Validation on the simplified medication adherence questionnaire (SMAQ) in renal transplant patients on tacrolimus.

BACKGROUND: Non-adherence to immunosuppressive medication is associated with graft loss and death. The simplified medication adherence questionnaire (SMAQ) is a short and reliable instrument for assessing adherence to medication. OBJECTIVE: Validation of a version of the SMAQ instrument adapted for use in transplant patients in a sample of kidney graft recipients. METHODS: Observational, longitudinal prospective study in 150 renal transplant patients on tacrolimus, over 18 years old, who had received a graft at least one year before. Basic sociodemographic and clinical data were recorded; patients completed the SMAQ twice (administered by doctor/nurse) and self-administered the Morisky-Green scale. The analysis database included 144 patients that met selection criteria and that provided the required data. Descriptive characteristics for all recorded parameters and psychometric characteristics of the questionnaire (reliability and validity) were studied. RESULTS: Mean age in the sample was 50.63 (12.44) years, 60.42% were men. Some 20.14% of patients had sub-target tacrolimus levels (<5 ng/ml), and unjustified variations in immunosuppressive drug levels were reported for 13.48%. Regarding SMAQ results, 39.01%/41.84% of patients were non-adherent (doctor/nurse administration); 22.38% according to the Morisky-Green scale. Interobserver agreement (kappa) was 0.821 (P<.001). The Cramer's-V statistic for convergent validity was 0.516 (P<.001). SMAQ scores were associated with unjustified variations in tacrolimus levels. In the prediction of tacrolimus levels (target vs subtarget), SMAQ compared to Morisky-Green provided a better classification of patients, with greater sensitivity and lower specificity. CONCLUSION: The questionnaire provides good levels of validity and interobserver agreement. An enhanced sensitivity is advantageous to better detect non-adherent patients for a better follow-up.

First cases of microsporidiosis in transplant recipients in Spain and review of the literature.

Microsporidia are currently considered emerging pathogens responsible for life-threatening infections in organ transplant recipients. Here, we describe the first cases of intestinal microsporidiosis by Enterocytozoon bieneusi genotype D in two non-HIV-infected renal transplant recipients from Spain. Previously reported cases of microsporidiosis in organ transplant recipients have also been reviewed, highlighting the necessity of considering organ transplant recipients a risk group for microsporidiosis. A systematic search for these parasites is recommended in cases of persistent diarrhea and in the differential diagnosis of other syndromes, such as chronic fever of unknown etiology.

[Severe acquired aplastic anemia: historical outcome of patients treated by allogeneic bone marrow transplantation from matched sibling donors. A study by the Spanish Group for Bone Marrow Transplantation in Children (GETMON)]. / Aplasia medular grave adquirida: evolución histórica de los resultados obtenidos con trasplante de progenitores hematopoyéticos de donante familiar. Estudio del Grupo Español para el Trasplante de Médula Osea en Niños (GETMON).

INTRODUCTION: Allogeneic haematopoietic stem-cell transplantation is the treatment of choice for acquired aplastic anaemia in children. Experience with this approach from Spanish Working Party for Bone Marrow Transplantation in Children in two sequential time periods (1982-1990 and 1991-2004) is reported. PATIENTS AND METHODS: Sixty two consecutive patients with a median age of 10 years were transplanted; 18 in the 1982-1990 period and 44 in the 1991-2004 period. Conditioning regimen consisted mainly of irradiation and cyclophosphamide in the first period (72 % of patients) and cyclophosphamide +/- anti-thymocyte globulin (62 %) in the second. Graft versus host disease prophylaxis consisted of cyclosporine in most patients (57/62). RESULTS: Fifty one patients are alive and disease-free at a median follow-up of 127 months. Five years probability of event-free survival is 82 %. The survival increased from 61 % to 91 % during the two time periods. Eleven patients died from graft failure or rejection (3), acute or chronic graft versus host disease and infection (4) or multi-organ failure (4). Univariate analysis identified two significant prognostic factors: interval diagnostic/transplant and time period of transplant (for both p = 0.03). CONCLUSIONS: This experience corroborates that allogeneic haematopoietic stem-cell transplantation is the best treatment for severe acquired aplastic anaemia, with a current disease-free survival of 90 % of patients.

Pharmacologic restoration of the early insulin response in pre-diabetic monkeys controls mealtime glucose excursions without peripheral hyperinsulinaemia.

AIMS/HYPOTHESIS: This study sought first to compare the pharmacodynamics and pharmocokinetics of two rapid-onset, rapidly-reversible insulinotropic agents, nateglinide and repaglinide, in pre-diabetic Cynomolgus monkeys and second to use these agents to assess the metabolic effects of early insulin secretion on prandial glucose control. METHODS: First, equipotent doses of nateglinide (20 mg/kg) and repaglinide (0.1 mg/kg) or vehicle were given intragastrically to overnight-fasted ketamine-anesthetized pre-diabetic Cynomolgus monkeys and samples were obtained for measurement of plasma glucose, insulin, glucagon, NEFA and drug concentrations. Second, nateglinide, repaglinide or vehicle were administered 10 min before a glucose-supplemented liquid meal and prandial glucose and insulin profiles were compared. RESULTS: Although oral administration of nateglinide and repaglinide elicited similar maximum increments of plasma insulin (+403 and +448 pmol/l, respectively), the effects of nateglinide were more rapidly manifest and less prolonged. With nateglinide, insulin increased within 10 min and returned to baseline within 50 min. After repaglinide, the first increase occurred at 30 min and insulin concentrations remained increased for 3.5 h post-dose. When given 10 min before a meal, nateglinide increased early, but not total insulin release (AUC(0-210)=108 vs 150 nmol/l min for nateglinide and vehicle, respectively) and reduced prandial glucose excursions by 78%. Repaglinide increased total insulin release (AUC(0-210)=298 nmol/l min) and reduced glucose excursions by 53%. CONCLUSION/INTERPRETATION: Nateglinide is more rapid-acting and rapidly-reversible than is repaglinide. By restoring a more physiologic insulin profile, nateglinide is more effective than repaglinide in controlling prandial glucose excursions with less hyperinsulinaemia.

[Atypical cytomegalovirus in renal transplantation: a new form of presentation]. / Citomegalovirus atípico en el trasplante renal: una nueva forma de presentación.

Infection due to cytomegalovirus (CMV) is the most frequent opportunistic infection following renal transplantation (RT). It is usually asymptomatic. Cytomegalovirus disease causes fever leucopenia, thrombocytopenia and slightly elevated transaminases. The development of severe invasive forms is uncommon nowadays with post-transplantation monitoring, prophylactic regimens in high-risk patients and early treatment with ganciclovir. We report two renal transplant recipients who presented with severe gastrointestinal bleeding as the first manifestation of CMV disease at 9 and 14 weeks after transplantation. In both patients repeated post-transplantation pp65 antigenemia monitoring was negative. One patient developed hypovolemic shock due to severe rectal bleeding; an atypical bleeding ulcer was detected in the ileocecal valve. The other patient presented with upper gastrointestinal hemorrhage from a bleeding duodenal ulcer. Histological and immunohistochemical study confirmed the diagnosis. Both patients were elderly and on triple therapy with tacrolimus, mycophenolate and prednisone. We discuss the role of mycophenolate and the new immunosuppressant agents as factors favoring a state of enhanced immunosuppression, which may facilitate the onset of severe atypical forms of CMV disease.

[Prevalence and risk factors for pressure ulcers]. / Prevalencia y factores de riesgo de úlceras por presión.

OBJECTIVES: To study prevalence of pressure ulcers among functionally impaired patients in the community and evaluate risk factors associated with the development of pressure ulcers in these patients.Design. Cross-sectional, observational study. SETTING: Community dwellers served by the Primary Health Care Area of Rincón de la Victoria in Málaga.Participants. All patients included in the <> (n=178). METHODS: A questionnaire was developed to ascertain demographic and health characteristics. Risk factors were evaluated with the Modified Norton Scale. The outcome variable of interest was presence or absence of pressure ulcers, their location and grade. The denominator used for the calculation of the prevalence was the total of evaluated patients. Results. Prevalence of pressure ulcers in our Basic Health Area was 12.9%. The most important sociodemographic characteristic associated with the presence of pressure ulcers in these patients was the educational attainment of the caregiver. Health varaibles of the patient were also associated with the risk of developing ulcers. CONCLUSIONS: Results indicate the need of diagnostic protocols with standardised instruments and prevention plans to reduce pressure ulcers in the community. Longitudinal studies are needed to evaluate interventions in this area.

Prevalencia y factores de riesgo de úlceras por presión / Prevalence and risk factors for pressure ulcers

Objetivo. Conocer la prevalencia de úlceras por presión (UPP) en pacientes incapacitados de una Zona Básica de Salud (ZBS) y caracterizar los factores de riesgo asociados a su aparición. Diseño. Estudio transversal observacional. Emplazamiento. ZBS Rincón de la Victoria (Málaga). Participantes. Pacientes incluidos en el Programa de Incapacitados (n = 178), de la ZBS, residentes en su domicilio o en una residencia geriátrica. Mediciones. Cuestionario específico con variables sociodemográficas y de salud. Para la valoración de factores de riesgo asociados con la formación de UPP, se utilizó la Escala de Norton Modificada (ENM). La variable resultado de interés fue la presencia o ausencia de UPP, localización y grado. El denominador para el cálculo de la prevalencia ha sido el total de pacientes valorados. Resultados. La prevalencia fue del 12,9 per cent. La característica sociodemográfica más significativa asociada con la presencia de úlceras en estos pacientes fue el nivel de instrucción del cuidador. Se constata asociación de determinadas variables del estado de salud del paciente con aparición de UPP. Conclusiones. Los resultados alertan a la necesidad de la realización de protocolos diagnósticos y de intervención comunitaria para reducir la presentación de UPP en pacientes incapacitados que viven en la comunidad (AU)

[Abdominal wall metastasis following surgical removal of colorectal carcinomas]. / Buikwandmetastasen na chirurgische verwijdering van colorectale carcinomen.

Abdominal wall metastases after laparoscopic resection of colorectal cancer have been reported by various authors. It appeared that abdominal wall metastases occur more frequently after laparoscopic than after conventional, open resection of colorectal cancer. However, the frequency of abdominal wall metastases after laparoscopic surgery varies from only 0 to 1.9% in centres with sufficient relevant experience, whereas after conventional resections the frequency is 0.8-3.3%. A randomized clinical study comparing laparoscopic with conventional resection of colon cancer is necessary to assess the optimal surgical approach to colon cancer. Such a trial has been set up.

Muscle subcellular localization and recruitment by insulin of glucose transporters and Na+-K+-ATPase subunits in transgenic mice overexpressing the GLUT4 glucose transporter.

Insulin-stimulated glucose uptake in skeletal muscle is mediated through the GLUT4 glucose transporter. Transgenic (TG) mice overexpressing human GLUT4 in skeletal muscle show an increased ability to handle a glucose load. Here, the participation of the overexpressed GLUT4 in the response to insulin was examined. In TG mouse muscle, the GLUT4 protein content was 10-fold higher in crude membrane (CM), sevenfold higher in internal membrane (IM), and 15-fold higher in a plasma membrane (PM)-rich fraction, relative to non-TG littermates. This suggested partial saturation of the normal sorting mechanisms. The distribution and abundance of the GLUT1 glucose transporter was not affected. Insulin injection (4.3 U/kg body wt) increased GLUT4 in the PM-rich fraction; the increase was threefold higher in TG than in non-TG mice. Insulin decreased the GLUT4 content of the IM in both animal groups and of a second, heavier intracellular membrane fraction only in TG mice. The net content of Na+-K+-pump subunits was 40-65% lower in CM from TG compared with non-TG littermates. In spite of this, insulin caused a three- to sixfold higher translocation of the alpha2 and beta1 subunits of the Na+-K+-pump in TG compared with non-TG animals. The results suggest that overexpression of GLUT4 confers to the muscle increased ability to translocate subunits of the Na+-K+-pump either as a direct consequence of the recruitment of glucose transporters or as an adaptation to the more demanding metabolic state.