Late-onset biopsy-proven lupus nephritis without other associated autoimmune diseases: severity and long-term outcome.

BACKGROUND/PURPOSE: Lupus nephritis (LN) usually develops within the first years of systemic lupus erythematosus (SLE) onset and rarely after that. There are scarce studies comparing early- versus late-onset nephritis (before versus after five years of SLE diagnosis). The aim of this study was to compare the severity and long-term outcome (after 7 years) in these two, late-onset and early-onset, nephritis groups. METHODS: This study included 93 patients from rheumatology tertiary centers from Brazil and Italy, all of them with biopsy-proven LN with > 7 years follow-up. Patients were divided in two groups: early-onset nephritis ( n = 75) and late-onset nephritis ( n = 18). Clinical and laboratorial data were obtained using a standardized electronic chart database protocol carried out at 1-6 months interval and established in 2000. Patients >50 years or with concomitant autoimmune diseases were excluded. Variables evaluated at the LN presentation were Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), creatinine, albumin, anti-DNA positivity and nephritis class. Variables evaluated at the long-term outcome (after 7 years) were Systemic Lupus International Collaborating Clinics Damage Index (SDI), creatinine, dialysis and mortality. RESULTS: The average time of LN presentation was 10.94 ± 3.73 years for the late-onset and 1.20 ± 1.60 years for the early-onset group. Their similar nephritis duration (12.44 ± 3.2 versus 13.28 ± 4.03 years, p = 0.41) and comparable mean ages (49.17 ± 9.9 versus 44.11 ± 10.8 years old, p = 0.06) allow a more accurate comparison. Regarding severity, late-onset was similar to early-onset group: SLEDAI (8 (range: 6-22) versus 12 (range: 2-24), p = 0.47), creatinine (1.36 ± 0.94 versus 1.36 ± 1.13 mg/dl, p = 0.99); albumin (2.84 ± 0.65 versus 2.59 ± 0.84 mg/dl, p = 0.30); proteinuria (3.77 ± 2.18 versus 5.01 ± 4.51 g/vol, p = 0.26); proliferative nephritis (44% ( n = 8) versus 60% ( n = 45), p = 0.23). There was also no difference in the long-term outcomes between groups: SDI (1 (range: 0-5) versus 0.5 (range: 0-5), p = 0.27); creatinine (2.04 ± 2.38 versus 1.69 ± 2.26 mg/dl, p = 0.56); dialysis (22% ( n = 4) versus 13% ( n = 10), p = 0.46) and mortality (0% ( n = 0) versus 12% ( n = 9), p = 0.19). CONCLUSION: This study provides novel evidence of comparable long-term outcomes between late-onset and early-onset nephritis, which is most likely explained by the observation that at presentation, the clinical, laboratorial and histological features of late-onset and early-onset nephritis are similar. This suggests that there should be no distinct treatment targets and therapeutic interventions for the late- and early-onset groups.

Vitamin D insufficiency is associated with lower physical function in patients with heart failure and diabetes.

Vitamin D deficiency is frequent among patients with heart failure (HF) and diabetes, disorders associated with exercise intolerance and muscle weakness. This study aims to search for associations between vitamin D sufficiency and physical function indexes in patients with HF and diabetes. A cross-sectional study of 146 HF patients, 39.7% with diabetes, at a Brazilian tertiary outpatient clinic was performed. Patients underwent clinical evaluation, 6-minute walk test (6 MWT), handgrip strength, physical activity level (IPAQ), and biochemical evaluations including serum 25-hydroxyvitamin D. Classification was done according to vitamin D status (≥ 30 ng/dL, sufficient) and presence/absence of diabetes in vitamin sufficient, no diabetes (DS-C, n = 25), vitamin sufficient, diabetes (DS-DM, n = 18), vitamin deficient, no diabetes (DD-C, n = 63), and vitamin deficient, diabetes (DD-DM, n = 40). Patients age was 55.4 ± 8 yrs; 70.5% had vitamin D deficiency. Clinical characteristics were similar among groups. Total time expended in physical activity was similar among groups (P = 0.26). DS-C covered higher distances in the 6 MWT (392 ± 60 m) versus DD-DM (309 ± 116 m); P = 0.024. Handgrip strength was similar among groups but tended to lower levels in DD-DM (P = 0.074) even after being adjusted to physical activity (P = 0.069). Vitamin D deficiency can influence physical function in HF diabetic patients.

Procalcitonin does discriminate between sepsis and systemic inflammatory response syndrome.

AIMS: To evaluate whether procalcitonin (PCT) and C reactive protein (CRP) are able to discriminate between sepsis and systemic inflammatory response syndrome (SIRS) in critically ill children. METHODS: Prospective, observational study in a paediatric intensive care unit. Kinetics of PCT and CRP were studied in patients undergoing open heart surgery with cardiopulmonary bypass (CPB) (SIRS model; group I1) and patients with confirmed bacterial sepsis (group II). RESULTS: In group I, PCT median concentration was 0.24 ng/ml (reference value <2.0 ng/ml). There was an increment of PCT concentrations which peaked immediately after CPB (median 0.58 ng/ml), then decreased to 0.47 ng/ml at 24 h; 0.33 ng/ml at 48 h, and 0.22 ng/ml at 72 h. CRP median concentrations remained high on POD1 (36.6 mg/l) and POD2 (13.0 mg/l). In group II, PCT concentrations were high at admission (median 9.15 ng/ml) and subsequently decreased in 11/14 patients who progressed favourably (median 0.31 ng/ml). CRP levels were high in only 11/14 patients at admission. CRP remained high in 13/14 patients at 24 h; in 12/14 at 48 h; and in 10/14 patients at 72 h. Median values were 95.0, 50.9, 86.0, and 20.3 mg/l, respectively. The area under the ROC curve was 0.99 for PCT and 0.54 for CRP. Cut off concentrations to differentiate SIRS from sepsis were >2 ng/ml for PCT and >79 mg/l for CRP. CONCLUSION: PCT is able to differentiate between SIRS and sepsis while CRP is not. Moreover, unlike CRP, PCT concentrations varied with the evolution of sepsis.

[Algal flora of Lake Amapá in Rio Branco, acre state, I: euglenophyceae]. / Ficoflórula do Lago Amapá em Rio Branco- Acre, I: Euglenophyceae.

The Euglenophyceae flora of Lake Amapá I, Rio Branco, Acre State, Brazil, constitutes a contribution to the phycological inventory of the State of Acre. It is based on the study of 15 samples collected with plankton net and by passing an open flask in areas with dense plankton concentrations. Samples were prepared and preserved with Transeau solution. Twenty five taxons were identified. Genera Euglena and Trachelomonas were the most frequently represented.

[Algal flora of Lake Amapá in Rio Branco, Acre State, II: chlorophyta]. / Ficoflórula do Lago Amapá em Rio Branco- Acre, II: chlorophyta.

In this study, 15 samples were collected on a bi-monthly basis, during the period between March and May 1994, and 3 additional samples were collected, one in each of the months of July, October and November 1994. All the samples were collected in Lake Amapá (lat. 10 degrees 2'36"S, long. 67 degrees 50'24"W), which is located in Rio Branco, Acre State, Brazil. Ten táxons, of Chlorophyta were registered: Botryococcaceae (2), Treubariaceae (1), Volvocaceae (2), Closteriaceae (3) e Desmidiaceae (2). All taxa identified are first citations for Acre State.

[The Medico-Social Cardiology Center of Coimbra. History and epilogue]. / Centro de Cardiologia Médico-Social de Coimbra. História e Epílogo.

The Medico-Social Cardiology Center of Coimbra, designed and founded by João Porto in 1941, played a remarkable (and pioneering) role in helping cardiac patients in the central part of Portugal. Its work was made possible by the commitment of many doctors, nurses and Social Center Bulletins. For a quarter of a century the number of medical and social interventions in favor of cardiac patients is truly remarkable. Meanwhile, improvements in the national social services--easier access to medical services, free semiology exams, subsidized drugs, state illness subsidies--caused a reduction of monetary contributions from both partners and wealthier and healthier cardiac patients. Little by little the Center's activity was reduced, which ultimately led to its recent dissolution. The Center's books were placed in the Archive of the University and its assets (bank deposits) were donated to the Association for the Development of Cardiology at the University Hospital in Coimbra. As its name suggests, the main goal of this non-profit association consists in the promotion of scientific and technological improvement of the Cardiology Department at the University Hospital of Coimbra.

[The outlook for medical ethics in the 1990s]. / Perspectivas da ética médica nos anos 90.

The evolution of medicine throughout time--in clinical practice, in scientific progress and in the development of new technologies of semeiology and therapeutics-, created a long list of ethical problems unknown before. If the Hippocratic oath remains valid nowadays, as a true monument of rare moral elegance, the truth is, that it began to be unable to cover all the new aspects created by the evolution of Medicine on one hand, and the transformation of the Society, on the other hand. Therefore, the confrontation of the traditional principles of Medical ethics with the new realities is mandatory, to analyse a long list of well defined questions such as, clinical trials, human experimentation, problems related with the creation of life and its ending, organ transplants molecular biology, medical genetics, analysis of, human genome and its consequences, new biotechnologies, as well as other questions that are covered by the broader aspect of bioethics, interlinking in this way several areas of knowledge. All the technologies used in clinical practice, radically changed the traditional relation between the doctor and the patient, and created not only a number of new problems, but also, clear threats to medical secrecy and patient privacy. The exponential increase in the number of terminal patients made for way some temptations (intensive care, euthanasia) and for the idea of developing a correct structure palliative Medicine.(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary heart tumors. Report of a clinical case]. / Os tumores cardíacos primários. A propósito de um caso clínico.

The authors describe the case of a 52-year-old patient with several hospitalizations due to acute pulmonary edema, clarified only during the performance of cardiac surgery for the correction of presumable mitral valvular pathology. A leiomiossarcome of the left auricle was concerned, which involved the posterior ring of the mitral valve, the interauricular septum and the orifices of the pulmonary veins. Due to the impossibility of proceeding with the complete resection of the tumor, the tumoral mass was wasted away in order to liberate the involved structures, this followed by chemotherapy. Two years since, the patient shows a generally deteriorated state, submitted to various hospitalizations due to cardiac insufficiency, having been objectivated hepatic metastization and recurrence of the primary neoplasm.

[Immunization with an anti-Lewis a antibody]. / Imunização por um anticorpo anti-Lewis a.

A case of immunological sensitization for a natural and irregular anti-Lewis a antibody, is presented. Immuno-hematologic studies of blood and saliva, and identification of seric antibody through a panel of phenotype red cells, were made.

[The development of cardiology in the last 40 years]. / A evolução da cardiologia nos últimos quarenta anos.

In order to correctly appreciate the way cardiology developed in the last 40 years, the "state-of-the-art" balance when the first World Congress took place, September-1950, in Paris, is made. The most current diagnostic methods were relatively scarce at the time-ECG, chest X ray, phonocardiography, pulse wave tracings, coupled with vectorcardiography and ballistocardiography, but in the well equipped hospitals right ventricular catheterization was already performed. The therapeutics of the important morbid situations-like congestive heart failure, arterial hypertension, myocardial infarction and ischemia was disappointing, but closed heart surgery was already taking place. Since then, things had changed suddenly. Over the last 40 years a marked scientific and technology explosion has emerged, that had benefited cardiology science, encompassing several broad areas, namely, patient approaching, pathophysiology understanding, the emergence of new drugs and clinical use, interventional cardiology and remarkable progress in open heart surgery. Imaging techniques development and other technology lead to a simple and accurate cardiac diagnosis. 24 hours ECG and blood pressure recording, and cardiac output measurement, greatly improves our medical knowledge. Computers development, representing the most significant technology advances, has given to cardiology non-predicted advances.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diabetes mellitus and coronopathy]. / Diabetes e coronariopatia.

Diabetes Mellitus represents an important public health problem in the most developed industrialized countries. Clinical presentations of diabetes are strongly related to the cardiovascular system, namely, coronary disease and angiopathic renal failure. Diabetes modifies the clinical course of arteriosclerosis by carrying the angiopathic process to a microvascular level, where typical microangiopathic lesions can be observed. The risk of developing atherosclerotic disease is 2-3 fold higher in diabetics than in nondiabetics and arterial hypertension reaches a prevalence of 40 to 80%. Authors analyse Arterial Hypertension in the context of Diabetes putting focus on the underlying pathophysiological mechanisms. Where considering the coronary disease (CD), its high prevalence among the diabetics is also emphasized, which is expressed by an increase of morbidity and mortality when compared to normal subjects. In diabetics not only the incidence of Acute Myocardial Infarction is higher, but also the long term prognosis is more complicated, a reality that the authors try to explain by anatomic and metabolic factors. The association of Diabetes plus hyperlipidemia represents undoubtedly one of the major factors that justify the worsening and progression of CD. Briefly, some interesting points that allow the understanding of this topic are described, pointing the pathogenic differences of types I and II and the clinical implications of their knowledge. Finally, the approach of Diabetes as a cardiovascular risk factor is discussed in a prophylactic perspective.

[Congestive heart insufficiency. Prophylactic aspects]. / Insuficiência cardíaca congestiva. Aspectos profiláticos.

Since the therapeutic advances prolong survival of many patients suffering from cardiovascular pathology--the prevalence of chronic heart failure (CHF) had just doubled, being a common entity in a world whose individuals present a great increase in longevity. These considerations justify the renewed interest in this particular syndrome. Concepts, pathophysiology and compensatory mechanisms are briefly summarized, putting emphasis on the advantage of pharmacologically interrupt the vicious loop of the compensatory mechanisms, that could play a deleterious role in the syndrome. Neurohormonal responses and the "pivotal" role of angiotensine II in CHF pathology are also discussed, emphasizing the benefits of angiotensin converting enzyme inhibitors (ACEI) when treating patients presenting heart failure. Questions addressed to its prescription at an early stage, (classes II and III of NYHA--to prevent the progressive exhaustion of the failing heart) are also considered. When approaching the preventive measures in a wide perspective, primary, secondary and tertiary types of preventive options are described. ACEI use for the least advanced clinical stages of CHF (class II and III) would represent a tertiary type of CHF prevention.

[Collapse of the aortic valve in dilated myocardiopathies: echocardiographic study]. / O colapso da válvula aórtica nas miocardiopatias dilatadas: estudo ecocardiográfico.

In order to clarify the early systolic partial closure (notching) of aortic valve in patients (pts) with dilated cardiomyopathy (DC), authors (AA) evaluated the M-mode echocardiograms corresponding to 41 pts with DC. Pts were separated in two groups, according to the presence of systolic notching: group A (18 pts) presenting systolic notching; group B (23 pts) in which no systolic notching was observed. For each group, the same echocardiographic parameters were evaluated related to aortic root, left atrium, left ventricule (LV), aortic valve and mitral valve. Both groups were compared statistically. Results--Group A presented a reduced motion of aortic root and greater initial maximal aortic cuspids separation. AA therefore conclude that in pts with DC the systolic notching has no eventual relation with mitral regurgitation. In this setting no conclusions about LV function can be inferred, and it is suggested that systolic notching may bear some relation with differences in the distribution of transvalvular aortic flow.