Modelling kidney outcomes based on MELD eras - impact of MELD score in renal endpoints after liver transplantation.

BACKGROUND: Acute kidney injury is a common complication in solid organ transplants, notably liver transplantation. The MELD is a score validated to predict mortality of cirrhotic patients, which is also used for organ allocation, however the influence of this allocation criteria on AKI incidence and mortality after liver transplantation is still uncertain. METHODS: This is a retrospective single center study of a cohort of patients submitted to liver transplant in a tertiary Brazilian hospital: Jan/2002 to Dec/2013, divided in two groups, before and after MELD implementation (pre-MELD and post MELD). We evaluate the differences in AKI based on KDIGO stages and mortality rates between the two groups. RESULTS: Eight hundred seventy-four patients were included, 408 in pre-MELD and 466 in the post MELD era. The proportion of patients that developed AKI was lower in the post MELD era (p 0.04), although renal replacement therapy requirement was more frequent in this group (p < 0.01). Overall mortality rate at 28, 90 and 365 days was respectively 7%, 11% and 15%. The 1-year mortality rate was lower in the post MELD era (20% vs. 11%, p < 0.01). AKI incidence was 50% lower in the post MELD era even when adjusted for clinically relevant covariates (p < 0.01). CONCLUSION: Liver transplants performed in the post MELD era had a lower incidence of AKI, although there were more cases requiring dialysis. 1-year mortality was lower in the post MELD era, suggesting that patient care was improved during this period.

Rapid determination of L-ascorbic acid content in vitamin C serums by ultra-high-performance liquid chromatography-tandem mass spectrometry.

OBJECTIVE: This study aimed to develop and validate a rapid, simple, accurate and precise analytical method for the quantification of L-AA in vitamin C serums. Moreover, the developed method was further applied to determine L-AA in eight different brands of vitamin C serums. A complementary study was also carried out to evaluate the stability of L-AA in the vitamin C serum samples after 15, 30, 45 and 60 days of storage at ambient temperature (15-35°C). METHODS: Ultra-high-performance liquid chromatography-tandem mass spectrometry was applied. RESULTS: Quantitative analyses were performed with a total chromatographic run time of 1.5 min by matrix-matched calibration, and the analytical curve was linear over the range of 1-1700 µg L-1 with a correlation coefficient of 0.9998. The limits of detection (LOD) and quantification (LOQ) were 0.3 and 1.0 µg L-1 , respectively. Intra- and inter-assay precisions, expressed in terms of relative standard deviation, ranged from 0.3% and 2.2%, respectively, and recoveries in concentration levels of 1 and 5 µg L-1 were 103.9% and 101.2%, respectively. The proposed analytical method was successfully applied to determine the L-AA content in eight commercial vitamin C serum samples. The stability of the target analyte in samples stored at ambient temperature (15-35°C) was evaluated throughout 60 days with a 15-day interval between analyses. At 0 days, L-AA content in samples ranged from 1.05 to 169.91 mg L-1 , which decreases over time. CONCLUSION: The proposed method could be powerful in routine analyses to ensure the quantification of L-AA in vitamin C serums since it proved to be a simple, reliable, fast, precise, accurate and sensitive analytical method.

OBJECTIF: Cette étude visait à développer et valider une méthode analytique rapide, simple, exacte et précise pour la quantification de l'acide L-ascorbique dans les sérums à la vitamine C. De plus, la méthode développée a été appliquée pour déterminer l'acide L-ascorbique dans huit différentes marques de sérums à la vitamine C. Une étude complémentaire a également été réalisée pour évaluer la stabilité de l'acide L-ascorbique dans les échantillons de sérum à la vitamine C après 15, 30, 45 et 60 jours de conservation à température ambiante (15 à 35 °C). MÉTHODES: La chromatographie en phase liquide à haute performance avec spectrométrie de masse en tandem a été employée. RÉSULTATS: Des analyses quantitatives ont été réalisées avec une durée totale d'exécution chromatographique de 1,5 minute par calibration matricielle appariée, et la courbe analytique était linéaire sur la plage de 1 à 1700 µg L-1 avec un coefficient de corrélation de 0,9998. La limite de détection (LD) et la limite de quantification (LQ) ont été déterminées à 0,3 et 1,0 µg L−1 , respectivement. Les précisions intra- et inter-essais, exprimées en termes d'écart-type relatif, étaient de 0,3 % et 2,2 %, respectivement, et les récupérations aux niveaux de concentration de 1 et 5 µg L-1 étaient de 103,9 % et 101,2 %, respectivement. La méthode analytique proposée a été employée avec succès pour déterminer la teneur en acide L-ascorbique de huit échantillons de sérum à la vitamine C commerciaux. La stabilité de l'analyte cible dans les échantillons conservés à température ambiante (15 à 35 °C) a été évaluée sur 60 jours avec un intervalle de 15 jours entre les analyses. À 0 jour, la teneur en acide L-ascorbique dans les échantillons était comprise entre 1,05 et 169,91 µg L-1 , ce qui diminue au fil du temps. CONCLUSION: La méthode proposée pourrait être puissante dans les analyses de routine pour assurer la quantification de l'acide L-ascorbique dans les sérums à la vitamine C puisqu'elle s'est avérée être une méthode analytique simple, fiable, rapide, précise, exacte et sensible.

Acute Kidney Injury and Renal Replacement Therapy in Critically Ill COVID-19 Patients: Risk Factors and Outcomes: A Single-Center Experience in Brazil.

BACKGROUND: Critically ill patients with COVID-19 may develop multiple organ dysfunction syndrome, including acute kidney injury (AKI). We report the incidence, risk factors, associations, and outcomes of AKI and renal replacement therapy (RRT) in critically ill COVID-19 patients. METHODS: We performed a retrospective cohort study of adult patients with COVID-19 diagnosis admitted to the intensive care unit (ICU) between March 2020 and May 2020. Multivariable logistic regression analysis was applied to identify risk factors for the development of AKI and use of RRT. The primary outcome was 60-day mortality after ICU admission. RESULTS: 101 (50.2%) patients developed AKI (72% on the first day of invasive mechanical ventilation [IMV]), and thirty-four (17%) required RRT. Risk factors for AKI included higher baseline Cr (OR 2.50 [1.33-4.69], p = 0.005), diuretic use (OR 4.14 [1.27-13.49], p = 0.019), and IMV (OR 7.60 [1.37-42.05], p = 0.020). A higher C-reactive protein level was an additional risk factor for RRT (OR 2.12 [1.16-4.33], p = 0.023). Overall 60-day mortality was 14.4% {23.8% (n = 24) in the AKI group versus 5% (n = 5) in the non-AKI group (HR 2.79 [1.04-7.49], p = 0.040); and 35.3% (n = 12) in the RRT group versus 10.2% (n = 17) in the non-RRT group, respectively (HR 2.21 [1.01-4.85], p = 0.047)}. CONCLUSIONS: AKI was common among critically ill COVID-19 patients and occurred early in association with IMV. One in 6 AKI patients received RRT and 1 in 3 patients treated with RRT died in hospital. These findings provide important prognostic information for clinicians caring for these patients.

Fall prevention education for people with multiple sclerosis: a randomized clinical trial.

BACKGROUND: Online spaced education (OSE) is a method recognized for promoting long-term knowledge retention, changing behaviors and improving outcomes for students and healthcare professionals. However, there is little evidence about its impacts on patient education. OBJECTIVES: The aim of this research was to compare knowledge retention using educational brochure and OSE on individuals with multiple sclerosis (MS) and to verify the impact of educational methods on fall outcome. METHODS: Individuals with MS (n = 230) were randomly assigned to two types of patient education-educational brochure (control) and OSE (intervention). During 12 weeks, the intervention group received multiple-choice tests on fall prevention. Knowledge retention, behavior change and fall incidence were assessed before intervention and after 3 and 6 months. The participants' satisfaction with the education method was also evaluated. RESULTS: Knowledge retention was similar between groups, and behavior change was observed in both groups. There was a significant reduction in fall rate in the intervention group, from 0.60 to 0.27 at 6 months (P < 0.001). Participants' satisfaction achieved an average of 8.75, with no differences between groups. CONCLUSION: Individuals demonstrated significant improvement in fall rate outcome in both groups with no significant difference. In regard to test scores and satisfaction, results were similar between groups.

Colombian experience in the treatment of hepatitis C with direct-acting antiviral agents.

There are few published real-world studies on hepatitis C in Latin America. This paper describes a cohort of Colombian subjects treated with direct-acting antiviral agents. A total of 195 patients from 5 hepatology centers in 4 Colombian cities were retrospectively studied. For each patient, serum biomarkers were obtained, and Child-Pugh, MELD, cirrhosis and fibrosis stage were calculated. Additionally, viral load was quantified at initiation, end of treatment and at 12 weeks of completion. Adverse effects were recorded. Patients with liver transplant were compared with non-transplanted patients in terms of serum biomarkers. The patients had received 9 different regimes. The most prevalent viral genotype was 1b (81.5%). Overall, 186 patients (95.4%) attained sustained virologic response. When comparing transplanted vs. non-transplanted patients, those in the non-transplanted group were more likely to have cirrhosis (52.6% vs. 12.5%, p = 0.0004). Pre-treatment viral load was higher in the transplant group (1 743 575 IQR = 1 038 062-4 252 719 vs. 345 769 IQR = 125 806-842 239; p < 0.0001) as well as ALT and AST levels (82.5 IQR 43.5-115.5 vs. 37.0 IQR = 24.7-73.3; p = 0.0009 and 70 IQR = 41-140 vs. 37 IQR = 24-68; p = 0.004 respectively). Adverse events were reported by 28.7% of the patients; asthenia (5.6%) was the most prevalent. Our results are comparable with those from other countries in terms of therapy and biomarkers. However, our cohort reported less adverse events. Further research is needed in the region.

Fatty acid composition and nutritional profiles of Brycon spp. from central Amazonia by different methods of quantification.

This study evaluated the fatty acid composition and the nutritional profile of Brycon cephalus and Brycon microlepis, fish species from the central Amazon basin, by different methods of quantification. The methods applied were: area normalization (MAN), internal standard (MIS), alternative theoretical (MAT) and alternative experimental (MAE). Significant differences were observed between the methods applied and the species studied. MAN supplied poor information about fatty acids composition and diet formulation, presenting only fatty acid profiles. MIS, MAT and MAE supplied fatty acids composition information on a mass basis. MAT and MAE overestimated results, whereas MIS presented the most accurate results. B. cephalus and B. microlepis showed high contents of approximately 65 mg g-1 of n-3 fatty acids. Eicosapentaenoic acid (EPA; 20:5n-3) and docosahexaenoic acid (DHA; 22:6n-3) content totaled, 104.37 mg 100 g-1 and 117.89 mg 100 g-1 for B. cephalus and B. microlepis, respectively. The nutritional profile of both fish species showed favorable indices for nutritional quality of the lipid fraction, indicating that both Brycon species are healthy dietary choices.

Evaluation of Influenza A H1N1 infection and antiviral utilization in a tertiary care hospital.

BACKGROUND: Influenza A H1N1 infections carry a significant mortality risk. This study describes inpatients with suspected and confirmed Influenza A H1N1 infection who were prescribed oseltamivir, the risk factors associated with infection, the association between infection and mortality, and the factors associated with in-hospital mortality in infected patients. METHODS: This study was a matched case-control study of hospitalized patients who underwent real-time polymerase chain reaction testing for Influenza A H1N1 and were treated with oseltamivir from 2009 to 2015 in a tertiary care hospital. Cases (patients with positive Influenza A H1N1 testing) were matched 1:1 to controls (patients with negative test results). RESULTS: A total of 1405 inpatients who underwent PCR testing and received treatment with oseltamivir were identified in our study and 157 patients confirmed Influenza A H1N1. Almost one third of patients with Influenza A H1N1 were diagnosed in the pandemic period. There was no difference in mortality between cases and controls. Immunocompromised status, requirement of vasoactive drugs, mechanical ventilation, acute hemodialysis, albumin administration, surgical procedures and thoracic procedures and length of stay were associated with increased risk of death in Influenza A H1N1 infected patients. CONCLUSIONS: We found no increased risk of mortality for patients with proven Influenza A H1N1 when compared to similar patients without confirmed Influenza.

Serum Soluble-Fas, Inflammation, and Anemia in Acute Kidney Injury.

Anemia is a common feature in critically ill patients. Serum soluble-Fas (sFas) levels are associated with anemia in chronic kidney disease. It is possible that sFas levels are also associated with anemia in acute kidney injury (AKI) patients. The study aims to investigate the relationship between serum levels of sFas, erythropoietin (Epo), inflammatory cytokines, and hemoglobin (Hb) concentration in critically ill patients with AKI. We studied 72 critically ill patients with AKI (AKI group; n = 53) or without AKI (non-AKI group; n = 19), and 18 healthy volunteers. Serum sFas, Epo, tumor necrosis factor-alpha (TNF-α), interleukin (IL)-6, IL-10, iron status, and Hb concentration were analyzed in all groups. We also investigated the correlation between these variables in the AKI group. Critically ill patients (AKI and non-AKI groups) had higher serum levels of Epo than healthy volunteers. Hb concentration was lower in the AKI group than in the other groups. Serum sFas, IL-6, TNF-α, and ferritin levels were higher in the AKI group. Hb concentration correlated negatively with serum IL-6 (r = -0.37, P = 0.008), sFas (r = -0.35, P = 0.01), and Epo (r = -0.27, P = 0.04), while serum sFas correlated positively with iron levels (r = 0.36, P = 0.008) and IL-6 (r = 0.28, P = 0.04) in the AKI group. In multivariate analysis, after adjusting for markers of inflammation and iron stores, only serum sFas levels (P = 0.03) correlated negatively with Hb concentration in the AKI group. Serum Epo and inflammatory cytokine levels are elevated in critically ill patients with or without AKI. Serum levels of sFas are elevated and independently associated with anemia in critically ill patients with AKI.

Autoimmune hepatitis - primary biliary cholangitis overlap syndrome. Long-term outcomes of a retrospective cohort in a university hospital. / Síndrome de superposición: hepatitis autoinmune y colangitis biliar primaria. Resultados a largo plazo de una cohorte retrospectiva en un hospital universitario.

BACKGROUND: Autoimmune hepatitis (AIH) with characteristics of primary biliary cholangitis (PBC) is known as overlap syndrome. Its prevalence and prognosis have not yet been determined comparatively with AIH. METHODS: A retrospective cohort study was conducted comparing patients diagnosed with AIH and AIH-PBC overlap syndrome, followed-up for seven years in a university hospital in Colombia, until 31 December 2016. RESULTS: A total of 210 patients were included (195 women, mean age 48.5years). Of these, 32 (15.2%) had AIH-PBC overlap syndrome. At diagnosis, no significant differences were found by demographic profile, positive autoantibodies (ANA, ASMA), except AMA (81.2% vs 3.9%, P<.001), and histological grade of fibrosis. The most frequent clinical presentations were nonspecific symptoms in AIH-PBC and acute hepatitis in AIH. Although there were no significant differences, AIH showed a greater biochemical response to immunosuppressive management (87.3% vs 74.2%, P=.061) and a greater number of relapses in those who achieved partial or complete remission during treatment (12.4% vs 7.63%; P=.727). Patients with AIH-PBC had greater progression to cirrhosis (22.2% vs 13.1%, P=.038), even in those who achieved partial or complete biochemical remission without relapse, with greater indication of orthotopic liver transplantation (P=.009), but not retransplantation (P=.183); there were no differences in mortality. CONCLUSIONS: AIH-PBC overlap syndrome accounts for a significant proportion of patients with AIH, with greater progression to cirrhosis, indication of liver transplantation and possibly retransplantation. This higher risk of adverse outcomes suggests closer monitoring, probably with follow-up until confirmed histopathological remission.

The impact of continuous renal replacement therapy on renal outcomes in dialysis-requiring acute kidney injury may be related to the baseline kidney function.

BACKGROUND: Many controversies exist regarding the management of dialysis-requiring acute kidney injury (D-AKI). No clear evidence has shown that the choice of dialysis modality can change the survival rate or kidney function recovery of critically ill patients with D-AKI. METHODS: We conducted a retrospective study investigating patients (≥16 years old) admitted to an intensive care unit with D-AKI from 1999 to 2012. We analyzed D-AKI incidence, and outcomes, as well as the most commonly used dialysis modality over time. Outcomes were based on hospital mortality, renal function recovery (estimated glomerular filtration rate-eGFR), and the need for dialysis treatment at hospital discharge. RESULTS: In 1,493 patients with D-AKI, sepsis was the main cause of kidney injury (56.2%). The comparison between the three study periods, (1999-2003, 2004-2008, and 2009-2012) showed an increased in incidence of D-AKI (from 2.56 to 5.17%; p = 0.001), in the APACHE II score (from 20 to 26; p < 0.001), and in the use of continuous renal replacement therapy (CRRT) as initial dialysis modality choice (from 64.2 to 72.2%; p < 0.001). The mortality rate (53.9%) and dialysis dependence at hospital discharge (12.3%) remained unchanged over time. Individuals who recovered renal function (33.8%) showed that those who had initially undergone CRRT had a higher eGFR than those in the intermittent hemodialysis group (54.0 × 46.0 ml/min/1.73 m2, respectively; p = 0.014). In multivariate analysis, type of patient, sepsis-associated AKI and APACHE II score were associated to death. For each additional unit of the APACHE II score, the odds of death increased by 52%. The odds ratio of death for medical patients with sepsis-associated AKI was estimated to be 2.93 (1.81-4.75; p < 0.001). CONCLUSION: Our study showed that the incidence of D-AKI increased with illness severity, and the use of CRRT also increased over time. The improvement in renal outcomes observed in the CRRT group may be related to the better baseline kidney function, especially in the dialysis dependence patients at hospital discharge.

Second opinion for degenerative spinal conditions: an option or a necessity? A prospective observational study.

BACKGROUND: Second opinions may improve quality of patient care. The primary objective of this study was to determine the concordance between first and second diagnoses and opinions regarding need for spinal surgery among patients with back or neck pain that have been recommended spinal surgery. METHODS: We performed a prospective observational study of patients who had been recommended for spinal surgery and received a second opinion between May 2011 and May 2012 at the Hospital Israelita Albert Einstein on the advice of their health insurance company. A physiatrist and orthopaedic surgeon independently performed the second assessment. If both agreed surgery was indicated, or consensus could not be reached, participants attended a spine review panel for a final recommendation. Descriptive analyses compared diagnoses and management plans of the first and second opinions. RESULTS: Of 544 referred patients, 16 (2.9%) did not meet inclusion criteria, 43 (7.9%) refused participation and 485 were included. Diagnoses differed from the first opinion for 290 (59.8%). Diagnoses of cervical and lumbar radiculopathy were concordant in 36/99 (36.4%) and 116/234 (49.6%) respectively. The second opinion was for conservative treatment for 168 (34.6%) participants, 27 (5.6%) were not considered to have a spine condition, and 290 (59.8%) were referred to the review board. 60 participants did not attend the board review and therefore did not receive a final recommendation. Board review was conservative treatment for an additional 67 participants, 20 were not considered to have a spine condition and 143 participants were recommended surgery. Overall, 33.6% received a final opinion of surgery (143/425) although only 66 (15.5%) received the same surgical recommendation, 235 (55.3%) were advised to have conservative treatment, and 47 (11.1%) were not considered to have a spinal diagnosis. CONCLUSIONS: We found a large discordance between first and second opinions regarding diagnosis and need for spinal surgery. This suggests that obtaining a second opinion could reduce potentially unnecessary surgery. TRIAL REGISTRATION: Current Controlled Trials ISRCTN07143259 . Registered 21 November 2011.

TNF-α depuration is a predictor of mortality in critically ill patients under continuous veno-venous hemodiafiltration treatment.

INTRODUCTION: Critically ill patients with acute kidney injury (AKI) present high mortality rates. The magnitude of inflammatory response could determine the prognosis of such patients. Continuous renal replacement therapy (CRRT) may play an important role in removing inflammatory mediators in patients with AKI. AIM: To investigate whether the magnitude of inflammatory mediator's removal is associated with mortality among critically ill patients on CVVHDF, a CRRT modality. METHODS: This study consisted of 64 critically ill patients requiring CVVHDF. Plasma levels of C3a, TNF-α, IL-10, IL-6, IL-1ß, sTNFRI and sTNFRII were determined by enzyme-linked immunosorbent assay (ELISA) at the beginning of CVVHDF and after 24h (outlet). Clearance of cytokines during the first 24h of CVVHDF was calculated. Clinical and laboratory data were acquired from patient's records data. RESULTS: Mean age of patients requiring CVVHDF was 63years, 67.2% were men and 87.3% were Caucasian. Thirty-five (35) patients (54.7%) died. Comparing non-survivors with the group of survivors we observed higher incidence of sepsis (68.6 versus 37.9%, p<0.05), higher APACHE II score (34.8±7.6 versus 29.2±7.1, p<0.05) and higher lactate levels (23.2±17.6 versus 16.4±6.6, p<0.05). According to the inter-tertile range of TNF-α clearance (ITR1 (<0.54); ITR2 (0.54-2.93); ITR3 (>2.93)) we found that those patients with higher TNF-α removal by RRT (ITR3) had a better survival. Multivariable analysis showed that lower clearance of TNF-α remained independently associated with high mortality after adjustment for sex, age, use of vasoactive drugs, APACHE II score sepsis, creatinine and lactate before CVVHDF (HR: 0.179, 95% IC: 0.049-0.661, p<0.01). CONCLUSION: The attenuation of inflammatory response may be related to the lower mortality observed on those patients with higher TNF-α removal by CVVHDF.

Agreement on the prescription of antimicrobial drugs.

BACKGROUND: There is universal awareness of the difficulties faced by doctors when prescribing antimicrobials. METHODS: Over a six-month period patients hospitalized in the ICU and under treatment with antibiotics and/or antifungals were eligible to participate in the study. The data were assessed by two infectious diseases specialists. Once completed, all case forms were sent independently to both evaluators (TZSC and ARM) by e-mail. Based on the data received, the evaluator completed a form automatically generated on the e-mail and returned it to the original mailbox for further analysis. We assessed the level of agreement between infectious disease specialists and the physicians directly responsible for the decision to begin antimicrobial therapy, as well as to assess the appropriateness of the regimen prescribed. RESULTS: Among the antimicrobial regimens prescribed to the 177 patients, 36% were considered inappropriate by specialist #1 and 38% were considered inappropriate by specialist #2. We found 78% agreement by at least one of the infectious disease specialists with the prescribed antimicrobial regimen, and in 49% of cases both specialists agreed with the prescribed regimen. Both disagreed with the prescribed regimen in 22% of the cases and they disagreed between themselves in 29% of the cases. CONCLUSION: This study highlights the difficulties in prescribing effective empirical antimicrobial therapy--they are of such magnitude that even two specialists in infectious diseases, well acquainted with our hospital's resistance patterns and our patients' profiles have considerable disagreement.

When microsurgery becomes the only lifesaving resource: An institutional experience treating patients from low-income backgrounds affected by posterior circulation brain aneurysms.

BACKGROUND AND OBJECTIVE: Aneurysms of the posterior cerebral circulation constitute a burdensome condition with high mortality and morbidity. In the modern era, there has been a trend toward favoring an endovascular approach over microsurgery for aneurysm cases. Nevertheless, this transition has yet to be mirrored in low-to-middle-income countries where endovascular therapy may not be widely available. Herein, we aim to illustrate our experience treating these challenging conditions in patients from low-income backgrounds and discuss the relevance of the clinical setting in the treatment decision. METHODS: The authors conducted a retrospective review of the health records of patients who received microsurgical treatment for aneurysms in the posterior circulation, including the basilar artery (BA), posterior cerebral artery (PCA), and posterior inferior cerebellar artery (PICA) in an institution providing treatment to people of low-income backgrounds. Epidemiological data, microsurgical technique, and neurological function were retrieved and analyzed. RESULTS: Surgical clipping was employed for 12 patients (75% female) harboring 15 aneurysms (87% in the posterior circulation and 62% ruptured at presentation). Aneurysms were predominately located in the BA (69%), followed by the PCA (15%) and PICA (15%). Among neurological complications, 25% of patients developed oculomotor nerve palsy. The mortality rate was 17% owing to complications such as cerebral vasospasm, infarction, and severe intracranial hypertension. At the 6-month follow-up, 90% of patients had a good clinical outcome (modified Rankin scale scores of 0-2). CONCLUSION: The present case series illustrates the manifest role of microsurgical techniques for posterior circulation aneurysms, particularly in a scenario where endovascular techniques are not easily accessible. Importantly, this clinical setting pressure could exhort trainees to strive for microsurgical mastery and gain a competitive advantage.

Unraveling the role of internal-external metal substitution in Zn3[Co(CN6)]2 for the styrene oxide-CO2 cycloaddition reaction.

We investigated the influence of the structural and textural properties along with the chemical environment of pure Zn3[Co(CN)6]2 in comparison with the modified phases on the catalytic performance in the cycloaddition reaction between styrene oxide and CO2. We relate these to the proposed reaction pathways and mechanisms. The natural cubic phase (ZnCoCn) was dehydrated to obtain the rhombohedral phase (ZnCoRn), while the stabilized cubic phase (ZnCoCs) was synthesized by substituting external zinc atoms with cadmium atoms. The rhombohedral stabilized phase (ZnCoRs) was achieved by the internal cobalt change with iron. All the materials were extensively characterized using X-ray diffraction (XRD), thermogravimetric analysis (TGA), differential scanning calorimetry (DSC), X-ray photoelectron spectroscopy (XPS), and N2 adsorption. The catalytic behavior of the four phases was tested. The crystalline structure of each phase was obtained, and by XPS, it was demonstrated that the chemical environments of all elements conforming to the rhombohedral stabilized phase are different from those of all other materials owing to the exchange of internal metals. The bulk textural properties were similar; only the ZnCoRs presented more micropore area but did not exceed the total surface area of the other materials. The product distribution and yield at reaction times of 2 h and 6 h were closer to those of the cubic phases. The natural rhombohedral phase exhibits the best performance. The tetrabutylammonium bromide (TBAB) and rhombohedral stabilized phase work together to yield a bigger copolymer quantity at the expense of the styrene carbonate (StCO3) production. From the proposed mechanism, the TBAB cation (TBA+) has a "protection" function that drives the closing of the StCO3 ring; however, the charge distribution anisotropy in the four nitrogen atoms generated by Co replacement in ZnCoRs could hold TBA+ as the reaction time progressed, causing an unavailability that triggered the copolymerization propagation step.

Improving the diagnosis of meningitis due to enterovirus and herpes simplex virus I and II in a tertiary care hospital.

BACKGROUND: Enterovirus and herpes simplex viruses are common causes of lymphocytic meningitis. The purpose of this study was to analyse the impact of the use molecular testing for Enteroviruses and Herpes simplex viruses I and II in all suspected cases of viral meningitis. METHODS: From November 18, 2008 to November 17, 2009 (phase II, intervention), all patients admitted with suspected viral meningitis (with pleocytosis) had a CSF sample tested using a nucleic acid amplification test (NAAT). Data collected during this period were compared to those from the previous one-year period, i.e. November 18, 2007 to November 17, 2008 (phase I, observational), when such tests were available but not routinely used. RESULTS: In total, 2,536 CSF samples were assessed, of which 1,264 were from phase I, and 1,272 from phase II. Of this total, a NAAT for Enterovirus was ordered in 123 cases during phase I (9.7% of the total phase I sample) and in 221 cases in phase II (17.4% of the total phase II sample). From these, Enterovirus was confirmed in 35 (28.5%, 35/123) patients during phase I and 71 (32.1%, 71/221) patients during phase II (p = 0.107). The rate of diagnosis of meningitis by HSV I and II did not differ between the groups (13 patients, 6.5% in phase I and 13, 4.7% in phase II) (p = 1.0), from 200 cases in phase I and 274 cases in phase II. CONCLUSIONS: The number of cases diagnosed with enteroviral meningitis increased during the course of this study, leading us to believe that the strategy of performing NAAT for Enterovirus on every CSF sample with pleocytosis is fully justified.

Impact of acute kidney injury exposure period among liver transplantation patients.

BACKGROUND: Acute kidney injury is a common complication of liver transplantation. In this single-centre retrospective observational study, we investigated the impact of acute kidney disease on liver recipient survival. METHODS: The study population consisted of patients who underwent a liver engraftment between January 2002 and November 2006, at a single transplantation centre in São Paulo, Brazil. Acute kidney injury diagnosis and staging were according to the recommendations of the Acute Kidney Injury Network and consisted of scanning the daily serum creatinine levels throughout the hospital stay. Patients requiring renal replacement therapy prior to transplantation, those who developed acute kidney injury before the procedure or those receiving their second liver graft were excluded from the study. RESULTS: A total of 444 liver transplantations were performed during the study period, and 129 procedures (29%) were excluded. The remaining 315 patients constituted the study population. In 207 procedures, the recipient was male (65%). The mean age of the population was 51 years. Cumulative incidence of acute kidney injury within 48 h, during the first week after transplantation, and throughout the hospital stay was 32, 81 and 93%, respectively. Renal replacement therapy was required within a week after the transplantation in 31 procedures (10%), and another 17 (5%) required replacement therapy after that period. Mean follow-up period was 2.3 years. Time in days from acute kidney injury diagnosis to initiation of replacement therapy or reaching serum creatinine peak was associated with lower overall survival even when adjusted for significant potential confounders (HR 1.03; 95% CI 1.01, 1.05; p=0.002). Overall, patients experiencing acute kidney injury lasting for a week or more before initiation of replacement therapy experienced a threefold increase in risk of death (HR 3.02; 95% CI 2.04, 4.46; p<0.001). CONCLUSIONS: Acute kidney injury after liver transplantation is remarkably frequent and has a substantial impact on patient survival. Delaying the initiation of renal replacement therapy in such population may increase mortality by more than 20% per day.

Neurovascular Microsurgical Experience Through 3-Dimensional Exoscopy: Case Report and Literature Review.

BACKGROUND: The microscope is important in neurosurgery, but it is not exempt from limitations. The exoscope has emerged as an alternative because it offers better 3-dimensional (3D) visualization and better ergonomics. We present our initial experience in vascular pathology using 3D exoscopy at the Dos de Mayo National Hospital to show the viability of the 3D exoscope in vascular microsurgery. We also provide a review of the literature. METHODS: In this work, the Kinevo 900 exoscope was used in 3 patients with cerebral (2) and spinal (1) vascular pathology. We evaluated the image quality, equipment management, ergonomics, educational utility, and 3D glasses and recorded the characteristics of the cases. We reviewed the experience of other authors as well. RESULTS: Three patients underwent surgery: 1 occipital cavernoma, 1 cerebral dural fistula, and 1 spinal dural fistula. Excellent 3D visualization with Zeiss Kinevo 900 exoscope (Carl Zeiss, Germany), surgical comfort, and educational utility occurred, and there were no complications. CONCLUSIONS: Our experience and that of other authors suggests that the 3D exoscope shows excellent visualization, better ergonomics, and an innovative educational experience. Vascular microsurgery can be performed safely and effectively.

Optimization of the extraction of phenolic compounds from the leaves of yerba mate (Ilex paraguariensis) through high hydrostatic pressure system using mixture design with process variables.

In this study, a mixture design with process variables was used to optimize the extraction of total phenolic compounds (TPC) from yerba mate leaves through high hydrostatic pressure extraction. The studied variables were pressure (50, 100, and 150 MPa), extraction time (10, 20, and 30 min), and solvent (water, glycerin, and 50% v/v water/50% v/v glycerin). The multiple linear regression model presented an excellent fit (R2 adjusted of 0.9792) and demonstrated the major influence of glycerin content on the water/glycerin mixture solvent for TPC extraction. Optimal process conditions obtained were 69% v/v water, 31% v/v glycerin, 50 MPa pressure, and 10 min time. PRACTICAL APPLICATION: The paper describes a novel extraction method to obtain phenolic compounds from yerba mate (compounds that can replace synthesized antioxidants in the food industry) using high hydrostatic pressure and environmentally friendly solvents. The extraction process was studied to optimize its performance, obtaining more phenolic compounds from the same amount of yerba mate.

First report on quality and purity assessment of sweet almond oil in Brazilian body oils by gas chromatography and mass spectrometry.

Sweet almond oil is a raw material with high-added value used in different products. Then, the aim of this study is to evaluate the quality and purity of 10 body oils based on sweet almond oils currently available in the Brazilian market. Fatty acid composition and triacylglycerol (TAG) profile were determined by gas chromatography with flame ionization detector (GC-FID) and atmospheric solids analysis probe mass spectrometry (ASAP-MS), respectively. The authenticity of samples was assessed using an analytical curve equation. Soybean oil was chosen as the adulterant because it is the cheapest vegetable oil commercialized in Brazil. Hierarchical clustering analysis (HCA) in conjunction with ASAP-MS classified product samples according to the type of vegetable oil (soybean and sweet almond oils). The addition of soybean oil (8.79% to 99.70%) was confirmed in samples. However, only two samples stated in their label the presence of soybean oil as an ingredient. These findings highlight the need for better oversight by regulatory bodies to ensure that consumers acquire high quality and authentic products based on equally high quality and purity of sweet almond oils.