New law of renal transplantation in Portugal associated with more acute rejection episodes and higher costs.

The new law implemented in August 2007 changed the criteria to select renal transplantation (RT) candidates in Portugal, favoring hyperimmunized subjects and those on the waiting list for a longer time, making human leukocyte antigen (HLA) compatibilities less important. The authors compared patients who received a deceased donor kidney between 2005 and 2010. Patients were divided in group A who underwent transplantation before August 2007 (n = 132) and group B (n = 125) after that date. We considered a value of P < .05. Overall mean age at RT was 46.6 ± 13.9 years with 58.8% men, 88% on hemodialysis (HD), with a mean dialysis time of 82.8 ± 119 months. Also, 10.5% of patients underwent a previous transplantation. The mean follow-up was 35 ± 17.1 months. Group B showed significant adverse differences, including dialysis time (50.9 vs. 117 months), length of hospitalization (14.4 vs. 23.2 days), need for HD (1 vs. 3.4 days), HLA match (3.3 vs. 1.4 compatibilities), previous sensitization (4.4% vs. 21.7%), acute rejection episodes in the 1st year (23% vs. 37%), greater use of immunosuppressive drugs, higher costs of induction therapy (2790 vs 4360ϵ), and greater costs of drugs during first hospitalization (3456 vs. 7144ϵ). Among the 16 subjects who lost their grafts, 7 were in group A (3 in the first year) and 9 in group B all in the first year. There was a 5.1% decrease in graft survival at 12 months (P = .07). Univariate analysis showed an association of acute rejection episodes with HLA mismatches, hyperimmunized patients, absence of immediate graft function, hospitalization time, longer HD need, and higher creatinine level at months 1, 2, 3, and 6. Multivariate analysis revealed acute rejection episodes to be associated with a lower number of HLA compatibilities (odds ratio = 0.65; 95% confidence interval, [0.46-0.9]). Application of the law has led to a greater number of acute rejection episodes in the first year and increased costs.

Upper limb tremor induced by peripheral nerve injury.

We report a patient with proximal right upper limb tremor, secondary to direct peripheral nerve lesion caused by prior thoracic surgery. Electromyography demonstrated neurogenic abnormalities and tremor in muscles innervated by the thoracodorsal and long thoracic nerves. Somatosensory evoked potentials, transcranial magnetic stimulation, and MRI of the cervical and thoracic spine were normal. Tremor persisted in REM and non-REM sleep. These findings suggest a peripheral generator.

[The factors triggering epileptic crises according to patients]. / Factores desencadeantes de crises epilépticas, de acordo com os doentes.

The authors were interested in knowing what epileptic patients think about seizure-inducing factors; whether they are convinced that their seizures are induced by any trigger factor and, if so, which factor it is. While mainly interested in the psychological reality of patients, data about objective factors could emerge from this study. An inquiry was made among the 1005 patients who attended the outpatient clinic for epilepsy of Santa Maria Hospital, Lisbon, during five months of 1994. Of the 308 that answered the inquiry, 147 could not recognise any inducing factor for their last seizure, while 144 mentioned such a factor (of the latter, some mentioned two or more factors acting together). Emotional factors were most often mentioned. Seventeen answers were discarded. In many instances, seizure-inducing factors are identified by the patients but difficult to objectivize by investigators, namely those of emotional type. Answers given by the patients might help doctors to provide patients with better care.

Sleep cycles and alpha-delta sleep in fibromyalgia syndrome.

OBJECTIVE: Fibromyalgia syndrome (FMS) is a musculoskeletal disorder characterized by generalized pain, localized tender points, chronic fatigue and nonrestorative sleep. Since sleep disturbances frequently occur in FMS and alpha intrusion in nonrapid eye movement (NREM) sleep probably associates with the nonrefreshing sleep, we prospectively studied the delta and alpha activity and alpha-delta ratio across sleep cycles, performing polysomnography in 10 patients with FMS and in 14 healthy control subjects. METHODS: Night long polysomnography recordings were performed in all subjects. Sleep scoring was done visually according to Rechtschaffen and Kales criteria. By means of spectral analysis the conventional electroencephalogram (EEG) frequency bands were automatically computed for the all night recordings. For alpha and delta power the integrated and normalized values were calculated for each sleep cycle, the evolution of these activities across successive sleep cycles was studied. RESULTS: Alpha-delta patterns occurred in almost all the patients who had also superficial and fragmented sleep with increased awakenings and reduced REM and slow wave sleep. Delta decay across sleep cycles was different in FMS and alpha activity was greater and declined, whereas the controls were persistently low throughout their sleep. Alpha-delta ratio increased progressively in successive sleep cycles; this was again different from controls. CONCLUSION: Patients with FMS presented a high frequency of subjective sleep disturbances, an increased incidence of alpha EEG NREM sleep and clear abnormalities in sleep cycle organization.