The safety and efficacy of stem cells for the treatment of severe community-acquired bacterial pneumonia: A randomized clinical trial.

PURPOSE: Evaluate the safety profile of expanded allogeneic adipose-derived mesenchymal stem cell (eASC) for the treatment of severe community-acquired bacterial pneumonia (CABP). MATERIALS AND METHODS: Randomized, multicenter, double-blind, placebo-controlled, phase 1b/2a trial. Patients with severe CABP were enrolled to receive intravenous infusions of Cx611 or placebo. The primary objective was safety including hypersensitivity reactions, thromboembolic events, and immunological responses to Cx611. The secondary endpoints included the clinical cure rate, ventilation-free days, and overall survival (Day 90). RESULTS: Eighty-three patients were randomized and received infusions (Cx611: n = 42]; placebo: n = 41]. The mean age was similar (Cx611: 61.1 [11.2] years; placebo: 63.4 [10.4] years). The number of AEs and treatment-emergent AEs were similar (243; 184 and 2; 1) in Cx611 and placebo respectively. Hypersensitivity reactions or thromboembolic events were similar (Cx611: n = 9; placebo: n = 12). Each study arm had similar anti-HLA antibody/DSA levels at Day 90. The clinical cure rate (Cx611: 86.7%; placebo: 93.8%), mean number of ventilator-free days (Cx611: 12.2 [10.29] days; placebo: 15.4 [10.75] days), and overall survival (Cx611: 71.5%; placebo: 77.0%) did not differ between study arms. CONCLUSION: Cx611 was well tolerated in severe CABP. These data provide insights for future stem cell clinical study designs, endpoints and sample size calculation. TRIAL REGISTRATION: NCT03158727 (retrospectively registered: May 09, 2017). Full study protocol: https://clinicaltrials.gov/ProvidedDocs/27/NCT03158727/Prot_000.pdf.

[Wish to hasten death in home palliative care. Look for your seven percent.] / El deseo de adelantar la muerte en cuidados paliativos domiciliarios. Busca tu siete por ciento.

OBJECTIVE: The wish to hasten death has been little researched in the area of Mediterranean countries and we are not aware of specific studies on its particularities in home care in our setting. The aim of this work was to investigate the prevalence and evolution of wish to hasten death in home care, analysing its relationship with physical, emotional, spiritual, ethical and social-family unrest. METHODS: Longitudinal observational study in palliative home care in Catalonia. 43 teams agreed on the level of complexity after the first visit and after the discharge of the patient with the HexCom model, which classifies the desire to anticipate death into Low complexity (no or sporadic manifestation); Medium (persistent desire that requires specific treatment); or High (persistent desire that is considered potentially refractory). For the comparison of proportions, Pearson's Chi-squared test was used and a multivariate logistic regression analysis was performed, in which the dependent variable corresponded to the desire to hasten initial death. The level of significance was p≤0.05. RESULTS: The total number of patients included in this study was 1,677, of whom 1,169 (69.7%) were oncologic. The prevalence of desire to hasten death was 6.67%. It was related to spiritual distress, especially lack of meaning (OR 3.25) and lack of connection (OR 3.81), to psychoemotional distress (OR 2.34) and to ethical distress. Protective factors were spiritual distress in relation to transcendence (OR 0.50), the caregiver being a partner (OR 0.50) and being cared for by a team that included psychology and social work (OR 0.34). The desire to anticipate death is stable in 71.6% of patients. CONCLUSIONS: The desire to anticipate death is a changing and complex phenomenon that can emerge at any time. The presence of psycho-emotional, spiritual-existential and ethical discomfort, especially in patients without a partner, should make us take a proactive attitude to identify it early.

OBJETIVO: El deseo de adelantar la muerte ha sido poco investigado en el área de los países mediterráneos y no conocemos estudios específicos sobre sus particularidades en atención domiciliaria en nuestro entorno. El objetivo de este trabajo fue investigar la prevalencia y la evolución del deseo de anticipar la muerte en atención domiciliaria, analizando su relación con el malestar físico, emocional, espiritual, ético y sociofamiliar. METODOS: Estudio observacional longitudinal en el ámbito de la atención domiciliaria paliativa en Catalunya. 43 equipos acordaron el nivel de complejidad tras la primera visita y tras el alta del paciente con el modelo HexCom, el cual clasifica el deseo de anticipar la muerte en complejidad Baja (manifestación nula o esporádica); Media (Deseo persistente que requiere tratamiento específico); o Alta (Deseo persistente que se considera potencialmente refractario). Para la comparación de proporciones se utilizó la prueba de Ji cuadrado de Pearson y se realizó un análisis de regresión logística multivariante, en el que la variable dependiente correspondía con el deseo de adelantar la muerte inicial. El nivel de significación fue p≤0,05. RESULTADOS: El número total de pacientes incluidos en este estudio fue de 1.677, de los cuales 1.169 (69,7%) eran oncológicos. La prevalencia de deseo de anticipar la muerte fue del 6,67%. Se relacionó con el malestar espiritual, ante todo con la falta de sentido (OR 3,25) y de conexión (OR 3,81), con el malestar psicoemocional (OR 2,34) y con el malestar ético. Fueron factores protectores el malestar espiritual en relación con la transcendencia (OR 0,50), que el cuidador fuese la pareja (OR 0,50) y ser atendido por un equipo en el que se incluyese psicología y trabajo social (OR 0,34). El deseo de anticipar la muerte fue estable en el 71,6% de los pacientes. CONCLUSIONES: El deseo de anticipar la muerte es un fenómeno cambiante y complejo que puede emerger en cualquier momento. La presencia de malestar psicoemocional, espiritual-existencial y ético, sobre todo en pacientes sin pareja, nos han de hacer tomar una actitud proactiva para identificarlo precozmente.

Evaluation of emotional and psycholinguistic problems in deaf and hard-of-hearing students in the Canary Islands.

OBJECTIVES: The current study evaluated deaf and hard-of-hearing students' mental health in terms of emotional and behavioral strengths and difficulties, as measured by the SDQ in the Canary Islands. Furthermore, it evaluated the students' psycholinguistic abilities using the Spanish version of the ITPA. METHODS: The Strengths and Difficulties Questionnaire (SDQ) was used to assess school children problems. The Illinois Test of Psycholinguistic Abilities measured student spoken and written linguistic abilities. RESULTS: Student self-reports yielded different SDQ scores to parent and teacher reports. Student spoken and written linguistic abilities varied according to ten covariates. DISCUSSION: Perceptions about the mental health of children differed according to the groups studied. Perceptions about student abilities in the classroom were different, particularly the ability to reproduce sequences of complex and non-significant figures by memory. CONCLUSION: Two outcomes emerged: a) conduct problems were the SDQ subscale that most distinguished children with cochlear implants from those with hearing aids, and b) tutor and specialist teacher experience appeared as the decisive influencing students' psycholinguistic abilities.

Trayectorias de complejidad en el final de la vida: un estudio multicéntrico prospectivo observacional longitudinal / End-of-life complexity trajectories: a prospective, longitudinal observational multicenter study

Antecedentes: La complejidad se ha convertido en un tema central en cuidados paliativos. Se describe la evolución de la complejidad en atención domiciliaria y su relación con la ubicación de la muerte. Métodos: Estudio observacional de una cohorte prospectiva en el ámbito de la atención provista por los equipos de soporte a la atención domiciliaria en Cataluña. Los equipos evaluaron y acordaron el nivel de complejidad tras la primera visita y al exitus. El modelo HexCom incluye seis áreas de necesidades (clínicas, psicológicas, espirituales, sociofamiliares, éticas y relacionadas con la muerte), con tres niveles de complejidad: alto, moderado y bajo. Resultados: n = 648 pacientes: oncológicos 426 (65,7 %). Murieron en casa 364 (56,2 %), aumentando hasta el 86,4 % en los enfermos con demencia y al 81 % en los enfermos con fragilidad (p < 0,001). La puntuación de complejidad aumentó de 42 a 114 (p < 0,001), y este aumento fue más acusado en el grupo neurológico (de 32 a 213, p < 0,001). Se halló una asociación lineal entre complejidad y ubicación de la muerte (p < 0,001). La complejidad clínica y la sociofamiliar se asociaron a la ubicación de la muerte fuera del domicilio (p < 0,000). Conclusiones: La complejidad aumenta a medida que nos acercamos a la muerte, y esto se cumple en los grupos de pacientes oncológicos, con fallo de órgano y en los pacientes neurológicos, pero no en la demencia y la fragilidad/multimorbilidad. La complejidad se asocia con la ubicación de la muerte, principalmente en las áreas clínica y sociofamiliar. (AU)

Background: Complexity has become a central issue in palliative care. The evolution of complexity in home care and its relationship to place of death are described. Methods: An observational, prospective cohort study in the context of the care provided by home care supporting teams in Catalonia. Teams evaluated and agreed upon a complexity level after their first visit and after patient demise. The HexCom model includes six need areas (clinical, psychological, spiritual, family environment, ethical, and related to death) with three levels of complexity: high, moderate, and low. Results: n = 648 patients, of which 426 (65.7 %) were cancer patients. A total of 364 (56,2 %) subjects died at home, this figure reaching up to 86.4 % for patients with dementia, and to 81 % for fragile patients (p < 0.001). The Complexity Score increased from 42 to 114 (p < 0.001), an increase that was most pronounced in the neurological group (from 32 to 213, p < 0.001). A linear relationship was found between complexity and place of death (p < 0.001). Clinical and family environment complexity was associated with places of death outside the place of residence (p < 0.000). Conclusions: Complexity increases as death is approached, a relationship that holds for cancer patients, patients with organ failure, and neurological patients, but not for those with dementia or fragility/multimorbidity. Complexity is associated to place of death, mainly in the clinical and family environment areas. (AU)

Assessing Face Validity of the HexCom Model for Capturing Complexity in Clinical Practice: A Delphi Study.

Capturing complexity is both a conceptual and a practical challenge in palliative care. The HexCom model has proved to be an instrument with strong reliability and to be valid for describing the needs and strengths of patients in home care. In order to explore whether it is also perceived to be helpful in enhancing coordinated and patient-centred care at a practical level, a methodological study was carried out to assess the face validity of the model. In particular, a Delphi method involving a group of 14 experts representing the full spectrum of healthcare professionals involved in palliative care was carried out. The results show that there is a high level of agreement, with a content validity index-item greater than 0.92 both with regard to the complexity model and the HexCom-Red, HexCom-Basic, and the HexCom-Clin instruments, and higher than 0.85 regarding the HexCom-Figure and the HexCom-Patient instruments. This consensus confirms that the HexCom model and the different instruments that are derived from it are valued as useful tools for a broad range of healthcare professional in coordinately capturing complexity in healthcare practice.

Human adipose mesenchymal stem cells modulate myeloid cells toward an anti-inflammatory and reparative phenotype: role of IL-6 and PGE2.

BACKGROUND: Mesenchymal stem cells (MSCs) activate the endogenous immune regulatory system, inducing a therapeutic effect in recipients. MSCs have demonstrated the ability to modulate the differentiation of myeloid cells toward a phagocytic and anti-inflammatory profile. Allogeneic, adipose-derived MSCs (ASCs) have been investigated for the management of complex perianal fistula, with darvadstrocel being the first ASC therapy approved in Europe in March 2018. Additionally, ASCs are being explored as a potential treatment in other indications. Yet, despite these clinical advances, their mechanism of action is only partially understood. METHODS: Freshly isolated human monocytes from the peripheral blood were differentiated in vitro toward M0 non-polarized macrophages (Mphs), M1 pro-inflammatory Mphs, M2 anti-inflammatory Mphs, or mature dendritic cells (mDCs) in the presence or absence of ASCs, in non-contact conditions. The phenotype and function of the differentiated myeloid populations were determined by flow cytometry, and their secretome was analyzed by OLINK technology. We also investigated the capacity of ASCs to modulate the phenotype and function of terminally differentiated M1 Mphs. The role of soluble factors interleukin (IL)-6 and prostaglandin E2 (PGE2) on the ability of ASCs to modulate myeloid cells was assessed using neutralization assays, CRISPR/Cas9 knock-down of cyclooxygenase 2 (COX-2), and ASC-conditioned medium assays using pro-inflammatory stimulus. RESULTS: Co-culture of monocytes in the presence of ASCs resulted in the polarization of Mphs and mDCs toward an anti-inflammatory and phagocytic phenotype. This was characterized by an increase in phagocytic receptors on the cell surface of Mphs (M0, M1, and M2) and mDCs, as well as modulation of chemokine receptors and reduced expression of pro-inflammatory, co-stimulatory molecules. ASCs also modulated the secretome of Mphs and mDCs, demonstrated by reduced expression of pro-inflammatory factors and increased expression of anti-inflammatory and reparative factors. Chemical inhibition of PGE2 with indomethacin abolished this modulatory effect, whereas treatment with a neutralizing anti-IL-6 antibody resulted in a partial abolishment. The knock-down of COX-2 in ASCs and the use of IL-1ß-activated ASC-conditioned media confirmed the key role of PGE2 in ASC-mediated myeloid modulation. In our in vitro experimental settings, ASCs failed to modulate the phenotype and function of terminally polarized M1 Mphs. CONCLUSIONS: The results demonstrate that ASCs are able to modulate the in vitro differentiation of myeloid cells toward an anti-inflammatory and reparative profile. This modulatory effect was mediated mainly by PGE2 and, to a lesser extent, IL-6.

A phase Ib/IIa, randomised, double-blind, multicentre trial to assess the safety and efficacy of expanded Cx611 allogeneic adipose-derived stem cells (eASCs) for the treatment of patients with community-acquired bacterial pneumonia admitted to the intensive care unit.

BACKGROUND: Community-acquired bacterial pneumonia (CABP) can lead to sepsis and is associated with high mortality rates in patients presenting with shock and/or respiratory failure and who require mechanical ventilation and admission to intensive care units, thus reflecting the limited effectiveness of current therapy. Preclinical studies support the efficacy of expanded allogeneic adipose-derived mesenchymal stem cells (eASCs) in the treatment of sepsis. In this study, we aim to test the safety, tolerability and efficacy of eASCs as adjunctive therapy in patients with severe CABP (sCABP). METHODS: In addition to standard of care according to local guidelines, we will administer eASCs (Cx611) or placebo intravenously as adjunctive therapy to patients with sCABP. Enrolment is planned for approximately 180 patients who will be randomised to treatment groups in a 1:1 ratio according to a pre-defined randomization list. An equal number of patients is planned for allocation to each group. Cx611 will be administered on Day 1 and on Day 3 at a dose of 160 million cells (2 million cells / mL, total volume 80 mL) through a 20-30 min (240 mL/hr) intravenous (IV) central line infusion after dilution with Ringer Lactate solution. Placebo (Ringer Lactate) will also be administered through a 20-30 min (240 mL/hr) IV central line infusion at the same quantity (total volume of 80 mL) and following the same schedule as the active treatment. The study was initiated in January 2017 and approved by competent authorities and ethics committees in Belgium, Spain, Lithuania, Italy, Norway and France; monitoring will be performed at regular intervals. Funding is from the European Union's Horizon 2020 Research and Innovation Program. DISCUSSION: SEPCELL is the first trial to assess the effects of eASCs in sCABP. The data generated will advance understanding of the mode of action of Cx611 and will provide evidence on the safety, tolerability and efficacy of Cx611 in patients with sCABP. These data will be critical for the design of future confirmatory clinical investigations and will assist in defining endpoints, key biomarkers of interest and sample size determination. TRIAL REGISTRATION: NCT03158727 , retrospectively registered on 9 May 2017.

Calidad de vida relacionada con la salud (CVRS) en niños de educación primaria de Islas Canarias que usan dispositivos auditivos / Health-Related Quality of Life (HRQoL) in children in Primary Education in the Canary Islands with cochlear implants or hearing aids

INTRODUCCIÓN: Los objetivos del estudio fueron: primero, evaluar la calidad de vida relacionada con la salud (CVRS) de niños y niñas con implantes cocleares (nIC) o audífonos (nAU) de educación primaria de Islas Canarias. Segundo, analizar las percepciones que los progenitores (padres o madres) tenían de la CVRS de los nIC o nAU y finalmente, explorar la homogeneidad de resultados entre los autoinformes de los nIC y nAU y los informes de sus progenitores sobre la CVRS. MATERIAL Y MÉTODOS: Se obtuvieron datos de 89 nIC y 63 nAU y sus 152 progenitores. Se utilizaron 2 instrumentos estandarizados: el Kid-KINDLR_children_7-13, el Kid_Kiddo-KINDLR_Parents_7-17 y un cuestionario con variables demográficas y audiológicas que respondieron nIC y nAU y sus progenitores. Mediante la prueba «t» de Student, ANOVA de una vía, análisis post hoc y 3 coeficientes de correlación de concordancia (CCC) se analizaron los 3 objetivos. RESULTADOS Y DISCUSIÓN: Los nIC mostraron una percepción de mejor CVRS en comparación con los nAU. Los nIC y nAU y sus padres fueron significativamente distintos en las provincias de Tenerife y Gran Canaria. Los nIC y nAU de Gran Canaria obtuvieron mejores resultados en las dimensiones bienestar emocional y familiar, mientras que los nIC y nAU de Tenerife destacaron en autoestima o amigos. Los progenitores de los niños con IC (pIC) tuvieron una puntuación promedio más alta en la percepción de la CVRS total y por dimensiones referida a sus hijos frente a los progenitores de los nAU. El acuerdo entre niños y sus progenitores fue bajo, excepto en la dimensión autoestima. Los nIC y sus progenitores percibieron mejor CVRS que los nAU y sus progenitores. Las autopercepciones de los nIC y nAU de la CVRS fueron inferiores a las informadas por sus progenitores. CONCLUSIONES: Los hallazgos sugieren que los nIC y nAU de educación primaria de las Islas Canarias han mantenido percepciones discrepantes de su CVRS, autopercibiendo los nIC mejor CVRS que los nAU. Los pIC han alcanzado una puntuación promedio más alta de la CVRS de sus hijos que la expresada por los progenitores de nAU por razones de pertenencia a una provincia. Los profesionales que trabajan con los nIC y nAU deben optimizar las dimensiones de la CVRS de los nIC y nAU

INTRODUCTION: The objectives of the study were first, to evaluate the health-related quality of life (HRQoL) of primary school children from the Canary Islands with cochlear implants (CIs) and hearing aids (HAs). And second, to analyse parents' perceptions of their children with CIs and HAs regarding HRQoL, and finally, to explore the agreement between the children's self-reports and their parents' reports concerning HRQoL. MATERIAL AND METHODS: Data consisted of 89 children with CIs and 63 children with HAs and their 152 parents. Two standardised instruments were used: Kid-KINDLR_children_7-13, Kid_Kiddo-KINDLR_Parents_ 7-17 and a demographic and audiological survey, which were answered by the children and their parents. Student's t-test, one-way ANOVA, post hoc analysis and 3 concordance correlation coefficients (CCC) were used to address the 3 objectives. RESULTS AND DISCUSSION: The children with CIs exhibited a perception of better HRQoL in comparison with the children with HAs. The children with CIs and HAs and their parents were significantly distinct in the provinces of Tenerife and Gran Canaria. The cchildren with CIs and HAs from Gran Canaria were better on Emotional well-being and Family, while the children with CIs and HAs from Tenerife emphasised Self-esteem or Friends. The parents of the children with CIs had a higher average score in the perception of the total HRQoL and per dimension related to their children compared to the parents of the children with HAs. The agreement between children and parents was low except in the Self-esteem dimension. The children with CIs and their parents demonstrated a perception of better HRQoL than the children with HAs and their parents. The children with CIs and HAs had lower self-perception of the HRQoL than their parents' reports. CONCLUSIONS: The findings suggest that the children with CIs and HAs in Primary Education in the Canary Islands have discrepant perceptions of their HRQoL; the children with CIs self-perceive better HRQoL than the children with HAs. The parents of the children with CIs achieved a higher average score of their children's HRQoL than the parents of the children with HAs due to their belonging to a province. Professionals working with CI and HA recipients need to be sensitive to psychological issues to optimise HRQoL dimensions in children with CIs and HAs

Health-related quality of life in children who use cochlear implants or hearing aids.

OBJECTIVES: First, this study aimed at evaluating the health-related quality of life (HRQoL) and socio-demographic characteristics of children with cochlear implants (CIs) and hearing aids (HAs) from the 2 provinces of the Canary Islands (Spain) on the Kid-KINDLR_children_7-13. The second goal was to analyze parental background factors and the perspectives of their children with CIs and HAs on Kid_Kiddo-KINDLR_Parents_ 7-17. Finally, the third objective was to explore agreement between children's self-reports and their parents' reports concerning HRQoL. DESIGN: The data consisted of 89 children with CIs and 63 children with HAs and their 89 parents, respectively. The socio-demographic characteristics of children and parental background factors included demographic and audiological variables. Student's t-test, one-way ANOVA, post hoc analysis and 4 concordance correlation coefficients (CCC) were used to address the 3 aims. RESULTS: Children with CIs exhibited a perception of better HRQoL in comparison with children with HAs. Among other differences, children with CIs and HAs and their parents were significantly distinct in Setting (i.e., provinces of Tenerife and Gran Canaria) (t = 2.921, p < 0.010). Moreover, parents were significantly different in some background factors (i.e., age, socioeconomic status, and learning). While Cohen's Kappa values for most dimensions were too small, the ICC and Student's t-test expressed only concordance in the overall HRQoL and Physical well-being. CONCLUSIONS: Children with CIs and their parents demostrated a perception of better HRQoL than children with HAs and their parents. Overall, children's self-ratings of HRQoL differed from their parents' reports.

Role of tissue factor in the procoagulant and antibacterial effects of human adipose-derived mesenchymal stem cells during pneumosepsis in mice.

BACKGROUND: Adult mesenchymal stem cells (MSCs) improve the host response during experimental sepsis in animals. MSCs from various sources express a procoagulant activity that has been linked to the expression of tissue factor. This study sought to determine the role of tissue factor associated with adipose-derived MSCs (ASCs) in their procoagulant and antibacterial effects during pneumonia-derived sepsis. METHODS: Mice were infused intravenously with ASCs or vehicle after infection with the common human pathogen Klebsiella pneumoniae via the airways. RESULTS: Infusion of freshly cultured or cryopreserved ASCs induced the expression of many genes associated with tissue factor signaling and coagulation activation in the lungs. Freshly cultured and cryopreserved ASCs, as well as ASC lysates, exerted procoagulant activity in vitro as determined by a fibrin generation assay, which was almost completely inhibited by an anti-tissue factor antibody. Infusion of cryopreserved ASCs was associated with a rise in plasma thrombin-antithrombin complexes (indicative of coagulation activation) and formation of multiple thrombi in the lungs 4 h post-infusion. Preincubation of ASCs with anti-tissue factor antibody prior to infusion prevented the rise in plasma thrombin-antithrombin complex concentrations but did not influence thrombus formation in the lungs. ASCs reduced bacterial loads in the lungs and liver at 48 h after infection, which was not influenced by preincubation with anti-tissue factor antibody. At this late time point, microthrombi in the lungs were not detected anymore. CONCLUSION: These data indicate that ASC-associated tissue factor is responsible for systemic activation of coagulation after infusion of ASCs but not for the formation of microthrombi in the lungs or antibacterial effects.

Human Adipose-Derived Mesenchymal Stem Cells Modify Lung Immunity and Improve Antibacterial Defense in Pneumosepsis Caused by Klebsiella pneumoniae.

Adult mesenchymal stem cells exert immunomodulatory effects that might improve the host response during sepsis. Knowledge on the effect of adipose-derived mesenchymal stem cells (ASCs) in sepsis is limited. Klebsiella (K.) pneumoniae is a common cause of gram-negative pneumonia and sepsis. This study sought to determine the effect of human ASCs on the host response during pneumosepsis in mice. Mice were infected with K. pneumoniae via the airways to induce a gradually evolving infection in the lung culminating pneumosepsis. One or 6 hours after infection, mice were infused intravenously with ASCs or vehicle, and euthanized after 16 hours or 48 hours, respectively. The effects of freshly cultured and cryopreserved ASCs were compared, the latter formulation being more clinically relevant. Intravenously administered ASCs were visualized in lung tissue by immunostaining at 1 and 3 hours, but not at 15 hours after infusion. Although early after infection, ASCs did not or only modestly influence bacterial loads, they reduced bacterial burdens in lungs and distant organs at 48 hours. ASCs reduced the lung levels of pro-inflammatory cytokines and attenuated lung pathology, but did not influence distant organ injury. ASCs strongly modified the lung transcriptome in uninfected mice and especially mice with pneumosepsis. Cryopreserved and cultured ASCs induced largely similar effects on the lung transcriptome. These data indicate that human ASCs induce profound immune modulatory effects in the lungs, resulting in reduced bacterial burdens and lung inflammation during pneumosepsis caused by a common human pathogen, suggesting that ASCs may be an adjunctive therapeutic in this condition. Stem Cells Translational Medicine 2019;8:785&796.

Extracellular Vesicles Released by Allogeneic Human Cardiac Stem/Progenitor Cells as Part of Their Therapeutic Benefit.

The positive effects of therapeutic human allogeneic cardiac stem/progenitor cells (hCPC) in terms of cardiac repair/regeneration are very likely mediated by paracrine effects. Our previous studies revealed the advantageous immune interactions of allogeneic hCPC and proposed them as part of the positive paracrine effects occurring upon their application postmyocardial infarction (MI). Currently, extracellular vesicles/exosomes (EV/Exs) released by stem/progenitor cells are also proposed as major mediators of paracrine effects of therapeutic cells. Along this line, we evaluated contribution of EV/Exs released by therapeutic hCPC to the benefit of their successful allogeneic clinical application. Through tailored allogeneic in vitro human assay models mimicking the clinical setting, we demonstrate that hCPC-released EV/Exs were rapidly and efficiently up-taken by chief cellular actors of cardiac repair/regeneration. This promoted MAPK/Erk1/2 activation, migration, and proliferation of human leukocyte antigens (HLA)-mismatched hCPC, mimicking endogenous progenitor cells and cardiomyocytes, and enhanced endothelial cell migration, growth, and organization into tube-like structures through activation of several signaling pathways. EV/Exs also acted as pro-survival stimuli for HLA-mismatched monocytes tuning their phenotype toward an intermediate anti-inflammatory pro-angiogenic phenotype. Thus, while positively impacting the intrinsic regenerative and angiogenic programs, EV/Exs released by therapeutic allogeneic hCPC can also actively contribute to shaping MI-inflammatory environment, which could strengthen the benefits of hCPC allogeneic interactions. Collectively, our data might forecast the application of allogeneic hCPC followed by their cell-free EV/Exs as a strategy that will not only elicit the cell-contact mediated reparative/regenerative immune response but also have the desired long-lasting effects through the EV/Exs. Stem Cells Translational Medicine 2019;8:911&924.

Endoscopic submucosal injection of adipose-derived mesenchymal stem cells ameliorates TNBS-induced colitis in rats and prevents stenosis.

BACKGROUND: Mesenchymal stem cells have potential applications in inflammatory bowel disease due to their immunomodulatory properties. Our aim was to evaluate the feasibility, safety and efficacy of endoscopic administration of adipose-derived mesenchymal stem cells (ASCs) in a colitis model in rats. METHODS: Colitis was induced in rats by rectal trinitrobenzenesulfonic acid (TNBS). After 24 h ASCs (107 cells) or saline vehicle were endoscopically injected into the distal colon. Rats were followed for 11 days. Daily weight, endoscopic score at days 1 and 11, macroscopic appearance at necropsy, colon length and mRNA expression of Foxp3 and IL-10 in mesenteric lymph nodes (MLN) were analyzed. RESULTS: Endoscopic injection was successful in all the animals. No significant adverse events or mortality due to the procedure occurred. Weight evolution was significantly better in the ASC group, recovering initial weight by day 11 (- 0.8% ± 10.1%, mean ± SD), whereas the vehicle group remained in weight loss (- 6.7% ± 9.2%, p = 0.024). The endoscopic score improved in the ASC group by 47.1% ± 5.3% vs. 21.8% ± 6.6% in the vehicle group (p < 0.01). Stenosis was less frequent in the ASC group (4.8% vs. 41.2%, p < 0.01). Colon length significantly recovered in the ASC group versus the vehicle group (222.6 ± 17.3 mm vs. 193.6 ± 17.9 mm, p < 0.001). The endoscopic score significantly correlated with weight change, macroscopic necropsy score and colon length. Foxp3 and IL-10 mRNA levels in MLN recovered with ASC treatment. CONCLUSIONS: ASC submucosal endoscopic injection is feasible, safe and ameliorates TNBS-induced colitis in rats, especially stenosis.

Identification of Potential Plasma microRNA Stratification Biomarkers for Response to Allogeneic Adipose-Derived Mesenchymal Stem Cells in Rheumatoid Arthritis.

The ability to identify and stratify patients that will respond to specific therapies has been transformational in a number of disease areas, particularly oncology. It is anticipated that this will also be the case for cell-based therapies, particularly in complex and heterogeneous diseases such as rheumatoid arthritis (RA). Recently, clinical results with expanded allogenic adipose-derived mesenchymal stem cells (eASCs) have indicated clinical efficacy in highly refractory RA patients. In this study, we set out to determine if circulating microRNAs (miRNAs) could be identified as potential biomarkers associated with response to eASCs in these RA patients. The miRNA expression profiles of pre-treatment plasma samples from responder and nonresponder patients were determined using microarrays. Ten miRNAs were identified that were differentially expressed in the responder group as compared to the nonresponder group. To confirm the differential expression of these 10 miRNA biomarkers, they were further assayed by quantitative reverse-transcriptase polymerase chain reaction (QRT-PCR). From this analysis, three miRNAs, miR-26b-5p, miR-487b-3p and miR-495-3p, were confirmed as being statistically significantly upregulated in the responder group as compared with the nonresponder group. Receiver operating characteristic analysis confirmed their diagnostic potential. These miRNAs could represent novel candidate stratification biomarkers associated with RA patient response to eASCs and are worthy of further clinical validation. Stem Cells Translational Medicine 2017;6:1202-1206.

Immunomodulatory Potential of Human Adipose Mesenchymal Stem Cells Derived Exosomes on in vitro Stimulated T Cells.

In the recent years, it has been demonstrated that the biological activity of mesenchymal stem cells (MSCs) is mediated through the release of paracrine factors. Many of these factors are released into exosomes, which are small membranous vesicles that participate in cell-cell communication. Exosomes from MSCs are thought to have similar functions to MSCs such as repairing and regeneration of damaged tissue, but little is known about the immunomodulatory effect of these vesicles. Based on an extensive bibliography where the immunomodulatory capacity of MSCs has been demonstrated, here we hypothesized that released exosomes from MSCs may have an immunomodulatory role on the differentiation, activation and function of different lymphocyte subsets. According to this hypothesis, in vitro experiments were performed to characterize the immunomodulatory effect of human adipose MSCs derived exosomes (exo-hASCs) on in vitro stimulated T cells. The phenotypic characterization of cytotoxic and helper T cells (activation and differentiation markers) together with functional assays (proliferation and IFN-γ production) demonstrated that exo-hASCs exerted an inhibitory effect in the differentiation and activation of T cells as well as a reduced T cell proliferation and IFN-γ release on in vitro stimulated cells. In summary, here we demonstrate that MSCs-derived exosomes are a cell-derived product that could be considered as a therapeutic agent for the treatment of inflammation-related diseases.

Adipose mesenchymal stromal cell function is not affected by methotrexate and azathioprine.

Given their capacity to modulate the immune response, adipose mesenchymal stem or stromal cells (ASCs) have been used as therapeutic tools to treat chronic inflammatory and autoimmune diseases both in preclinical and clinical studies. Patients enrolled in such clinical trials are often concomitantly treated with immunomodulatory drugs such as methotrexate (MTX) or azathioprine (AZA). Therefore it is necessary to investigate the possible impact of these drugs on ASC function to learn if there are any interactions that would affect the therapeutic effects of either component and thus the clinical outcome of the trials. ASCs were cultured in the absence or presence of MTX or AZA and the effects on viability, proliferation, immunomodulatory properties, and immunogenic features were studied in vitro. The drugs did not affect the viability and proliferative capacity of ASCs. When the drugs and the ASCs were concomitantly used to inhibit lymphocyte proliferation, no synergistic or antagonizing inhibitory effects were found. MTX and AZA did not impair the capacity of ASCs to induce the generation of regulatory T cells in vitro. These data confirm that the immunomodulating features of ASCs are fully functional after exposure to these drugs. Interestingly, whereas MTX did not affect the capacity of natural killer (NK) cells to lyse allogeneic ASCs in vitro, AZA protected allogeneic ASCs from NK cell lysis.

Proteomic characterization of adipose tissue constituents, a necessary step for understanding adipose tissue complexity.

The original concept of adipose tissue as an inert storage depot for the excess of energy has evolved over the last years and it is now considered as one of the most important organs regulating body homeostasis. This conceptual change has been supported by the demonstration that adipose tissue serves as a major endocrine organ, producing a wide variety of bioactive molecules, collectively termed adipokines, with endocrine, paracrine and autocrine activities. Adipose tissue is indeed a complex organ wherein mature adipocytes coexist with the various cell types comprising the stromal-vascular fraction (SVF), including preadipocytes, adipose-derived stem cells, perivascular cells, and blood cells. It is known that not only mature adipocytes but also the components of SVF produce adipokines. Furthermore, adipokine production, proliferative and metabolic activities and response to regulatory signals (i.e. insulin, catecholamines) differ between the different fat depots, which have been proposed to underlie their distinct association to specific diseases. Herein, we discuss the recent proteomic studies on adipose tissue focused on the analysis of the separate cellular components and their secretory products, with the aim of identifying the basic features and the contribution of each component to different adipose tissue-associated pathologies.

Nonleukemic myeloid dendritic cells obtained from autologous stem cell products elicit antileukemia responses in patients with acute myeloid leukemia.

BACKGROUND: Dendritic cell (DC)-based immunotherapeutic protocols are being developed to treat acute myeloid leukemia (AML). So far, DCs for clinical use are obtained from leukemic blasts or from monocytes, after 6 to 10 days of ex vivo culture. However, DC precursors are easily driven to DCs in short-term culture. We tested if DC precursors contained in peripheral blood stem cell (PBSC) products obtained from AML patients can be used to induce antileukemia responses. STUDY DESIGN AND METHODS: PBSCs obtained from 30 consecutive AML patients were tested. Myeloid DCs (MDCs) were purified by immunomagnetic selection and screened for cytogenetic and/or molecular abnormalities by fluorescence in situ hybridization (FISH) or polymerase chain reaction (PCR) assays. MDCs were matured and pulsed with autologous blast lysates and tested for stimulatory capability against AML cells. RESULTS: A median of 0.62 × 10(6) MDCs (range, 0.04-3.25)/mL were quantified in PBSC products. Isolated MDC expressed Class I and II HLA but CD86, CD54, and CCR5 partially. By FISH or PCR assay, these MDCs lacked cytogenetic or molecular abnormalities detected in leukemia cells at diagnosis. MDCs achieved a maturated stage (mature-MDCs) after 24-hour ex vivo culture with tumor necrosis factor-α and autologous blast lysates. These mature-MDCs were capable of stimulating autologous peripheral blood effectors to exert cytotoxicity against autologous leukemia cells and HL-60 cell line. CONCLUSION: We conclude that PBSCs obtained for autologous stem cell transplantation can constitute a novel source of MDCs to design feasible vaccination trials.

Modified tumour antigen-encoding mRNA facilitates the analysis of naturally occurring and vaccine-induced CD4 and CD8 T cells in cancer patients.

The development of effective anti-cancer vaccines requires precise assessment of vaccine-induced immunity. This is often hampered by low ex vivo frequencies of antigen-specific T cells and limited defined epitopes. This study investigates the applicability of modified, in vitro-transcribed mRNA encoding a therapeutically relevant tumour antigen to analyse T cell responses in cancer patients. In this study transfection of antigen presenting cells, by mRNA encoding the tumour antigen NY-ESO-1, was optimised and applied to address spontaneous and vaccine-induced T cell responses in cancer patients. Memory CD8+ T cells from lung cancer patients having detectable humoral immune responses directed towards NY-ESO-1 could be efficiently detected in peripheral blood. Specific T cells utilised a range of different T cell receptors, indicating a polyclonal response. Specific killing of a panel of NY-ESO-1 expressing tumour cell lines indicates recognition restricted to several HLA allelic variants, including a novel HLA-B49 epitope. Using a modified mRNA construct targeting the translated antigen to the secretory pathway, detection of NY-ESO-1-specific CD4+ T cells in patients could be enhanced, which allowed the in-depth characterisation of established T cell clones. Moreover, broad CD8+ and CD4+ T cell responses covering multiple epitopes were detected following mRNA stimulation of patients treated with a recombinant vaccinia/fowlpox NY-ESO-1 vaccine. This approach allows for a precise monitoring of responses to tumour antigens in a setting that addresses the breadth and magnitude of antigen-specific T cell responses, and that is not limited to a particular combination of known epitopes and HLA-restrictions.