBL-deficient genotypes was 3.3 times higher than in patients with non-deficient genotypes, only APS was independently associated with cardiovascular events. This suggests that the higher frequency of thrombotic events in SLE patients carrying MBL-deficient genotypes might be related to coexisting APS.

Testicular hypotrophy in varicocele: pre and postoperative echographic follow-up in the pediatric age.

AIM: Varicocele is characterised by an anomalous tortuosity and dilation of the veins of the pampiniform plexus. The etiopathogenetic mechanisms are still unclear, but a correlation seems to exist between varicocele and testicular development, with possible repercussions on the testicle's functionality. The aim of this study is to evaluate gonadic trophism through echographic monitoring in the pre and postoperative phases in patients affected by idiopathic varicocele with testicular hypotrophy in order to evaluate the treatment's benefits. METHODS: Sixty-six patients (mean age 12,5; range 10-17) consecutively operated for left idiopathic varicocele were considered. Of these, 27 had ipsilateral testicular hypotrophy and thus they were included in the study. Fifteen were operated upon in videolaparoscopy (VLS), and 12 by the classic open inguinal access. The mean follow-up was 18 months (6-24 months). The data were analyzed by nonparametric Mann-Whitney U test. RESULTS: An increase in the testicular volume was observed clinically and by ultrasound in 13 of the 15 patients treated by VLS and in 9 of the 12 patients operated by traditional means. The nonparametric Mann-Whitney U test showed a significativity between pre and post-operative values. CONCLUSION: The testicular trophic healing observed in 81.5% of the operated patients leads to the belief that an early correction can allow a rapid volumetric increase and an improved function of the gonad.

Comparative quantification of umbilical cord blood CD34+ and CD34+ bright cells using the ProCount-BD and ISHAGE protocols.

The total number of CD34+ cells is the most relevant clinical parameter when selecting human umbilical cord blood (HUCB) for transplantation. The objective of the present study was to compare the two most commonly used CD34+ cell quantification methods (ISHAGE protocol and ProCount - BD) and analyze the CD34+ bright cells whose 7-amino actinomycin D (7AAD) analysis suggests are apoptotic or dead cells. Twenty-six HUCB samples obtained at the Placental Blood Program of New York Blood Center were evaluated. The absolute numbers of CD34+ cells evaluated by the ISHAGE (with exclusion of 7AAD+ cells) and ProCount (with exclusion of CD34+ bright cells) were determined. Using the ISHAGE protocol we found 35.6 +/- 19.4 CD34+ cells/microL and with the ProCount method we found 36.6 +/- 23.2 CD34+ cells/microL. With the ProCount method, CD34+ bright cell counts were 9.3 +/- 8.2 cells/microL. CD34+ bright and regular cells were individually analyzed by the ISHAGE protocol. Only about 1.8% of the bright CD34+ cells are alive, whereas a small part (19.0%) is undergoing apoptosis and most of them (79.2%) are dead cells. Our study showed that the two methods produced similar results and that 7AAD is important to exclude CD34 bright cells. These results will be of value to assist in the correct counting of CD34+ cells and to choose the best HUCB unit for transplantation, i.e., the unit with the greatest number of potentially viable stem cells for the reconstitution of bone marrow. This increases the likelihood of success of the transplant and, therefore, the survival of the patient.

Comparative quantification of umbilical cord blood CD34+ and CD34+ bright cells using the ProCount™-BD and ISHAGE protocols

The total number of CD34+ cells is the most relevant clinical parameter when selecting human umbilical cord blood (HUCB) for transplantation. The objective of the present study was to compare the two most commonly used CD34+ cell quantification methods (ISHAGE protocol and ProCount™ - BD) and analyze the CD34+ bright cells whose 7-amino actinomycin D (7AAD) analysis suggests are apoptotic or dead cells. Twenty-six HUCB samples obtained at the Placental Blood Program of New York Blood Center were evaluated. The absolute numbers of CD34+ cells evaluated by the ISHAGE (with exclusion of 7AAD+ cells) and ProCount™ (with exclusion of CD34+ bright cells) were determined. Using the ISHAGE protocol we found 35.6 ± 19.4 CD34+ cells/æL and with the ProCount™ method we found 36.6 ± 23.2 CD34+ cells/æL. With the ProCount™ method, CD34+ bright cell counts were 9.3 ± 8.2 cells/æL. CD34+ bright and regular cells were individually analyzed by the ISHAGE protocol. Only about 1.8 percent of the bright CD34+ cells are alive, whereas a small part (19.0 percent) is undergoing apoptosis and most of them (79.2 percent) are dead cells. Our study showed that the two methods produced similar results and that 7AAD is important to exclude CD34 bright cells. These results will be of value to assist in the correct counting of CD34+ cells and to choose the best HUCB unit for transplantation, i.e., the unit with the greatest number of potentially viable stem cells for the reconstitution of bone marrow. This increases the likelihood of success of the transplant and, therefore, the survival of the patient.

From leading role to the backstage: mesenchymal stem cells as packaging cell lines for in situ production of viral vectors.

Gene therapy is based on the genetic manipulation of target cells. The genetic information required to genetically engineer these cells can be delivered through non-viral or viral vectors that present different biologic properties. The production of viral vectors for gene therapy depends on the nature of the cells transfected with plasmids containing the genetic information for recombinant viral assemblage. These so-called packaging cell lines (PCL) can be injected into the target organ, for the in situ transduction of target cells. There have been recent reports about the capacity of mesenchymal stem cells (MSCs) to target tumor cells. Different research groups, including our own, have isolated these MSCs, but they have not yet been studied as potential PCL to produce viral vectors. We propose here that a MSC packaging cell line could be employed for in situ gene therapy of solid tumors. The tropism of MSCs for tumor cells may render this PCL more efficient in that microenvironment, producing viral vectors for longer periods of time, shifting MSCs from target cell to the backstage level of viral gene therapy.

Functional characterization of cell hybrids generated by induced fusion of primary porcine mesenchymal stem cells with an immortal murine cell line.

Bone marrow mesenchymal stem cells (MSC) integrate into various organs and contribute to the regeneration of diverse tissues. However, the mechanistic basis of the plasticity of MSC is not fully understood. The change of cell fate has been suggested to occur through cell fusion. We have generated hybrid cell lines by polyethylene-glycol-mediated cell fusion of primary porcine MSC with the immortal murine fibroblast cell line F7, a derivative of the GM05267 cell line. The hybrid cell lines display fibroblastic morphology and proliferate like immortal cells. They contain tetraploid to hexaploid porcine chromosomes accompanied by hypo-diploid murine chromosomes. Interestingly, many hybrid cell lines also express high levels of tissue-nonspecific alkaline phosphatase, which is considered to be a marker of undifferentiated embryonic stem cells. All tested hybrid cell lines retain osteogenic differentiation, a few of them also retain adipogenic potential, but none retain chondrogenic differentiation. Conditioned media from hybrid cells enhance the proliferation of both early-passage and late-passage porcine MSC, indicating that the hybrid cells secrete diffusible growth stimulatory factors. Murine F7 cells thus have the unique property of generating immortal cell hybrids containing unusually high numbers of chromosomes derived from normal cells. These hybrid cells can be employed in various studies to improve our understanding of regenerative biology. This is the first report, to our knowledge, describing the generation of experimentally induced cell hybrids by using normal primary MSC.

Myositis ossificans in children: description of a clinical case with a rare localization.

Myositis ossificans (MO) also defined as myosteosis or hematoma ossificans, is a benign condition presenting as an heterotopic, well- defined neoformation in muscles and soft tissues. It was first described by Guy Patyn in 1692 and defined in its histopathological aspects by Von Dusch in 1868. It most frequently has a post-traumatic onset (60-75% of cases), usually following small repeated traumas or a single bruising episode. MO is rare in subjects under 10 years of age, whereas it is more frequent in teen-age athletes, and over 50% of cases are diagnosed in the third decade of life. Its etiopathogenesis in unknown, although it is associated with a traumatic event in 75% of cases. MO most common localizations are arms, legs, shoulders and hands, rarely chest. The lesion presents with different degrees of maturation and diagnostic tools are echotomography (ECT) as a primary investigation, and NMR for a better diagnostic assessment. Because of the self-limiting nature of the lesion and its spontaneous resolution, a conservative treatment is advised along with radiological follow-up which is most indicated in the presence of either typical MO features or highly suggestive ECT o NMR findings. In case of uncertain diagnosis, relevant muscular function impairment, considerable lesion dimension or severe pain, exeresis and histological examinations are suggested. The present paper describes and discusses a clinical case of MO in a child, with a rare localization.

Mesenchymal stem cells: isolation, in vitro expansion and characterization.

Mesenchymal stem cells (MSC), one type of adult stem cell, are easy to isolate, culture, and manipulate in ex vivo culture. These cells have great plasticity and the potential for therapeutic applications, but their properties are poorly understood. MSCs can be found in bone marrow and in many other tissues, and these cells are generally identified through a combination of poorly defined physical, phenotypic, and functional properties; consequently, multiple names have been given to these cell populations. Murine MSCs have been directly applied to a wide range of murine models of diseases, where they can act as therapeutic agents per se, or as vehicles for the delivery of therapeutic genes. In addition to their systemic engraftment capabilities, MSCs show great potential for the replacement of damaged tissues such as bone, cartilage, tendon, and ligament. Their pharmacological importance is related to four points: MSCs secrete biologically important molecules, express specific receptors, can be genetically manipulated, and are susceptible to molecules that modify their natural behavior. Due to their low frequency and the lack of knowledge on cell surface markers and their location of origin, most information concerning MSCs is derived from in vitro studies. The search for the identity of the mesenchymal stem cell has depended mainly on three culture systems: the CFU-F assay, the analysis of bone marrow stroma, and the cultivation of mesenchymal stem cell lines. Other cell populations, more or less related to the MSC, have also been described. Isolation and culture conditions used to expand these cells rely on the ability of MSCs, although variable, to adhere to plastic surfaces. Whether these conditions selectively favor the expansion of different bone marrow precursors or cause similar cell populations to acquire different phenotypes is not clear. The cell populations could also represent different points of a hierarchy or a continuum of differentiation. These issues reinforce the urgent need for a more comprehensive view of the mesenchymal stem cell identity and characteristics.

Polyethylene glycol-mediated fusion between primary mouse mesenchymal stem cells and mouse fibroblasts generates hybrid cells with increased proliferation and altered differentiation.

Bone marrow-derived mesenchymal stem cells (MSCs) can differentiate into different cell lineages with the appropriate stimulation in vitro. Transplantation of MSCs in human and other animal models was found to repair tissues through the fusion of transplanted MSCs with indigenous cells. We have generated mouseâmouse hybrid cell lines in vitro by polyethylene glycol-mediated fusion of primary mouse MSCs with mouse fibroblasts to investigate the characteristics of hybrid cells, including their potentials for proliferation and differentiation. Similar to the parental MSCs, hybrid cells are positive for the cell-surface markers CD29, CD44, CD49e, and Sca-1, and negative for Gr-1, CD11b, CD13, CD18, CD31, CD43, CD45, CD49d, CD90.2, CD445R/B220, and CD117 markers. The hybrid cells also produce a high level of tissue nonspecific alkaline phosphatase compared to the parental cells. Conditioned medium of hybrid cells contain biologically active factors that are capable of stimulating proliferation of other cells. Although the parental MSCs can differentiate into adipogenic and osteogenic lineages, hybrid cells held disparate differentiation capacity. Hybrid cell lines in general have increased proliferative capacity than the primary MSCs. Our study demonstrates that proliferative hybrid cell lines can be generated in vitro by induced fusion of both immortal and primary somatic cells with primary MSCs.

Immunophenotype of hematopoietic stem cells from placental/umbilical cord blood after culture

Identification and enumeration of human hematopoietic stem cells remain problematic, since in vitro and in vivo stem cell assays have different outcomes. We determined if the altered expression of adhesion molecules during stem cell expansion could be a reason for the discrepancy. CD34+CD38- and CD34+CD38+ cells from umbilical cord blood were analyzed before and after culture with thrombopoietin (TPO), FLT-3 ligand (FL) and kit ligand (KL; or stem cell factor) in different combinations: TPO + FL + KL, TPO + FL and TPO, at concentrations of 50 ng/mL each. Cells were immunophenotyped by four-color fluorescence using antibodies against CD11c, CD31, CD49e, CD61, CD62L, CD117, and HLA-DR. Low-density cord blood contained 1.4 ± 0.9 percent CD34+ cells, 2.6 ± 2.1 percent of which were CD38-negative. CD34+ cells were isolated using immuno-magnetic beads and cultured for up to 7 days. The TPO + FL + KL combination presented the best condition for maintenance of stem cells. The total cell number increased 4.3 ± 1.8-fold, but the number of viable CD34+ cells decreased by 46 ± 25 percent. On the other hand, the fraction of CD34+CD38- cells became 52.0 ± 29 percent of all CD34+ cells. The absolute number of CD34+CD38- cells was expanded on average 15 ± 12-fold when CD34+ cells were cultured with TPO + FL + KL for 7 days. The expression of CD62L, HLA-DR and CD117 was modulated after culture, particularly with TPO + FL + KL, explaining differences between the adhesion and engraftment of primary and cultured candidate stem cells. We conclude that culture of CD34+ cells with TPO + FL + KL results in a significant increase in the number of candidate stem cells with the CD34+CD38- phenotype.