Potentially inappropriate prescribing of drugs in elderly patients on chronic hemodialysis treatment
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PURPOSE: The aim of this study was to determine the prevalence of potentially inappropriate drug prescription (PIP) in older patients who were on chronic hemodialysis treatment and to explore the factors that lead to PIP. MATERIALS AND METHODS: The study was performed at the Department of Nephrology, Clinical Center Nis, Serbia. It included patients who were 65 years old and older who suffered from the end-stage of kidney failure and were treated by hemodialysis. Univariate and subsequent multivariate logistic regression was used to analyze risk factors for PIP or omission (PPO) according to the STOPP and START criteria. RESULTS: The study included 83 patients. According to the START criteria, PPO was found in 18 (22%) patients, and 32 (39%) patients experienced PIPs according to the STOPP criteria. The following factors were associated with PIP according to the START criteria: a number of comorbidities, reading the patient leaflet, and having the habit of drinking coffee. According to the STOPP criteria, polypharmacy was associated with PIP (OR = 1.287, p = 0.021): each additional drug increased the risk of potentially inadequate medications (PIM) by 28.7%. CONCLUSION: Adequate consideration of potential risk factors, as well as the implementation of valid criteria for assessment of PIP, are just some of the measures that would contribute to solving complex therapeutic problems and designing strategies for rational prescribing according to the individual characteristics of patients.
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25OHVitamin D Levels in a Canarian Pediatric Population with and without Type 1 Diabetes: The Role of Acidosis.

The role of Vitamin D in the development of type 1 diabetes (T1D) is controversial. The Canary Islands have the highest incidence of childhood-onset T1D in Spain and one of the highest in Europe. We aimed to evaluate 25OHVitamin D concentrations in a Canarian pediatric population, to assess the existence of seasonal variation, to study their association with T1D, and to evaluate the role of acidosis in its levels. In a retrospective, case-control study, we obtained data from 146 T1D patients (<15 years of age) and 346 control children; 25OHVitamin D concentrations were assessed in serum by automatic ChemiLuminescence ImmunoAssay technology. We found significantly higher 25OHVitamin D levels in the summer and autumn months and an inverse correlation between T1D and age; 25OHVitamin D sufficiency was similar in both groups (44.5% vs. 45.1%), with significant differences in the percentage of patients presenting vitamin D deficiency (11.6% (T1D) vs. 16.4% (controls)). When stratified according to the presence of ketoacidosis at sampling, only patients with acidosis showed lower 25OHVitamin D concentrations than controls. Despite its subtropical geographic location, Vitamin D deficiency is frequent in children in Gran Canaria, and 25OHVitamin D concentrations show seasonal variation. After adjusting for acidosis, no differences were found between children with and without T1D.

Polymorphous low grade adenocarcinoma of the buccal mucosa.

PLGA is a rare tumor of the salivary gland that is limited, to a great extent, to the minor salivary glands. However, the most common subsite being the hard or soft palate. This study presents clinical report of PLGA located very rarely on the buccal mucosa, with brief overview on the importance of adequate surgical therapy, PH analysis and cooperation with a pathologist. KEY WORDS: Buccal Mucosa, Multidisciplinary Management PLGA.

Curcumin and Diclofenac Therapeutic Efficacy Enhancement Applying Transdermal Hydrogel Polymer Films, Based on Carrageenan, Alginate and Poloxamer.

Films based on carrageenan, alginate and poloxamer 407 have been formulated with the main aim to apply prepared formulations in wound healing process. The formulated films were loaded with diclofenac, an anti-inflammatory drug, as well as diclofenac and curcumin, as multipurpose drug, in order to enhance encapsulation and achieve controlled release of these low-bioavailability compounds. The obtained data demonstrated improved drug bioavailability (encapsulation efficiency higher than 90%), with high, cumulative in vitro release percentages (90.10% for diclofenac, 89.85% for curcumin and 95.61% for diclofenac in mixture-incorporated films). The results obtained using theoretical models suggested that curcumin establishes stronger, primarily dispersion interactions with carrier, in comparison with diclofenac. Curcumin and diclofenac-loaded films showed great antibacterial activity against Gram-positive bacteria strains (Bacillus subtilis and Staphylococcus aureus, inhibition zone 16.67 and 13.67 mm, respectively), and in vitro and in vivo studies indicated that curcumin- and diclofenac-incorporated polymer films have great potential, as a new transdermal dressing, to heal wounds, because diclofenac can target the inflammatory phase and reduce pain, whereas curcumin can enhance and promote the wound healing process.

Don't Think That Kids Aren't Noticing: Indirect Pathways to Children's Fear of COVID-19.

The present study is couched within Rachman's three-pathway theory of fear acquisition (Rachman, 1977, 1991). Besides the direct contact with the objects of fear, this model also includes two indirect pathways to fear acquisition: negative information transmission and modeling. The study aims to explore the contribution of these three factors to the level of children's fear of COVID-19. The sample consisted of 376 children (59.6% girls), aged 7-19 (M age = 12.77, SDage = 3.57), and one of their parents (M age = 42.88, SDage = 6.00). The survey was conducted online during the COVID-19 national state of emergency in the Republic of Serbia. The children assessed their fear of COVID-19, general fearfulness, negative information transmission, and modeling by their parents, as well as the level of exposure to negative information outside their home. The parents assessed their own fear of COVID-19 and trait anxiety. Parents' anxiety, children's age, and children's general fearfulness were used as covariates. The results of our path analysis provide support for Rachman's notion of indirect pathways. The more the parents were afraid of COVID-19, the more they expressed this (either verbally or through their behavior), which in turn led to an increase in the children's fear of COVID-19. Furthermore, children's exposure to negative information related to COVID-19, provided by their teachers and peers or stemming from the media, directly contributed to the level of children's fear. The results of the study emphasize the importance of caregivers' behavior during global health crises and provide some clues as to what caregivers may do to protect their children's mental health in such circumstances.

Aging, aluminium and basal forebrain lesions modify substrate kinetics of erythrocyte membrane Na,K-ATPase in the rat.

Several studies suggested that the activity of erythrocyte Na,K-ATPase declines with aging. Here, it is postulated that alterations in the substrate kinetics of the erythrocyte membrane Na,K-ATPase could be more aggravated in conditions of brain cholinergic dysfunction seen in Alzheimer's disease than in normal aging. To test this hypothesis, we compared the Na,K-ATPase activity (Vmax/Km parameters) in aged rats with those in young rats with brain cholinergic dysfunction induced by electrolytic-, kainic acid-lesioned nucleus basalis magnocellularis (NBM) or by intracerebroventricular AlCl_{3} administration. In the above mentioned groups, Vmax values were significantly lower in comparison to the control animals. Furthermore, Km values were significantly higher in animals with electrolytic-induced NBM lesions, AlCl_{3} treated rats and aged animals. However, Km was significantly lower in kainic acid-induced NBM lesions compared to the control group. The Na,K-ATPase catalytic efficiency, estimated by the ratio Vm/Km, decreased as followed: young animals > aged animals > kainic acid lesion > electrolityc lesion > AlCl_{3}. Our data suggest that neurodegenerative processes similar to those seen in Alzheimer's disease affect the sodium/potassium pump functionality which might be detected in peripheral blood erythrocyte membranes.

Modulatory effect of curcumin on ketamine-induced toxicity in rat thymocytes: Involvement of reactive oxygen species (ROS) and the phosphoinositide 3-kinase (PI3K)/protein kinase B (Akt) pathway.

Ketamine is a widely used anesthetic in pediatric clinical practice. Previous studies have demonstrated that ketamine induces neurotoxicity and has a modulatory effect on the cells of the immune system. Here, we evaluated the potential protective effect and underlying mechanisms of natural phenolic compound curcumin against ketamine-induced toxicity in rat thymocytes. Rat thymocytes were exposed to 100 µM ketamine alone or combined with increasing concentrations of curcumin (0.3, 1, and 3 µM) for 24 hours. Cell viability was analyzed with CCK-8 assay kit. Apoptosis was analyzed using flow cytometry and propidium iodide as well as Z-VAD-FMK and Z-LEHD-FMK inhibitors. Reactive oxygen species (ROS) production and mitochondrial membrane potential [MMP] were measured by flow cytometry. Colorimetric assay with DEVD-pNA substrate was used for assessing caspase-3 activity. Involvement of phosphoinositide 3-kinase (PI3K)/protein kinase B (Akt) signaling pathway was tested with Wortmannin inhibitor. Ketamine induced toxicity in cells, increased the number of hypodiploid cells, caspase-3 activity and ROS production, and inhibited the MMP. Co-incubation of higher concentrations of curcumin (1 and 3 µM) with ketamine markedly decreased cytotoxicity, apoptosis rate, caspase-3 activity, and ROS production in rat thymocytes, and increased the MMP. Application of Z-VAD-FMK (a pan caspase inhibitor) or Z-LEHD-FMK (caspase-9 inhibitor) with ketamine effectively attenuated the ketamine-induced apoptosis in rat thymocytes. Administration of Wortmannin (a PI3K inhibitor) with curcumin and ketamine significantly decreased the protective effect of curcumin on rat thymocytes. Our results indicate that ketamine-induced toxicity in rat thymocytes mainly occurs through the mitochondria-mediated apoptotic pathway and that the PI3K/Akt signaling pathway is involved in the anti-apoptotic effect of curcumin.

Simultaneous self-created transobturator tape and laparoscopic extraperitoneal vaginal support in patients with stress urinary incontinence and prolapse of the anterior and apical vaginal compartments.

OBJECTIVE: Stress urinary incontinence (SUI) is frequently associated with prolapse of the apical and anterior vaginal compartments. The standard treatment of SUI is transobturator tape (TOT). The usual treatment of prolapse (anterior colporrhaphy) has a high recurrence rate. The aim of this study is to evaluate the results of the treatment of SUI and concomitant anterior and apical prolapse with self-created transobturator tape and simultaneous laparoscopic anterior and apical support. STUDY DESIGN: A total of 36 patients with SUI and prolapse of the anterior and apical compartments were underwent operations. The mean follow-up was 18 months. Self-created transobturator tape and laparoscopical support of the anterior and apical compartment prolapse were performed in all patients. The most important symptoms of prolapse and incontinence, the anatomical outcome, and complications were evaluated before and after the surgery. RESULTS: Treatment of incontinence and anterior and apical prolapse was successful in 33/36 (91.7%), 30/36 (83.3%) and 31/36 (86.1%) patients, respectively (p<0.0001). There is a significant reduction of vaginal bulging and pelvic pressure (p<0.0001). Frequency and urgency were significantly reduced (p<0.0007 and p<0.03 respectively). There was no significant deterioration of the posterior compartment. The most important complications were bladder perforation in 2/36 (5.5%) patients and temporary urinary retention in 3/36 (8.3%) patients (Clavien-Dindo grade 3). CONCLUSION: Simultaneous laparoscopic anterior and lateral extraperitoneal support and transobturator tape are effective in the treatment of patients with both conditions.

TGF-ß-Id1 signaling opposes Twist1 and promotes metastatic colonization via a mesenchymal-to-epithelial transition.

ID genes are required for breast cancer colonization of the lungs, but the mechanism remains poorly understood. Here, we show that Id1 expression induces a stem-like phenotype in breast cancer cells while retaining epithelial properties, contrary to the notion that cancer stem-like properties are inextricably linked to the mesenchymal state. During metastatic colonization, Id1 induces a mesenchymal-to-epithelial transition (MET), specifically in cells whose mesenchymal state is dependent on the Id1 target protein Twist1, but not at the primary site, where this state is controlled by the zinc finger protein Snail1. Knockdown of Id expression in metastasizing cells prevents MET and dramatically reduces lung colonization. Furthermore, Id1 is induced by transforming growth factor (TGF)-ß only in cells that have first undergone epithelial-to-mesenchymal transition (EMT), demonstrating that EMT is a prerequisite for subsequent Id1-induced MET during lung colonization. Collectively, these studies underscore the importance of Id-mediated phenotypic switching during distinct stages of breast cancer metastasis.

Id1 maintains embryonic stem cell self-renewal by up-regulation of Nanog and repression of Brachyury expression.

Understanding the mechanism by which embryonic stem (ES) cells self-renew is crucial for the realization of their therapeutic potential. Earlier, overexpression of Id proteins was shown to be sufficient to maintain mouse ES cells in a self-renewing state even in the absence of serum. Here, we use ES cells derived from Id deficient mice to investigate the requirement for Id proteins in maintaining ES cell self-renewal. We find that Id1(-/-) ES cells have a defect in self-renewal and a propensity to differentiate. We observe that chronic or acute loss of Id1 leads to a down-regulation of Nanog, a critical regulator of self-renewal. In addition, in the absence of Id1, ES cells express elevated levels of Brachyury, a marker of mesendoderm differentiation. We find that loss of both Nanog and Id1 is required for the up-regulation of Brachyury, and ectopic Nanog expression in Id1(-/-) ES cells rescues the self-renewal defect, indicating that Nanog is the major downstream target of Id1. These results identify Id1 as a critical factor in the maintenance of ES cell self-renewal and suggest a plausible mechanism for its control of lineage commitment.

[Multiple gigantic renal cysts].

INTRODUCTION: Cystic renal lesions are very heterogeneous lesions which differ in ethiopathogenesis, morphological and clinical manifestations, and also in evolution and therapy. Classification of cystic lesions is complex, symptomatology is poor, and diagnosis is based on complete radiological diagnostic procedures. CASE REPORT: We presented a 20-year old patient with mild subjective symptoms. Objectively, he was without positive clinical signs and changes in biochemistry of blood. Using ultrasonography (US) multiple serous simple cysts were found in both kidneys. Using computed tomography (CT) multiple serous cysts were found, without changes in cystic walls, with preserved renal parenchyma and without cystic changes on other parenchymatous organs. CONCLUSION: Although renal cystic lesions are frequent in adult population, this is a rare example of a young adult man with simple, gigantic, serous cysts which do not produce clinical manifestations nor functional renal difficulty so far.

[Histopathological characteristics and coexpression of p53 and p16(INK4a) proteins in renal cancer].

BACKGROUND/AIM: Renal carcinoma represents histologically heterogeneous group of malignant tumors, with various clinical aggressiveness. The frequency of p53 mutation in primal renal carcinoma is rare, although there are information about its heterogeneous accumulation. The loss of protein p16 expression in primal renal carcinoma is detected in 20-30% of the cases. The aim of this paper was to determine frequency of mutated protein p53 and expression of protein p16(INK4a) in renal carcinoma, to analyze their correlative relation and relation with the examined clinicopathological parameters. METHODS: The examination included 12 patients (66.7% men, 33.3% women), with patohistologically verified renal carcinoma. Expression of mutated form of protein p53 and protein p16 was determined in tissue samples, by immunohistochemical analysis using of mice monoclonical antibodies produced by DAKO, Denmark RESULTS: In 9 (75%) of the cases was detected mutated protein p53, of whom 66.6% had higher histological gradus of tumor (G3-4) and higher pathological stadium of the disease (pT3a-b) at the same time. In 7 (58.3%) and 5 (41.7%) of the cases expression of protein p16, the loss of expression of protein p16 were detected respectively. A statistically significant positive correlation was determined between pathological stadium of disease (TNM) and the degree of tumor differentiation (G) (p = 0.834; p < 0.001), as well as between TNM and mitotic index (p = 0.622; p = 0.031). CONCLUSION: A mutated form of protein p53 exists in 75% of the cases with the renal carcinoma and 66.6% of then have higher histological gradus of tumor and higher stadium of tumor disease at the same time. Coexpression of mutated protein p53 and protein p16(INK4a) in renal carcinoma is not statistically significant and it is not in correlation with clinicopathological parameters. Immunohistochemical analysis of mutated protein p53 in renal carcinoma can have predictive significance.

[Superficial urinary bladder tumors treatment results--a 10-year experience].

BACKGROUND/AIM: The most common urinary bladder tumors are superficial tumors. Due to their tension to relapse and progress towards deeper layers after surgical therapy, an adequate therapy significantly contributed to the improvement of the results of urinary bladder tumors treatment. Staging and gradus of the tumor, presence of the cardnoma in situ (CIS) or relapses significantly influenced the choice of the therapy. The aim of this study was to ascertain the effectiveness of the intravesicelly applied BCG (Bacille Colmette-Guerin) vaccine or chemiotherapy in the prevention of the relapses and further progression of superficial urinary bladder tumors. METHODS: All of the diagnosed superficial tumors of bladder were removed by transurethral resection (TUR). After receiving the patohistological finding they were subjected to adjuvant therapy, immune BCG vaccine or chemiotherapy (epirubicin, doxorubicin, mitomycin-C). The third group did not accept adjuvant therapy, but had regularly scheduled cystoscopic controls. The appearance of relapses, progression of stage and gradus of the tumor, as well as possible unwanted effects of adjuvant therapy were registered. RESULTS: The applied immunotherapy (BCG) influenced decreased tumor relapses (7%) and statistically important difference between patients who had taken adjuvant chemotherapy (relapses 18.4%) and those without this therapy was acknowledged. Gradus of tumor did not show statistically significant difference on tumor relapse. A significantly longer period of time in the appearance of tumor relapse after BCG (29.33 months), had significant importance comparing to chemio (9.44 months) or non-taken adjuvant therapy (9.84 months). Very small number of unwanted effects suggested an obligatory undertaking adjuvant therapy after TUR of superficial tumors. CONCLUSION: A significant decrease of relapses as well as avoidance of further progression of urinary bladder tumors, has introduced adjuvant therapy in all of the protocols, while the dosing scheme is not unique yet due to trying to find the optimal dose, the length of application and possible dose maintenance.

[Determination of factor Xa inhibition doses of low-molecular heparin, nadroparin and reviparin in urological patients].

BACKGROUND/AIM: The inhibition of factor Xa (FX) by the use of low-molecular heparin (LMH) is important clinical procedure in patients with moderate and high risk for the development of venous thromboembolism (VTE) and pulmonary embolism (PE). The aim of this study was to determine the level of inhibition of FXa by the use of prophylactic doses of LMH nadroparin-calcium and reviparine-sodium which were applied in urological patients with moderate risk for VTE and PE. METHODS: The examination included 80 urological patients divided into 4 groups after urological, uroradiological and anesthesiological preoperative preparation and categorization of anesthesiological risk according to the ASA III classification. The first two groups, of 20 patients each, received the recommended doses of LMH in accordance with the preoperative risk, and an inhibition of FXa 48 hours after the surgical operation and four hours after the administration of LMH was determined. Heptest and homogenous anti-Xa test were used for monitoring of FXa inhibition. Since the obtained anti Xa values were not satisfactory, two more groups were formed and given double the recommended doses. In these new groups, inhibition of FXa was in recommended range. Standard descriptive statistical parameters were used for describing the characteristics of the people from the formed groups. RESULTS: All the patients examined were clinically estimated as patients of moderate risk, for VTE and PE. There were no statistically significant difference in body weight of the patients who received nadroparin-calcium 0.3 ml and reviparine sodium 0.25 ml and those who received their double doses, respectively. The level of FXa inhibition in the group in which the dose of nadroparin-calcium of 0.6 ml was applied was statistically significantly higher than in the group which received the dose of 0.3 ml (Mann-Whitney U test: Z = 5.416; p < 0.0001). The level of FXa in the group given reviparine-sodium 0.5 ml was significantly higher than in the group which received the half of this dose (Mann Whitney U test: Z = 5.416; p < 0.0001). This research did not confirm a statistically significant difference in the levels of FXa inhibition in patients who received nadroparincalcium as VTE and PE prophylaxis in the dose of 0.6 ml and those who received reviparin-sodium 0.5 ml (in two doses of 0.25 ml) (Mann-Whitney U test: Z = 0.163; p > 0.05). CONCLUSION: According to biochemical monitoring, the recommended doses of LMH are insufficient for the prophylactic inhibition of FXa in urological patients with moderate risk for VTE and PE, so the higher doses which inhibit FXa are recommended.

Targeting prostaglandin E2 receptors as an alternative strategy to block cyclooxygenase-2-dependent extracellular matrix-induced matrix metalloproteinase-9 expression by macrophages.

COX-2-dependent prostaglandin (PG) E2 synthesis regulates macrophage MMP expression, which is thought to destabilize atherosclerotic plaques. However, the administration of selective COX-2 inhibitors paradoxically increases the frequency of adverse cardiovascular events potentially through the loss of anti-inflammatory prostanoids and/or disturbance in the balance of pro- and anti-thrombotic prostanoids. To avoid these collateral effects of COX-2 inhibition, a strategy to identify and block specific prostanoid-receptor interactions may be required. We previously reported that macrophage engagement of vascular extracellular matrix (ECM) triggers proteinase expression through a MAPKerk1/2-dependent increase in COX-2 expression and PGE2 synthesis. Here we demonstrate that elicited macrophages express the PGE2 receptors EP1-4. When plated on ECM, their expression of EP2 and EP4, receptors linked to PGE2-induced activation of adenylyl cyclase, is strongly stimulated. Forskolin and dibutryl cyclic-AMP stimulate macrophage matrix metalloproteinase (MMP)-9 expression in a dose-dependent manner. However, an EP2 agonist (butaprost) has no effect on MMP-9 expression, and macrophages from EP2 null mice exhibited enhanced COX-2 and MMP-9 expression when plated on ECM. In contrast, the EP4 agonist (PGE1-OH) stimulated macrophage MMP-9 expression, which was inhibited by the EP4 antagonist ONO-AE3-208. When compared with COX-2 silencing by small interfering RNA or inhibition by celecoxib, the EP4 antagonist was as effective in inhibiting ECM-induced proteinase expression. In addition, ECM-induced MMP-9 expression was blocked in macrophages in which EP4 was silenced by small interfering RNA. Thus, COX-2-dependent ECM-induced proteinase expression is effectively blocked by selective inhibition of EP4, a member of the PGE2 family of receptors.

[Effect of donor-specific blood transfusion on the outcome of kidney transplantation]. / Uticaj donor-specificnih transfuzija krvi na ishod transplantacije bubrega.

Donor specific transfusion (DST) is proclaimed to improve graft survival in living related kidney transplantation (LRTx). The aim of the present study was to estimate the influence of DST on LRTx graft function, acute rejection rate (AR) and survival in the early and late posttransplant period. Fifty-five LRTx patients (grafted in the same year, and matched for recipients' and donor's age, sex) were included into the study. Ninety pts received DST: 4 patients were excluded from further evaluation (3 developed positive cross match reaction and one patients received cadaver graft) and 15 patients subsequently underwent LRTx from their respective blood donors (group 1). Their outcome was compared with 15 patients who had never been transfused before (group 2) and 25 random transfused patients (group 3). Besides similar patients' and donors' sex and age, kidney transplantations were performed in the same period. Graft functions were followed-up 6-60 months after LRTx. DST protocol consists of 3 x 150 ml potentially related donor's fresh whole blood at 2-week intervals (DST1, DST2, DST3) with 3 days azathioprine administration (2 mg/kg bw, one, day before to one day after DST administration). Donor specific cytotoxic antibodies were determined before DST1, at the day of DST2, DST3 and 14 and 28 days after DST3. All patients were grafted at least one month after the DST3. Immunosuppressive protocol consisted of three drugs. There is no difference in HLA mismatches, MLC answer, and pretransplant panel reactive antibodies level between groups. One patient from group 2 lost their graft in the first postTx month (acute tubular necrosis). A better graft function was preserved in patients from groups 1 and 3 than group 2 in the observed periods. Number of patients with acute rejection was unsignificantly different: 5/15 from group 1, 12/25 from group 3 but 8/10 patients from group 2. However, the acute rejection rate was lower in patients from group 1. One and five-year graft survival was 100% for grafts from groups 1 and 3, while it is gradually decreased for group 2 grafts: 84.5% and 57%. Our results confirmed the beneficial effect of blood transfusion on LRTx renal graft function and survival and DST on the incidence of acute rejection.