Clinical case
Autologous mesenchymal stem cells and cutaneous autograft as a treatment for chronic ulcer secondary to diabetes mellitus 2
Células troncales mesenquimales autólogas e injerto cutáneo autólogo para tratamiento de una úlcera crónica secundaria a diabetes mellitus tipo 2
Gamaliel Benítez-Arvízua,
, Ícela Palma-Laraa, René Vazquez-Camposb, Raimundo Alfonso Sesma-Villalpandob, Alberto Parra-Barrerac, Gisela Gutiérrez-Iglesiasc
Corresponding author
gamaliel.benitez@imss.gob.mx
Corresponding author at: Av. Salvador Díaz Mirón s/n, esq. Plan de San Luís, Col.: Casco de Santo Tomás Miguel Hidalgo, C.P. 11340 Ciudad de México, D.F., Mexico. Tel.: +52 57 29 63 00 ext. 62811.
Corresponding author at: Av. Salvador Díaz Mirón s/n, esq. Plan de San Luís, Col.: Casco de Santo Tomás Miguel Hidalgo, C.P. 11340 Ciudad de México, D.F., Mexico. Tel.: +52 57 29 63 00 ext. 62811.
a Departamento de Laboratorio de Morfología Celular, Escuela Superior de Medicina, Instituto Politécnico Nacional, México D.F., Mexico
b Servicio de Ortopedia, Hospital General de Puebla, Secretaria de Salud del estado de Puebla, Puebla, Puebla, Mexico
c Departamento de Laboratorio de Medicina Regenerativa y Cáncer, Escuela Superior de Medicina, Instituto Politécnico Nacional, México D.F., Mexico
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Salvador Díaz Mirón s/n, esq. Plan de San Luís, Col.: Casco de Santo Tomás Miguel Hidalgo, C.P. 11340 Ciudad de México, D.F., Mexico. Tel.: +52 57 29 63 00 ext. 62811." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Células troncales mesenquimales autólogas e injerto cutáneo autólogo para tratamiento de una úlcera crónica secundaria a diabetes mellitus tipo 2" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 997 "Ancho" => 744 "Tamanyo" => 94438 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Application of autologous graft and autologous mesenchymal cells.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Diabetes mellitus type 2 has become a global problem. It is estimated that in the year 2030 a 70% concentration of patients with this disease will live in developing countries, and Mexico will Rank sixth or seventh in the international league.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> If we take into consideration current trends and behaviour patterns of diabetes mellitus type 2 patients, the long-term complications of this disease, which include nephropathy, retinopathy, peripheral vascular disease and neuropathy pose a real challenge to the medical profession due to their complexity.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2,3</span></a> It is estimated that 15–25% of diabetes mellitus type 2 patients will develop a chronic ulcer during their lifetime, and this population is also 10–20 times more likely to undergo non-traumatic amputation of a limb, compared with the population which does not present with this pathology.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4–9</span></a> The social impact of this type of lesion must be considered, since the average duration of an ulcer is between 12 and 13 months; nearly 70% of patients who have had an ulcer will present with at least one other ulcer during their lifetime, with a consequential estimated loss of 2 million working days from inability to work.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> In 2010 alone it was estimated that Mexico spent 778,427,475 US dollars on DM2 medical attention<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">11–17</span></a> (US$343,226,541 on direct costs and US$435,200,934 on indirect costs),<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> and nearly 33% of direct care costs of diabetes mellitus type 2<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">11–17</span></a> was spent on treating chronic ulcers.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">One of the problems we encounter on treating this type of lesion is the low probability of success, since under the best conditions only 50% of all cases remit, and for the other 50% of patients the ulcers are one of the main reasons for amputation, with an estimated one-year survival for 70% of patients and five years for 20%.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> Regarding the organic characteristics leading to the ulcers, including insufficient tissue perfusion from microvasculature damage,<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2,3</span></a> treatment based on cells or their products (cell therapy) has recently been proposed to improve microvasculature repair mechanisms and stimulate re-epithelisation.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a> These new alternatives propose a treatment based on mesenchymal stem cells, on the premise that these cells produce modulators which affect both the inflammatory response and growth factors for tissue regeneration.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">11,22</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Mesenchymal stem cells are formed during embryonic life in the mesoderm, giving rise to connective tissue, bone, muscle and cartilage. Once the embryo has formed stem cells reserves remain almost throughout the whole body and they may be identified, as may their function, through the use of specific cell markers. These cells have been identified in bone marrow, the umbilical cord, fatty tissue and placenta tissue. Clinically they may be used in ulcers of diverse aetiology, with the exception of neoplastic ulcers.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this paper is to share our recorded experience with autologous mesenchymal stem cells as treatment for a patient with a chronic ulcer secondary to diabetes mellitus type 2.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">11–17</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Clinical case</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 67 year old man with a 15 year history of diabetes mellitus type 2 was assessed by the Orthopaedic Unit in the Hospital General de Puebla for a chronic ulcer (of one-year duration) in the right pelvic limb, which had spread from the inner side of the foot on the sole, involving the first and second toes, up the inner side of the leg to its middle third. Culture testing of the lesion revealed <span class="elsevierStyleItalic">Staphylococcus</span> sp. and <span class="elsevierStyleItalic">Escherichia coli.</span> Given the conditions of the ulcer and the fact that this was a multi-treated patient, therapeutic amputation or the use of mesenchymal stem cells with autologous skin graft was indicated. Subsequent to describing the procedures, the risks and probabilities of both improvements from both procedures, the patient chose mesenchymal stem cells and autologous skin graft and gave his written consent to the same.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The first step consisted in keeping the patient hospitalised whilst the infection was controlled using third generation cephalosporins; an initial debridement was performed, in addition to the amputation of the first and second toes. Four further surgical interventions were performed (with 15 day spacing between each one). During the first surgical intervention scarification of the injury was made and puncture of the spinae for the obtainment of 60<span class="elsevierStyleHsp" style=""></span>ml of bone marrow; citrate phosphate dextrose was used to prevent coagulation of the specimen and for cell maintenance; the specimen was then submitted for processing in the Laboratorio de Medicina Regenerativa in coordination with the Laboratorio de Morfología de la Escuela Superior de Medicina del Instituto Politécnico Nacional to obtain and cultivate the mesenchymal stem cells for 30 days.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Mesenchymal stem cell isolation</span><p id="par0035" class="elsevierStylePara elsevierViewall">The mesenchymal stem cells were obtained by bone marrow aspiration of the ileum using a 60<span class="elsevierStyleHsp" style=""></span>ml syringe with citrate phosphate dextrose as the anti-coagulant. The aspired material was diluted in a sterile medium of 1:2 parts with a solution of sterile PBS1× and centrifuged at a density gradient of NycoPrepTM 1.077<span class="elsevierStyleHsp" style=""></span>g/ml, for 30<span class="elsevierStyleHsp" style=""></span>min at 1500<span class="elsevierStyleHsp" style=""></span>rpm. Mononuclear cells were separated from the interface and were washed on 2 occasions with PBS1× solution, centrifuged for 10<span class="elsevierStyleHsp" style=""></span>min at 2000<span class="elsevierStyleHsp" style=""></span>rpm and seeded into 25<span class="elsevierStyleHsp" style=""></span>cm (CORNING) Petri dishes with 5<span class="elsevierStyleHsp" style=""></span>ml of poietics human mesenchymal stem cells medium, at 37<span class="elsevierStyleHsp" style=""></span>°C and 5% of CO<span class="elsevierStyleInf">2</span>; this was supplemented with 1× antibiotic–antimicotic. After 3 days it was washed with the 1× citrate phosphate dextrose solution to remove non adherent cells and a fresh medium was added.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Once a cellular confluence of 70–80% had been obtained, the adherent cells were detached using an EDTA trypsin solution (0.025%, GIBCO) and incubated for 10<span class="elsevierStyleHsp" style=""></span>min at 37<span class="elsevierStyleHsp" style=""></span>°C. The cells were washed with PBS and seeded into a 2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>103<span class="elsevierStyleHsp" style=""></span>cell/ml solution in 100<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm (CORNING) Petri dishes now with 10<span class="elsevierStyleHsp" style=""></span>ml of DMEM/F-12 and an addition of 10% SFB and antibiotics. These cells were reseeded up to three times for assessment of membrane markers by flow cytometry; their plasticity/cellular differentiation to osteoblasts and adipocytes was also assessed.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Characterisation of the mesenchymal stem cells was performed by assessing the surface markers (anti-CD73, anti-CD90 anti-CD105, anti-CD14, anti-HLA-DR, anti-CD13 and anti-CD45) by flow cytometry. The results obtained showed that new cells expressed high levels of CD73, CD90, CD105 and CD13. However, they did not express haematopoietic markers such as CD45, CD14 and HLA-DR.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Cellular plasticity was assessed whilst cultivating the cells in the presence of specific differentiating media including: <span class="elsevierStyleItalic">StemPro Adipocyte Differentiation Basal Medium and StemPro Ostecyte/Chondrocyte Differentiation Basal Medium</span> (GIBCO) for 15 days. The results obtained indicated that our cells are able to differentiate themselves from both adipocytes and osteoblasts.</p><p id="par0055" class="elsevierStylePara elsevierViewall">During the second and third surgical intervention surgical cleaning of the site was carried out, and during the fourth intervention the autologous mesenchymal stem cells were placed on a clean site suspended in platelet-rich plasma, with a distribution of 1 million cells per cm<span class="elsevierStyleSup">2</span>, after which an autologous cutaneous graft of 15<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cm (mesh) taken from the ipsilateral thigh was inserted. The graft was covered with vaseline-covered gauzes and 500<span class="elsevierStyleHsp" style=""></span>mg ciprofloxacin was administered for 2 weeks. The patient was assessed on a weekly basis, with the total integration of the graft being documented 2 weeks later; 6 months later the patient was able to put weight on the limb, and after a year he continued to be complication free. The patient's evolution is shown in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1–4</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">It is of note that the preparation of autologous mesenchymal stem cells from bone marrow was carried out in the Laboratorio de Medicina Regenerativa y Cáncer in coordination with the Laboratorio de Morfología, both from the Escuela Superior de Medicina del Instituto Politécnico Nacional, complying with criteria established by the Sociedad Internacional de Terapia Celular (ISCT), which includes verification of identity by flow cytometry expressing main (positive) markers CD105, CD73, CD90 and not expressing mainly (negative) CD45, CD34, HLA-DR<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> ones, in addition to trypan blue verification of cellular viability at 95% and confirming the presence of a bacteria-free solution through a culture, and with the verification of the cellular morphology under a simple microscope. Moreover, as a control measure, an aliquot of the autologous mesenchymal stem cells was taken from the wound, which were later recovered, sown and multiplied again in the laboratorio de Medicina Regenerativa y Cáncer of the Instituto Politécnico Nacional, with confirmation of their biological characteristics (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Diabetes mellitus type 2<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">11–17</span></a> and its complications is a major financial drain on global health systems, and Mexico is no exception. It will rank high among countries in 2030 and economic pressure for care resulting from this disease is increasing disproportionately.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8,19</span></a> Chronic ulcers are one of the main complications, and are one of the main causes of amputation due to complex management and treatment.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">6–10,18–20</span></a> During the last 3 decades the rise in cellular therapies has enabled other therapeutic options to become available, thus changing this scenario to such an extent that they are now considered to be better cost-effective options,<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">13,14</span></a> and are now included in international ulcer management guidelines such as those from Sociedad de Atención de Heridas,<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">15–17</span></a> and those of several hospital protocols, such as the Mount Sinai Hospital in New York.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Mesenchymal stem cells have been successfully used with this type of lesion due to their ability to regulate inflammatory processes and regenerate tissue through factors such as interleukin-10 and interleukin-4, in addition stimulating new vessel growth by vascular growth factor, growth factor derived from platelets, recruiting of keratinocytes, markings for the migration of native stem cells and finally remodelling of the wound through regulation of keratinocytes and the presence of growth factor β and metaloproteinases,<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> key elements for tissue regeneration.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The transdisciplinary approach enabled this patient to preserve his limb. Correct disease management by the medical and surgical team from the orthopaedic Unit of the Hospital General de Puebla to control infection and clean the site, together with the obtainment of autologous mesenchymal stem cells from the Laboratorio de Medicina Regenerativa y Cáncer, in coordination with the Laboratorio de Morfología, both from the Escuela Superior de Medicina of the Instituto Politécnico Nacional with the highest quality characteristics, enabled acceptance of the graft by the patient and the ulcer wound bed to be covered. Under other conditions the limb would have been amputated. The existence of strong cooperation between the transdisciplinary team was key in this regard, since if one person does not appropriately carry out his or her role the success of treatment may be compromised.</p><p id="par0080" class="elsevierStylePara elsevierViewall">This type of transdisciplinary approach has enabled patients to be treated in a non conventional therapeutic manner, offering them an alternative option to amputation.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conclusion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The use of a cell-based therapy – and in this particular case mesenchymal stem cells – is a global reality with benefits for both patients and health care systems. The use of these techniques is feasible in our area and its impact on the population affected by this type of disease would be high, with subsequent improvement in quality of life and lower health care expenditure.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflict of interests</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres591730" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec607290" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres591729" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Caso clínico" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec607289" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Clinical case" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Mesenchymal stem cell isolation" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 9 => array:2 [ "identificador" => "xack199031" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-03-12" "fechaAceptado" => "2014-10-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec607290" "palabras" => array:3 [ 0 => "Mesenchymal stem cells" 1 => "Chronic ulcer" 2 => "Type 2 diabetes mellitus" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec607289" "palabras" => array:3 [ 0 => "Células troncales mesenquimales" 1 => "Úlcera crónica" 2 => "Diabetes mellitus tipo 2" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diabetes mellitus 2 has become a global problem. It is estimated that 15–25% of patients could develop a chronic ulcer in their life, and nearly 33% of direct care costs of the diabetes mellitus 2 is spent on treating these ulcers. Mesenchymal stem cells have emerged as a promising cell source for the treatment of these ulcers.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical case</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The case is presented of a 67 year-old male with a history of diabetes mellitus, acute myocardial infarction, and chronic ulcer involving right foot and part of his leg. He was treated with mesenchymal stem cell management, resulting in skin graft integration and full coverage of the lesion.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The implementation of mesenchymal stem cell techniques for treatment of chronic ulcer is feasible. The impact on the population would lead to a significant improvement in their quality of life and reduce healthcare spending.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Antecedentes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La diabetes mellitus tipo 2 se ha convertido en un problema a nivel mundial. Se estima que del 15 al 25% de los pacientes desarrollarán una úlcera crónica a lo largo de su vida, y cerca del 33% de los costos directos de atención a diabetes mellitus tipo 2 se gasta en la atención de estas úlceras. Las células troncales mesenquimales han surgido como una fuente celular prometedora para el tratamiento de este tipo de úlceras.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Caso clínico</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Masculino de 67 años con antecedentes de diabetes mellitus tipo 2, infarto agudo de miocardio y úlcera crónica en miembro inferior derecho que involucra la cara interna del pie y parte de la pierna derecha; se le trató con células troncales mesenquimales, resultando una adecuada integración del injerto de piel y la cobertura total de la lesión.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusión</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La implementación de células troncales mesenquimales para el tratamiento de la úlcera crónica es factible. El impacto en la población sería importante, al mejorar la calidad de vida de los pacientes y disminuir los costos de atención.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Caso clínico" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Benítez-Arvízu G, Palma-Lara Í, Vazquez-Campos R, Sesma-Villalpando RA, Parra-Barrera A, Gutiérrez-Iglesias G. Células troncales mesenquimales autólogas e injerto cutáneo autólogo para tratamiento de una úlcera crónica secundaria a diabetes mellitus tipo 2. Cir Cir. 2015;83:532–536.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 996 "Ancho" => 750 "Tamanyo" => 91420 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Wound area involved.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 997 "Ancho" => 744 "Tamanyo" => 94438 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Application of autologous graft and autologous mesenchymal cells.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 774 "Ancho" => 750 "Tamanyo" => 88420 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient assessments after 7 days.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 982 "Ancho" => 750 "Tamanyo" => 95463 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patient after 3 months.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 795 "Ancho" => 750 "Tamanyo" => 56997 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Light microscope of mesenchymal cells obtained from the patient.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global estimates of the prevalence of diabetes for 2010 and 2030" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.E. 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Dr. Gerardo Rayón Nieva for his invaluable collaboration.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/24440507/0000008300000006/v1_201512240036/S2444050715001370/v1_201512240036/en/main.assets" "Apartado" => array:4 [ "identificador" => "44602" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Clinical Cases" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24440507/0000008300000006/v1_201512240036/S2444050715001370/v1_201512240036/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444050715001370?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 11 | 4 | 15 |
| 2024 September | 26 | 10 | 36 |
| 2024 August | 33 | 7 | 40 |
| 2024 July | 22 | 3 | 25 |
| 2024 June | 23 | 7 | 30 |
| 2024 May | 19 | 3 | 22 |
| 2024 April | 24 | 12 | 36 |
| 2024 March | 31 | 7 | 38 |
| 2024 February | 16 | 7 | 23 |
| 2024 January | 40 | 5 | 45 |
| 2023 December | 39 | 13 | 52 |
| 2023 November | 26 | 7 | 33 |
| 2023 October | 31 | 3 | 34 |
| 2023 September | 16 | 9 | 25 |
| 2023 August | 19 | 7 | 26 |
| 2023 July | 15 | 6 | 21 |
| 2023 June | 27 | 5 | 32 |
| 2023 May | 64 | 7 | 71 |
| 2023 April | 65 | 7 | 72 |
| 2023 March | 48 | 5 | 53 |
| 2023 February | 22 | 6 | 28 |
| 2023 January | 30 | 3 | 33 |
| 2022 December | 17 | 9 | 26 |
| 2022 November | 40 | 15 | 55 |
| 2022 October | 23 | 10 | 33 |
| 2022 September | 23 | 20 | 43 |
| 2022 August | 26 | 10 | 36 |
| 2022 July | 21 | 7 | 28 |
| 2022 June | 30 | 13 | 43 |
| 2022 May | 23 | 8 | 31 |
| 2022 April | 21 | 6 | 27 |
| 2022 March | 52 | 12 | 64 |
| 2022 February | 26 | 6 | 32 |
| 2022 January | 72 | 9 | 81 |
| 2021 December | 45 | 8 | 53 |
| 2021 November | 32 | 10 | 42 |
| 2021 October | 28 | 10 | 38 |
| 2021 September | 35 | 11 | 46 |
| 2021 August | 23 | 12 | 35 |
| 2021 July | 12 | 15 | 27 |
| 2021 June | 18 | 9 | 27 |
| 2021 May | 22 | 6 | 28 |
| 2021 April | 30 | 18 | 48 |
| 2021 March | 20 | 12 | 32 |
| 2021 February | 14 | 6 | 20 |
| 2021 January | 14 | 14 | 28 |
| 2020 December | 23 | 10 | 33 |
| 2020 November | 19 | 10 | 29 |
| 2020 October | 17 | 11 | 28 |
| 2020 September | 20 | 9 | 29 |
| 2020 August | 16 | 6 | 22 |
| 2020 July | 12 | 9 | 21 |
| 2020 June | 17 | 10 | 27 |
| 2020 May | 15 | 9 | 24 |
| 2020 April | 13 | 4 | 17 |
| 2020 March | 19 | 2 | 21 |
| 2020 February | 27 | 12 | 39 |
| 2020 January | 16 | 5 | 21 |
| 2019 December | 23 | 12 | 35 |
| 2019 November | 15 | 8 | 23 |
| 2019 October | 16 | 4 | 20 |
| 2019 September | 25 | 3 | 28 |
| 2019 August | 26 | 3 | 29 |
| 2019 July | 26 | 16 | 42 |
| 2019 June | 58 | 9 | 67 |
| 2019 May | 117 | 14 | 131 |
| 2019 April | 52 | 18 | 70 |
| 2019 March | 27 | 6 | 33 |
| 2019 February | 24 | 9 | 33 |
| 2019 January | 23 | 8 | 31 |
| 2018 December | 23 | 3 | 26 |
| 2018 November | 20 | 4 | 24 |
| 2018 October | 29 | 13 | 42 |
| 2018 September | 17 | 6 | 23 |
| 2018 August | 13 | 16 | 29 |
| 2018 July | 14 | 7 | 21 |
| 2018 June | 22 | 5 | 27 |
| 2018 May | 12 | 9 | 21 |
| 2018 April | 10 | 10 | 20 |
| 2018 March | 18 | 3 | 21 |
| 2018 February | 18 | 1 | 19 |
| 2018 January | 10 | 1 | 11 |
| 2017 December | 18 | 1 | 19 |
| 2017 November | 22 | 2 | 24 |
| 2017 October | 20 | 3 | 23 |
| 2017 September | 16 | 5 | 21 |
| 2017 August | 9 | 8 | 17 |
| 2017 July | 11 | 2 | 13 |
| 2017 June | 18 | 1 | 19 |
| 2017 May | 16 | 2 | 18 |
| 2017 April | 15 | 19 | 34 |
| 2017 March | 7 | 73 | 80 |
| 2017 February | 15 | 2 | 17 |
| 2017 January | 8 | 0 | 8 |
| 2016 December | 22 | 3 | 25 |
| 2016 November | 30 | 6 | 36 |
| 2016 October | 32 | 12 | 44 |
| 2016 September | 32 | 7 | 39 |
| 2016 August | 43 | 4 | 47 |
| 2016 July | 23 | 4 | 27 |
| 2016 June | 40 | 10 | 50 |
| 2016 May | 29 | 15 | 44 |
| 2016 April | 32 | 11 | 43 |
| 2016 March | 37 | 17 | 54 |
| 2016 February | 43 | 28 | 71 |
| 2016 January | 37 | 23 | 60 |
| 2015 December | 9 | 6 | 15 |
Show all