ELMO CPAP: an innovative type of ventilatory support for COVID-19-related acute respiratory distress syndrome.

OBJECTIVE: To assess whether the use of ELMO, a helmet for noninvasive ventilation created in Brazil, had a positive impact on the prognosis of patients with hypoxemic respiratory failure caused by severe COVID-19. METHODS: This is a retrospective study of 50 critically ill COVID-19 patients. Epidemiological, clinical, and laboratory data were collected on ICU admission, as well as before, during, and after ELMO use. Patients were divided into two groups (success and failure) according to the outcome. RESULTS: ELMO use improved oxygenation parameters such as Pao2, Fio2, and the Pao2/Fio2 ratio, and this contributed to a gradual reduction in Fio2, without an increase in CO2, as determined by arterial blood gas analysis. Patients in the success group had significantly longer survival (p < 0.001), as determined by the Kaplan-Meier analysis, less need for intubation (p < 0.001), fewer days of hospitalization, and a lower incidence of acute kidney injury in comparison with those in the failure group. CONCLUSIONS: The significant improvement in oxygenation parameters, the longer survival, as reflected by the reduced need for intubation and by the mortality rate, and the absence of acute kidney injury suggest that the ELMO CPAP system is a promising tool for treating ARDS and similar clinical conditions.

ELMO CPAP: an innovative type of ventilatory support for COVID-19-related acute respiratory distress syndrome / ELMO-CPAP: um suporte ventilatório inovador para síndrome do desconforto respiratório agudo por COVID-19

ABSTRACT Objective: To assess whether the use of ELMO, a helmet for noninvasive ventilation created in Brazil, had a positive impact on the prognosis of patients with hypoxemic respiratory failure caused by severe COVID-19. Methods: This is a retrospective study of 50 critically ill COVID-19 patients. Epidemiological, clinical, and laboratory data were collected on ICU admission, as well as before, during, and after ELMO use. Patients were divided into two groups (success and failure) according to the outcome. Results: ELMO use improved oxygenation parameters such as Pao2, Fio2, and the Pao2/Fio2 ratio, and this contributed to a gradual reduction in Fio2, without an increase in CO2, as determined by arterial blood gas analysis. Patients in the success group had significantly longer survival (p < 0.001), as determined by the Kaplan-Meier analysis, less need for intubation (p < 0.001), fewer days of hospitalization, and a lower incidence of acute kidney injury in comparison with those in the failure group. Conclusions: The significant improvement in oxygenation parameters, the longer survival, as reflected by the reduced need for intubation and by the mortality rate, and the absence of acute kidney injury suggest that the ELMO CPAP system is a promising tool for treating ARDS and similar clinical conditions.

RESUMO Objetivo: Avaliar se o uso do ELMO, um capacete para ventilação não invasiva criado no Brasil, teve impacto positivo no prognóstico de pacientes com insuficiência respiratória hipoxêmica por COVID-19 grave. Métodos: Estudo retrospectivo com 50 pacientes críticos com COVID-19. Dados epidemiológicos, clínicos e laboratoriais foram coletados na admissão na UTI e antes, durante e após o uso do ELMO. Os pacientes foram divididos em dois grupos (sucesso e falha) de acordo com o desfecho. Resultados: O uso do ELMO melhorou parâmetros de oxigenação como Pao2, Fio2 e relação Pao2/Fio2, e isso contribuiu para uma redução gradual da Fio2, sem aumento do CO2, conforme determinado pela gasometria arterial. Os pacientes do grupo sucesso apresentaram sobrevida significativamente maior (p < 0,001), conforme determinado pela análise de Kaplan-Meier, menor necessidade de intubação (p < 0,001), menos dias de hospitalização e menor incidência de lesão renal aguda em comparação com os do grupo falha. Conclusões: A significativa melhora nos parâmetros de oxigenação, a maior sobrevida, refletida pela menor necessidade de intubação e pela taxa de mortalidade, e a ausência de lesão renal aguda sugerem que o sistema ELMO CPAP é uma ferramenta promissora para o tratamento da SDRA e de condições clínicas semelhantes.

Proteinuria and serum creatinine after 12 months of treatment for lupus nephritis as predictors of long-term renal outcome: a case-control study.

BACKGROUND: Lupus nephritis (LN) is a major source of morbidity and mortality in patients with systemic lupus erythematosus (SLE), with 10-25% of patients progressing to end-stage renal disease (ESRD). OBJECTIVE: This study aims to elucidate the predictive capabilities of 24-h proteinuria (24PTU) and serum creatinine (sCr) after 12 months of treatment with respect to long-term renal outcomes in LN in a single-center cohort of LN patients. METHODS: A retrospective analysis was performed on 214 patients diagnosed with LN followed in our center. Values of 24PTU and sCr were assessed at baseline and after 3, 6 and 12 months, and after 5 years and/or the last evaluation. Chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 for 3 months or longer. End-stage renal disease (ESRD) was defined as the need for permanent dialysis. Receiver operating characteristics curves (ROC) were used to test the best cut-off value of 24PTU and sCr at 12 months who predict bad long-term renal outcomes. RESULTS: The mean follow-up period was 11.2 ± 7.2 years. The best cut-off values for 24PTU and sCr as predictor of CKD were, respectively, 0.9 g/24 h and 0.9 mg/dL. ROC curve for 24PTU had a slightly lower performance than ROC curve for sCr as predictor for CKD (PTU AUC = 0.68; sCr AUC = 0.70), but sensitivity and specificity were better for 24PTU (24PTU: sensitivity = 63.5%, specificity = 71.2%; sCr: sensitivity = 54.8%, specificity = 75.3%). When the outcome was ESRD the best cut-off points were 0.9 g/24hs and 1.3 mg/dL for 24PTU and sCr, respectively, and the curve performance was better for 24PTU (PTU AUC = 0.72; sCr AUC = 0.61). CONCLUSIONS: In this ethnically diverse population with LN followed for a long time (> 10 years), levels of 24PTU > 0.9/day at 12 months was a good predictor of bad long-term renal outcome. The serum creatinine > 0.9 mg/dL and > 1.3 mg/dL at 12 months were also good predictors of CKD and ESRD, respectively. Patients with 24PTU < 0.9 g/day and sCr < 1.3 mg/dL at 12 months are not likely to develop ESRD because of the high negative predictive values (NPV) (93.2% and 82%). 24PTU and sCr are relevant as components for a treat-to-target strategy for LN treatment, since their high NPV corroborates their importance as good predictors of long-term renal outcome.

Proteinuria and serum creatinine after 12 months of treatment for lupus nephritis as predictors of long-term renal outcome: a case-control study

Abstract Background: Lupus nephritis (LN) is a major source of morbidity and mortality in patients with systemic lupus erythematosus (SLE), with 10-25% of patients progressing to end-stage renal disease (ESRD). Objective: This study aims to elucidate the predictive capabilities of 24-h proteinuria (24PTU) and serum creatinine (sCr) after 12 months of treatment with respect to long-term renal outcomes in LN in a single-center cohort of LN patients. Methods: A retrospective analysis was performed on 214 patients diagnosed with LN followed in our center. Values of 24PTU and sCr were assessed at baseline and after 3, 6 and 12 months, and after 5 years and/or the last evaluation. Chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 for 3 months or longer. End-stage renal disease (ESRD) was defined as the need for permanent dialysis. Receiver operating characteristics curves (ROC) were used to test the best cut-off value of 24PTU and sCr at 12 months who predict bad long-term renal outcomes. Results: The mean follow-up period was 11.2 ± 7.2 years. The best cut-off values for 24PTU and sCr as predictor of CKD were, respectively, 0.9 g/24 h and 0.9 mg/dL. ROC curve for 24PTU had a slightly lower performance than ROC curve for sCr as predictor for CKD (PTU AUC = 0.68; sCr AUC = 0.70), but sensitivity and specificity were better for 24PTU (24PTU: sensitivity = 63.5%, specificity = 71.2%; sCr: sensitivity = 54.8%, specificity = 75.3%). When the outcome was ESRD the best cut-off points were 0.9 g/24hs and 1.3 mg/dL for 24PTU and sCr, respectively, and the curve performance was better for 24PTU (PTU AUC = 0.72; sCr AUC = 0.61). Conclusions: In this ethnically diverse population with LN followed for a long time (> 10 years), levels of 24PTU > 0.9/day at 12 months was a good predictor of bad long-term renal outcome. The serum creatinine > 0.9 mg/dL and > 1.3 mg/dL at 12 months were also good predictors of CKD and ESRD, respectively. Patients with 24PTU < 0.9 g/day and sCr < 1.3 mg/dL at 12 months are not likely to develop ESRD because of the high negative predictive values (NPV) (93.2% and 82%). 24PTU and sCr are relevant as components for a treat-to-target strategy for LN treatment, since their high NPV corroborates their importance as good predictors of long-term renal outcome.

Exploring the causes of the high incidence of delayed graft function after kidney transplantation in Brazil: a multicenter study.

This retrospective multicenter (n = 18) cohort study evaluated the incidence, risk factors, and the impact of delayed graft function (DGF) on 1-year kidney transplant (KT) outcomes. Of 3992 deceased donor KT performed in 2014-2015, the incidence of DGF was 54%, ranging from 29.9% to 87.7% among centers. Risk factors (lower-bound-95%CI OR upper-bound-95%CI ) were male gender (1.066 1.2491.463 ), diabetic kidney disease (1.053 1.2961.595 ), time on dialysis (1.005 1.0071.009 ), retransplantation (1.035 1.3971.885 ), preformed anti-HLA antibodies (1.011 1.3831.892 ), HLA mismatches (1.006 1.0661.130 ), donor age (1.011 1.0171.023 ), donor final serum creatinine (sCr) (1.239 1.3171.399 ), cold ischemia time (CIT) (1.031 1.0431.056 ), machine perfusion (0.401 0.5420.733 ), and induction therapy with rabbit antithymocyte globulin (rATG) (0.658 0.8000.973 ). Duration of DGF > 4 days was associated with inferior renal function and DGF > 14 days with the higher incidences of acute rejection, graft loss, and death. In conclusion, the incidence and duration of DGF were high and associated with inferior graft outcomes. While late referral and poor donor maintenance account for the high overall incidence of DGF, variability in donor and recipient selection, organ preservation method, and type of induction agent may account for the wide variation observed among transplant centers.

The Impact of Hypothermic Pulsatile Machine Perfusion Versus Static Cold Storage: A Donor-Matched Paired Analysis in a Scenario of High Incidence of Delayed Kidney Graft Function.

BACKGROUND The present study analyzed the impact of hypothermic pulsatile machine perfusion (MP) following a long period of static cold (SC) storage in the peculiar Brazilian scenario of high incidence of delayed graft function (DGF), despite good donor characteristics. MATERIAL AND METHODS A retrospective analysis, with a 1-year follow-up, of 206 recipients of donor-matched paired kidneys was performed. Of the 206 donor kidneys, 103 were maintained exclusively in static cold storage (SC group) and 103 were kept on machine perfusion after a period of SC preservation (MP group). All donors were brain dead. RESULTS Only 4.9% of the kidneys were from expanded-criteria donors. Static cold ischemia time (CIT) in the SC group was 20.8±4.1 hours vs. 15.8±6.2 hours in the MP group (P<0.001). Dynamic CIT in the MP group was 12.3±5.7 hours. MP significantly reduced DGF incidence (29.1% vs. 55.3%, P<0.001), and this effect was confirmed in multivariable analysis (OR, 1.115; 95% CI, 1.033-1.204, P=0.001). No differences were observed between the groups with regard to DGF duration, length of hospital stay, incidence of primary nonfunction and acute rejection, graft loss, death, or renal function. CONCLUSIONS In this Brazilian setting, MP following a long period of SC preservation was associated with reduced DGF incidence in comparison with SC storage without MP.

Hospital Cost of Complications After Kidney Transplant.

BACKGROUND: Kidney transplant is considered the best treatment of rehabilitation for chronic kidney disease, but clinical and/or surgical complications may occur after transplant. The study aimed to assess the cost of complications after kidney transplant. MATERIALS AND METHODS: This is a descriptive, retrospective, and exploratory study that used data from Hospital Information System ("Sistema de Informação Hospitalar"). We identified the patients with records of kidney transplant in the states of northern and northeastern Brazil in 2013. These patients were followed up through the records, specifically from 2013 to 2017. The variables analyzed were sex, age, and period after transplant of readmissions (early, intermediate, or late), the main complications within 4 years after the kidney transplant, and cost of hospital admissions. RESULTS: There were 893 patients with records of kidney transplant in the regions of the study. During the follow-up period, 319 patients had complications. Most hospital readmissions involved male patients (63.6%; n = 203). Mean age was 45 (SD, 15.14) years. Patients developed complications mainly in the early period after transplant (70.22%; n = 224). The number of hospital admissions was 758. The main complications were regarding urinary tract (72.02%; n = 546), infections (19.79%; n = 150), and vascular and/or pulmonary (2.90%; n = 22). The total cost for the treatment of these complications was US $528,329.51. CONCLUSIONS: By analyzing the data it was possible to identify that there is a significant cost involved in the treatment of complications after kidney transplant.

The impact of deceased donor maintenance on delayed kidney allograft function: A machine learning analysis.

BACKGROUND: This study evaluated the risk factors for delayed graft function (DGF) in a country where its incidence is high, detailing donor maintenance-related (DMR) variables and using machine learning (ML) methods beyond the traditional regression-based models. METHODS: A total of 443 brain dead deceased donor kidney transplants (KT) from two Brazilian centers were retrospectively analyzed and the following DMR were evaluated using predictive modeling: arterial blood gas pH, serum sodium, blood glucose, urine output, mean arterial pressure, vasopressors use, and reversed cardiac arrest. RESULTS: Most patients (95.7%) received kidneys from standard criteria donors. The incidence of DGF was 53%. In multivariable logistic regression analysis, DMR variables did not impact on DGF occurrence. In post-hoc analysis including only KT with cold ischemia time<21h (n = 220), urine output in 24h prior to recovery surgery (OR = 0.639, 95%CI 0.444-0.919) and serum sodium (OR = 1.030, 95%CI 1.052-1.379) were risk factors for DGF. Using elastic net regularized regression model and ML analysis (decision tree, neural network and support vector machine), urine output and other DMR variables emerged as DGF predictors: mean arterial pressure, ≥ 1 or high dose vasopressors and blood glucose. CONCLUSIONS: Some DMR variables were associated with DGF, suggesting a potential impact of variables reflecting poor clinical and hemodynamic status on the incidence of DGF.

Potentially inappropriate medications in older kidney transplant recipients: a Brazilian prevalence study.

Background Older kidney transplant recipients take a larger number of medications than younger patients, but there is currently no evidence that this affects health outcomes or that is it associated with potentia medicine-related problems. Objective To evaluate the prevalence and number of potentially inappropriate medications in older kidney transplant recipients and also the possible associated factors (sex, age, comorbidities, number of medications, etc.). Setting A renal post-transplant ambulatory outpatient clinic of a university hospital in Fortaleza, Brazil. Method PIMs were defined according to the Beers criteria, version 2015. Medications were classified following the Anatomical Therapeutic Chemical Classification System. Chi squared tests and analysis of variance were used for the analyses. Main outcome measure Prevalence of potentially inappropriate medications and medication groups with higher prevalence rates of PIMs, including associated factors. Results Among 143 kidney transplant recipients, 77.6% had at least one potentially inappropriate medication as part of their prescription regime. Medication groups that were most implicated in PIM are medicines that act on the alimentary tract and metabolism (55.9%), cardiovascular system (32.2%) and nervous system (21.7%). We detected a high prevalence (63.6%) of self-medication (use of OTC medicines without indication of a healthcare professional) among the population studied. There was a statistically significant association between the number of prescribed medications and the presence of potentially inappropriate medication in the prescription regime (P < 0.01). Conclusion Our data draw attention to the need of medicine therapy management by clinical pharmacists and clinicians in this group of patients and also assessing the real clinical impacts of these medications in the prescription regimes of elderly renal transplant patients.

Spectrum of acute kidney injury associated with cocaine use: report of three cases.

BACKGROUND: The consequences of cocaine use are multisystemic, such as, for instance, renal failure, hepatotoxicity and pulmonary toxicity, with renal alterations being the focus of the present study. The use of substances that modify the base composition of cocaine (or adulterants) aiming to potentiate its effects also has an impact on these manifestations. The present study aims to report three cases with different diagnosis of acute kidney injury related to cocaine use. CASE PRESENTATION: Case 01 - A 30-year-old female patient, who regularly used cocaine, started to have lower-limb edema, which showed a progressive and ascending evolution, affecting the face a few days later, associated with an isolated febrile episode and oligoanuria. The presence of cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA) was verified: reactive 1:80, with renal biopsy compatible with rapidly progressive glomerulonephritis (RPGN). Case 02 - A 34-year-old female patient, with difficult-to-control hypertension and a frequent user of cocaine, showed generalized sudden edema together with diffuse and progressive pruritus associated with oliguria, fever, nausea, and vomiting. Schistocyte screening was positive, with negative direct Coombs test, and negative serologies for hepatitis B, C and HIV, as well as negative anti-double-stranded DNA, Anti-SSA and Anti-SSB. The renal biopsy was compatible with thrombotic microangiopathy, associated with moderate interstitial fibrosis and acute tubular necrosis Case 03 - A 25-year-old male patient who had been a cocaine user for 5 years had a sudden onset of generalized disabling myalgia (especially in the lower limbs) associated with recent frontotemporal headache, palpitation, dizziness, and a non-measured febrile episode; the patient had used cocaine at the night before symptom onset. CPK was 1731 U/L.The final probable diagnosis was AKI secondary to cocaine-induced rhabdomyolysis. CONCLUSIONS: In conclusion basically, 05 etiologies of acute kidney injury should always be remembered: rhabdomyolysis, thrombotic microangiopathy, vasculitis, acute interstitial nephritis and renal infarction. Emphasis should be given to rhabdomyolysis due to its higher prevalence. Considering the increasing rates of cocaine use, especially with the use of adulterating substances, these pathologies will likely be increasingly prevalent.

Prevalence of clinically validated primary causes of end-stage renal disease (ESRD) in a State Capital in Northeastern Brazil / Prevalência das causas primárias de doença renal crônica terminal (DRCT) validadas clinicamente em uma capital do Nordeste brasileiro

ABSTRACT Introduction: Knowledge of validated primary causes of end-stage renal disease (ESRD) is extremely relevant in the realm of public health. The literature lacks validated studies on the primary causes of ESRD. Objective: The aim of this study was to estimate the prevalence of the causes of ESRD in a State Capital in Northeastern Brazil. Methods: This cross-sectional study was based on the analysis of medical records of patients on hemodialysis at five specialized centers in Fortaleza, CE, Brazil. Deaths and patients referred to other centers outside Fortaleza were excluded from the study. The data of 830 patients were initially collected, but 818 remained enrolled after the exclusion criteria were applied, the equivalent to 48% of the patents on dialysis in the city. Results: 61.1% of the patients were males. Twenty-two percent of all enrolled individuals were aged 60-69 years. Patient mean age was 55.7 ± 16 years. The most common validated cause of ESRD was unknown (35.3%), followed by diabetes mellitus (26.4%), adult polycystic kidney disease (6.2%), graft failure (6.2%), obstructive uropathy (5.7%), and primary glomerulonephritis (5.3%). Before validation, primary hypertension was the most frequent cause of chronic kidney disease (22.9%), decreased to 3.8% after validation. Conclusion: The data contradicted national studies reporting primary hypertension as the main cause of chronic kidney disease (CKD). A high rate of unknown causes and categorization bias were observed mainly in relation to primary hypertension as a cause of CKD, which affects the overall prevalence of causes of ESRD in patients on dialysis.

RESUMO Introdução: O conhecimento das causas primárias, validadas, de doença renal crônica terminal (DRCT) é primordial no contexto epidemiológico da doença. Existe uma lacuna na literatura em termos de estudos validados sobre tais causas. Objetivo: Estimar a prevalência das causas de DRCT em uma capital do Nordeste brasileiro. Métodos: Estudo transversal baseado na análise dos prontuários de pacientes em hemodiálise de cinco centros especializados em Fortaleza, CE. Foram excluídos casos de óbito no período da coleta e de transferências para outras unidades fora do município em questão. Coletou-se dados de 830 pacientes, restando 818 após aplicação dos critérios de exclusão, o correspondente a 48% dos pacientes que dialisam na cidade. Resultados: Observou-se que 61,1% dos pacientes eram do sexo masculino. A faixa etária mais prevalente foi 60 a 69 anos, 22%. A idade média foi 55,7 ± 16 anos. A causa mais comum de DRCT pós-validação foi indeterminada, 35,3%; seguida por diabetes mellitus, 26,4%; doença renal policística do adulto, 6,2%; falência do enxerto, 6,2%; uropatia obstrutiva, 5,7%; e glomerulonefrite primária, 5,3%. Antes da validação, a hipertensão primária foi a causa mais frequente de DRCT, com 22,9%, e, após validação, caiu para 3,8%. Conclusão: Os dados contrariam estudos nacionais que afirmam que a primeira causa de DRCT seria hipertensão primária. Evidenciou-se alta taxa de causas desconhecidas e viés de classificação, principalmente com relação à HAS primária como causa de DRCT, o que afeta a prevalência geral das causas de DRCT dos pacientes em diálise.

Prevalence of clinically validated primary causes of end-stage renal disease (ESRD) in a State Capital in Northeastern Brazil.

INTRODUCTION: Knowledge of validated primary causes of end-stage renal disease (ESRD) is extremely relevant in the realm of public health. The literature lacks validated studies on the primary causes of ESRD. OBJECTIVE: The aim of this study was to estimate the prevalence of the causes of ESRD in a State Capital in Northeastern Brazil. METHODS: This cross-sectional study was based on the analysis of medical records of patients on hemodialysis at five specialized centers in Fortaleza, CE, Brazil. Deaths and patients referred to other centers outside Fortaleza were excluded from the study. The data of 830 patients were initially collected, but 818 remained enrolled after the exclusion criteria were applied, the equivalent to 48% of the patents on dialysis in the city. RESULTS: 61.1% of the patients were males. Twenty-two percent of all enrolled individuals were aged 60-69 years. Patient mean age was 55.7 ± 16 years. The most common validated cause of ESRD was unknown (35.3%), followed by diabetes mellitus (26.4%), adult polycystic kidney disease (6.2%), graft failure (6.2%), obstructive uropathy (5.7%), and primary glomerulonephritis (5.3%). Before validation, primary hypertension was the most frequent cause of chronic kidney disease (22.9%), decreased to 3.8% after validation. CONCLUSION: The data contradicted national studies reporting primary hypertension as the main cause of chronic kidney disease (CKD). A high rate of unknown causes and categorization bias were observed mainly in relation to primary hypertension as a cause of CKD, which affects the overall prevalence of causes of ESRD in patients on dialysis.

Dengue in renal transplant recipients: Clinical course and impact on renal function.

AIM: To present clinical characteristics from renal transplant recipients with dengue fever and its impact on graft function. METHODS: We retrospectively evaluated 11 renal transplant recipients (RTR) with dengue infection confirmed by laboratory test, between January 2007 and July 2012, transplanted in the Renal Transplant Center of Walter Cantídio University Hospital from Federal University of Ceará. RESULTS: Positive dengue serology (IgM) was found in all patients. The mean time between transplant and dengue infection was 43 mo. Fever was presented in all patients. Nine patients presented with classical dengue and two (18%) with dengue hemorrhagic fever. All cases had satisfactory evolution with complete recovery of the symptoms. The time for symptom resolution varied from 2 to 20 d, with an average of 9 d. An increase of creatinine after the infection was observed in three (27.2%) patients with no clinically impact on the kidney graft function. CONCLUSION: RTR with dengue infection seems to have a clinical presentation and evolution similar to those seen in the general population, with no long-term damage to patient and to the graft.

Early diagnosis of lip cancer preceded by a persistent actinic lesion in a kidney transplant patient: a case report.

Lip cancer is 65 times more likely to occur in kidney transplant patients than in members of the general population. Immunosuppression drugs taken by the transplant patients have been associated with this increased occurrence. This case report shows the progression from actinic cheilosis to squamous cell carcinoma (SCC) in the lower lip of a 58-year-old man receiving immunosuppressive therapy 9 years after undergoing a kidney transplant. Earlier incisional biopsies had resulted in a histological diagnosis of actinic cheilosis. However, the last incisional biopsy showed histological results compatible with SCC, and oncological surgery was performed. Eight months post-surgery, the patient was free of cancer and metastasis. Frequent dental follow-up visits allowed for the early diagnosis, proper treatment, and an improved prognosis for this patient.

Pharmaceutical care in transplant patients in a university hospital: pharmaceutical interventions

A descriptive and prospective study was conducted on the pharmaceutical care in the post-transplant outpatient clinic of Hospital Universitario Walter Cantidio of Universidade Federal do Ceará (HUWC/UFC), in Fortaleza- Ceará in the period of April to October of 2011. The aim of the present study was to describe the pharmaceutical interventions performed in a Pharmaceutical Care service structured in the liver and kidney transplant outpatient clinic of an academic hospital. The Pharmaceutical interventions (PI) were classified according to Sabater et al.(2005), with significance based on Riba et al.(2000) and the Negative Outcomes associated with Medication (NOM) established at the Third Consensus of Granada. Statistical analyses were performed using the Epi Info v.3.5.1 program and hypothesis tests were done with the SigmaPlot v.10.0 program. A chi-squared (X²) test was utilized for statistical analysis of the sample. A total of 97 patients were followed, where 54 problems related to medications were identified and 139 PI performed. The main PI were in education of the patient about treatment (n=111; 80%) (p<0.05), while the significance of all interventions were appropriate, where 83.4% (n=116) of PI performed in the study period were shown to be "significant" (p<0.05). Through pharmaceutical care, the pharmacist is capable of monitoring the pharmacotherapeutic treatment and intervening when necessary, while being part of the multiprofessional team caring for the transplant patient.

Trata-se de um estudo de descritivo e prospectivo, realizado durante o atendimento farmacêutico nos ambulatórios de pós-transplante do Hospital Universitário Walter Cantídio da Universidade Federal do Ceará (HUWC/UFC), em Fortaleza-Ceará no período de abril a outubro de 2011. O presente trabalho objetiva apresentar as intervenções farmacêuticas realizadas em um serviço de Atenção Farmacêutica (ATENFAR) estruturado nos ambulatórios do transplante hepático e renal de um Hospital Universitário. As intervenções farmacêuticas (IF) foram classificadas de acordo com Sabater et al.(2005), a significância baseadas em Riba et al.(2000) e os Resultados Negativos associados a Medicamentos (RNM) fundamentados no Terceiro Consenso de Granada. As análises estatísticas foram realizadas no programa Epi Info v.3.5.1 e os testes de hipótese foram feitos no programa SigmaPlot v.10.0. O teste estatístico utilizado para análise da amostra foi o qui-quadrado (X²). Foram acompanhados 97 pacientes, identificados 54 problemas relacionados aos medicamentos e realizadas 139 intervenções farmacêuticas. As principais IF realizadas foram na educação do paciente sobre o tratamento (n=111; 80%) (p<0,05), já enquanto a significância todas as intervenções foram apropriadas, sendo que 83,4% (n=116) das IF realizadas no período do estudo mostram ser "significantes" (p<0,05). O farmacêutico, através do exercício da ATENFAR, é capaz de monitorar o tratamento farmacoterapêutico e intervir, quando necessário, integrando-se a equipe multiprofissional no cuidado ao paciente transplantado.

Association between stress and breast cancer in women: a meta-analysis.

The objective of the current meta-analysis was to verify the association between stressful life events and primary breast cancer incidence in women. A total of 618 studies from 1982-2007 were found in the PubMed, LILACS, and Cochrane Library databases. Methodological quality was evaluated according to the Downs & Black criteria. Eight studies were selected (six case-controls and two cohorts). The studies were grouped in three analyses, two of which based on the categories widowhood and divorce and the other based on self-rated intensity and frequency of stressful events. Relative risks were: widowhood 1.04 (95%CI: 0.75-1.44; p = 0.800); divorce 1.03 (95%: 0.72-1.48; p = 0.850); and intensity/frequency of stress 1.73 (95%CI: 0.98-3.05; p = 0.059). We conclude that stressful life events as a whole are not associated with risk of breast cancer in women. However, it is not possible to rule out high-intensity stress as a risk factor for breast cancer.

Association between stress and breast cancer in women: a meta-analysis / Associação entre estresse e câncer de mama feminino: metanálise

The objective of the current meta-analysis was to verify the association between stressful life events and primary breast cancer incidence in women. A total of 618 studies from 1982-2007 were found in the PubMed, LILACS, and Cochrane Library databases. Methodological quality was evaluated according to the Downs & Black criteria. Eight studies were selected (six case-controls and two cohorts). The studies were grouped in three analyses, two of which based on the categories widowhood and divorce and the other based on self-rated intensity and frequency of stressful events. Relative risks were: widowhood 1.04 (95 percentCI: 0.75-1.44; p = 0.800); divorce 1.03 (95 percent: 0.72-1.48; p = 0.850); and intensity/frequency of stress 1.73 (95 percentCI: 0.98-3.05; p = 0.059). We conclude that stressful life events as a whole are not associated with risk of breast cancer in women. However, it is not possible to rule out high-intensity stress as a risk factor for breast cancer.

O objetivo da presente metanálise foi verificar a associação de eventos de vida produtores de estresse com a incidência primária do câncer de mama entre as mulheres. Foram encontrados 618 estudos nas bases PubMed, LILACS e Biblioteca Cochrane Library, no período de 1982-2007. A qualidade metodológica foi avaliada pelos critérios de Downs & Black. Foram selecionados oito estudos, sendo seis caso-controle e dois de coorte. Os estudos foram agrupados em três análises, duas em virtude das categorias viuvez e divórcio, e uma considerando a intensidade autopercebida e freqüência de eventos. O risco relativo em relação à viuvez foi 1,04 (IC95 por cento: 0,75-1,44; p = 0,800); ao divórcio foi 1,03 (IC95 por cento: 0,72-1,48; p = 0,850), e em relação ao grau intensidade/freqüência de estresse foi 1,73 (IC95 por cento: 0,98-3,05; p = 0,059). Concluímos que os eventos de vida produtores de estresse não têm associação de risco com câncer de mama feminino. O estresse de alta intensidade não permite eliminar a possibilidade de associação de risco para o câncer de mama.

Adesão ao tratamento farmacológico em pacientes com doença renal crônica / Medication compliance in patients with chronic kidney disease

Introdução: A não-adesão ao tratamento farmacológico prejudica o alcance dos resultados terapêuticos no retardo da progressão da doença renal crônica(DRC). O objetivo do presente estudo foi mensurar a prevalência da não-adesão ao tratamento farmacológico e avaliar os motivos apontados pelos pacientes para o comportamento não aderente. Método: Estudo transversal envolvendo 130 pacientes com DRC do ambulatório de nefrologia de um hospitaluniversitário, com idade média de 48,8 + 15,8 anos, em uso contínuo de algum medicamento anti-hipertensivo ou imunossupressor e que não estivessemsendo submetidos a qualquer terapia de substituição renal. A adesão foi mensurada através do método do auto-relato em uma entrevista com questionário. Foram considerados não aderentes pacientes que relataram ter ingerido menos de 80% dos comprimidos prescritos de pelo menos um medicamento. Foram coletados dados sociodemográficos, clínico-laboratoriais e os motivos alegados pelos pacientes para não aderir ao tratamento. Resultados: A prevalênciada não-adesão ao tratamento farmacológico foi de 18,5%. A falta de acesso aos medicamentos foi o motivo mais relatado pelos pacientes (54,5%) para a não-adesão. Não houve diferença estatisticamente significante entre a não-adesão ao tratamento com anti-hipertensivos e com imunossupressores.Discussão: Empregando o mesmo método, outros estudos encontraram prevalências de não-adesão ao tratamento da hipertensão e do diabetes variando entre 4% e 37,8%. Conclusões: Uma parcela significativa de pacientes estudados foi considerada não aderente ao tratamento farmacológico. A falta de acesso aos medicamentos permanece como uma causa de não-adesão, sugerindo a necessidade de melhorias na assistência farmacêutica.

Background: Medication noncompliance hinders the accomplishment of the therapeutic goals of delaying the progression of chronic kidney disease (CKD).The aim of the present study was to calculate the prevalence of medication noncompliance and to assess the reasons mentioned by the patients for theirnoncompliant behavior. Methods: A cross-sectional study was performed with 130 CKD patients from a nephrology outpatient university clinic, average age of 48.8 + 15.8 years old, continuously taking some self-administered antihypertensive or immunosuppressive drug and who were not on renal replacementtherapy. Noncompliance was measured through the self-reporting method (during an interview). Patients were considered noncompliant if they had taken less than 80% of the prescribed medication of any antihypertensive or immunosuppressive drug. Survey data showed sociodemographic, clinical, andlaboratorial characteristics and the reasons mentioned by the patients for their non-compliance. Results: Prevalence of medication noncompliance was 18.5%. Lack of access to medicine was the most commonly reported problem with medication use (54.5%). There was no statistically significant difference between the antihypertensive drug noncompliance and the immunosuppressive drug noncompliance. Discussion: Using the same method other studieshave reported prevalence of antihypertensive and hypoglycemic drug noncompliance ranging from 4 to 37.8%. Conclusions: A significant share of the studied patients was considered noncompliant to the pharmacotherapy. Lack of access to medicine remains as an important cause of medicationnoncompliance, suggesting the need for improvement in pharmaceutical assistance.