using GFR we can classify the patients according to KDOQI stage of chronic disease. However, this choice also presented issues: only 37 of our patients had a known reference sCr and so we could correctly define functionalrecovery only for them. Moreover, the percentage ofpatients with known reference sCr was much different among the groups: 33% in G1/G2 but 63% in G3/G4. Another issue is determining at what point renalrecovery must be evaluated: at hospital discharge, after 90 days, after 1 year, etc. Schmitt et al asserted that evaluating renalrecovery at discharge is not effective, especially for patients older than 65 years . Our study, which included only patients with little co-morbidity and discharged without requiring dialysis, showed that the median time to reach their highest GFR was one year. However, by one year 14 of our patients were still improving GFR, which stabilized only by 18 months, guiding our decision to evaluate renalrecovery by 18 months instead of 12 months year. Additionally, there was a significant range in times to achieve higher GFR, and the patients with best renal function recovery had the shortest time: less than 6 months. Thus, at 6 months or discharge, it is not possible to be confident in estimating GFR by sCr in a patient who had such a severe and catabolic disease as AKI. The loss of muscular mass will show a deceptively low sCr and so will be unreliable to be used as an estimate of GFR. In support of this hypothesis, in G1 the patients had a rapid increase in GFR in the first 6 months after the event and thereafter showed a decline in GFR (figure 2). We can speculate that the recoveryof GFR occurred faster than the recoveryof muscular mass. Our study suggests that the best parameter to evaluate renalrecovery is GFR at 18 months after AKI, as compared to the reference GFR. Collins et al also suggest that renalrecovery must be defined relative to baseline GFR . Evaluation at one year after AKI is also a viable option since most ofpatients who had AKI will likely have sCr tested by that time, regardless of the type of doctor who is attending him or her .
This review will focus on long-term outcomes afteracutekidneyinjury (AKI). Surviving AKI patients have a higher late mortality compared with those admitted without AKI. Recent studies have claimed that long-term mortality in patientsafter AKI varied from 15% to 74% and older age, presence of previous co-morbidities, and the incomplete recoveryofrenal function have been identified as risk factors for reduced survival. AKI is also associated with progression to chronic kidney (CKD) disease and the decline ofrenal function at hospital discharge and the number and severity of AKI episodes have been associated with progression to CKD. IN the most studies, recoveryofrenal function is defined as non- dependence on renal replacement therapy which is probably too simplistic and it is expected in 60-70% of survivors by 90 days. Further studies are needed to explore the long-term prognosis of AKI patients.
Background. Throughout life, the kidneys perform the essential task of filtering waste products (from the normal breakdown of tissues and from food) and excess water from the blood to make urine. Chronic kidney disease (caused, for example, by diabetes) gradually destroys the kidneys’ filtration units (the nephrons), eventually leading to life- threatening end-stage kidney disease. However, the kidneys can also stop working suddenly because ofinjury, infection, or poisoning. Acutekidneyinjury (AKI) is much more common than end-stage kidney disease and its incidence is increasing worldwide. In the US, for example, the number of hospitalizations that included an AKI diagnosis rose from 4,000 in 1996 to 23,000 in 2008. Moreover, nearly half ofpatients with AKI will die shortly after the condition develops. Symptoms of AKI include changes in urination, swollen feet and ankles, and tiredness. Treatments for AKI aim to prevent fluid and waste build up in the body and treat the underlying cause (e.g., severe infection or dehydration) while allowing the kidneys time to recover. In some patients, it is sufficient to limit the fluid intake and to reduce waste build-up by eating a diet that is low in protein, salt, and potassium. Other patients need renal replacement therapy (RRT), life-supporting treatments such as hemodialysis and hemofiltration, two processes that clean the blood by filtering it outside the body.
The outcomes of death and infection (MRSA and MSSA) were evaluated based on the 30 day carriage pattern as well as the dynamic carriage pattern over the study period. Death occurred in 1500 patients (8.4% of the study cohort), with an increasing rate with higher carriage burden at the 30-day baseline; 7.6% of never colonized, 15.0% of intermittently colonized, and 18.6% of always colonized patients died during follow-up. The mean follow-up time was 17.5, 16.5, and 17.2 months and the mean time to death from initial screening was 4.7, 4.5, and 4.9 months, respectively, in the never, intermittent and always colonized groups. Compared to non-colonized patients, those with intermittent or always colo- nized carriage patterns had a greater than 2-fold increased risk of death (HR 2.09; 95% CI 1.73;2.53 and HR 2.58; 95% CI 2.18;3.05, respectively) (figure 3a). After accounting for age, number of screening tests in the follow-up period, number ofacute care and longterm care admissions, total acute care and longterm care hospital days, diabetes, renal disease, HIV infection, decubitus ulcer, eczema, and antibiotic exposure, the risk of death remained significantly elevated among always (HR 1.91; 95% CI 1.60;2.28) and intermittently colonized (HR 1.75; 95% CI 1.45;2.12) patients. When accounting for changes in carriage pattern over the study period (the dynamic carriage pattern), the adjusted risk of death was even higher among patients always colonized as compared to patients remaining non-colonized (HR 2.44; 95% CI 2.04;2.91).
underwent cardiac surgery and were followed for 100 months thereafter. The authors found that, during the follow-up period, mortality was significantly higher in patients with postoperative deterioration ofrenal function and that survival remained lower regardless of whether there was recoveryofrenal function after hospital discharge. The mechanisms involved in this process are not fully understood, because AKI can be an early sign that other systems and organs are also negatively affected, and the sum of those dysfunctions could contribute to and explain the higher mortality and lower survival among individuals developing AKI after cardiac surgery.
All outpatients 18 years of age and older scheduled for elective coronary angiography or ventriculography were eligible for inclusion in this study. A nurse, blinded to the trial hypothesis and from whom the random sequence of allocation to treatment was concealed, enrolled 500 eligible outpatients, excluding those who: were less than 18 years of age, received an iodinated contrast medium intravascularly within 30 days before evaluation for inclusion, received emergency coronary catheterization, experi- enced pulmonary edema or acutely decompensated congestive heart failure, were using nonsteroidal anti-inflammatory drugs or metformin at the time of the study, or declined to participate in the trial. No patient received theophylline, dopamine, or mannitol during the study.
Mechanical ventilation was instituted for 86% of the studied cases, and there was no signiicant association between the need for MV and AKI. here was, however, a signiicant association between PaO 2 /FiO 2 at admission and AKI, evidencing the impact of AKI in lung function. An independent risk factor associated with AKI was PaO 2 /FiO 2 ≤200 mmHg. Positive pressure ventilation alters venous return, cardiac preload, pulmonary vascular resistance and cardiac afterload. Accordingly, a decrease in several parameters ofrenal function, including GFR, renal blood low and free water clearance, has been noted during positive pressure ventilation. (17) Blood gas
descreveram 6 pacientes submetidos à diálise que, além de soluços incoercíveis, apresentaram outros sintomas de distúr- bios neurológicos como confusão men- tal, agitação psicomotora, coma e con- vulsões, com um paciente indo a óbito. Posteriormente, outros relatos confirma- ram essas alterações em pacientes renais crônicos em diálise e em pacientes com doença renal crônica (DRC) que ainda não eram submetidos à diálise. 4-6 Foram publi-
The suspicion of metastases from HCC to the thyroid is very dificult due to the lack of symptoms, a fact that delays the diagnosis. Toshima and cols. (14) reported a similar case of a 74-year-old man who under- went hepatectomy for HCC. About 22 months later, des-gamma-carboxy prothrombin levels were elevated in the presence of normal alpha-fetoprotein. However, no recurrent HCC was detected using contrast-enhan- ced CT, bone scintigraphy, and upper gastrointestinal endoscopy. Physical examination revealed no palpable neck nodule and the patient had no symptoms. Only luorine-18 luorodeoxyglucose positron emission to- mography/computed tomography (FDG-PET/CT) was able to detect a small nodule in the thyroid, which was conirmed to be metastatic HCC by ine needle biopsy. In the present case, alpha-fetoprotein levels re- mained high after hepatectomy, a inding that suggests the presence of a synchronous tumor, but this suspi- cion was not conirmed by imaging exams, although no PET/CT scan had been done. After 17 months, the patient complained of dysphagia when a new thyroid nodule was detected, and the biopsy conirmed a metas- tatic HCC to the thyroid. It is likely that the tumor was already present when the hepatectomy was performed.
is very helpful in facilitating the completeness of dissection at minimal expense of damaging the neurovascular bundle otherwise (6). A postoperative penile sensory change is no more observed as usual. Similarly, the prevalence of penile lump can be minimized while using finer 6-0 nylon suture to replace a coarser-unabsorble ones. Besides from these interesting observational factors in this study in order to avoid the penile shortage which was frequently complained postoperatively by patients who underwent either a modified Nesbit procedure or a tunical plication surgery despite it is not remarkable from surgeon’s view, a grafting surgery was, therefore, meticulously developed and recommended despite it is challenging and might be away from consensus (7,8). Accordingly, on penile morphological surgery all procedures seem intriguing rather than easygoing uro-surgical entities, which should be more exhaustive preoperatively as advised by authors in this study. Overall, it appears that neither surgical methodology nor surgical outcome for penile curvature correction, including tunical plication method, has been elucidated already. Further scientific study is warranted.
The annual incidence is about 150 per million in the UK, but this figure is six times greater in the >80 years old group. Prerenal azotemia is considered as the most serious reason in community or hospital acquired acuterenal failure (ARF). A 67-year-old middle age male was admitted to the hospital with a chief complaint of generalized weakness, volume depletion and dysuria. He has treated with metronidazole for diarrhoea caused by Clostridium difficile considered as the precipitating factor for the ARF. The patient has severe osteoarthritis and takes high dose non-steroidal anti-inflammatory drugs from the last two years. He also complains for obstructive sleep apnea (OSA) and obesity. He has controlled hypertension was on lisinopril to control blood pressure. ARF is quite common, occurring in 80 million populations. Urinary obstruction should be excluded (a cause in around 5-10 of cases) because this is readily reversible if it is diagnosed early. A renal US will be sufficient to identify obstruction in 95 of cases. Most cases of ARF are expected to pre renal failure/acute tubular necrosis (ATN) 70-80%. Risk factor for development for at ATN are old age, drugs (non- steroidal anti-inflammatory drugs, gentamicin), sepsis, and chronic kidney disease and must be considered.
Formalin-fixed paraffin-embedded tissue (FFPE) sections were deparaffinized in an incubator at 65uC for 40–60 minutes and rehydrated to 95% ethyl alcohol. The slides were incubated in Luxol Fast Blue solution (0.1% in 95% ethyl alcohol) at 56uC overnight. Subsequently the slides were cooled down to room temperature and washed in 95% ethyl alcohol and distilled water. Subsequently samples were incubated in a lithium carbonate solution (0.1%) for 5 minutes in 70% ethyl alcohol until the grey matter was clear and the white matter was sharply defined. The slides were placed in distilled water. After dehydration the slides were mounted with mounting medium (Tissue Tek, Coverslipping Resin, Sakura Finetek USA Inc, Torrance, CA; www.sakuraus. com) and pictures were taken with Aperio (Aperio ePathology). Stainings from a minimum of 4 successive slices per brain were quantitatively analysed. Quantitative analysis of ipsilateral hemi- sphere translucence was performed using Adobe Photoshop CS5 extended: images at the same magnification were straightened and the size of each image was adjusted to 7206540 pixels. The area of the entire ipsilateral hemisphere was selected by a rectangular marquee. The size of the marquee was saved and used for all images. Translucency of the selected areas was determined in the RGB setting at 0.299 - red, 0.587 - green, 0.114 - blue.
Introdução: É imprescindível a correta es- timativa do gasto energético de repouso (GER), que pode apresentar considerável variação diária no paciente crítico com le- são renal aguda (LRA). Objetivo: Avaliar a variabilidade diária do GER medido por calorimetria indireta (CI) em pacientes com LRA e indicação dialítica e identificar as va- riáveis clínicas associadas ao GER. Métodos: O GER foi medido no dia da indicação do procedimento dialítico e nos quatro dias subsequentes. Também foram avaliados pa- râmetros que podem influenciar o GER. As diferenças diárias foram analisadas pelo mo- delo linear generalizado para medidas repeti- das, com distribuição gama, além da correla- ção de Spearman e regressão linear múltipla. Resultados: Foram 301 medidas de CI reali- zadas em 114 pacientes, com idade de 60,65 ± 16,9 anos e 68,4% do sexo masculino. O GER médio foi de 2081 ± 645 Kcal, com aumento no dia 5 (2270 ± 556 Kcal), quan- do comparado aos dias 2 e 3 (2022 ± 754; 2022 ± 660 kcal, respectivamente, p = 0,04); quando normalizado para peso, não houve diferença significante no GER (kcal/kg/dia) durante o acompanhamento. GER correla- cionou-se positivamente com temperatura corporal, contagem total de leucócitos, pro- teína C reativa, volume minuto (VM), fração inspirada de oxigênio (FiO 2 ), aparecimento de nitrogênio ureico (UNA), peso corporal e estatura e inversamente com idade. Após a regressão linear múltipla, somente VM, FiO 2 e peso corporal e idade se correlacionaram independentemente. Conclusão: Pacientes com LRA dialíticos apresentam GER está- vel. O GER foi associado independentemen- te com FiO 2 , VM, peso e idade. Assim, re- quisitos ventilatórios precisam ser avaliados diariamente para que alterações necessárias na prescrição dietética sejam feitas.
Background/Aims. Studies on 46,XY partial gonadal dysgenesis (PGD) have focused on molecular, gonadal, genital, and hormone features; little is known about follow-up. Our aim was to analyze long-term outcomes of PGD. Methods. Retrospective longitudinal study conducted at a reference service in Brazil. Ten patients were irst evaluated in the 1990s and followed up until the 2010s; follow- up ranged from 13.5 to 19.7 years. All were reared as males and had at least one scrotal testis; two bore NR5A1 mutations. Main outcomes were: associated conditions, pubertal development, and growth. Results. All patients had normal motor development but three presented cognitive impairment; ive had various associated conditions. At the end of the prepubertal period, FSH was high or high-normal in 3/6 patients; LH was normal in all. At the last evaluation, FSH was high or high-normal in 8/10; LH was high or high-normal in 5/10; testosterone was decreased in one. Final height in nine cases ranged from −1.57 to 0.80 SDS. All had spontaneous puberty; only one needed androgen therapy. Conclusions. here is good prognosis for growth and spontaneous pubertal development but not for fertility. hough additional studies are required, screening for learning disabilities is advisable.
Methods: The search for, and selec- tion and analysis of, observational stu- dies that assessed the health-related qua- lity of life of intensive care unit survivors in the electronic databases LILACS and MEDLINE® (accessed through Pub- Med) was performed using the indexed MESH terms “quality of life [MeSH Terms]” AND “critically illness [MeSH Terms]”. Studies on adult patients wi- thout specific prior diseases published in English in the last 5 years were included in this systematic review. The citations were independently selected by three reviewers. Data were standardly and in- dependently retrieved by two reviewers, and the quality of the studies was asses- sed using the Newcastle-Ottawa scale.
The current evidence base provides a poor guide for clinicians who are planning treatment and predicting recovery in the acute phases after ankle sprain . Further research is needed to develop prognostic models in the primary care setting. Family doctors and Accident and Emergency practitioners often have little time to assess musculoskeletal injuries therefore the key is to develop simple prognostic models . We have provided some evidence towards a refined clinical examination model. Clinicians should be mindful ofpatients with ankle sprain presenting with persistent pain on medial palpation and painful active dorsiflexion. Additional followup in the sub-acute phases should be considered and could facilitate more accurate prognostication of longer term function.
Improvements in CHD outcomes were based on few robust scientific data. Congenital cardiology has suffered from a lack of indisputable evidence. There have been less than 30 prospective randomized trials worldwide, and some did not reveal a clear benefit of one approach over the other. Many decisions result from individual or institutional preference, anecdotal cases or specific institutional protocols. Clinical practice guidelines for CHD are mostly class II recommendations (treatments are reasonable or may be considered) based on type C evidence (experts’ consensus, case studies or standard of care). In sum, evidence- based medicine is lacking in CHD. These shortcomings result from the CHD being a group of rare diseases with diverse presentations, mostly treated in small and autonomous practices and lack of suitable research end-points. In recent years, this problem has been well recognized, and the development of evidence-based practice based on multicenter consortia is considered one of the most important future trends for CHD in the next decade. 2
All patients received a regimen of 3–6 MU IFN-a thrice weekly plus ribavirin 800–1200 mg per-day for 24 weeks. Of the 102 patients, 81 who were followed up more than 24 weeks after end of treatment (EOT) were enrolled into the present long-termfollow- up study. During the follow-up period, liver function tests, HBV serological markers and HBV DNA were tested at an interval of 6 months. HBsAg, antibody to HBsAg (anti-HBs), hepatitis B e antigen (HBeAg), antibody to HBeAg (anti-HBe), and anti-HCV were detected with commercially available enzyme-linked immu- nosorbent assay kits (Abbott Laboratories, North Chicago, IL, USA) in each local laboratory unit. Serum HBV DNA was determined by a standardized automated quantitative PCR assay (Cobas Amplicor HBV Monitor; Roche Diagnostics; detection limit 200 copies/ml). Serum HCV RNA levels were measured using the branched DNA assay (VERSANT HCV-RNA 3.0. Assay, Bayer Diagnostics, Emeryville, CA, USA; quantification limit 615 IU/ml). The study was conducted according to the guidelines of the Declaration of Helsinki, with the principles of good clinical practice, and was approved by local ethics committees for patient’s chart review and data analysis without informed consent.
The study published in volume 96(5) on the effectiveness and safety of stents in patients with chronic renal failure¹ raised our interest in this topic, so we would like to ask the authors: Considering the deaths, infarctions and MACE that occurred more in the group ofpatients with chronic
1) was characterized by severe and rapidly progressive renal failure, defined by a two-fold increase in SCr to a level ≥2.5 mg/dL within two weeks. Even though HRS-1 could develop spontaneously, it frequently follows a precipitating factor, such as bacterial infec- tion, gastrointestinal bleeding, major surgical intervention or acute hepatitis occurring in a cirrhotic patient. HRS type 2 (HRS-2) is characterized by moderate and steady or slowly progressive decrease in renal function, accompanied by signs of liver failure and arterial hypotension to a lesser degree than in patients with HRS-1. The dominant clinical characteristic ofpatients with HRS-2 is tense ascites with poor response to diuretic therapy; refractory ascites. It is noteworthy that patients with HRS-2 are particularly susceptible to developing HRS-1. Median survival ofpatients with HRS-2 (6 months) is significantly lower than that of cirrhotic patients with ascites and preserved renal function (30) . After the adoption of the