A Single-center, Retrospective Study of Focal Segmental Glomerulosclerosis after Kidney Transplantation: Evolutive Analysis.

Background: Focal segmental glomerulosclerosis (FSGS) has a high recurrence rate after renal transplantation, which significantly impacts renal graft survival. However, the factors related to recurrence remain unclear. Objective: This study aimed to analyze focal segmental recurrence and evolution of glomerulosclerosis after renal transplantation. Methods: This was a descriptive, retrospective study involving 88 adults who underwent renal transplantation within a 15-year period. Demographic and clinical characteristics, as well as the occurrence of graft loss, were analyzed. Over the study period, 88 patients with a diagnosis of FSGS after transplantation were identified. Results: The mean age of the patients (n=54, males) was 29.1 years. Transplants with deceased donors predominated (60.9%). Calcineurin and prednisone inhibitors were present in 96.4% of the initial immunosuppression regimens. The mean time of onset of proteinuria greater than 0.5 g/g was 20.51 days. At 60 months after transplantation, 44.16% of the patients had partial remission, 25.97% had complete remission, and 29.87% had no remission. However, 50.60% of the patients developed graft loss throughout the analyzed period. Eight patients (9.4%) died within 60 months, of which five (62.5%) were attributed to infection. Conclusion: Our results indicate that FSGS after renal transplantation is a disease of high recurrence that is commonly precocious, and the histological alterations in light microscopy are not simultaneous to the appearance of proteinuria. Hypertension is considered a risk factor causing progression and recurrence. Thus, prospective studies are required to better evaluate progression and recurrence factors.

Effect of Denosumab on Bone Mineral Density and Markers of Bone Turnover among Postmenopausal Women with Osteoporosis.

The aim of this study was to evaluate the effect of denosumab (Dmab) on bone mineral density (BMD) and bone turnover markers after 1 year of treatment. Additionally, the effect of Dmab in bisphosphonate-naïve patients (BP-naïve) compared to patients previously treated with bisphosphonates (BP-prior) was analyzed. This retrospective study included 425 postmenopausal women treated with Dmab for 1 year in clinical practice conditions in specialized centers from Argentina. Participants were also divided according to previous bisphosphonate treatment into BP-naïve and BP-prior. A control group of patients treated with BP not switched to Dmab matched by sex, age, and body mass index was used. Data are expressed as mean ± SEM. After 1 year of treatment with Dmab the bone formation markers total alkaline phosphatase and osteocalcin were significantly decreased (23.36% and 43.97%, resp.), as was the bone resorption marker s-CTX (69.61%). Significant increases in BMD were observed at the lumbar spine, femoral neck, and total hip without differences between BP-naïve and BP-prior. A better BMD response was found in BP-prior group compared with BP treated patients not switched to Dmab. Conclusion. Dmab treatment increased BMD and decreased bone turnover markers in the whole group, with similar response in BP-naïve and BP-prior patients. A better BMD response in BP-prior patients versus BP treated patients not switched to Dmab was observed.

Silencing of P-glycoprotein increases mortality in temephos-treated Aedes aegypti larvae.

Re-emergence of vector-borne diseases such as dengue and yellow fever, which are both transmitted by the Aedes aegypti mosquito, has been correlated with insecticide resistance. P-glycoproteins (P-gps) are ATP-dependent efflux pumps that are involved in the transport of substrates across membranes. Some of these proteins have been implicated in multidrug resistance (MDR). In this study, we identified a putative P-glycoprotein in the Ae. aegypti database based on its significantly high identity with Anopheles gambiae, Culex quinquefasciatus, Drosophila melanogaster and human P-gps. The basal ATPase activity of ATP-binding cassette transporters in larvae was significantly increased in the presence of MDR modulators (verapamil and quinidine). An eightfold increase in Ae. aegypti P-gp (AaegP-gp) gene expression was detected in temephos-treated larvae as determined by quantitative PCR. To analyse the potential role of AaegP-gp in insecticide efflux, a temephos larvicide assay was performed in the presence of verapamil. The results showed an increase of 24% in temephos toxicity, which is in agreement with the efflux reversing effect. RNA interference (RNAi)-mediated silencing of the AaegP-gp gene caused a significant increase in temephos toxicity (57%). In conclusion, we have demonstrated for the first time in insects that insecticide-induced P-gp expression can be involved in the modulation of insecticide efflux.

Assessment of takotsubo (ampulla) cardiomyopathy using iodine-123 metaiodobenzylguanidine scintigraphy.

PURPOSE: To evaluate the role of cardiac sympathetic innervation in patients whose clinical features consisted of chest pain, transient ST-segment elevation, left ventricular apical akinesis, minimal elevation of cardiac enzymes, and onset of symptoms shortly after a severe stress condition. MATERIAL AND METHODS: Five female patients, mean age 67+/-14 years, underwent thoracic 123I-MIBG (planar and SPECT) and 67Ga citrate (planar) scans within 5 days after the onset of symptoms. The 123I-MIBG myocardial washout rate between early (30 min) and delayed (3 hours) planar images was calculated. All patients presented findings consistent with takotsubo-like syndrome. Echocardiograms showed the characteristic wall motion pattern of significant apical dysfunction. Acute-phase coronary angiographies revealed a non-obstructive pattern. A peculiar apical akinesis and basal normokinesis were observed on the ventriculograms. RESULTS: Impairment of cardiac neuronal uptake of 123I-MIBG based on a reduction of the heart-to-mediastinum uptake ratio was observed in all patients, while the washout rate was raised in four patients. All patients presented an apical uptake defect in the 123I-MIBG SPECT and planar images and a normal 67Ga scintigraphy. CONCLUSION: Our data indicate that ampulla cardiomyopathy (AC) is associated with a cardiac sympathetic innervation deficit characterized by a reduced global 123I-MIBG uptake and an apical uptake defect. The lack of 67Ga uptake in the acute phase of this syndrome indicates that AC is probably not associated with an inflammatory process.

Morbidity of laparoscopic surgery for complicated appendicitis: an international study.

BACKGROUND: Although laparoscopic appendectomy has some advantages over open appendectomy, some reports do show more postoperative intraabdominal abscesses. METHODS: A retrospective review of complicated appendicitis managed surgically by eight surgical groups from six countries was undertaken. Among 3,433 patients with appendicitis, 1,017 (29.5%) had complicated appendicitis, which included perforated or gangrenous appendicitis with or without localized or disseminated peritonitis. There were 74 preoperative abscesses (7.4%) and 5 small bowel obstructions. RESULTS: One patient died. There were 29 postoperative intraabdominal abscesses (2.8%) and 112 mostly minor complications. Conversion to laparotomy was necessary for 28 patients (2.7%). The surgical time ranged from 32 to 132 min (mean, 62 min), and the hospital stay ranged from 1 to 18 days (mean, 3.5 days). CONCLUSIONS: The morbidity rates, particularly for intraabdominal abscesses, were less for laparoscopic appendectomy in complicated appendicitis than those reported in the literature for open appendectomy, whereas operating times and hospital stays were similar.

Influência da temperatura de armazenamento e do sistema de utilização do tanque de expansão sobre a qualidade microbiológica do leite cru / Influence of the temperature of storage and of the system of utilization of the tank of expansion about the microbiological quality of the raw milk

Objetivou-se com o presente estudo avaliar a influência da temperatura de armazenamento e do sistema de utilização do tanque de refrigeração sobre a qualidade microbiológica do leite cru. Foram analisadas 1.215 amostras quanto a contagem bacteriana total (CBT), através da metodologia de citometria de fluxo. Nas amostras abaixo de 4,0ºC , entre 4,1 e 7,0ºC e acima de 7,0ºC a CBT média foi 2.733.000 UFC / ml, 3.641.000 UFC / ml e 5.687.000 UFC / ml, respectivamente. A CBT média das amostras provenientes de tanques coletivos foi 5.536.000 UFC / ml e das colhidas em tanques individuais foi 2.604.000 UFC / ml, sendo significativamente diferente (p<0,05). Observou-se que 70,21 por cento das amostras analisadas apresentaram CBT abaixo de 1.000.000 de UFC / ml. A baixa qualidade microbiológica das amostras sugere predominantemente a ocorrência de falhas na higiene de ordenha.

[Clinical, humoral and scintigraphic assessment of a bisphosphonate as potential treatment of diaphyseal dysplasia: Ribbing and Cammurati-Engelmann diseases]. / Evaluación clínica, humoral y centellográfica de un bisfosfonato como posible tratamiento en dos casos de displasias diafisarias: las enfermedades de Ribbing y Camurati-Engelmann.

Cammurati-Engelmann's Disease or Progressive Diaphyseal Dysplasia (PDD), is a rare autosomal dominant disorder, sometimes non hereditable, which begins in childhood, and is characterized by symmetrical excess of osseous apposition in diaphysis and metaphysis of long bones. In severe cases skull and vertebrae could be involved. Clinically, patients refer limb pain, muscular weakness and atrophy, easy fatigability and waddling gait. Later on S. Ribbing described an illness that he thought was a separate entity with sclerosis and enlargement of diaphysis of femora and tibiae, which begins after puberty, is less extensive, not always symmetric and without gait or neurological involvement. Some authors think it may be an adult form of the PDD. As no specific treatments are available we report one case of each entity, treated with the bisphosphonate pamidronate, by the oral route. A white female, 69 years old, with clinic and radiology of Ribbing's Disease, had positive scintigraphy in the affected areas and elevated bone biochemical markers: Serum alkaline phosphatase (SAP): 57 UKA. Total urinary hydroxyproline (THP): 60 mg/24 h. Bone Gla protein (BGP): 40 ng/ml. Considering the high bone turnover treatment with oral pamidronate, 400 mg/day plus Calcium 1g/day was started, dose was then progressively reduced. After two months pain almost disappeared, and THP became normal: 14 mg/24 h; with normalization of BGP values: 8 ng/ml, and a decrease of SAP: 21 UKA, 99mTc MDP uptake by affected bones decreased after 1 year of treatment. Because of these results we decided to begin treatment in a white female 17 years old, 32 kg weight, 1.47 m height with PDD characteristics and also a high bone turnover (THP: 95 mg/24 h. SAP: 32 UKA). After six months of Calcium 1 g/day, given with meals, and oral pamidronate 100 mg/day, she became painless with normal strength and gait, almost normalization of THP (48 mg/24 h). Although a small decrease of SAP, and no charges in scintigraphy. These results obtained with pamidronate suggest that it may be useful to treat dysplasias with high bone turnover.

Involvement of a pharmacy department in a hospital's transition to patient-centered care.

This article will describe our hospital's transition to a patient-centered care environment as a response to rising costs within the hospitals and a desire to improve the quality of patient care through systems improvement. The involvement of pharmacy managers in the new organizational structure will be detailed, as well as their new roles and responsibilities as care center leaders. The traditional pharmacy management structure has been replaced by a team approach to decision making and problem solving. Challenges exist to the pharmacy managers as they reorganize to accommodate new responsibilities within the care centers. Opportunities exist within this setting to support pharmaceutical care.

Cutaneous leishmaniasis in south-eastern Paraguay: a study of an endemic area at Limoy.

An epidemiological study was performed on leishmaniasis in a newly established community in south-eastern Paraguay. 149 persons, of 172 inhabitants, were thoroughly examined by clinical, parasitological and immunological (leishmanin skin test) examinations. 88 of those examined (59%) were clinically positive for dermal and nasal (mucosal) lesions or dermal scars, while 74 (50%) were positive by the leishmanin test. Of the 88 persons, 66 (75%) were positive for both leishmanial (dermal and nasal) signs and skin test; these subjects were therefore considered to be leishmaniasis patients. Most of the patients (60%) had a single dermal lesion. Among the 66 leishmaniasis patients, serious mucosal (nasal septum) lesions were observed in the 41 subjects: 2 had destruction of the septum, 8 had ulceration and 31 had erythema. In this community the persons with dermal and/or nasal problems had been treated with meglumine antimonate (Glucantime), without any precise diagnosis having been made by parasitological or immunological examination. The socio-economical and socio-medical points of view aspects are discussed.

Pharmacy-controlled documentation of drug allergies.

The implementation of a pharmacy-enforced policy for documenting drug allergies is described. After two incidents at a 600-bed teaching hospital in which patients experienced severe allergic reactions to drugs, an audit was conducted to evaluate the existing drug allergy documentation policy. Physicians documented allergies in medical charts and treatment orders for 68% and 78% of patients, respectively; no initial drug orders contained this information. Nurses documented allergies in admission assessments, medication records, and charts for 71%, 61%, and 15% of patients, respectively. Only 2% of pharmacy computerized drug profiles contained allergy information. A new policy for drug allergy documentation was instituted. Physicians provide allergy information on the first written drug order. Nurses independently solicit allergy information and check it against that provided by the physician. Pharmacists enter the information into the patient's drug profile. If the information has not been obtained, the drug is not dispensed. Repeat audits two months and one year after the policy was put in place showed significant improvements in the completeness and accuracy of drug allergy documentation by pharmacists and physicians. In general, documentation by nurses did not improve to the degree found for pharmacists and physicians. A policy that gave pharmacists the primary responsibility for ensuring that drug allergy information was obtained before drugs were dispensed was effective in improving allergy documentation by physicians and pharmacists.

The application of computerized clinical files to hospital pharmacy practice.

As more hospital pharmacies move in the direction of computer access, the profession must identify more clinical applications for computer programming. The roles of the hospital pharmacist and pharmacy technician are changing, and the profession is moving in the direction of increased clinical involvement. The computer is becoming the mainstay of hospital pharmacy practice. Enhancement of computer technology is essential to assist the hospital pharmacist in assimilating all relevant data in order to provide optimal oversight of drug therapy. As more data become available on drugs, optimal use of drugs, and factors which place the patient at risk for developing reactions to drugs, we must place less reliance on committing all facts to memory and recognize that the computer is a necessary solution to optimizing patient care.

Changing use patterns of plasma volume expanders through educational intervention.

Use patterns of the plasma volume expanders albumin and hetastarch were evaluated before and after an educational program promoting the preferential use of hetastarch was implemented in a 700-bed teaching hospital. The high acquisition cost and periodic shortages of 5% albumin injection prompted the implementation in March 1985 of a target drug program that would encourage the use of 6% hetastarch injection in place of albumin whenever possible. Purchases of albumin and hetastarch were monitored from August 1984 to March 1985 and again from April to November 1985 to determine how much and where these agents were being used. Criteria and guidelines for the use of plasma volume expanders were developed by the pharmacy with physician input. Senior attending physicians who had been identified as primary decision makers in the clinical use of albumin were asked to abide by the guidelines; also, pharmacists conducted inservice educational programs on the use of hetastarch. Patterns of albumin and hetastarch use changed significantly (p less than 0.05) after the educational program was implemented. From August 1984 to March 1985, the mean number of units of albumin and hetastarch purchased monthly were 325.5 and 0.4, respectively. These numbers changed to 195.3 and 163.1 units, respectively, from April to November 1985. The monthly cost avoidance associated with this change was $5127, which extrapolates to $61,526 annually. An educational program can be effective in controlling hospital expenditures for plasma volume expanders. However, clinicians should be aware of the potential adverse effects of hetastarch and should avoid using it in excessive amounts or in patients with underlying coagulopathies.

Stability and cost analysis of clindamycin-gentamicin admixtures given every eight hours.

Stability and costs of a mixture of clindamycin and gentamicin in a single carrier solution for every-eight-hour i.v. administration were analyzed. Duplicate solutions containing clindamycin 900 mg (as the phosphate salt) and gentamicin 100 mg (as the sulfate salt) in 5% dextrose injection 150 mL in flexible plastic containers were prepared. Samples withdrawn at 0-24 hours were visually inspected and assayed for content of both drugs. Clindamycin concentrations were determined by high-performance liquid chromatography and gentamicin concentrations by fluorescence-polarization immunoassay. Preparation and administration times were measured in two trials to determine cost differences between every-eight-hour administration of the two-antibiotic mixture and separate administration of the two drugs (four daily doses of clindamycin and three of gentamicin). No precipitate was seen. Concentrations of both drugs after 24 hours were greater than 90% of initial concentrations. Total daily costs (per patient) for labor, drug, and carrier solution were $3.08 less when the two drugs were mixed and administered every eight hours. At the concentrations studied, clindamycin and gentamicin mixed together in 5% dextrose injection are stable for 24 hours. Administration of this drug mixture every eight hours is safe and less costly than separate administration of the two drugs.