Do HLA class II genes protect against pulmonary tuberculosis? A systematic review and meta-analysis.

Pulmonary tuberculosis (PTB) develops by a complex combination of environmental, immunological and socioeconomic factors and genetic susceptibility. The human leukocyte antigen (HLA) is the most polymorphic biological system and plays an essential role in the immune response against PTB. The aim of this study was to carry out a systematic review and meta-analysis evaluating the relationship between HLA-DRB1, HLA-DQB1 and HLA-DQA1 gene polymorphisms as possible risk or protective factors for PTB. A systematic search of the PubMed and Scopus databases was conducted following the guidelines described in the PRISMA statement. Fifty-six alleles were included in the meta-analysis. In the total pooled results, HLA-DRB1*08:03 (OR 1.95, CI 1.29-2.96), HLA-DQB1*06:01 (OR 1.78, CI 1.39-2.28), HLA-DQB1*06:09 (OR 2.27, 95 % CI 1.04-4.96) and HLA-DQA1*01:01 (OR 2.12, CI 1.11-4.03) genes were related to higher susceptibility to PTB. Conversely, the presence of the genes HLA-DRB1*07:01 (OR 0.74, CI 0.56-0.97), HLA-DQB1*03:01 (OR 0.77, CI 0.61-0.97), HLA-DQB1*04:02 (OR 0.57, CI 0.39-0.83), HLA-DQA1*04:01 (OR 0.50, CI 0.26-0.95) and HLA-DQA1*05:01 (OR 0.66, CI 0.48-0.92) demonstrated protection against PTB. In an analysis by ethnic subgroups, we found more genetic associations in Caucasians than in Asians. These findings suggest that HLAs may be used as markers for acquisition and development of PTB. To strengthen PTB susceptibility/resistance, we recommend further multicentric studies in different geographic regions, with certainty of controls' exposure to M. tuberculosis by use of marker of latent or active PTB, with analysis stratified by ethnic groups, with descriptions of specific alleles and carrying out immunological functionality tests.

[Home paracentesis in palliative care performed by primary care doctors: Presentation of a case]. / Paracentesis evacuadora domiciliaria en cuidados paliativos realizada por profesionales de atención primaria. Presentación de un caso.

Home paracentesis is a relatively simple and safe. Applied in the field of palliative home care by primary care physicians significantly increases patient comfort and gratitude from both patient and family, and avoids continuous visits to hospital emergency services to perform this technique on a regular basis. The patient is terminal, usually with pain, with distant metastases and multiple symptoms, where transfers by ambulance, waiting times, continuous admissions and discharges, have a big impact. We report a case of a patient with end-stage hepatocellular carcinoma in which we performed home paracentesis in collaboration with the palliative care support team of our hospital, with good results. Home monitoring by the primary care physician can help to improve both the care and the quality of life of these patients by increasing coordination between care levels and avoid hospital admissions.

Paracentesis evacuadora domiciliaria en cuidados paliativos realizada por profesionales de atención primaria. Presentación de un caso / Home paracentesis in palliative care performed by primary care doctors: presentation of a case

La paracentesis evacuadora domiciliaria es una técnica relativamente sencilla y segura. Aplicada en el ámbito de los cuidados paliativos domiciliarios por parte de los médicos de atención primaria aumenta de forma considerable el bienestar del paciente y la gratitud tanto de éste como de sus familiares, al evitarle los continuos traslados a los servicios de urgencias hospitalarios para realizar dicha técnica de forma periódica. Se trata de pacientes terminales, habitualmente con dolor, con metástasis a distancia y síntomas múltiples, en los que los traslados en ambulancia, esperas, ingresos y altas continuos tienen un gran impacto. Presentamos el caso de un paciente con hepatocarcinoma en estadio terminal en el que hemos realizado una paracentesis evacuadora domiciliaria con buenos resultados en colaboración con el equipo de soporte de cuidados paliativos de nuestra área hospitalaria. El seguimiento domiciliario por el médico de atención primaria puede contribuir a mejorar tanto la asistencia como la calidad de vida de estos pacientes al aumentar la coordinación entre niveles y evitar ingresos hospitalarios (AU)

Home paracentesis is a relatively simple and safe. Applied in the field of palliative home care by primary care physicians significantly increases patient comfort and gratitude from both patient and family, and avoids continuous visits to hospital emergency services to perform this technique on a regular basis. The patient is terminal, usually with pain, with distant metastases and multiple symptoms, where transfers by ambulance, waiting times, continuous admissions and discharges, have a big impact. We report a case of a patient with end-stage hepatocellular carcinoma in which we performed home paracentesis in collaboration with the palliative care support team of our hospital, with good results. Home monitoring by the primary care physician can help to improve both the care and the quality of life of these patients by increasing coordination between care levels and avoid hospital admissions (AU)

Ambulatory blood pressure monitoring in kidney transplant patients: RETENAL study.

Hypertension is common following renal transplantation, affecting up to 80% of transplant recipients. It is generally accepted that hypertension is associated with poor graft survival and reduced life expectancy, contributing to increased cardiovascular risk factors and mortality rates. The aim of the study was to compare the blood pressure (BP) control in kidney transplant patients through the use of ambulatory BP monitoring (ABMP) versus office BP measurements (oBP). A multicenter, cross-sectional, observational study was conducted in 30 nephrology/kidney transplant units. Eligible patients included hypertensive cadaveric kidney transplant recipients aged <70 years, with a functioning kidney for at least 1 year and with an estimated glomerular filtration ≥30 mL/min/1.73 m(2) and a serum creatinine < 2.5 mg/dL. Recorded data included demographic characteristics, oBP, and ABPM and labroatory investigations. The 868 patients showed a mean recipient age of was 53.2 ± 11.6 years and mean follow-up after transplantation, 5.5 ± 2.8 years. Mean systolic and diastolic oBP were 140.2 ± 18 and 80.4 ± 10 mm Hg, respectively. Seventy-six percent of patients had oBP higher than or equal to 130/80 mm Hg. Mean 24 hour ABPM were 131.5 ± 14 and 77.4 ± 8.7 mm Hg for systolic and diastolic BP, respectively. Using the ABPM, we observed that 36.5% of subjects were controlled (mean 24-hour BP < 130/85 mm Hg). The two methods (oBP and ABPM) showed significant agreement. After ABPM, 65% of patients diagnosed as true controlled hypertension were considered to have white-coat RH. In clinical practice ABPM may help for better adjustment of drugs for adequate BP control.

Information channels and the dynamics of uptake of living kidney donors: a retrospective study in a reference area.

INTRODUCTION: Activity in renal transplantation at our center continues to grow due to the gradual increase in living donor kidney transplantations (LDKT). Our objective was to describe the generation process of living donation in our area of influence including two provinces and 18 chronic kidney disease (CKD) treatment units in particular the origin of paired donor/recipients and information channels. METHODS: We included all actual and discarded potential donors from 2005 to 2009. History and telephone interviews provided a description of the cases, sources and process information. RESULTS: Among 95 potential pairs we performed 44 LDKT during this period. The recipients were predialysis (38%), on dialysis (54%), or after prior transplantation (8%). Among the 10 dialysis centers, the referral rate ranged between 0 and 8.6 pairs per 100 patients. We contacted 78 (83%) donors for an interview, among whom 53% first learned of LDKT when the recipient already had advanced CKD at predialysis or dialysis stages. Television was the main means of this first knowledge (38%), followed by the health care staff. LDKT was not primarily a treatment option offered by the nephrologist for 65% of subjects; however, the nephrologists were the major reference sources followed by the Internet and transplant coordinators. CONCLUSIONS: The majority of donations are initiated before the recipient is on dialysis, but eventuates predialysis in only 38% of cases. The possibility of being referred seems to be influenced by the recipient's treatment center. We need a more proactive role of nephrologists to offer this therapeutic option. This study identified the importance of public information to identify targets and design strategies to disseminate quality information on LDKT.

Calcimimetics and bone mineral density in renal transplant patients with persistent secondary hyperparathyroidism.

BACKGROUND: The persistence of secondary hyperparathyroidism plays an important role in posttransplant bone loss. Calcimimetics are efficient to control metabolic alterations associated with this problem, but there are few publications that assess their effects on bone density. PATIENTS AND METHODS: This prospective study assessed the effects of a single daily dose of cinacalcet on calcemia, phosphatemia, parathyroid hormone (PTH), and bone densitometry (femur and spine) values of 27 renal transplant patients with stable kidney function, calcium > 10.5 mg/dL, and PTH > 65 pg/mL. RESULTS: A preliminary study after 6 months showed decreased calcemia (11.05 +/- 0.5 to 10.18 +/- 0.6 mg/dL; P < .0001), reduced levels of intact PTH (iPTH; 258 +/- 104 to 209.61 +/- 127 pg/mL; P < .05), and increased phosphatemia (2.38 +/- 0.45 to 2.54 +/- 0.3 mg/dL; P < .05). We also observed an increase in femoral neck bone mass with improved T score (-1.36 +/- 1.19 to -1.05 +/- 0.84 g/cm(2); P < .05). CONCLUSIONS: Cinacalcet was effective in the management of posttransplant persistent secondary hyperparathyroidism, resulting in decreased calcemia and iPTH, while also improving femoral neck bone loss. Longer-term studies with control groups are needed to determine the drug's influence on overall bone mineral density.

Mujer de 34 años con astenia extrema de larga evolución. Abordaje multidisciplinar / A 34-year old woman with extreme long course asthenia. Multidisciplinary approach

El síndrome de fatiga crónica (SFC) es una afección relativamente poco frecuente, aunque se estima que está infradiagnosticada. Su diagnóstico es complejo y necesariamente multidisciplinar. Los criterios definitorios de caso se establecieron por el Center for Disease Control (CDC) en 1988 y fueron consensuados y simplificados por Fukuda et al en 1994. Se trata de una enfermedad globalmente poco conocida por los profesionales, a pesar de su severidad, tendencia a la cronicidad y carecer en la actualidad de un tratamiento eficaz. Presentamos un caso clínico de una paciente de nuestra consulta diagnosticada de SFC. El interés del caso radica en la tortuosidad de todo el proceso previo hasta llegar al diagnóstico, en el que se ha invertido casi tres años, debido a la complejidad de la sintomatología y a la necesidad de excluir cualquier tipo de patología que pueda producir fatiga de forma crónica. La positividad de determinadas pruebas diagnósticas o la concurrencia de otras patologías asociadas pueden interferir en la demora de dicho diagnóstico, como ocurre en el caso que presentamos. Una vez concluidos todos los estudios, y establecido el diagnóstico, la falta de unidades específicas para realizar el seguimiento de estos pacientes hace que dicha responsabilidad recaiga sobre el médico de Atención Primaria

Chronic fatigue syndrome (CFS) is a relatively uncommon disease although it is estimated to be underdiagnosed. Its diagnosis is complex and must be multidisciplinary. The defining criteria of the case were established by Center for Disease Control (CDC) in 1988 and were agreed on and simplified by Fukuda et al. in 1994. This disease is little known worldwide by the professionals in spite of its severity, tendency to become chronic and currently lacks an effective disease. We present a clinical case of a female patients diagnosed in our clinic of CFS. The interest of this case is found in the indirect pathway during all the previous steps to reach a diagnosis. It took almost three years, due to the complexity of the symptoms and the need to exclude all types of diseases that could cause chronic fatigue. The positivity of certain diagnostic tests or the concurrence of other associated diseases may interfere in the delay of such diagnosis, as occurred in the case we are presenting. Once all the studies are concluded and the diagnosis established, the lack of specific units to conduct the follow-up of these patients throws the responsibility of them on the primary health care doctor

Influence of renal insufficiency on pharmacokinetics of ACYL-glucuronide metabolite of mycophenolic acid in renal transplant patients.

The acyl glucuronide of mycophenolic acid (AcMPAG) is a metabolite with in vitro immunosuppressive activity. The chemical properties of acyl glucuronides have been associated with the toxicity of some drugs. The aim of our study was to analyze the influence of renal insufficiency on the pharmacokinetics of AcMPAG. Areas under the 12-hour curve (AUC(0-12h)) of MPA, glucuronide of MPA (MPAG), and AcMPAG were determined by high performance liquid chromatography performed in 20 renal transplantation patients under treatment with mycophenolate mofetil (MMF), cyclosporine, and steroids. They were divided between a group with preserved renal function (group I, mean creatinine clearance [Clcr] of 105 +/- 7 mL/min) and one with advanced renal insufficiency (group II, mean Clcr of 27 +/- 5 mL/min). There was no difference in MMF dose or MPA-AUC(0-12h) values between groups. Mean predose levels of AcMPAG-C0 and AcMPAG-AUC(0-12h) were much higher in group II than in group I (0.5 +/- 2 vs 1.6 +/- 1 microg/mL and 12 +/- 2 vs. 32 +/- 19 microg*h/mL respectively, P < .005). The present data suggested that AcMPAG, a metabolite with immunosuppressive activity that may be related to toxic effects of MPA, is renally eliminated. Its levels can significantly rise in patients with renal insufficiency. Although further studies with more patients are required to determine the role of AcMPAG in MPA toxicity, we believe that this accumulation may be of clinical relevance.

Cerebelitis postinfecciosa por virus de Epstein-Barr. Presentación de un caso clínico / Postinfectious cerebellitis induced by Epstein-Barr virus. A clinical case report

La infección por el virus de Epstein-Barr (VEB) tiene una distribución mundial. Es especialmente frecuente en niños y adultos jóvenes. Su principal manifestación clínica es la mononucleosis infecciosa. Habitualmente el curso clínico es benigno, llegando a ser subclínica en algunas ocasiones. Las complicaciones neurológicas son muy poco frecuentes y se observan en un porcentaje inferior al 1% de todos los afectados. En los adultos su presentación se considera excepcional. En este trabajo presentamos el caso clínico de un paciente adulto joven sin antecedentes de interés, que en el curso de una infección aguda por VEB desarrolló una cerebelitis postinfecciosa. El interés de este caso clínico radica en la secuencia con la que han ido apareciendo los síntomas en el tiempo y su carácter excepcional. El enfoque diagnóstico se hizo desde Atención Primaria. La evolución ha sido satisfactoria y en la actualidad, 2 meses después de la fase aguda, se encuentra prácticamente asintomático

Epstein-Barr virus (EBV) infection has a worldwide distribution. It is especially frequent in children and young adults. Its main clinical manifestation is infectious mononucleosis. The clinical course is usually benign, and sometimes subclinical. The neurological complications are very rare and are observed in a percentage less than 1% of all those affected. Its presentation is considered to be rare in adults. In this work, we present the clinical case of a young adult patient with no background of interest who, during the course of an acute infection due to EBV, developed postinfectious cerebellitus. The interest of this clinical case is found in the sequence in which the symptoms have been appearing in time and its rare character. The diagnostic approach was made from primary care. Evolution has been satisfactory and currently, 2 months after the acute phase, the patient is practically asymptomatic

Multimodality imaging for focus localization in pediatric pharmacoresistant epilepsy.

UNLABELLED: Multiple structural and functional imaging modalities are available to localize the epileptogenic focus. In pre-surgical evaluation of children with pharmacoresistant epilepsy, investigations with the maximum yield should be considered in order to reduce the complexity of the workup. OBJECTIVE: To determine the extent to which PET, ictal/interictal SPECT and its co-registration with the patient's MRI contributes to correct localization of the epileptogenic focus, surgical intervention and to the post surgical outcome in paediatric patients. METHODS: The study population included children and adolescents with pharmacoresistant epilepsy (n = 50) who underwent preoperative evaluation, surgery and had postoperative follow-up for at least 12 months. Outcome was measured by postoperative seizure frequency using Engel's classification. RESULTS: Thirty-nine patients (78%) became completely seizure free after surgical intervention. The likelihood to benefit from surgical treatment was significantly higher if localization with more imaging modalities (MRI, PET, SPECT) were concordant with respect to the resected brain area (p < 0.01). Preoperative PET examination provided better localizing information in patients with extratemporal epilepsy and/or dysplastic lesions, whereas SPECT was found to be superior to PET in patients with temporal lobe epilepsy and/or tumors (p < 0.05). No significant difference was noted in the surgical outcome in younger or older age group, in children with or without special education needs. CONCLUSION: In paediatric epilepsy pre-surgical evaluation, the combined use of multiple functional imaging modalities for a precise localisation of the epileptogenic focus is worthwhile for both extratemporal and temporal lobe epilepsy, also when EEG and MRI alone are non-contributive, given the potential benefit of complete postoperative seizure control.

Incidencia de complicaciones en anestesia regional, análisis en un hospital universitario. Estudio de Corte Transversal / Incidence of complications in regional anesthesia, analysis in a university hospital. Study of Cross section

Durante el año 2005 se realizaron 11.588 procedimientos bajo anestesia en el hospital universitario Fundación Santa Fe de Bogotá -FSFB-,de los cuales el 16,5 por ciento (1915) fueron con anestesia regional. En general no existen datos estadísticos en la literatura colombiana con respecto a las complicaciones de la anestesia regional, y específicamente en hospitales con residentes en entrenamiento. Mediante un estudio de corte transversal, se midió la incidencia de las complicaciones de anestesia regional, utilizando un muestreo aleatorio, durante un año se recolectaron 212 casos. El 5,1 por ciento presentó algún tipo de complicación, de las cuales sólo el 0,6 por ciento, fueron complicaciones mayores, reportada como punción dural advertida. En total fueron 147 anestesias neuroaxiales, de las cuales una paciente (0,6 por ciento) presentó cefalea postpunción, cinco pacientes (el 2,35 por ciento), fueron bloqueos fallidos y dos pacientes (0,95 por ciento) presentaron alteración neurológica tipo parestesias, de las cuales sólo una: la neuropraxia del plexo braquial, requirió seguimiento continuo . Se administraron un total de 1300 anestesias neuroaxiales durante el año, se registraron ocho (8) cefaleas postpunción dural, siendo la causa más frecuente de complicaciones, con una adherencia del 89 por ciento a la guía de practica clínica, basada en la evidencia, del Departamento de Anestesia de la FSFB para el tratamiento de la misma. La incidencia de complicaciones de anestesia regional en el Hospital Universitario Fundación Santa Fe de Bogotá se encuentra por debajo de lo reportado en la literatura, pues el ser un Hospital Universitario no constituye un factor adicional de riesgo que aumente las complicaciones, en procedimientos permanentemente supervisados...

Corticosteroid-responsive postmalaria encephalopathy characterized by motor aphasia, myoclonus, and postural tremor.

OBJECTIVES: To study the clinical spectrum of an acute severe encephalopathy occurring in 2 patients after recovery from falciparum malaria infection and to compare it with the reported clinical features of the postmalaria neurological syndrome. DESIGN: Case report. SETTING: Tertiary care hospital. PATIENTS: Two patients presented with acute onset of fluctuating motor aphasia, severe generalized myoclonus, and postural tremor. Additional signs were cerebellar ataxia, and in 1 patient, generalized epileptic seizures. Magnetic resonance imaging of the brain revealed patchy white matter lesions in 1 patient. Clinically, the patients' conditions continued to worsen until corticosteroids were introduced, the use of which induced a rapid, albeit incomplete, recovery. CONCLUSIONS: We describe a new, severe variant of the still poorly defined postmalaria neurological syndrome. We propose a preliminary classification of this syndrome, according to its clinical characteristics, as follows: a mild or localized form, characterized by isolated cerebellar ataxia or postural tremor; a diffuse, but relatively mild encephalopathic form, characterized by acute confusion or epileptic seizures; and a severe, corticosteroid-responsive encephalopathy that is characterized by motor aphasia, generalized myoclonus, postural tremor, and cerebellar ataxia.

Anti-liver-kidney microsome antibody-positive autoimmune hepatitis associated with alopecia.

A 14-year-old girl presented with anti-liver-kidney microsome autoimmune hepatitis preceded by alopecia 3 years earlier. Both pathologies were greatly improved by immunosuppressive therapy. Alopecia is a newly reported extrahepatic manifestation of type 2 autoimmune hepatitis. Its appearance could alert the clinician to an increased risk of autoimmune hepatitis in children.