Use of Peritoneovenous Shunt for the Management of Refractory Ascites.

BACKGROUND: Guidelines for the management of refractory ascites (RA) recommend transjugular intrahepatic portosystemic shunting (TIPS), diuretics, and paracentesis as the main strategies, discouraging use of surgical peritoneovenous shunts (PVSs). However, PVSs, including both Denver (DS) or saphenoperitoneal (SPS) modalities, may still have indications. Herein we report our experience with PVSs in the context of modern surgical and anesthetic management. METHODS: In our unit, PVSs are offered to patients with ascites refractory to diuretics in which TIPS are contraindicated. Heart function and spontaneous bacterial peritonitis must be assessed before surgical indication. RESULTS: Seven procedures were performed on 5 patients (6-DS, 1-SPS) in 2013. Their mean age was 61 (range, 54-68) years. In 3 patients, the indication was RA without options for liver transplant; 2 patients were on the waiting list for liver transplantation, which were performed to improve renal function and quality of life (QOL). The median hospital stay was 6.5 (range, 3-12) days. All patients were alive after 12 months. One patient died 2 years after the first DS and another later died due to liver insufficiency with patency of the DS. The ascites was well-controlled in 4 of 5 patients at up to 48 months of follow-up. Decreases in diuretics doses, proper weight maintenance, and a dramatic improvement in QOL (measured by a modified Ascites Symptom Inventory-7 [ASI-7] test) were observed after the procedures. CONCLUSION: PVSs are useful for the treatment of patients with RA who develop resistance to common therapies, leading to a major improvement in QOL. These surgical procedures should be included in the armamentarium of experienced liver surgeons.

Practical guidelines for diagnosing hypersensitivity reactions to nonsteroidal anti-inflammatory drugs.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the drugs most frequently involved in hypersensitivity reactions. These reactions include various clinical entities with different mechanisms leading to the release of inflammatory mediators. Characterization of patients based on clinical manifestations and suspected underlying mechanisms is critical for implementation of adequate diagnostic procedures and patient management. Our objectives were to prepare a systematic review of available scientific evidence and to provide general guidelines for the diagnosis and management of patients with hypersensitivity reactions to NSAIDs. We also propose a practical algorithm for the diagnosis of specific types of hypersensitivity to NSAIDs and provide recommendations for the management of hypersensitive patients.

Practical guidelines for diagnosing hypersensitivity reactions to nonsteroidal anti-inflammatory Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the drugs most frequently involved in hypersensitivity reactions. These reactions include various clinical entities with different mechanisms leading to the release of inflammatory mediators. Characterization of patients based on clinical manifestations and suspected underlying mechanisms is critical for implementation of adequate diagnostic procedures and patient management. Our objectives were to prepare a systematic review of available scientific evidence and to provide general guidelines for the diagnosis and management of patients with hypersensitivity reactions to NSAIDs. We also propose a practical algorithm for the diagnosis of specific types of hypersensitivity to NSAIDs and provide recommendations for the management of hypersensitive patients (AU)

Los antiinflamatorios no esteroideos (AINE) es el grupo farmacológico que más frecuentemente ha sido relacionado con las reacciones de hipersensibilidad. Estos cuadros incluyen entidades clínicas muy variadas, producidas por diferentes mecanismos, tanto inmunológicos como no inmunológicos. La caracterización de los pacientes que presentan estas reacciones se fundamenta, en las manifestaciones clínicas y la sospecha del mecanismo subyacente que la ha producido, lo que conduce a la puesta en práctica del procedimiento diagnóstico adecuado y la posterior orientación del paciente. El objetivo de este trabajo es elaborar una revisión sistemática, con las pruebas científicas disponibles, facilitando las directrices generales de diagnóstico y en consecuencia la actitud a tomar en este tipo de pacientes. Se propone un algoritmo práctico de diagnóstico para cada tipo específico de hipersensibilidad a AINE, así como proporcionar las recomendaciones a seguir en el manejo de los pacientes sensibilizados (AU)

Molecular differentiation of species of the genus Zungaro (Siluriformes, Pimelodidae) from the Amazon and Paraná-Paraguay River basins in Brazil.

Fish species of the Zungaro genus (Siluriformes, Pimelodidae) are amongst the largest migratory fish in Latin America and have considerable economic importance for commercial fishing in Brazil. However, natural populations of this large catfish are experiencing a severe decline. There are significant taxonomical inconsistencies for this fish. Two geographically separated species of the fish were initially described, one endemic in the Amazon and another in the Paraná-Paraguay River basins. A taxonomic review had recently proposed that there is only one Zungaro species in Brazil, based on morphological data. We made a molecular study of Zungaro populations in an attempt to solve taxonomical inconsistencies and to analyze genetic diversity in natural populations of this genus. We analyzed two regions of the mitochondrial DNA (the control region and the ATPase 6 gene region) of individuals sampled from the Paraná-Paraguay River and Amazon River basins. Analyses based on p-distances and maximum likelihood phylogenetic models showed a genetic difference between populations corresponding to different species. Genetic differentiation between Zungaro populations was at the same level as that observed between other Siluriformes species, using the same DNA sequences. We conclude that Zungaro species of the Paraná-Paraguay River basin do not belong to the same species found in the Amazon basin. This finding has a significant implication for conservation of this fish, given that populations are disappearing at a high rate in the Paraná-Paraguay River basin, mainly due to impoundments.

Temporal and spatial patterns of aquatic macrophyte diversity in the Upper Paraná River floodplain.

Although the importance of long-term data has been emphasized by ecologists in recent years, little is known about how communities may change over time. In this study, we describe the general patterns of aquatic macrophyte diversity in the Paraná River floodplain observed during six years of study. Temporal changes in community composition were also evaluated. Data on the presence or absence of aquatic macrophytes were collected between March 2002 and March 2008, in six lakes associated with three rivers. Different analytical strategies were used to evaluate the dynamics of aquatic macrophyte communities between the different systems in the floodplain. The composition of aquatic macrophytes differed among the rivers, mainly with respect to the different vegetation life forms (floating, submersed, emergent and rooted with floating stems). The temporal similarity of species composition during the six years and the beta-diversity index indicated that the month-to-month species turnover was, in general, lower in the connected lakes, which are directly influenced by the river. Probably the water level fluctuation is a selective force that contributes to maintaining diversity or richness. Our findings indicated the importance of abiotic characteristics and connectivity of the lakes in determining macrophyte composition and community stability over a long time frame.

Temporal and spatial patterns of aquatic macrophyte diversity in the Upper Paraná River floodplain / Padrões temporais e espaciais da diversidade de macrófitas aquáticas na planície de inundação do Alto Rio Paraná

Although the importance of long-term data has been emphasized by ecologists in recent years, little is known about how communities may change over time. In this study, we describe the general patterns of aquatic macrophyte diversity in the Paraná River floodplain observed during six years of study. Temporal changes in community composition were also evaluated. Data on the presence or absence of aquatic macrophytes were collected between March 2002 and March 2008, in six lakes associated with three rivers. Different analytical strategies were used to evaluate the dynamics of aquatic macrophyte communities between the different systems in the floodplain. The composition of aquatic macrophytes differed among the rivers, mainly with respect to the different vegetation life forms (floating, submersed, emergent and rooted with floating stems). The temporal similarity of species composition during the six years and the beta-diversity index indicated that the month-to-month species turnover was, in general, lower in the connected lakes, which are directly influenced by the river. Probably the water level fluctuation is a selective force that contributes to maintaining diversity or richness. Our findings indicated the importance of abiotic characteristics and connectivity of the lakes in determining macrophyte composition and community stability over a long time frame.

Estudos utilizando ampla escala temporal ainda são escassos na ecologia, mesmo considerando sua importância no estudo de comunidades. Esse trabalho teve como objetivo principal descrever padrões gerais sobre a diversidade de macrófitas aquáticas na planície de inundação do Alto Rio Paraná utilizando uma ampla escala temporal (seis anos de estudo). Mudanças na composição das comunidades ao longo do tempo também foram avaliadas. Dados de presença ou ausência de macrófitas foram obtidos entre Março de 2002 e Março de 2008 em seis lagoas associadas a três rios na planície de inundação. Diferentes técnicas foram utilizadas para avaliar a dinâmica das comunidades de macrófitas aquáticas entre os diferentes ambientes. De maneira geral, a composição das comunidades foi dissimilar entre os diferentes rios, principalmente considerando os diferentes grupos funcionais de macrófitas (flutuante livre, submersa, emergente e enraizada com folha flutuante). A similaridade temporal na composição de espécies e o índice de diversidade beta indicaram que a substituição de espécies ao longo dos meses foi, de maneira geral, menor nas lagoas conectadas ao rio principal. Provavelmente, a flutuação no nível da água representa uma pressão seletiva que ajuda a manter a diversidade de espécies nas lagoas diretamente influenciadas pelo rio. Os resultados desse estudo indicaram a importância das características abióticas e da conectividade das lagoas na composição e estabilidade temporal das comunidades de macrófitas aquáticas na planície de inundação do Alto Rio Paraná.

The study of aquatic macrophytes in Neotropics: a scientometrical view of the main trends and gaps / O estudo de macrófitas aquáticas na região neotropical: uma visão cienciométrica dos principais padrões e lacunas

Aquatic macrophytes comprises a diverse group of organisms including angiosperms, ferns, mosses, liverworts and some macroalgae that occur in seasonally or permanently wet environments. Among other implications, aquatic macrophytes are highly productive and with an important structuring role on aquatic environments. Ecological studies involving aquatic plants substantially increased in the last years. However, a precise view of researches devoted to aquatic macrophytes in Neotropics is necessary to reach a reliable evaluation of the scientific production. In the current study, we performed a scientometrics analysis of the scientific production devoted to Neotropical macrophytes in an attempt to find the main trends and gaps of researches concerning this group. The publication devoted to macrophytes in Neotropics increased conspicuously in the last two decades. Brazil, Argentina, Mexico and Chile were the most productive among Neotropical countries. Our analyses showed that the studies dealt mostly with the influences of aquatic macrophytes on organisms and abiotic features. Studies with a predictive approach or aiming to test ecological hypothesis are scarce. In addition, researches aiming to describe unknown species are still necessary. This is essential to support conservation efforts and to subsidize further investigations testing ecological hypotheses.

Macrófitas compreendem um diverso grupo de organismos macrofíticos, incluindo angiospermas, samambaias, musgos, hepáticas e algumas macroalgas que ocorrem em ambientes sazonalmente ou permanentemente inundados. Dentre outras implicações, as macrófitas aquáticas são altamente produtivas e com um importante papel na estruturação nos ambientes aquáticos. Estudos ecológicos envolvendo plantas aquáticas cresceram substancialmente nos últimos anos. Entretanto, uma visão precisa das pesquisas sobre macrófitas na região Neotropical é necessária para uma avaliação confiável da produção científica. No presente estudo, uma análise cienciométrica sobre macrófitas Neotropicais foi realizada com o intuito de identificar os principais padrões e lacunas nas pesquisas sobre esse grupo biológico. As publicações sobre macrófitas na região Neotropical cresceu conspicuamente nas últimas duas décadas. Brasil, Argentina, México e Chile foram os mais produtivos dentre os países Neotropicais. As análises mostraram que os estudos enfocaram principalmente as influências das macrófitas nos organismos e nas características abióticas. Estudos com uma abordagem preditiva ou testando hipóteses ecológicas são escassos. Adicionalmente, pesquisas com o objetivo de descrever espécies desconhecidas ainda são necessárias. Isso é essencial para subsidiar esforços de conservação e investigações futuras testando hipóteses ecológicas.

Acute generalized exanthematous pustulosis due to tetrazepam.

Tetrazepam is a benzodiazepine that is widely used in Spain as a muscle relaxant, with occasional cutaneous side effects. We report a patient who developed a generalized pruriginous cutaneous reaction compatible with acute generalized exanthematous pustulosis (AGEP) due to tetrazepam. Patch tests with bromazepam, diazepam, and tetrazepam were negative at 48 and 72 hours; however, the tetrazepam patch showed a positive reaction at 10 days. Immunohistochemical studies revealed a mononuclear infiltrate composed of CD4+ and CD8+ T lymphocytes. Analysis of interleukin (IL) 8 expression by quantitative polymerase chain reaction revealed increased IL-8 mRNA levels in patch test-positive skin. Lymphoblast transformation test (LTT) was positive with tetrazepam but not with diazepam. Positive patch test and LTT suggested that tetrazepam-specific lymphocytes might be responsible for a T cell-mediated reaction. These results support previous data suggesting an important role for IL-8 and drug-specific T cells in the pathogenesis ofAGEP and imply that the reaction was specific to tetrazepam with no cross-reactivity to other benzodiazepines.

[Keratoderma palmoplantaris varians (striata et areata), a form of chronic idiopathic acrokeratosis described by Degos]. / Queratodermia palmoplantar varians (striata et areata) tipo acroqueratosis esencial crónica de Degos.

We report a case of a 15-year-old boy with hyperkeratotic lesions that were linear or striated on the palms and nummular on the soles. He was the only family member known to be affected, suggesting that the condition could be attributed to a de novo mutation or the recessive form of keratoderma palmoplantaris striata, described by Degos as chronic idiopathic acrokeratosis. The lesions did not improve with topical treatments (keratolytic agents, emollients, or corticosteroids) or oral retinoids. We observed that scratching of the affected areas was the main reason for deterioration of the lesions.

Non-immediate reactions to beta-lactams: diagnostic value of skin testing and drug provocation test.

BACKGROUND: beta-Lactam (BL) antibiotics can induce non-immediate skin reactions, frequently manifested as exanthema or urticaria. The time between drug intake and the reaction appearance is generally 24-48 h. Because the mechanisms involved are not completely understood, diagnostic tests for these reactions have still to be fully validated. OBJECTIVE: To evaluate the role of skin and drug provocation tests (DPTs) in the diagnosis of patients with non-immediate reactions to BL. METHODS: We evaluated a group of 22 patients who developed maculopapular exanthema or urticarial exanthema after BL intake. Diagnosis was confirmed by DPT with BL. Intradermal/patch testing was performed with benzylpenicilloyl, minor determinant mixture, amoxicillin (AX), ampicillin (AMP) and the culprit drug in patients and in 22 negative controls. Immunohistochemical studies were done in the affected skin at the acute phase of the reaction and after a delayed positive skin test/DPT. IFN-gamma and IL-4 were quantified in peripheral mononuclear cells, obtained during the positive response to DPT and after resolution of the symptoms. RESULTS: From the total number of cases, 12 patients developed urticarial exanthema and 10 maculopapular exanthema after DPT. Only two of the 22 patients (9%) had a positive delayed intradermal skin test: one to AX/AMP and the other to cloxacillin. Biopsies showed a mononuclear CD4, CD8 infiltrate and activated and memory cells. The cytokine expression showed a Th1 pattern in patients, in contrast with the Th0 pattern in controls. CONCLUSION: In patients with non-immediate reactions to BLs (maculopapular exathema or urticarial exanthema), the sensitivity of skin testing is low and DPT may be required to establish the diagnosis. The reproducibility of the reactions and the cytokine pattern expressed during the acute episode support a T cell-induced non-immediate response.

Queratodermia palmoplantar varians (striata et areata) tipo acroqueratosis esencial crónica de Degos / Keratoderma palmoplantaris varians (Striata et Areata), a form of chronic idiopathic described by Degos

Paciente varón de 15 años de edad con lesiones hiperqueratósicas con disposición lineal o estriada en las palmas y numular en plantas. Era el único miembro afecto conocido de su familia, por lo que se podría tratar de una mutación de novo o de la forma recesiva de queratosis palmoplantar estriata varians, denominada por Degos «acroqueratosis esencial crónica». Las lesiones no mejoraron con los tratamientos tópicos instaurados (queratolíticos, emolientes y corticoides) ni con retinoides orales. Se pudo constatar que el rozamiento o fricción de las zonas afectas era el principal factor de empeoramiento de las mismas (AU)

We report a case of a 15-year-old boy with hyperkeratotic lesions that were linear or striated on the palms and nummular on the soles. He was the only family member known to be affected, suggesting that the condition could be attributed to a de novo mutation or the recessive form of keratoderma palmoplantaris striata, described by Degos as chronic idiopathic acrokeratosis. The lesions did not improve with topical treatments (keratolytic agents, emollients, or corticosteroids) or oral retinoids. We observed that scratching of the affected areas was the main reason for deterioration of the lesions (AU)

The study of aquatic macrophytes in Neotropics: a scientometrical view of the main trends and gaps.

Aquatic macrophytes comprises a diverse group of organisms including angiosperms, ferns, mosses, liverworts and some macroalgae that occur in seasonally or permanently wet environments. Among other implications, aquatic macrophytes are highly productive and with an important structuring role on aquatic environments. Ecological studies involving aquatic plants substantially increased in the last years. However, a precise view of researches devoted to aquatic macrophytes in Neotropics is necessary to reach a reliable evaluation of the scientific production. In the current study, we performed a scientometrics analysis of the scientific production devoted to Neotropical macrophytes in an attempt to find the main trends and gaps of researches concerning this group. The publication devoted to macrophytes in Neotropics increased conspicuously in the last two decades. Brazil, Argentina, Mexico and Chile were the most productive among Neotropical countries. Our analyses showed that the studies dealt mostly with the influences of aquatic macrophytes on organisms and abiotic features. Studies with a predictive approach or aiming to test ecological hypothesis are scarce. In addition, researches aiming to describe unknown species are still necessary. This is essential to support conservation efforts and to subsidize further investigations testing ecological hypotheses.

Aspectos clínicos de la alergia alimentaria: patrones en alergia a alimentos durante los primeros años de vida / Clinical aspects of food allergy: food allergy patterns during the first years of life

No disponible

Up-regulation of CCL17, CCL22 and CCR4 in drug-induced maculopapular exanthema.

BACKGROUND: Maculopapular exanthema has been reported to be the most frequently drug-induced cutaneous reaction. Although T lymphocytes are involved in the pathomechanism of this disease, little is know about the recruitment of these cells to the skin. OBJECTIVE: The aim of this work is to study the role of the chemokines TARC/CCL17 and MDC/CCL22 in the lymphocyte trafficking to affected skin in drug-induced exanthemas. METHODS: Real-time PCR was performed to quantify gene expression levels of CCL17, CCL22 and their receptor CCR4 in lesional skin biopsies and in peripheral blood mononuclear cells from patients. CCL27 and CCL22 proteins were detected in the skin by immunochemistry. Protein expression of CCR4 was determined by flow cytometry in peripheral blood lymphocytes. Functional migration assays to CCL17 and CCL22 were assessed to compare the migratory responses of peripheral blood lymphocytes from patients and healthy subjects. RESULTS: CCL17 and CCL22 were up-regulated in maculopapular exanthema-affected skin. CCR4 mRNA levels and protein expression were increased in peripheral blood mononuclear cells during the acute phase of the disease. The increased expression of the receptor was consistent with a higher response of peripheral blood lymphocytes to CCL17 and CCL22 compared with the migratory response in healthy donors. CONCLUSION: TARC/CCL17 and MDC/CCL22 might cooperate in attracting T lymphocytes to skin in drug-induced maculopapular exanthemas.

Nonimmediate reactions to systemic corticosteroids suggest an immunological mechanism.

BACKGROUND: Administration of corticosteroids (CS) by different routes may cause varying types of allergic reactions, thereby hampering their further use in affected patients. In order to verify an immunological involvement we evaluated a group of patients with symptoms compatible with nonimmediate allergic reactions to CS. METHODS: Studies included patch and intradermal tests, immunohistochemical studies and controlled administration to reproduce the response. The cytokines interleukin (IL)-4, interferon (IFN)-gamma and tumor necrosis factor (TNF)-alpha were quantified in peripheral blood during the response. RESULTS: Of 32 subjects evaluated presenting nonimmediate urticaria or exanthema, 21 were finally considered positive after re-exposure. The drugs most frequently involved were betamethasone and dexamethasone. Fewer than half the patients responded to prednisolone whilst some responded to three or more CS. Hydrocortisone and deflazacort were well tolerated by all the patients. Subjects with a positive intradermal or patch test had a perivascular mononuclear cell infiltrate with the presence of CD4 and CD8 lymphocytes positive for CD45RO+ (memory) and CD69 (activation marker) cells. Monitoring peripheral blood during the acute response showed expression of IFN-gamma and TNF-alpha, with downregulation of IL-4. CONCLUSION: Adverse systemic responses to different CS are suggestive of a nonimmediate reaction. The symptoms elicited together with the immunlogical studies suggest a T-cell mediated response. The response to closely related CS was especially marked between betamethasone and dexamethasone, whereas hydrocortisone and deflazacort were well tolerated.

The diagnostic interpretation of basophil activation test in immediate allergic reactions to betalactams.

BACKGROUND: Basophil activation by allergens, including drugs, has been used to determine sensitivity and to study IgE recognition and cross-reactivity. OBJECTIVE: We sought to determine the sensitivity and specificity of a basophil activation test (Basotest) in patients with immediate allergic reactions to betalactams, with a later comparison between patients who were selective (those recognizing the culprit drug excluding benzylpenicillin (BP)) and cross-reactors (those recognizing several penicillin determinants including BP). METHODS: Basotest to different haptens was performed in 70 patients with immediate allergic reactions to betalactams, classified into three groups: (A) skin test positive independently of CAP/RAST immunoassay value, (B) skin test negative and CAP/RAST positive, and (C) skin test and CAP/RAST negative but drug provocation test positive. Basotest was carried out by flow cytometry following the manufacturer's instructions using different betalactam determinants and results expressed as a stimulation index. RESULTS: Of the 70 patients, 34 (48.6%) were positive to Basotest (sensitivity: 48.6%), 31 (44.3%) to CAP/RAST and 46 (65.7%) to either one or the other. Considering the different groups, Basotest was positive in 50.9% of patients in Group A, 60% in Group B and 14.3% in Group C. The specificity was 91.3%. Positivity to the haptens was 28.6% to amoxicillin (AX), 21.7% to BP, 20% to benzylpenicilloyl-poly-l-lysine, 12.5% to ampicillin and 2.2% to minor determinant mixture. In patients with cephalosporin reactions, Basotest to the culprit cephalosporin was positive in 77.7%. There were differences between the two reactor groups in the sensitivity of Basotest (selective to AX=50%, cross-reactors=28.6%; chi(2)=10.809, P=0.004) and in the CAP/RAST (selective to AX=28.6%, cross-reactors=61.9%; chi(2)=8.944, P=0.011). CONCLUSIONS: The sensitivity of Basotest is similar to immunoassays (CAP/RAST). Sensitivity is improved when used in combination. Although further studies are required, Basotest results for cephalosporin allergy seem very promising. This technique does not help differentiate between selective reactors and cross-reactors.

Skin test evaluation in nonimmediate allergic reactions to penicillins.

BACKGROUND: Nonimmediate reactions (NIR) to aminopenicillins (AP) are frequent. Although patch testing (PT) and intradermal testing (IT) are used for diagnosis, comparative results have never been adequately performed. We compared PT and IT in subjects with NIR to AP. METHODS: Twenty-one subjects with NIR to AP and positive IT were re-evaluated. Skin tests were performed with amoxicillin (AX) and ampicillin (AM) at different concentrations in petrolatum, 50, 25, and 5% w/w, for PT and in saline, 20, 2, and 0.2 mg/ml for both PT and IT. Skin biopsies from the site of the positive response were studied with haematoxylin-eosin and immunohistochemistry. RESULTS: In the re-evaluation, one case was IT and PT negative and was excluded; 20 were IT positive and 18 PT positive for both AX and AM. Decreasing concentrations of AP induced a reduction in positivity in both methods when diluted in saline, but not when mixed in petrolatum (PT only). With both PT and IT, immunohistochemical studies showed a perivascular mononuclear infiltrate with CD4 and CD8 memory cells expressing perforin and granzyme B. CONCLUSIONS: Both tests appear valuable for the diagnosis of NIR to AP. However, IT diagnosed more patients than PT. The vehicle (saline or petrolatum) had no influence on the response, although in the former the concentration was critical. The immunohistochemical analysis showed skin infiltrates compatible with a T-cell drug reaction.