Long-Term Outcomes of Biological Therapy in Crohn's Disease Complicated With Internal Fistulizing Disease: BIOSCOPE Study From GETECCU.

INTRODUCTION: The prevalence of penetrating complications in Crohn's disease (CD) increases progressively over time, but evidence on the medical treatment in this setting is limited. The aim of this study was to evaluate the effectiveness of biologic agents in CD complicated with internal fistulizing disease. METHODS: Adult patients with CD-related fistulae who received at least 1 biologic agent for this condition from the prospectively maintained ENEIDA registry were included. Exclusion criteria involved those receiving biologics for perianal disease, enterocutaneous, rectovaginal, anastomotic, or peristomal fistulae. The primary end point was fistula-related surgery. Predictive factors associated with surgery and fistula closure were evaluated by multivariate logistic regression and survival analyses. RESULTS: A total of 760 patients from 53 hospitals (673 receiving anti-tumor necrosis factors, 69 ustekinumab, and 18 vedolizumab) were included. After a median follow-up of 56 months (interquartile range, 26-102 months), 240 patients required surgery, with surgery rates of 32%, 41%, and 24% among those under anti-tumor necrosis factor, vedolizumab, or ustekinumab, respectively. Fistula closure was observed in 24% of patients. Older patients, ileocolonic disease, entero-urinary fistulae, or an intestinal stricture distal to the origin of the fistula were associated with a higher risk of surgery, whereas nonsmokers and combination therapy with an immunomodulator reduced this risk. DISCUSSION: Biologic therapy is beneficial in approximately three-quarters of patients with fistulizing CD, achieving fistula closure in 24%. However, around one-third still undergo surgery due to refractory disease. Some patient- and lesion-related factors can identify patients who will obtain more benefit from these drugs.

Real-World Evidence of Tofacinitib in Ulcerative Colitis: Short-Term and Long-Term Effectiveness and Safety.

INTRODUCTION: The objective of this study was to assess the durability, short-term and long-term effectiveness, and safety of tofacitinib in ulcerative colitis (UC) in clinical practice. METHODS: This is a retrospective multicenter study including patients with UC who had received the first tofacitinib dose at least 8 weeks before the inclusion. Clinical effectiveness was based on partial Mayo score. RESULTS: A total of 408 patients were included. Of them, 184 (45%) withdrew tofacitinib during follow-up (mean = 18 months). The probability of maintaining tofacitinib was 67% at 6 m, 58% at 12 m, and 49% at 24 m. The main reason for tofacitinib withdrawal was primary nonresponse (44%). Older age at the start of tofacitinib and a higher severity of clinical activity were associated with tofacitinib withdrawal. The proportion of patients in remission was 38% at week 4, 45% at week 8, and 47% at week 16. Having moderate-to-severe vs mild disease activity at baseline and older age at tofacitinib start were associated with a lower and higher likelihood of remission at week 8, respectively. Of 171 patients in remission at week 8, 83 (49%) relapsed. The probability of maintaining response was 66% at 6 m and 54% at 12 m. There were 93 adverse events related to tofacitinib treatment (including 2 pulmonary thromboembolisms [in patients with risk factors] and 2 peripheral vascular thrombosis), and 29 led to tofacitinib discontinuation. DISCUSSION: Tofacitinib is effective in both short-term and long-term in patients with UC. The safety profile is similar to that previously reported.

Prediabetes is a risk factor for cardiovascular disease following renal transplantation.

Prediabetes and post-transplant diabetes mellitus affect about 20-30% of renal transplant patients. The latter is a risk factor for cardiovascular disease. However, no clear evidence linking prediabetes and cardiovascular disease is available. To study this we analyzed the impact of prediabetes on cardiovascular disease in 603 renal transplant patients followed with repeated oral glucose tests for up to five years and a long term survival evaluation. Prediabetes and post-transplant diabetes mellitus were defined at 12 months after transplantation to avoid their high reversibility rate before this period. 73 cardiovascular events were observed. The incidence of events was significantly higher in patients with either prediabetes, (17%; 0.023 person/year) or post-transplant diabetes mellitus (20%; 0.028 person/year) than in normal individuals, (7%; 0.0095 person/year). The incidence of events was comparable between prediabetes and post-transplant diabetes mellitus. Prediabetes at 12 months was a risk factor for cardiovascular events in univariate and multivariate Cox survival analyses (hazard ratio 2.24, 95% confidence interval 1.11-4.52). Prediabetes at three months and hemoglobin A1c at 12 months were not significantly associated with cardiovascular disease. Thus, prediabetes is a risk factor for cardiovascular disease in renal transplantation, a population at high risk for cardiovascular events. Since prediabetes is potentially a reversible condition, there is an opportunity to prevent cardiovascular disease in this population.

Implementation of evidence on the nurse-patient relationship in psychiatric wards through a mixed method design: study protocol.

BACKGROUND: Psychiatric nurses are aware of the importance of the therapeutic relationship in psychiatric units. Nevertheless, a review of the scientific evidence indicates that theoretical knowledge alone is insufficient to establish an adequate therapeutic alliance. Therefore, strategies are required to promote changes to enhance the establishment of the working relationship. The aims of the study are to generate changes in how nurses establish the therapeutic relationship in acute psychiatric units, based on participative action research and to evaluate the effectiveness of the implementation of evidence through this method. METHODS/DESIGN: The study will use a mixed method design. Qualitative methodology, through participative action research, will be employed to implement scientific evidence on the therapeutic relationship. A quasi-experimental, one-group, pre-test/post-test design will also be used to quantitatively measure the effectiveness of the implementation of the evidence. Participants will consist of nurses and patients from two psychiatric units in Barcelona. Nurses will be selected by theoretical sampling, and patients assigned to each nurses will be selected by consecutive sampling. Qualitative data will be gathered through discussion groups and field diaries. Quantitative data will be collected through the Working Alliance Inventory and the Interpersonal Reactivity Index. Qualitative data will be analysed through the technique of content analysis and quantitative data through descriptive and inferential statistics. DISCUSSION: This study will help to understand the process of change in a nursing team working in an inpatient psychiatric ward and will allow nurses to generate knowledge, identify difficulties, and establish strategies to implement change, as well as to assess whether the quality of the care they provide shows a qualitative improvement.

RAS/MAPK pathway hyperactivation determines poor prognosis in undifferentiated pleomorphic sarcomas.

BACKGROUND: Undifferentiated pleomorphic sarcoma (UPS) constitutes the most common subtype of soft tissue sarcoma. However, UPS is clinically and molecularly poorly understood, in great extent due to its intrinsic phenotypic and cytogenetic complexity, which in turn results in the absence of specific prognostic or predictive biomarkers. The RAS/mitogen-activated protein kinases (MAPK) and phosphoinositide 3-kinase inhibitor (PI3K)/mammalian target of rapamycin (mTOR) pathways are considered to be 2 major mechanisms for sarcoma proliferation and survival and to the authors' knowledge their role in UPS remains unclear. The objective of the current study was to investigate whether the RAS/MAPK and PI3K/mTOR pathways are activated in UPS, and whether pathway activation is associated with outcome. METHODS: Records for patients diagnosed and treated for UPS in the study institution between 2000 and 2009 were reviewed. Phosphorylation status of 4E-binding protein (4E-BP1), eukaryotic translation initiation factor 4E (eIF-4E), S6-RP, and ERK 1/2, together with total forms of 4E-BP1 and eIF-4E, were assessed using immunohistochemistry in paraffin-embedded tumor tissue. Mutational analysis for KRAS; NRAS; BRAF; and phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha (PIK3CA) oncogenic mutations was performed as well. RESULTS: Critical lymph nodes within the RAS/MAPK and PI3K/mTOR pathways were found to be activated in >80% of UPS cases. Hyperactivation of the RAS/MAPK pathway, as assessed by expression of phosphorylated ERK 1/2, was found to independently predict a higher risk of disease recurrence and impaired overall survival. Only a KRAS A146V mutation was detected in 1 tumor. CONCLUSIONS: The RAS/MAPK and PI3K/mTOR pathways are activated in the majority of cases of UPS. The RAS/MAPK pathway distinguishes a subgroup of patients with localized UPS with a worse outcome.

The Therapeutic Relationship in Inpatient Psychiatric Care: A Narrative Review of the Perspective of Nurses and Patients.

PURPOSE: To study the significance of 'therapeutic relationship' between nurses and patients within the context of a psychiatric hospital. METHOD: Narrative literature review. Content analysis. FINDINGS: The significance of the therapeutic relationship is quite similar for both nurses and patients in psychiatric hospital units. Nevertheless, several factors may separate the two positions: the time available for the relationship, the negative perceptions on the part of both parties, and the insecurity of the setting. PRACTICE IMPLICATIONS: Increased knowledge and understanding of the significance of the therapeutic relationship from the perspective of nurses and patients would allow the strengthening of areas of mutual interest.

Psoriasis induced by antiTNF therapy in inflammatory bowel disease: Therapeutic management and evolution of both diseases in a nationwide cohort study.

BACKGROUND: some patients with inflammatory bowel disease (IBD) treated with antiTNF develop drug-induced psoriasis (antiTNF-IP). Several therapeutic strategies are possible. AIMS: to assess the management of antiTNF-IP in IBD, and its impact in both diseases. METHODS: patients with antiTNF-IP from ENEIDA registry were included. Therapeutic strategy was classified as continuing the same antiTNF, stopping antiTNF, switch to another antiTNF or swap to a non-antiTNF biologic. IP severity and IBD activity were assessed at baseline and 16, 32 and 54 weeks. RESULTS: 234 patients were included. At baseline, antiTNF-IP was moderate-severe in 60 % of them, and IBD was in remission in 80 %. Therapeutic strategy was associated to antiTNF-IP severity (p < 0.001). AntiTNF-IP improved at week 54 with all strategies, but continuing with the same antiTNF showed the worst results (p = 0.042). Among patients with IBD in remission, relapse was higher in those who stopped antiTNF (p = 0.025). In multivariate analysis, stopping antiTNF, trunk and palms and soles location were associated with antiTNF-IP remission; female sex and previous surgery in Crohn´s disease with IBD relapse. CONCLUSION: skin lesions severity and IBD activity seem to determine antiTNF-IP management. Continuing antiTNF in mild antiTNF-IP, and swap to ustekinumab or switch to another antiTNF in moderate-severe cases, are suitable strategies.

Kinetics and mechanisms of the unimolecular elimination of 2,2-diethoxypropane and 1,1-diethoxycyclohexane in the gas phase: experimental and theoretical study.

The gas-phase thermal elimination of 2,2-diethoxypropane was found to give ethanol, acetone, and ethylene, while 1,1-diethoxycyclohexane yielded 1-ethoxycyclohexene and ethanol. The kinetics determinations were carried out, with the reaction vessels deactivated with allyl bromide, and the presence of the free radical suppressor cyclohexene and toluene. Temperature and pressure ranges were 240.1-358.3 °C and 38-102 Torr. The elimination reactions are homogeneous, unimolecular, and follow a first-order rate law. The rate coefficients are given by the following Arrhenius equations: for 2,2-diethoxypropane, log k(1) (s(-1)) = (13.04 ± 0.07) - (186.6 ± 0.8) kJ mol(-1) (2.303RT)(-1); for the intermediate 2-ethoxypropene, log k(1) (s(-1)) = (13.36 ± 0.33) - (188.8 ± 3.4) kJ mol(-1) (2.303RT)(-1); and for 1,1-diethoxycyclohexane, log k = (14.02 ± 0.11) - (176.6 ± 1.1) kJ mol(-1) (2.303RT)(-1). Theoretical calculations of these reactions using DFT methods B3LYP, MPW1PW91, and PBEPBE, with 6-31G(d,p) and 6-31++G(d,p) basis set, demonstrated that the elimination of 2,2-diethoxypropane and 1,1-diethoxycyclohexane proceeds through a concerted nonsynchronous four-membered cyclic transition state type of mechanism. The rate-determining factor in these reactions is the elongation of the C-O bond. The intermediate product of 2,2-diethoxypropane elimination, that is, 2-ethoxypropene, further decomposes through a concerted cyclic six-membered cyclic transition state mechanism.

Determinants of mechanical restraint in an acute psychiatric care unit.

BACKGROUND: Despite numerous attempts to reduce the use of mechanical restraint (MR), this technique continues to be widely applied in many acute psychiatric care settings. In order to reduce MR, a better understanding of the variables associated with its use and duration in different clinical environments is essential. AIM: To determine the proportion of patients subjected to MR and the duration thereof in two acute care psychiatric units; and to identify the variables associated with the use and duration of MR. METHODS: Descriptive study of all patients admitted to the acute psychiatric units at the Parc de Salut Mar (Barcelona, Spain) in the year 2018. The number and percentage of patients subjected to MR, as well as the duration of each episode were assessed. The following data were also registered: sociodemographic characteristics, psychiatric diagnosis, and presence of cultural and/or language barriers. Multivariate analyses were performed to assess determinants of MR and its duration. RESULTS: Of the 464 patients, 119 (25.6%) required MR, with a median of 16.4 h per MR. Two factors - a diagnosis of psychotic disorder [Odds ratios (OR) = 0.22; 95%CI: 0.06-0.62; P = 0.005] and the presence of a language barrier (OR = 2.13; 95%CI: 1.2-3.7; P = 0.007) - were associated with a significantly higher risk of MR. Male sex was associated with a longer duration of MR (B = -19.03; 95%CI: -38.06-0.008; P = 0.05). CONCLUSION: The presence of a language barrier and a psychotic disorder diagnosis are associated with a significantly higher risk of MR. Furthermore, male sex is associated with a longer duration of MR. Individualized restraint protocols that include the required tools are necessary to ultimately limit the use of mechanical restraint.

Experimental and theoretical studies of the homogeneous, unimolecular gas-phase elimination kinetics of trimethyl orthovalerate and trimethyl orthochloroacetate.

The rates of gas-phase elimination of trimethyl orthovalerate and trimethyl orthochloroacetate have been determined in a static system, and the reaction Pyrex vessels have been deactivated with the product of decomposition of allyl bromide. The reactions are unimolecular and follow a first-order rate law. The working temperature and pressure ranges were 313-410 degrees C and 40-140 Torr, respectively. The rate coefficients for the homogeneous reaction are given by the following Arrhenius expressions: for trimethyl orthovalerate: log k (s(-1)) = [(14.00 +/- 0.28) - (196.3 +/- 1.7) (kJ/mol)] (2.303RT)(-1), (r = 0.9999); and for trimethyl orthochloroacetate: log k (s(-1)) = [(13.54 +/- 0.21) - (209.3 +/- 1.9)(kJ/mol)](2.303RT)(-1), (r = 0.9998). The theoretical calculations of the kinetic and thermodynamic parameters were carried out by using B3LYP, B3PW91, MPW1PW91, and PBEPBE methods. The theoretical results show reasonably good agreement with the experimental energy and enthalpy of activation values when using the B3PW91/6-31++G** method for trimethyl orthovalerate and PBEPBE /6-31++G** for trimethyl orthochloroacetate. These calculations suggest a molecular concerted nonsynchronous mechanism where C-OCH(3) bond polarization, in the sense C(delta+)...(delta-)OCH(3), is the rate-determining step. The increase in electron density of the oxygen atom at OCH(3) eases the abstraction of the hydrogen of the adjacent C-H bond in a four-membered cyclic structure to give methanol and the corresponding unsaturated ketal. The electron-donor substituent enhances decomposition rates by stabilizing the positive charge developing in the transition state at the carbon bearing the three methoxy groups, whereas the electron-withdrawing substituent destabilizes this charge, thus retarding the reaction.

Prediabetes in patients receiving tacrolimus in the first year after kidney transplantation: a prospective and multicenter study.

BACKGROUND: Tacrolimus-based immunosuppression, the most widely used regimen in kidney transplantation, increases the risk of new onset diabetes after transplantation (NODAT). However, the prevalence, evolution and risk factors of different prediabetic alterations: impaired fasting glucose, impaired glucose tolerance, and provisional diabetes, have not been established. METHODS: In this multicenter and prospective study we evaluated 154 nondiabetic kidney transplant recipients receiving tacrolimus, mycophenolate mofetil and low dose steroids. An oral glucose tolerance test was performed 3 and 12 months after transplantation and prediabetes was defined by American Diabetes Association criteria. RESULTS: Prediabetes was highly prevalent and showed little variation between 3 and 12 months (36% and 33%, respectively). Impaired glucose tolerance was the most frequent abnormality observed (23% and 25%, respectively) observed. In addition, 20% of recipients showed NODAT by 1 year. Multivariate analysis showed that age (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 1.004-1.14), pretransplant body mass index (OR: 1.3, CI: 1.09-1.6) and triglyceride/high density lipoprotein-cholesterol ratio, a marker of insulin resistance, (OR: 1.4, CI: 1.05-1.9) were independent risk factors for prediabetes. CONCLUSION: One in two recipients with tacrolimus-based immunosuppresion showed prediabetes or NODAT by 1 year posttransplantation when properly investigated. Older age and high pretransplant body mass index and triglyceride/high density lipoprotein-cholesterol ratio were risk factors for prediabetes. These findings may help applying early interventions to prevent the disorder.

Kinetics and mechanisms of the homogeneous, unimolecular gas-phase elimination of trimethyl orthoacetate and trimethyl orthobutyrate.

The gas-phase elimination kinetics of the title compounds have been examined over the temperature range of 310-369 degrees C and pressure range of 50-130 Torr. The reactions, in seasoned vessels, are homogeneous, unimolecular, and follow a first-order rate law. The products are methanol and the corresponding methyl ketene acetal. The rate coefficients are expressed by the Arrhenius equation: for trimethyl orthoacetate, log k1 (s(-1)) = [(13.58 +/- 0.10) - (194.7 +/- 1.2) (kJ mol(-1))](2.303RT)(-1)r = 0.9998; and for trimethyl orthobutyrate, log k1(s(-1)) = [(13.97 +/- 0.37) - (195.3 +/- 1.6) (kJ mol(-1))](2.303RT)(-1)r = 0.9997. These reactions are believed to proceed through a polar concerted four-membered cyclic transition state type of mechanism.

Long-term follow-up of aortic intramural hematoma: predictors of outcome.

BACKGROUND: Aortic intramural hematoma (IMH) evolves very dynamically in the short-term to regression, dissection, or aortic rupture. The aim of the present study was to assess the long-term clinical and morphological evolution of medically treated IMH. METHODS AND RESULTS: Fifty of 68 consecutive patients with aortic IMH monitored clinically and by imaging techniques at 3, 6, and 12 months and annually thereafter were prospectively studied. Mean follow-up was 45+/-31 months. In the first 6 months, total IMH regression was observed in 14 and progression to aortic dissection in 18 patients; in 14 of these, the dissection was localized, and 12 later developed pseudoaneurysm. At the end of follow-up, the IMH had regressed completely without dilatation in 17 patients (34%), progressed to classical dissection in 6 (12%), evolved to fusiform aneurysm in 11 (22%), evolved to saccular aneurysm in 4 (8%), and evolved to pseudoaneurysm in 12 (24%). Evolution to dissection was related to echolucency (P<0.02) and to longitudinal extension of IMH (P<0.01). Multivariate analysis showed an independent association between regression and smaller maximum aortic diameter and between aneurysm formation and atherosclerotic ulcerated plaque and absence of echolucent areas in IMH. CONCLUSIONS: The most frequent long-term evolution of IMH is to aortic aneurysm or pseudoaneurysm. Complete regression without changes in aorta size is observed in one third of cases, and progression to classical dissection is less common. A normal aortic diameter in the acute phase is the best predictor of IMH regression without complications, and absence of echolucent areas and atherosclerotic ulcerated plaque are associated with evolution to aortic aneurysm.

Hyperinsulinemia and hyperfiltration in renal transplantation.

BACKGROUND: Insulin-resistance hyperinsulinemia is a novel risk factor for renal disease in the general population. Glomerular hyperfiltration has been proposed as an early consequence of hyperinsulinemia. METHODS: In this multicenter cohort study, we analyzed 202 patients without diabetes before or after renal transplantation during the first posttransplant year. Insulin was measured at 3 and 12 months. The majority of patients (91%) were on calcineurin inhibitors. Patients were classified as with persistent normo or hyperinsulinemia when situated below or above the median value of insulin (3 months: 9 muU/mL; 12 months: 8.74 muU/mL) at both periods. The 3 to 12 months percent change in calculated creatinine clearance (3-12 months DeltaCrCL) was calculated. RESULTS: Patients with persistent hyperinsulinemia showed a higher increase in 3 to 12 months DeltaCrCL compared with those with persistent normoinsulinemia (12% [-20/40] vs. -0.03% [-12/18], P=0.035). We performed a multivariate linear regression analysis with the 3 to 12 months DeltaCrCL as the dependent variable and different factors that may induce hyperfiltration, including persistent hyperinsulinemia, as covariates. Persistent hyperinsulinemia was a risk factor for increased CrCL (beta 0.09, 95% CI 0.07/0.12, P=0.035). CONCLUSION: In nondiabetic recipients during the first posttransplant year, hyperinsulinemia induced increments in CrCL. As this may herald future renal dysfunction, hyperinsulinemia should not be ignored as a potential target in this population.

Effect of CLA supplementation to low-protein diets on the growth performance, carcass characteristics, plasma urea nitrogen concentration, and fatty acid profile in the meat of pigs

To analyze the effect of conjugated linoleic acid (CLA) on the meat of pigs (0,1%) and three crude protein (CP) levels (nursery: 20.5, 16.0, 14.5%; growing: 16, 14.5, 11.5%; and finishing: 14.0, 12.5, 11% CP), studies were conducted with 36 hybrid (Yorkshire×Landrace×Duroc) barrows (17.3-83.5 kg), which were individually penned and allotted in a completely randomized design in a factorial (2×3) arrangement for 84 d. The analysis by phases indicated that CP level affected some variables. Average daily gain, average daily feed intake, fat free lean gain, backfat thickness, longissimus muscle area and final body weight were reduced (P≤0.05) feeding the lowest CP diet in nursery and growing pigs. Plasma urea nitrogen concentration was also lower (P≤0.05) in the growing and finishing phases when fed the lowest CP level. The global analysis showed that all the analyzed variables (except feed gain ratio, lean meat percentage and plasma urea nitrogen concentration) were reduced (P≤0.05) in the pigs fed low-protein diets; plasma urea nitrogen concentration tended to be lower (P=0.07) when CP was reduced. The fatty acid profile of the meat (semimembranosus and longissimus muscles) indicated that CLA addition increased CLA isomers and total saturated fatty acids, and reduced the total monounsaturated fatty acids (P≤0.05). α-Linolenic acid was lowered in longissimus muscle of pigs fed LPD (P=0.08). These results indicated that reducing the crude protein concentration in the diet of fattening pigs from 20.5 to 16.0% in nursery phase; from 16.0 to 14.5% in growing stage; and from 14.0 to 12.5% in finishing pigs, did not negatively affect the growth performance, nor carcass characteristics. The results also showed that the addition of CLA did not improve pig response and the concentration of unsaturated fatty acids and total lipids altered the feeding LPD.

Aerobic bioremediation of chlorobenzene source-zone soil in flow-through columns: performance assessment using quantitative PCR.

Flow-through aquifer columns were operated for 12 weeks to evaluate the benefits of aerobic biostimulation for the bioremediation of source-zone soil contaminated with chlorobenzenes (CBs). Quantitative Polymerase Chain Reaction (qPCR) was used to measure the concentration of total bacteria (16S rRNA gene) and oxygenase genes involved in the biodegradation of aromatic compounds (i.e., toluene dioxygenase, ring hydroxylating monooxygenase, naphthalene dioxygenase, phenol hydroxylase, and biphenyl dioxygenase). Monochlorobenzene, which is much more soluble than dichlorobenzenes, was primarily removed by flushing, and biostimulation showed little benefit. In contrast, dichlorobenzene removal was primarily due to biodegradation, and the removal efficiency was much higher in oxygen-amended columns compared to a control column. To our knowledge, this is the first report that oxygen addition can enhance CB source-zone soil bioremediation. Analysis by qPCR showed that whereas the biphenyl and toluene dioxygenase biomarkers were most abundant, increases in the concentration of the phenol hydroxylase gene reflected best the higher dichlorobenzene removal due to aerobic biostimulation. This suggests that quantitative molecular microbial ecology techniques could be useful to assess CB source-zone bioremediation performance.

Unmasking glucose metabolism alterations in stable renal transplant recipients: a multicenter study.

BACKGROUND AND OBJECTIVES: Emerging information indicates that glucose metabolism alterations are common after renal transplantation and are associated with carotid atheromatosis. The aims of this study were to investigate the prevalence of different glucose metabolism alterations in stable recipients as well as the factors related to the condition. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A multicenter, cross-sectional study was conducted of 374 renal transplant recipients without pre- or posttransplantation diabetes. A standard 75-g oral glucose tolerance test was performed. RESULTS: Glucose metabolism alterations were present in 119 (31.8%) recipients: 92 (24.6%) with an abnormal oral glucose tolerance test and 27 (7.2%) with isolated impaired fasting glucose. The most common disorder was impaired glucose tolerance (17.9%), and an abnormal oral glucose tolerance test was observed for 21.5% of recipients with a normal fasting glucose. By multivariate analysis, age, prednisone dosage, triglyceride/high-density lipoprotein cholesterol ratio, and beta blocker use were shown to be factors related to glucose metabolism alterations. Remarkably, triglyceride levels, triglyceride/high-density lipoprotein cholesterol ratio, and the proportion of recipients with impaired fasting glucose were already higher throughout the first posttransplantation year in recipients with a current glucose metabolism alteration as compared with those without the condition. CONCLUSIONS: Glucose metabolism alterations are common in stable renal transplant recipients, and an oral glucose tolerance test is required for its detection. They are associated with a worse metabolic profile, which is already present during the first posttransplantation year. These findings may help planning strategies for early detection and intervention.

Leishmaniasis visceral: veinte años de experiencia clínica en población pediátrica en un hospital de referencia en Chiapas / Visceral leishmaniasis: 20 years of clinical experience in a pediatric population of a reference hospital in Chiapas, Mexico

Introducción. El objetivo de este trabajo fue describir la experiencia clínica en el diagnóstico y el tratamiento de la leishmaniasis visceral en pacientes menores de 15 años atendidos, durante el periodo 1990-2010, en el Hospital General Dr. Rafael Pascasio Gamboa de Tuxtla Gutiérrez, Chiapas. Métodos. Este fue un estudio descriptivo retrospectivo que se llevó a cabo a través de la revisión de los expedientes clínicos existentes, los reportes epidemiológicos del archivo del servicio de epidemiología y los resúmenes clínicos archivados en el servicio de Pediatría del Hospital General Dr. Rafael Pascasio Gamboa de Tuxtla Gutiérrez, Chiapas. Se incluyeron todos los pacientes con diagnóstico de leishmaniasis visceral confirmado por serología, por inmunofluorescencia indirecta y por la presencia de amastigotos en el aspirado de medula ósea. Se recolectaron los datos clínicos y los epidemiológicos. Resultados. Durante el periodo 1990-2010 se registraron 72 niños con el diagnóstico de leishmaniasis visceral. Se descartaron 9 casos por no reunir los datos indispensables para el análisis. Los 63 casos que se analizaron presentaron una edad comprendida entre 2 meses y 13 años; 56 (88%) fueron menores de 5 años. La relación con respecto al género (femenino-masculino) fue de 1:1.2. Se presentó fiebre en el 100% de los casos; esplenomegalia en 97%, hepatomegalia en 87% y pancitopenia en 95%. La serología para leishmania por inmunofluorescencia indirecta fue > 1:32, positiva en 98% de los casos y la presencia de amastigotos en 79% de los aspirados de médula ósea. En cinco niños se identificó Leishmania chagasi en medio de cultivo 3N (Nicolle-Novy-McNeal). Se presentó desnutrición en 75% de los niños. Conclusiones. En el estado de Chiapas, se debe considerar el diagnóstico de leishmaniasis visceral en pacientes con fiebre, hepatoesplenomegalia y pancitopenia y se debe iniciar precozmente la búsqueda del parásito para evitar el desgaste que sufren los niños, lo que los conduce a la desnutrición y los pone en riesgo de muerte.

Background. We undertook this study to describe the clinical experience in diagnosis and treatment of visceral leishmaniasis in patients <15 years of age who were treated from 1990-2010 in the Hospital General Dr. Rafael Pascacio Gamboa of Tuxtla Gutiérrez, Chiapas. Methods. This was a retrospective descriptive study. We reviewed the clinical files and epidemiological reports from the Department of Pediatrics of the Hospital General Dr. Rafael Pascacio Gamboa of Tuxtla Gutiérrez, Chiapas. All patients with a diagnosis of visceral leishmaniasis confirmed by serology, indirect immunofluorescence and the presence of amastigotes in the bone marrow aspirate were included. Epidemiological and clinical data were collected. Results. From 1990-2010, 72 children with the diagnosis of visceral leishmaniasis were reported. Nine cases were discarded because necessary data for the analysis were not collected. Sixty three subjects who were analyzed were between 2 months and 13 years of age; 56 (88%) were <5 years of age. Female:male ratio was 1:1.2. Fever was present in 100% of the cases, splenomegaly in 97%, hepatomegaly in 87% and pancytopenia in 95%. Serology for leishmania by indirect immunofluorescence was >1:32, positive in 98% of cases. The presence of amastigotes was found in 79% of the bone marrow aspirates. Leishmania chagasi was identified in culture medium 3N (Nicolle-Novy-McNeal) in five children; 75% of the children presented malnutrition. Conclusions. In the state of Chiapas, diagnosis of visceral leishmaniasis should be considered in patients with fever, hepatosplenomegaly, and pancytopenia. The search for the parasite should be begun early to avoid clinical deterioration and pain, which leads to malnutrition and puts patients at risk of dying.