Clostridioides difficile infection in a long-term convalescence hospital: A real tale of pitfalls and outdated therapy.

OBJECTIVE: The aim of the study was to know the characteristics and risk factors of Clostridioides difficile infection (CDI) in a long-term hospital is key to improve its management. METHODS: Retrospective study with 37 patients, along 43 months. We describe demographic variables, clinical data, time to diagnosis, treatment, and evolution. RESULTS: Analysis of 46 episodes (37 patients, mean age=82.2 years). 77.8% were absolutely dependent, 41.7% had chronic kidney disease, 64.9% had received antibiotics in the previous three months, 40.5% received antibiotics at diagnosis. It was the first episode in 78.4%, and first recurrence in 21.6%. Therapy was started in the first 24 hours after diagnosis in 89.2%, mostly metronidazole. 83.3% recovered, 3 patients died from CDI, diagnosis was registered in the discharge report in 91.1%. CONCLUSIONS: Previous antibiotic therapy, high grade of dependency and renal failure were the main risk factors. There is room for improvement in CDI management at our hospital.

Hemoglobin (Hb) Val de Marne (Hb Footscray) in Brazil: the first case report.

Hemoglobin (Hb) variants involving alpha-chains are less common in the global population than Hb variants resulting from beta-chain alterations. Generally, alpha-chain Hb variants are caused by point mutations affecting alpha-1 and/or alpha-2 genes of the alpha-globin cluster (HBA1 and HBA2). In Brazil, the most prevalent alpha-chain Hb variant is Hb Hasharon. In this study, we present the first case of an Hb Val de Marne variant in the Americas, specifically in Brazil.

Influence of class I and II HLA alleles on inhibitor development in severe haemophilia A patients from the south of Brazil.

Congenital haemophilia A is a chromosome-linked recessive disorder caused by the deficiency or reduction of factor VIII (FVIII) pro-coagulant activity. During treatment, some patients develop alloantibodies (FVIII inhibitors) that neutralize the action of exogenously administered FVIII. Currently, the presence of these inhibitors is the most serious adverse event found in replacement therapy. Some studies have suggested that genetic factors influence the development of the FVIII coagulation inhibitors. To identify the class I and II alleles that may be influencing the formation of inhibitors in severe haemophilic patients. Genotyping of the class I (HLA-A, -B and -C) and class II (HLA-DRB1, -DQA1 and -DQB1) alleles of 122 patients with severe haemophilia A, including 36 who had developed antibodies to factor VIII, was performed. After the comparison of the group without inhibitors and the group with inhibitors, HLA-C*16 [Odds ratio (OR) = 7.73; P = 0.0092] and HLA-DRB1*14 (OR = 4.52; P = 0.0174) were found to be positively associated with the formation of the inhibitors. These results confirm that HLA alleles are involved in inhibitor production and could be used as a tool for recognition of groups at high risk of possible inhibitor development in Southern Brazilian haemophilic patients.

Exploring the opinion of CKD patients on dialysis regarding end-of-life and Advance Care Planning.

Advance care planning (ACP) and the subsequent advance directive document (ADD), previously known as "living wills", have not been widely used in Spain. The Ethics Group from the Spanish Society of Nephrology has developed a survey in order to investigate the opinion of dialysis patients regarding the ADD and end-of-life care. Patients received documentation explaining ACP and filled out a survey about their familiarity with and approval of the ADD. Seven hospital dialysis centres participated in the study for a total of 416 active dialysis patients. Questionnaires were distributed to 263 patients, 154 of which answered (69.2% completed them without assistance). The rates for ADD implementation (7.9%) and designation of a representative person (6.6%) were very low. Most of the patients clearly expressed their wishes about irreversible coma, vegetative state, dementia and untreatable disease. More than 65% did not want mechanical ventilation, chronic dialysis, tube feeding or resuscitation if cardiorespiratory arrest occurred. They reported that an ADD could be done before starting dialysis but most thought that it should be offered only to those who requested it (65% vs 34%). In conclusion, patients have clear wishes about end-of-life care, although these desires had not been documented due to the very low implementation of the ADD.

[Clinical and biochemical characteristics of predialysis patients in terms of 25 hydroxy vitamin D levels]. / Características clínicas y bioquímicas de pacientes en prediálisis con respecto a los niveles de 25 hidroxivitamina D.

INTRODUCTION: Decreased levels of 25 hydroxyvitamin D (25[OH]D) have been reported in patients with chronic kidney disease (CKD). The pleiotropic effects of vitamin D are known to go beyond mineral metabolism. OBJECTIVES: The aims of this study were to: 1) Determine the 25(OH)D levels in predialysis outpatients. 2) Find out the clinical and biochemical characteristics of patients with 25(OH)D deficiency, and predictive factors for the deficiency. PATIENTS AND METHODS: An observational study in 79 predialysis outpatients was performed. Clinical and biochemical parameters were analysed in terms of nutrition, inflammation and mineral metabolism in relation to serum levels of 25(OH)D. Levels of 25(OH)D lower than 15ng/ml were considered to be deficient. RESULTS: Serum levels of 25(OH)D were deficient in 41 patients (52%). The comparative study regarding levels of vitamin 25(OH)D showed the group of patients with a deficiency, i.e. those with less than 15ng/ml, were older (70 ± 11.97 vs. 61 ± 14.5; p = 0.005), had a greater body mass index, BMI, (30±4.06 vs. 27.1 ± 5.08; p = 0.003) and increased proteinuria (1.42g/24h (0.53-2.96) vs. 0.51 (0.20-1.48), p = 0.009). This group included a greater number of diabetic patients: 20 (76.9%) vs. 6 (23%), p = 0.002. They had a higher level of parathyroid hormone (PTH): 359 (239-658) vs. 233 (129-323), p = 0.000; and more patients were under treatment with Calcitriol: 28 (62.2%) vs. 17 (37.8%), p = 0.024. In the multivariate analysis, high levels of PTH (OR 13.38; CI 95% [2.94-60.89]; p=0.001), increased proteinuria (OR 4.41; CI 95% [1.12-17.25]; p = 0.033); and being diabetic (OR 5.713; CI 95% [1.43-22.77]; p = 0.014) were independent predictor factors for patients with 25(OH)D deficiency. CONCLUSIONS: In our study, we observed a high prevalence of 25(OH)D deficiency among patients with CKD. The increased levels of PTH, the increase of proteinuria and the presence of diabetes were independent predictors for 25(OH)D deficiency.

[Sclerosing encapsulating peritonitis: a latent threat. Changes of posture in surgery treatment]. / Peritonitis esclerosante: una amenaza latente. Cambio de actitud en el tratamiento quirúrgico.

UNLABELLED: Sclerosing Encapsulating Peritonitis (SEP) is a rare but serious complication of continuous ambulatory peritoneal dialysis (CAPD) with a high morbi-mortality. We describe our experience with patients was diagnostic of SEP, their characteristics in CAPD and their clinic evolution after diagnosis. 190 CAPD patients were follow-up during 17 years. Eight patients (4.2%) developed SEP. Average age 45+/-14 years (range 29-64 years), four was male. Time in CAPD was 72+/-29 months (range 24-120 months). All patients have peritonitis previously (mean 3+/-1). We observe a change in peritoneum characteristics (D/P Cr 4), with an average of 0.6+/-0.1 at one year of CAPD, versus 0.82+/-0.08 at the end of CAPD, with statistic significance (p<0.001). There are increases in use of hypertonic bags: 53%+/-28 at beginning versus 91%+/-27 at end, with statistic significance (p<0.009). All patients show tendency to hyperphosphoremia (mean 6.7+/-0.7 mg/dl), with product calcium-phosphorus 68.4+/-8.3. Five patients (62.5%) have a previous renal transplant, one lost due to early graft thrombosis and two lost due to acute rejection. Six patients (75%) have a previous abdominal surgery, although was extra peritoneal in all cases. The diagnosis of SEP was clinic suspicion in all cases, suggestive radiological data (intestinal handle group) and laparoscopy showing SEP (cocoon) with histological confirmation (fibrosis and peritoneal calcification) in four cases. The treatment was medical in six cases associated with surgery in four of them. The medical treatment was tamoxifen and/or corticosteroids, associated with total parenteral nutrition in two patients and enteral nutrition in one. Surgery in six patients: three as urgent surgery (all died) and three as programme surgery (two live still). Etiology of died was: three for sepsis, one for peritonitis after bowel perforation, one for severe problems of nutrition. The average survival of three patients alive was 38+/-17 months, two of them had programme surgery, and one with functioning transplant we opt for conservative treatment. The actuarial survival at 24 months was 51%. CONCLUSION: The SEP is a serious entity with high mortality. Although our short experience doesn't can indicate a concrete treatment, our personal impression is that early surgery associated with corticosteroids treatment may improve the prognostic.

Treatment of hirudin overdosage in a dialysis patient with heparin-induced thrombocytopenia with mixed hemodialysis and hemofiltration treatment.

We report a patient who developed type II heparin-induced thrombocytopenia (HIT) and accidentally received a recombinant hirudin (r-hirudin) overdosage. Treatment with hemodialysis (HD) using high-flux polysulfone dialyzer and hemofiltration was performed. Length of treatment was adjusted, monitoring activated partial thromboplastin time (aPTT) to 1.5-2.5 times the mean of the normal range. She developed deep venous thrombosis and occlusion of vascular access. Only after cessation of heparin lock catheter, platelet count began to increase. After one year of treatment with acenocoumarol and additional low-dose r-hirudin, neither bleeding nor thrombotic episodes have been reported.

[Telemedicine and follow up of peritoneal dialysis patients]. / Utilidad de la telemedicina en el seguimiento de los pacientes en diálisis peritoneal.

UNLABELLED: Mean-term experience in the use of Telemedicine in Peritoneal Dialisis (PD) patients is limited as well as its cost-benefit. The main objective of this work is to evaluate Telemedicine utility in mean-long term control of stable PD patients, analyzing if the televisit (TV) could substitute 50% of the programed inhospital consults (HC) the time spent in both visit modalities, the quality of patient-personel contact as well as how image and sound have been perceived. Visit resolution was analyzed taking into account the need of HC after a TV; We also have studied if it would be possible to retrain patients in the dialisis technique with telemedicine, and we have checked the patient perceived quality and calculate the real and social costs. METHODS: during 18 months, the system has been implanted to 19 patients with 7 +/- 4 follow up (range 3-17). A Falcon videoconference kit at patient's place was used, connected to the home television set. In the hospital there was a computer with a videoconference card, webcam and software meeting point which permits the control of patient's camera from the hospital. Both are connected by a 3RDSI line system. A monthly programmed HC or TV has been made. If more controls had been required, they have been made by TV Time spent was recorded on each TV and patients and staff questionary were inquired. RESULTS: (a) PATIENTS: mean age 44 +/- 8 years, 13 (68%) male. 12 (63%) had elemental educational level and 7 (37%) mean-superior. 17 (89%) were actively working. The PD technique was: CAPD 6 (32%) and APD13 (68%). (b) Televisits: 103 TV have been made. 22 +/- 9 minutes were spent on each TV less than in the HC, 33 +/- 8 minutes (p < 0.01). There were technical problems related with lines in 21 TV, but only in 4 the connection was not possible. 92 TV (89%) were made on time, 99 (96%) had a good image quality and 96 (93%) had a correct sound. 100% of patients perceived TV as close to HC. In 90 TV (87%) medical treatment was modified. Only in 4 cases (3.9%) patients needed an hospital visit. According to patient's valuation, TV replaced correctly to HC in 97 instances (94%) and in 97 (97%) in staff opinion. In all cases (100%) catheter exit site could be evaluated as well as edema presence. Retraining was possible in all cases. There was a save in nurse's time and patient's time and also, a save in physical hospital space. Initial investment apart, the daily cost increment was scarce (1.5 Euro) taking into account that there is a save in time for patients and personnel, save in physical space in hospital and in sanitary transport. CONCLUSION: Telemedicine is useful from the clinical point of view in the mean-term for stable patients in PD. Daily cost increment is scarce and there is a save in time for patients and personnel, save in physical space in hospital and in sanitary transport.

Anticoagulant and antithrombotic activities of a chemically sulfated galactoglucomannan obtained from the lichen Cladonia ibitipocae.

A galactoglucomannan (GGM), isolated from the lichen Cladonia ibitipocae, consisted of a (1-->6)-linked main chain of alpha-mannopyranose units, substituted by alpha- and beta-D-galacto (alpha- and beta-D-Galp)-, beta-D-gluco (beta-D-Glcp)- and alpha-D-mannopyranosyl (alpha-D-Manp) groups, and was sulfated giving a sulfated polysaccharide (GGM-SO4) with 42.2% sulfate corresponding to a degree of substitution of 1.29. NMR studies indicated that after sulfation, the OH-6 groups of galactopyranosyl and mannopyranosyl units were preferentially substituted. GGM-SO4 was investigated in terms of its in vitro anticoagulant and in vivo antithrombotic properties. Those of the former were evaluated by its activated partial thromboplastin (APTT) and thrombin time (TT), using pooled normal human plasma, and compared with that of 140 USP units mg(-1) for a porcine intestinal mucosa heparin. Anticoagulant activity was detected in GGM-SO4, but not in GGM. The in vivo antithrombotic properties of GGM-SO4 were evaluated using a stasis thrombosis model in Wistar rats, intravenous administration of 2 mg kg(-1) body weight totally inhibiting thrombus formation. It caused dose-dependent increases in tail transection bleeding time. The results obtained showed that this sulfated polysaccharides is a promising anticoagulant and antithrombotic agent.

[Acute hyperphosphatemia secondary to phosphate administration for bowel preparation]. / Hiperfosforemia aguda tras preparación para colonoscopia.

We report a 75-years-old woman, stable on a three-weekly hemodialysis program over a period of 3 years, who develop acute hyperphosphatemia secondary to phosphate administration for bowel preparation. The quick clinical diagnosis and the treatment with intensive hemodialysis resulted in a correction of hyperphosphatemia, hypocalcemia, acidemia and other electrolyte abnormalities. The phosphate cathartics are contraindicated in patients with severe renal insufficient or in dialysis program. Our case shows the severe side effects secondary to injudicious use of sodium phosphate cathartics.

[Antiproteinuric effect of renin-angiotensin system blockade in patients with normal/lower than 115 mmHg systolic blood pressure]. / Efecto antiproteinúrico del bloqueo del sistema renina-angiotensina (SRA) en pacientes con presión arterial sistólica inferior o igual a 115 mmHg.

UNLABELLED: The renoprotective effect of renin-angiotensin system (RAAS) blockade by ACE inhibitors (ACEI) or AT1 receptor antagonists (ARA) in chronic proteinuric nephropathies is well known. Most studies have related this beneficial effect with the antihypertensive and antiproteinuric properties of these drugs, but this aspect has not been extensively analyzed in patients with normal/low values of blood pressure. We studied nineteen patients with different chronic proteinuric nephropathies that started ACEI or ARA because of proteinuria and despite systolic blood pressure (SBP) < or = 115 mmHg. Short and long-term tolerance to treatment as well as evolution of renal function parameters were recorded. RESULTS: At baseline, SBP was 110.2 +/- 2.6 mmHg (105-115) an diastolic blood pressure (DBP) 68.6 +/- 4.3 (60-75). Initial low doses of ACEI or ARA were well tolerated. After 6 months of treatment, proteinuria decreased by 46% of baseline, from 2.1 +/- 1.8 g/day to 1.1 +/- 0.8 g/day, without significant changes in BP or renal function. After a 48 +/- 27 months follow up, proteinuria decreased to 0.7 +/- 0.6 g/day (68% of basal values). Renal function and BP did not show significant changes during follow up. CONCLUSIONS: RAAS blockade by ACEI/ARA induces a significant antiproteinuric and renoprotective effect in proteinuric patients with normal/low levels of BP Initial doses of ACEI/ARA were well tolerated.

Results of kidney transplantation in recipients over 70 years of age: experience at a single center.

We performed 41 kidney transplants in patients >70 years (35 single and 6 dual), with a mean recipient age of 72+/-2 years, from January 1990 to December 2001. Mean age of the donors was 69+/-12 years. Immunosuppression used triple therapy with steroids, mycophenolate mofetil, and cyclosporine or tacrolimus. Cold ischemia time was 23+/-3 hours. The incidence of primary nonfunction was 4.8%, and delayed graft function 58.5%. Acute rejection incidence was 12%. The actuarial patient survival rates at 12, 24, and 36 months were 82.5%, 82.5%, and 75%, respectively. Actuarial survival rates of the grafts censuring for death of the recipient with a functioning graft were 89.5%, 86%, and 68%, respectively. Nine of the 18 graft losses were due to recipient death. Overall, renal transplant recipients >70 years showed good results. The principal cause of graft loss was recipient death.

[Immunoallergic interstitial nephritis vs. cholesterol atheroembolism. Differentiating characteristics]. / Nefritis intersticial inmunoalérgica vs ateroembolismo de colesterol. Características diferenciales.

The commonest clinical presentation of both immunoalergic interstitial nephritis (IIN) and atheroembolic renal disease (ATD) is an acute renal failure accompanied by skin lesions and eosinophilia. As a consequence, differential diagnosis between both entities is often very difficult. We have performed a comparative retrospective study of those patients diagnosed as having IIN or ATD in our Hospital in the period 1980-2000. A total of 42 patients have been diagnosed of IIN and 16 of ATD. Demographic data, as well as clinical and laboratory parameters and outcomes of every studied patient were analysed. We found a significantly higher prevalence of male sex (100% vs 57%, p < 0.01), previous history of hypertension (100% vs 55%, p < 0.01), chronic renal insufficiency (56% vs 17%, p < 0.01), ischemic heart disease (56% vs 14%, p < 0.001), peripheral ischemic disease, endovascular procedures (87% vs 7%, p < 0.001) and anticoagulant treatments (25% vs 5%, p < 0.001) among patients with ATD as compared with IIN, respectively. On the contrary, previous infections (45% vs 12%, p < 0.01) and exposure to new drugs (100% vs 40%, p < 0.001) were significantly more frequent among IIN patients in compare with ATD. ATD patients showed skin lesions consisting of livedo reticularis and digital infarcts (63% vs 31%, p < 0.05) accompanied by blood pressure increase (100% vs 24%, p < 0.001), whereas IIN patients showed fever (41% vs 19%, p < 0.05) and cutaneous rash as significant clinical manifestations, respectively. The number of ATD patients with proteinuria > 1 g/24 h was significantly higher, but no differences between both groups in the prevalence of urinary sediment abnormalities were observed. The prevalence of absolute eosinophilia was high in both groups (88% among ATD patients, 64% among IIN patients; pNS). Prognosis of both entities was clearly different: Almost all patients with ATD died (69%) or evolved to end-stage renal failure, whereas most patients with IIN showed a recovery of renal function after withdrawal of responsible drugs and steroid treatment. In summary, the analysis of clinical and laboratory data allows an initial differential diagnosis in patients suspected as having IIN or ATD.

CDMA and TDMA based neural nets.

CDMA and TDMA telecommunication techniques were established long time ago, but they have acquired a renewed presence due to the rapidly increasing mobile phones demand. In this paper, we are going to see they are suitable for neural nets, if we leave the concept "connection" between processing units and we adopt the concept "messages" exchanged between them. This may open the door to neural nets with a higher number of processing units and flexible configuration.