Photocatalytic activity enhancement of two-step and one-pot synthesis of Pd/ZnO nanocomposites: an experimental and DFT study.

Pd/ZnO nanocomposites were successfully synthesized by means of one and two pot synthesis and applied in the photodegradation of Rh6G. The nanocomposites were characterized by XRD, SEM, TEM, FTIR and micro-Raman spectroscopies. It was found the presence of PdZn2, PdO and agglomerated particles in the support surface for the Palladium-based nanocomposites fabricated by one-pot route; the two-step method allowed the formation of spherical Pd nanoparticles, with homogeneous distribution in the nanocomposite matrix, with an average size of 2.16 nm. The results show higher photocatalytic efficiency for the samples fabricated under the two-step approach compared to the one-pot synthesis. Based on experimental results, density functional theory (DFT) calculations were carried out to understand the enhancement photocatalytic of Pd/ZnO nanocomposites. To achieve it, the ZnO (001) and (101) surfaces were built and decorated by different Pd coverages. The theoretical results indicated two different photocatalytic mechanisms. In ZnO (001) case, the electrons flowed from surface to Pd, generating the superoxide radical anion (⋅O2-). Furthermore, the density of states of the ZnO (001) surface was modified by impurity Pd-d states at proximity to the conduction states, which may work as electron acceptors states. On the other hand, we found that the electrons flow from Pd to ZnO (101) surface, inducing the formation of ⋅OH and ⋅O2- for the degradation of Rh6G. The density of states of the ZnO (101) revealed a reduction in its bandgap, due to Pd-d states localized above valence states. Hence, our theoretical results suggest that the Pd-d states may facilitate the mobility of electrons and holes in (001) and (101) surfaces, respectively, reducing the rate of charge recombination.

Hepatocellular Carcinoma in Ceará: Epidemiology and Treatment in a Reference Liver Transplant Center in Northeast Brazil.

Hepatocellular carcinoma remains a significant worldwide malignancy and an important cause of cancer-related death. The incidence is increasing globally. In Latin America, there is no consistent data on the epidemiology of hepatocellular carcinoma. However, Brazil is considered a country with an intermediate incidence of this liver neoplasm. In the state of Ceará, situated in the northeast region of Brazil, there are no consistent clinical and epidemiologic data on the actual incidence and the treatment of hepatocellular carcinoma. The purpose of this article is to describe epidemiologic characteristics and treatment forms of patients with hepatocellular carcinoma who were treated in a Liver Transplant Center. A retrospective observational study was conducted using the database from the register of 299 patients with hepatocellular carcinoma between June 2004 and February 2022. Only patients born in Ceará were included. Therefore, most patients were eligible, based on the Milan Criteria, to undergo liver transplantation with a Model End Stage Liver Disease score of 12.48 ± 4.66 points, and the waiting list time was approximately 7 months with 8.7% hepatocellular carcinoma recurrence after liver transplant. A total of 38.5 % of cases were outside the Milan criteria at the time of cancer diagnosis, and transarterial chemoembolization was the main treatment choice. In conclusion, the diagnosis of hepatocellular carcinoma in Ceará mainly occurs in male patients with hepatitis C or alcoholism, with a mean age of 61.55 years and a previous diagnosis of liver disease. Liver transplantation was the best curative therapeutic form in patients with cirrhosis and hepatocellular carcinoma in Ceará, where a significant number of patients were diagnosed with intermediate and advanced-stage hepatocellular carcinoma, so public health policies are important for the screening and monitoring of liver disease.

Portable gamma-camera for the diagnosis of brain death diagnosis. / Minigammacámara portátil para el diagnóstico de muerte encefálica.

OBJECTIVE: To evaluate the feasibility of using the Sentinella® portable gamma-camera for the diagnosis of brain death (BD). DESIGN: A prospective, observational feasibility study was carried out. SETTING: Intensive Care Unit of a third level hospital. PATIENTS: Consecutive recording was made of the adults diagnosed with brain death based on clinical criteria following admission to the Intensive Care Unit in the period from January to December 2017. INTERVENTIONS: The procedure was performed at the patient bedside with the intravenous administration of technetium 99 metastable hexamethylpropylene amine oxime. The absence of perfusion in the cerebral hemispheres and brainstem was described as a pattern consistent with BD. The diagnosis was correlated to the transcranial Doppler and / or electroencephalographic findings. RESULTS: A total of 66.1% of the patients were men with an average age of 60 years [IQR: 51-72]. The most frequent causes resulting in BD were hemorrhagic stroke (48.2%, n=27), followed by traumatic brain injury (30.4%, n=17), ischemic stroke (10.7%, n=6) and post-cardiac arrest anoxic encephalopathy (7.1%, n=4). A clinical diagnosis of BD was made in all cases, and the portable gamma-camera confirmed the diagnosis in 100% of the patients with a pattern characterized by the absence of brain perfusion. In addition, the results were compared with the transcranial Doppler findings in 46 patients, confirming the presence of diastolic reverberation and / or systolic peaks. The electroencephalographic tracing was obtained in 10 cases, with the appearance of electrical silence, due to the absence of an acoustic window in the transcranial Doppler study. CONCLUSIONS: A portable gamma-camera could be a useful and feasible tool for the diagnosis of BD.

Practical document on the management of hyponatremia in critically ill patients. / Documento práctico del manejo de la hiponatremia en pacientes críticos.

Hyponatremia is the most prevalent electrolyte disorder in Intensive Care Units. It is associated with an increase in morbidity, mortality and hospital stay. The majority of the published studies are observational, retrospective and do not include critical patients; hence it is difficult to draw definitive conclusions. Moreover, the lack of clinical evidence has led to important dissimilarities in the recommendations coming from different scientific societies. Finally, etiopathogenic mechanisms leading to hyponatremia in the critical care patient are complex and often combined, and an intensive analysis is clearly needed. A study was therefore made to review all clinical aspects about hyponatremia management in the critical care setting. The aim was to develop a Spanish nationwide algorithm to standardize hyponatremia diagnosis and treatment in the critical care patient.

Outcomes of Liver Transplant Recipients With Model for End-Stage Liver Disease Exception: Single-Center Experience in the Northeast of Brazil.

The Model for End-Stage Liver Disease (MELD) exception policy in liver transplantation is based on symptoms and clinical conditions not included in the calculated MELD score. Therefore, patients with chronic liver disease, like refractory ascites, chronic encephalopathy, recurrent cholangitis, and refractory pruritus, may benefit with extra points. The objective of this study was to establish the profile of the patients submitted to liver transplantation with MELD exceptions based on symptoms in the University Hospital Walter Cantídio, Ceara, Brazil, between the years of 2012 and 2015, analyzing donor and recipient data, with special attention to patients with refractory ascites and recurrent encephalopathy, including survival rates. The results demonstrated acceptable survival rates for MELD exception patients (78.4% in 3 years), showing that maybe this allocation criterion should be maintained, or even expanded.

Finite-size correction scheme for supercell calculations in Dirac-point two-dimensional materials.

Modern electronic structure calculations are predominantly implemented within the super cell representation in which unit cells are periodically arranged in space. Even in the case of non-crystalline materials, defect-embedded unit cells are commonly used to describe doped structures. However, this type of computation becomes prohibitively demanding when convergence rates are sufficiently slow and may require calculations with very large unit cells. Here we show that a hitherto unexplored feature displayed by several 2D materials may be used to achieve convergence in formation- and adsorption-energy calculations with relatively small unit-cell sizes. The generality of our method is illustrated with Density Functional Theory calculations for different 2D hosts doped with different impurities, all of which providing accuracy levels that would otherwise require enormously large unit cells. This approach provides an efficient route to calculating the physical properties of 2D systems in general but is particularly suitable for Dirac-point materials doped with impurities that break their sublattice symmetry.

Protocolos para evaluación de desempeño en equipos médicos / Protocols for performance evaluation in medical equipment / Protocolos para avaliação de desempenho em equipamentos médicos

Resumen Las instituciones prestadoras de servicios de salud deben disponer de un control de calidad para los equipos médicos que garantice total confiabilidad en su funcionamiento y resultados, logrando el cumplimiento de los requisitos establecidos por las especificaciones técnicas y normas. En este contexto, las pruebas de desempeño en equipos biomédicos evalúan el desempeño, funcionamiento y cumplimiento de especificaciones de estos para brindar información confiable sobre su funcionamiento. En este trabajo se desarrolla un protocolo de evaluación de equipos médicos que permite cuantificar su desempeño, para esto se tiene en cuenta la información general del equipo, su estado y recomendaciones del fabricante entre otros; obteniendo un protocolo que pueda ser aplicado a diferentes tipos de equipos y que brinde información confiable y objetiva, en función de todos los aspectos que involucran su funcionamiento.

Abstract Healthcare service providers must count on the availability of quality control for their medical equipment which will assure total reliability in its operation, as well as results, thus complying with technical specifications and standards. Within this study, a medical equipment evaluation protocol is developed to quantify said equipment performance. In this context, performance tests in biomedical equipment assess the performance, operation, and compliance of biomedical equipment specifications to provide reliable information on its performance. This paper develops a protocol of evaluation for medical equipment that enables the quantification of its performance. To achieve this, it takes into account the general information of the equipment, its condition, as well as, manufacturer recommendations, among others, obtaining a protocol that can be applied to different types of equipment and that provides reliable and objective information, in terms of all the aspects that involve its operation.

Resumo As instituições prestadoras de serviços de saúde devem dispor de um controle de qualidade para as equipas médicas que garanta total fiabilidade em seu funcionamento e resultados, conseguindo o cumprimento dos requisitos estabelecidos pelas especificações técnicas e normas. Neste contexto, as provas de desempenho em equipas biomédicos avaliam o desempenho, funcionamento e cumprimento de especificações destes para brindar informação confiável sobre seu funcionamento. Neste trabalho desenvolve-se um protocolo de avaliação de equipamentos médicos que permite quantificar seu desempenho, para isto se tem em conta a informação geral do equipamento, seu estado e recomendações do fabricante entre outros; obtendo um protocolo que possa ser aplicado a diferentes tipos de equipamentos e que brinde informação confiável e objetiva, em função de todos os aspectos que envolvem seu funcionamento.

Chikungunya Infection in Solid Organ Transplant Recipients.

BACKGROUND: Chikungunya virus (CHIKV) is an emerging mosquito-borne disease that causes acute febrile polyarthralgia and arthritis. CHIKV has spread rapidly to the Americas and, in Brazil, autochthonous cases are increasingly been reported. Solid organ transplant (SOT) recipients who travel to or live in CHIKV endemic areas are under high risk of acquiring the disease. Few data exist regarding the clinical characteristics of CHIKV infections in this population. We report the first case series of CHIKV infection in SOT recipients. METHODS: We retrospectively evaluated 13 cases of CHIKV infection in SOT recipients between January 2016 and December 2016 confirmed by laboratory tests and transplanted in the Renal and Liver Transplant Units of Walter Cantídio University Hospital from Federal University of Ceará. RESULTS: Positive CHIKV serology (enzyme-linked immunosorbent assay immunoglobulin M) was found in all patients (9 kidney and 4 liver transplant recipients). All of these patients had been living in endemic areas for dengue and CHIKV in the past months before the illness. The mean time between transplantation and CHIKV infection was of 7.2 years. Fever presented in 11 (84.6%) patients and 5 (38.5%) presented with a maculopapular rash. All cases had joint symptoms: 11 (84.6%) with symmetrical and peripheral polyarthralgia/polyarthritis and 2 (15.3%) with monoarthralgia/monoarthritis. Six (46%) patients had a joint complaint that lasted 3 months. Two patients had concomitant positive dengue serology (enzyme-linked immunosorbent assay immunoglobulin M). There were no cases of complications or deaths. CONCLUSION: SOT with CHIKV infection seems to have a clinical presentation and evolution similar to those seen in the general population, with no apparent damage to the graft.

Diseño de modelo de capacitación en procesos asistenciales relacionados con dispositivos médicos / Training model design in healthcare services involving medical devices / Desenho de modelo de capacitação em processos assistenciais relacionados com dispositivos médicos

El continuo mejoramiento de la calidad en la atención en salud evidencia la necesidad de ejecutar planes constantes de capacitación al personal asistencial, tanto en procesos institucionales como en uso seguro de tecnologías biomédicas. Para ello se requiere definir el personal que garantice la implementación de las capacitaciones sin afectar la prestación de servicios de salud de la institución, considerando el número de personas a capacitar y los servicios a los cuales pertenecen, el tiempo necesario para capacitarlo en un tema, y el tamaño de los grupos de trabajo del personal asistencial. En este artículo se presenta un modelo de capacitaciones dirigido al personal asistencial, diseñado a partir de modelos instruccionales que favorecen la formación del conocimiento y habilidades, sustentado en el modelo pedagógico de la Universidad de Antioquia y la metodología Análisis, Diseño, Desarrollo, Implementación y Evaluación. El modelo presentado entrega los parámetros para diseñar un plan de capacitaciones que permita impactar sobre el personal asistencial, sin afectar los servicios de la institución, y que esto se refleje en la calidad de la atención en salud.

The continued improvement of quality in health care services evidences the need to implement regular training plans for nursing staff, both in institutional programs and safe use of health care technology. It is thus necessary to establish a training team to guarantee that implementation of the training does not affect the institution's provision of health care services, considering the number of people to train and the departments to which they belong, the time necessary to train the staff on a subject, and the nursing staff working group's size. This article presents a training model for nursing staff based on instructional models that encourage the construction of knowledge and skills, themselves based on the pedagogical model of the University of Antioquia and the Analysis, Design, Development, Implementation and Evaluation methodology. The model presented provides the parameters to design a training plan that impacts nursing staff without affecting the institution's services, and which is reflected in the quality of health care.

A contínua melhoria da qualidade na atenção em saúde evidência a necessidade de executar planos constantes de capacitação ao pessoal assistencial, em processos institucionais como no uso seguro de tecnologias biomédicas. Para isso, se requer definir o pessoal que garanta implementar as capacitações sem afetar a prestação de serviços de saúde da instituição, considerando o número de pessoas para capacitar e os serviços aos quais pertencem, o tempo necessário para capacitá-lo num tema, e o tamanho dos grupos de trabalho do pessoal assistencial. Neste artigo apresenta-se um modelo de capacitações dirigido ao pessoal assistencial, desenhado a partir de modelos instrutivos que favorecem a formação do conhecimento e habilidades, sustentado no modelo pedagógico da Universidade de Antioquia e a metodologia Análise, Desenho, Desenvolvimento, Implementação e Avaliação. O modelo apresentado entrega os parâmetros para desenhar um plano de capacitações que permita impactar sobre o pessoal assistencial, sem afetar os serviços da instituição, e que isto se reflita na qualidade da atenção em saúde.

Liver Transplantation in Patients With Niemann-Pick Disease--Single-Center Experience.

Niemann-Pick disease (NPD) is a rare syndrome caused by abnormal intracellular sphingomyelin lipid storage in cells known as "Pick cells." NPD can start in childhood or develop insidiously, with a predilection for reticuloendothelial cells and the nervous system. NPD is a heterogeneous clinical, and biomolecular disorder which has 6 variants. There is no curable treatment for NPD. Generally, the treatment for all types of Niemann-Pick disease is to support. Type B NPD (NPD-B) is mostly characterized by hepatosplenomegaly, which can evolve to hepatic cirrhosis. In patients who progress to liver failure, liver transplantation may be improve liver function. The Transplant Service of Hospital Universitário Walter Cantídio performed its first liver transplants in patients with NPD-B with good results, demonstrating the efficacy of this procedure in selected cases.

STUDY OF THE EVALUATION PROCESS OF CLASS II DEVICES IN THE UNITED STATES AND THE RELATION WITH THE ORIGIN AND PREPARATION OF THE MANUFACTURERS / ESTUDIO DEL PROCESO DE EVALUACIÓN DE DISPOSITIVOS DE CLASE II EN LOS ESTADOS UNIDOS Y LA RELACIÓN CON EL ORIGEN Y LA PREPARACIÓN DE LOS FABRICANTES / ESTUDO DO PROCESSO DE AVALIAÇÃO DE DISPOSITIVOS DE CLASSE II NOS ESTADOS UNIDOS E DA RELAÇÃO COM A ORIGEM E DESENVOLVIMENTO DE FABRICANTES

The global production of medical devices has increased due to growth in developing countries, hence the evaluation of pre marketing medical devices is needed to provide safety for patients and operators of such technology. In the US evaluation of medical devices is done before marketing depending on the type of device to be introduced. To market Class II devices the developer must present the application 510 (k) by which a study of "approval" of the new device is made to an existing one. However, many producers from different countries take more time to fulfill the requirements of the study indicating that they might not be fully prepared. This article aims to return the number of devices, the duration of study time and device manufacturer's countries applying the study to know the countries that are best prepared in assessing their technology. A database of the FDA was used to establish the countries applying the test 510 (k). A hierarchical classification of countries by discriminating variables as the average length of study and number of studies requested by each country was used. Three groups of countries which are discriminated according to the study duration and the number of devices presented were classified. The first group contains countries that had large amounts of equipment evaluation and had short duration of the study period. Such countries are traditionally recognized as strong producing countries of medical devices. The second group is contrary to the first, countries that submitted few devices and the duration of the study was higher indicating that they are not well prepared for technology assessment. The third group presents variability in the amount of devices presented; however the duration of the study is relatively constant for all countries in this group, which can be classified as developing countries for the production of medical devices. It is necessary to strengthen the production of Class II medical devices in Latin America. The duration of the studies evaluating devices is a great source of information to predict the best prepared countries when assessing their technology manufacturers.

La producción mundial de dispositivos médicos ha aumentado debido al crecimiento en los países en desarrollo, por lo tanto, es necesaria la evaluación de los productos sanitarios previos al ingresar al mercadeo para proporcionar seguridad a los pacientes y a los operadores de este tipo de tecnología. En los EEUU la evaluación de dispositivos médicos se hace antes de la comercialización en función del tipo de dispositivo a ser introducido. Para la comercialización de dispositivos de Clase II el promotor debe presentar la solicitud 510 (k) por la que se hace un estudio de "aprobación" del nuevo dispositivo a uno ya existente. Sin embargo, muchos productores de diferentes países toman más tiempo para cumplir con los requisitos del estudio indicando que no están preparados por completo. Este artículo tiene como objetivo analizar el número de dispositivos devueltos, la duración del tiempo de estudio y los países del fabricante del dispositivo que aplican al estudio para conocer los países que están mejor preparados para evaluar su tecnología. Se utilizó una base de datos de la FDA para establecer los países que aplican la prueba de 510 (k). Se utilizó una clasificación jerárquica de los países discriminando variables como la duración media de estudio y el número de estudios solicitados por cada país. Tres grupos de países fueron clasificados divididos de acuerdo a la duración del estudio y el número de dispositivos presentados. El primer grupo contiene países que tenían grandes cantidades de evaluación de equipos y tuvieron corta duración en el período de estudio. Esos países son tradicionalmente reconocidos como países productores fuertes de dispositivos médicos. El segundo grupo es contrario al primero, los países que presentaron dispositivos y la duración del estudio fue mayor, lo que indica que no están bien preparados para la evaluación de la tecnología. El tercer grupo presenta una variabilidad en la cantidad de dispositivos presentados, sin embargo, la duración del estudio es relativamente constante para todos los países de este grupo, que pueden ser calificados como los países en desarrollo para la producción de dispositivos médicos. Es necesario fortalecer la producción de dispositivos médicos de Clase II en América Latina. La duración de los estudios de evaluación de dispositivos es una gran fuente de información para predecir los países mejor preparados en la evaluación de sus fabricantes de tecnología.

A produção mundial de dispositivos médicos tem aumentado devido ao crescimento nos países em desenvolvimento, portanto, a avaliação de dispositivos médicos antes da comercialização é necessário para garantir a segurança para pacientes e operadores deste tipo de tecnologia. Nos EEUU a avaliação do dispositivo médico é feito antes da comercialização de acordo com o tipo de dispositivo a ser introduzido. Para a comercialização de dispositivos de Classe II o promotor deve apresentar a solicitação 510 (k) com a qual se faz um estudo de "aprovação" do novo dispositivo a um já existente. No entanto, muitos produtores de diferentes países levam mais tempo para cumprir os requisitos do estudo indicando que eles não estão completamente despreparados. Este artigo tem por objetivo analisar o número de dispositivos devolvidos, a duração do tempo do estudo e os países do fabricante do dispositivo que aplicam o estudo para determinar os países que estão em melhores condições para avaliar a sua tecnologia. Um banco de dados do FDA foi usado para estabelecer os países que aplicam o teste de 510 (k). Foi utilizada uma classificação hierárquica dos países que discriminam variáveis, tais como a duração média de estudo e número de estudos solicitados por cada país. Três grupos de países foram classificados divididos de acordo com a duração do estudo e o número de dispositivos apresentados. O primeiro grupo composto por países com grandes quantidades de avaliação de equipamentos e que tiveram uma curta duração no período de estudo. Estes países são tradicionalmente reconhecidos como fortes países produtores de dispositivos médicos. O segundo grupo é contrário ao primeiro, os países que apresentaram os dispositivos e da duração do estudo foi maior, indicando que eles não estão bem preparados para a avaliação da tecnológica. O terceiro grupo apresenta uma variabilidade do número de dispositivos apresentados, no entanto, a duração do estudo é relativamente constante para todos os países neste grupo, podem ser classificados como países em desenvolvimento, para a produção de dispositivos médicos. É necessário reforçar a produção de dispositivos médicos da classe II na América Latina. A duração dos estudos de avaliação de dispositivos é uma grande fonte de informação para prever o melhor preparado para avaliar fornecedores de tecnologia.

ADAPTACIÓN DE UNA METODOLOGÍA PARA LOS PROCESOS DE ADQUISICIÓN DE SISTEMAS DE AIRE ACONDICIONADO EN SERVICIOS DE SALUD / ADAPTATION OF A METHODOLOGY FOR PROCUREMENT PROCESSES OF AIR CONDITIONING SYSTEMS IN HEALTH SERVICES / ADAPTAÇÃO DE UMA METODOLOGIA PARA OS PROCESSOS DE AQUISIÇÃO DE SISTEMAS DE AR CONDICIONADO NOS SERVIÇOS DE SAÚDE

La adquisición efectiva de tecnologías en salud está enfocada al mejoramiento de la calidad y eficiencia, en la prestación de los servicios de salud ya que es un proceso complejo. Dentro de este proceso se destacan la evaluación técnica y clínica. El objetivo de la evaluación de tecnologías en salud es recolectar, analizar y sintetizar información y conocimiento para contribuir a mejorar la toma de decisiones en la práctica médica y en las políticas de salud. En este trabajo se presenta una evaluación en procesos de adquisición de sistemas de aire acondicionado en servicios de salud, basada en la definición de variables en campos de evaluación; dichas variables cuantifican lo técnico y funcional del equipo en su entorno clínico y económico. De igual manera, se pretende impulsar en los departamentos de ingeniería clínica la implementación de metodologías de amplia aceptación y efectividad que tienen como objetivo primordial la adquisición de tecnologías en salud basados en la evidencia.

The effective acquisition of health technologies is focused on improving the quality and efficiency in the provision of health services as it is a complex process. Within this process the technical and clinical evaluation are highlighted. The objective of the health technology assessment is to collect, analyze, and synthesize information and knowledge to help improve decisionmaking in medical practice and health policy. This paper presents an evaluation process of acquiring air conditioning systems in health care facilities, based on the definition of variables into a field evaluation; these variables quantify the technical and functional team in their clinical and economic environment. Similarly, it is intended to promote in clinical engineering departments, the implementation of widely accepted methodologies and effectiveness that have, as its primary objective, the acquisition of technologies in evidence-based health.

A aquisição efetiva das tecnologias da saúde é focada na melhoria da qualidade e eficiência na prestação de serviços de saúde, pois é um processo complexo. Dentro deste processo se destaca a avaliação técnica e clínica. O objetivo da avaliação de tecnologias em saúde é coletar, analisar e sintetizar informações e conhecimentos para ajudar a melhorar a tomada de decisão na prática médica e a política de saúde. Neste trabalho se apresenta um processo de avaliação de aquisição de sistemas de ar condicionado nos serviços de saúde, com base na definição de variáveis no campo da avaliação; essas variáveis vão quantificar o técnico e o funcional do equipamento em seu ambiente clínico e econômico. Da mesma forma, pretende-se promover nos departamentos clínicos de engenharia a aplicação de metodologias amplamente aceitas e eficácia que têm como objetivo principal a aquisição de tecnologias em saúde baseada em evidências.

L-Alanyl-Glutamine Attenuates Oxidative Stress in Liver Transplantation Patients.

BACKGROUND: Ischemia/reperfusion injury during liver transplantation can cause severe damage to the graft. The objective of this randomized, double-blind study was to evaluate the possible protective effects of L-alanyl-glutamine on the liver graft. METHODS: The sample included 33 patients from a liver transplantation service in Northeastern Brazil. Before cold ischemia, the patients received 50 g of L-alanyl-glutamine (treatment group) or saline (control group) through the portal vein. The graft was biopsied at the time of recovery, at the beginning of warm ischemia, and at the end of transplantation to determine malondialdehyde (MDA), heat-shock protein (Hsp)70, nuclear factor kappa-beta (NFkB), superoxide dismutase (SOD), and reduced glutathione (GSH) levels. RESULTS: The blood parameters were similar in the two groups. In the treatment group, MDA did not increase at the beginning of cold ischemia and decreased at the end of transplantation. This phenomenon was not observed in the control group. GSH, SOD, Hsp70, and NFkB levels were similar in the two groups. CONCLUSIONS: Our findings suggest that preconditioning with L-alanyl-glutamine attenuates the effects of ischemia/reperfusion-related oxidative stress and reduces lipid peroxidation in the grafts of liver transplantation patients.

Severe Acute Anemia After Liver Transplantation in an Elderly Jehovah's Witness Treated With High-dose Erythropoietin and Ferric Carboxymaltose: A Case Report.

BACKGROUND: There is no standard treatment for patients with severe anemia who refuse blood transfusion or cannot receive red blood cells. CASE REPORT: After an orthotopic liver transplantation, an elderly Jehovah's Witness who refused blood transfusion presented with severe acute anemia with hemorrhagic shock. The calculated red blood cell loss was near 70%. Associated with surgical treatment and supportive measures, the patient was treated with high-dose erythropoietin and ferric carboxymaltose. RESULTS: The patient presented a rapid increase in hemoglobin concentration and reticulocyte count with resolution of hemorrhagic shock after the proposed pharmacologic treatment combined with local hemostatic measures. She was transferred to a low-risk unit 4 days after transplantation and was discharged from the hospital on day 10. The hemoglobin concentration was normal 35 days after the bleeding event. CONCLUSION: This case demonstrated that a protocol with high-dose erythropoietin and ferric carboxymaltose may be an option for patients with severe anemia who refuse blood transfusion or cannot receive red blood cells.

Ten-year experience with liver transplantation for hepatocellular carcinoma in a Federal University Hospital in the Northeast of Brazil.

Hepatocellular carcinoma (HCC) is the most frequent and important primary liver tumor, with annual worldwide incidence of over 1 million cases, accounting for at least 500,000 deaths per year. The majority of cases of HCC occur in the setting of liver cirrhosis. In this retrospective, descriptive, and analytical study, between May 2002 and April 2012, 664 liver transplantations (LT) were conducted at a Federal University Hospital in the Northeast of Brazil, among which 140 LT were performed in patients with HCC. The tumor was more frequent in men with an average age of 56 years and infected with hepatitis C virus, many with a history of alcohol abuse. Alpha-fetoprotein was not useful in the diagnosis, and imaging methods have failed to diagnose the nodules in 19 patients (13.6%). Transarterial chemoembolization was the most-used bridging therapy to inhibit tumor growth for patients with HCC eligible for transplantation. The implementation of the Model for End Stage Liver Disease score in 2006 brought benefits to these patients. The rate of HCC recurrence after LT was 8.57% and occurred more often in the first 2 years after transplantation, with the liver graft being the most common site. Significant risk factors for recurrence were a long time on the LT waiting list, number of liver nodules over 3.5, and the presence of vascular invasion. In conclusion, LT for HCC leads to excellent long-term survival, with relatively few patients dying from tumor recurrence.

Results from a liver transplant center in northeastern Brazil that performed more than 100 transplants in 2011.

BACKGROUND: Orthotopic liver transplantation is an essential approach performed in several centers around the world. Our center lies in northeastern Brazil and has performed this procedure since 2002. In 2011, 126 liver transplants were performed at our institution. METHODS: This study is a retrospective and descriptive analysis of the data collected from the medical records of those transplants. Epidemiological and clinical aspects were considered in this evaluation. The outcome analysis considered overall survival rates within 30 days and 1 year after transplantation. RESULTS: The sample of 124 patients showed 60% of all patients came from other regions, particularly the North and Midwest regions of Brazil, which had a combined population of >30 million in 2011. The most frequent etiologies for end-stage liver disease were hepatitis C and alcoholism. The average calculated MELD (Model for end-stage liver disease) was 21.0. Patient survival curves were 88.4% after 30 days and 81.5% after 1 year. CONCLUSION: The development of effective perioperative management for this procedure resulted in improved outcomes. Our center's performance is based on a multidisciplinary approach performed by qualified personnel, careful pre- and postoperative follow-up and continuous improvement of services.

[Markers for early detection of alterations in carbohydrate metabolism after acute myocardial infarction]. / Marcadores para la detección precoz de las alteraciones del metabolismo hidrocarbonado tras un infarto agudo de miocardio.

OBJECTIVES: Undiagnosed abnormal glucose metabolism is often seen in patients admitted with acute myocardial infarction, although there is no consensus on which patients should be studied with a view to establishing an early diagnosis. The present study examines the potential of certain variables obtained upon admission to diagnose abnormal glucose metabolism. DESIGN: A prospective cohort study was carried out. SETTING: The Intensive Care Unit of Arrixaca University Hospital (Murcia), Spain. PATIENTS: A total of 138 patients admitted to the Intensive Care Unit with acute myocardial infarction and without known or de novo diabetes mellitus. After one year, oral glucose tolerance testing was performed. MAIN OUTCOMES: Clinical and laboratory test parameters were recorded upon admission and one year after discharge. Additionally, after one year, oral glucose tolerance tests were made, and a study was made of the capacity of the variables obtained at admission to diagnose diabetes, based on the ROC curves and multivariate analysis. RESULTS: Of the 138 patients, 112 (72.5%) had glucose metabolic alteration, including 16.7% with diabetes. HbA1c was independently associated with a diagnosis of diabetes (RR: 7.28, 95%CI 1.65 to 32.05, P = .009), and showed the largest area under the ROC curve for diabetes (0.81, 95%CI 0.69 to 0.92, P = .001). CONCLUSIONS: In patients with acute myocardial infarction, HbA1c helps identify those individuals with abnormal glucose metabolism after one year. Thus, its determination in this group of patients could be used to identify those subjects requiring a more exhaustive study in order to establish an early diagnosis.

Single-center transfusion rate for 555 consecutive liver transplantations: impact of two eras.

Orthotopic liver transplantation (OLT) is the treatment of choice for patients with acute or chronic end-stage liver disease, irresectable primary liver tumor, and metabolic disorders. Historically, OLT has been associated with considerable blood loss and the need for transfusions. However, over the years there has been reduction is need for blood products. The aim of this article was to compare two distinct eras for perioperative blood transfusion rate among patients undergoing OLT; Era I, 200 transplantations in 188 patients, and Era II, 355 transplantations in 339 patients. The donor mean age was 33.70 (Era I) versus 35.34 (Era II). Cause of death in both eras was traumatic brain injury followed by cerebral vascular accident. Organ recipient data showed a mean age of 48.87 (Era I) versus 46.49 (Era II). During Era I patients with Child B (56.8%) prevailed, followed by Child C (35.4%) and Child A (7.8%). In Era II also patients with Child B (53.1%) prevailed, followed by Child C (39.6%) and Child A (7.3%). The prevalence of hepatocellular carcinoma (HCC) during Era I was 9% (18) and in Era II 20% (71). The use of blood products in the perioperative period: was as follows packed red blood cells 1.76 (Era I) versus 0.57 (Era II) units; fresh frozen plasma 1.89 (Era I) versus 0.49 (Era II) units; platelets 2.16 (Era I) versus 0.28 (Era II) units; and cryoprecipitate 0.08 (Era I) versus 0.03 (Era II) units. OLT using the piggyback technique was performed with a transfusion rate below <30%, and it reduced blood loss and prevented severe hemodynamic instability.

[Drug treatment adjustment to the clinical guidelines in octagenarians with acute myocardial infarction]. / Ajuste del tratamiento farmacológico a las guías de práctica clínica en pacientes octogenarios con infarto agudo de miocardio.

OBJECTIVES: To determine whether there is a linear association of age and aspirin, betablockers, angiotensin-converting enzyme inhibitors and statins; the extent to which elderly patients receive these treatments; and whether age is independently associated with these treatments. DESIGN: A prospective cohort study. SETTING: Coronary Unit of two hospitals in the Region of Murcia (Spain). PATIENTS: Consecutive patients admitted with the diagnosis of acute myocardial infarction between January 1998 and January 2008. INTERVENTIONS: None. MAIN OUTCOMES: Those related to the administration of aspirin, betablockers, angiotensin-converting enzyme inhibitors and statins during stay in the Coronary Care Unit. RESULTS: Regarding the remaining patients, octogenarians received a similar proportion of angiotensin-converting enzyme inhibitors (70.8% vs. 69.3%, p=0.41) and less often aspirin (90.4% vs. 94.6%, p<0.001), betablockers (44.4% vs. 69.4%, p<0,001) and statins (47.6% vs. 64.7%, p<0.001). We were only able to demonstrate an abrupt and significant decrease in the use of statins after 80 years of age. Patient age was independently associated with the use of betablockers (OR 0.59; 95%CI 0.47 - 0.73) and statins (OR 0.78; 95%CI 0.65 - 0.95). The lesser administration of these drugs was also associated with early mortality (OR 0.17, 95%CI 0.09 to 0.33 and OR 0.14; 95%CI 0.08 to 0.23, respectively). CONCLUSIONS: Octogenarians less often receive aspirin, betablockers and statins, though old age was not an independent factor associated with lesser aspirin use.