Outcomes of Kidney Transplantations Under the Philippine Health Insurance Corporation's Type Z Benefit Package at the National Kidney and Transplant Institute, Philippines.

BACKGROUND: Under the Universal Health Care Program of the Department of Health, the Philippine Health Insurance Corporation (PHIC) launched the Case Type Z benefit package for kidney transplantation, providing the largest amount (USD $13,300.00) for any single medical procedure. The objective of this study was to describe under the PHIC Case Type Z Benefit Package for kidney transplantation at the National Kidney and Transplant Institute and kidney transplantation outcomes under this package. METHODS: Included in the benefit were standard risk recipients between 10 and 70 years of age with at least 1 human leukocyte antigen (HLA) DR match with the donor, panel-reactive antibody (PRA) less than 20%, and absence of donor-specific antibody (DSA). Previous transplantations, malignancy, hepatitis B and C, human immunodeficiency virus (HIV) positivity, cytomegalovirus (CMV) R-/D+, congestive heart failure, and liver cirrhosis were exclusion criteria. Patients were evaluated by a medical social worker according to their family's financial status. RESULTS: Since June 2012, a total of 261 patients have received the benefit, with 44 under service, 37 with fixed co-pay and 180 with variable co-pay. Of the living donor kidney transplants, 98% had immediate graft function, with 2.3% (6/261) acute rejection rates at 1 year. The total cost of hospitalization was within the benefit for living donor kidney transplants (less than USD 8000.00) but exceeded it in all cases of deceased donor kidney transplants. CONCLUSIONS: The successful use of and excellent outcomes under the Case Type Z benefit demonstrated how collaboration among government agencies, health care providers, and pharmaceutical companies could result in a program that improved the access to health care for Filipino patients with end-stage renal disease.

Abscesos hepáticos múltiples por Gemella morbillorum / Multiple hepatic abscesses due to Gemella morbillorum

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[The current clinical spectrum of pulmonary thromboembolism]. / El espectro clínico actual del tromboembolismo pulmonar.

BACKGROUND. Mortality in pulmonary thromboembolism (PTE) decreases considerable when it is diagnosed early. The suspicion based on clinical and complementary data is essential for an early diagnosis. METHODS. Retrospective review of the clinical features in patients diagnosed of PTE in an Internal Medicine department from January 1993 to December 1999. RESULTS. A total of 117 patients with PTE were identified. The median age was 68.8 years. Sixty-six patients (56.4%) had one or more risk factors for PTE. The most common risk factor was immobilization (37.6%). Dyspnea was the most common symptom (74.4%) and tachypnea the most common sign (66.7%). Fever/low grade fever and leukocytosis were present in 16.2% and 31.6% of patients, respectively. Respiratory failure, alkalosis and hypocapnia were present in 44.4%, 38.5% and 47% of patients, respectively. An alveolar-arterial oxygen gradient > 20 mmHg was demonstrated in 96.6% of patients. Chest radiographs and electrocardiograms were normal in 52.1% and 23.9% of patients, respectively. A vein echo-duplex of the lower limbs demonstrated deep vein thrombosis (DVT) in 52.1% of patients. The hospital mortality rate was 6.8%. CONCLUSIONS. PTE still affects older patients mainly and frequently known risk factors are not detected. The presence of fever/low grade fever and/or leukocytosis does not rule out PTE. Both chest radiographs and electrocardiograms may be normal. Not demonstrating DVT in the lower limbs by the vein echo-duplex does not rule out PTE. The hospital mortality rate has not decreased considerably in the last few years.

El espectro clínico actual del tromboembolismo pulmonar / The current clinical spectrum of pulmonary thromboembolism

Fundamento. La mortalidad del tromboembolismo pulmonar (TEP) disminuye de manera considerable cuando es diagnosticado precozmente. La sospecha basada en los datos clínicos y complementarios es fundamental en el diagnóstico precoz. Métodos. Revisión retrospectiva de las características de los pacientes diagnosticados de TEP en un servicio de Medicina Interna entre enero de 1993 y diciembre de 1999. Resultados. Identificamos 117 pacientes con TEP. La edad media fue 6 8 ,8 años. Sesenta y seis pacientes (5 6 ,4 %) tuvieron uno o varios factores de riesgo conocidos para TEP. El factor de riesgo más frecuente fue la inmovilización (3 7 ,6 %). La disnea (7 4 ,4 %) y la taquipnea (6 6 ,7 %) fueron, respectivamente, el síntoma y el signo más frecuente. Un 16,2% y un 31,6% de los casos presentó fiebre/ febrícula y leucocitosis. Un 44,4%, un 38,5% y un 47% de los pacientes presentaron insuficiencia respiratoria, alcalosis e hipocapnia, respectivamente. Un 9 6 ,6 % tuvo un gradiente alvéolo-arterial de oxígeno > 2 0 mmHg. La radiografía de tórax y el electrocardiograma fueron normales en el 52,1% y en el 23,9% de los casos, respectivamente. El eco-dúplex venoso de miembros inferiores demostró una trombosis venosa profunda (TVP) en el 5 2 ,5 % de los casos. La mortalidad intrahospitalaria fue del 6 ,8 %. Conclusiones. El TEP sigue afectando preferentemente a personas mayores, y con frecuencia no existe un factor de riesgo conocido. La presencia de fiebre/ febrícula y/ o leucocitosis no excluye un TEP. Un gradiente alvéolo-arterial de oxígeno normal es excepcional en el TEP. La radiografía de tórax y el electrocardiograma pueden ser normales. La no demostración de una TVP en miembros inferiores mediante eco-dúplex venoso no permite excluir un TEP. La mortalidad intrahospitalaria del TEP no ha disminuido considerablemente en los últimos años (AU)

Background. Mortality in pulmonary thromboembolism (PTE) decreases considerable when it is diagnosed early. The suspicion based on clinical and complementary data is essential for an early diagnosis. Methods. Retrospective review of the clinical features in patients diagnosed of PTE in an Internal Medicine department from January 1993 to December 1999. Results. A total of 117 patients with PTE were identified. The median age was 6 8 .8 years. Sixty- six patients (5 6 .4 %) had one or more risk factors for PTE. The most common risk factor was immobilization (37.6%). Dyspnea was the most common symptom (7 4 .4 %) and tachypnea the most common sign (6 6 .7 %). Fever/ low grade fever and leukocytosis were present in 1 6 .2 % and 3 1 .6 % of patients, respectively. Respiratory failure, alkalosis and hypocapnia were present in 4 4 .4 %, 3 8 .5 % and 4 7 % of patients, respectively. An alveolar-arterial oxygen gradient > 2 0 mmHg was demonstrated in 9 6 .6 % of patients. Chest radiographs and electrocardiograms were normal in 5 2 .1 % and 2 3 .9 % of patients, respectively. A vein echo-duplex of the lower limbs demonstrated deep vein thrombosis (DVT) in 5 2 .1 % of patients. The hospital mortality rate was 6 .8 %. Conclusions. PTE still affects older patients mainly and frequently known risk factors are not detected. The presence of fever/ low grade fever and/ or leukocytosis does not rule out PTE. Both chest radiographs and electrocardiograms may be normal. Not demonstrating DVT in the lower limbs by the vein echo-duplex does not rule out PTE. The hospital mortality rate has not decreased considerably in the last few years (AU)

[Polyneuropathy in critically ill patients: a seldom recognized cause of dependence on mechanical ventilators]. / Polineuropatía del paciente crítico pediátrico: una causa poco reconocida de dependencia al respirador.

INTRODUCTION: Neuromuscular complications, in a critical care unit, are a cause of morbidity in children and prolonged dependence on a mechanical ventilator. Polyneuropathy of the critical patient is such a complication and is seen in patients on mechanical respiratory assistance. OBJECTIVE: To discuss the neurological and electrophysiological clinical findings of polyneuropathy of the critical patient. CLINICAL CASE: We evaluated four patients who initially required mechanical respiratory assistance, three for lung disorders and one for acute encephalopathy, who developed prolonged dependence on mechanical ventilators in the year 1999. In all these patients electromyography showed primary axon nerve disorders with secondary demyelination of all four limbs and phrenic nerve involvement. CONCLUSIONS: Clinical suspicion and use of suitable electrophysiological techniques permits identification of this condition in the severely ill paediatric patient. Better recognition of the condition and investigation of the etiological factors would help to develop suitable measures for prevention and treatment.

Polineuropatía del paciente crítico pediátrico:una causa poco reconocida de dependencia al respirador / Polyneuropathy in critically ill patients: a seldom recognized cause of dependence on mechanical ventilators

Introducción. Las complicaciones neuromusculares, en la Unidad de Cuidados Intensivos, son causa de morbilidad en niños y dependencia prolongada del respirador. La polineuropatía del paciente crítico (PPC) es una complicación que se observa en pacientes en asistencia respiratoria mecánica (ARM). Objetivo. Discutir el cuadro clínico neurológico y electrofisiológico de la PPC. Pacientes y métodos. Se evaluaron cuatro pacientes que inicialmente requirieron ARM, tres por compromiso pulmonar y uno por encefalopatía aguda, y que desarrollaron dependencia prolongada del respirador, durante el año 1999. La electromiografía mostró en todos los casos compromiso neurógeno axónico primario con desmielinización secundaria de cuatro miembros y afectación del nervio frénico. Conclusiones. La sospecha clínica y la realización de técnicas electrofisiológicas adecuadas permiten la identificación de este cuadro en el paciente pediátrico extremadamente enfermo. Un mejor reconocimiento de esta entidad y la investigación de factores etiológicos conducirán a lograr adecuadas medidas de tratamiento y prevención en un futuro (AU)

Microtubule-associated protein-2 located in growth regions of rat hippocampal neurons is highly phosphorylated at its proline-rich region.

Neuronal morphogenesis is regulated, among other factors, by microtubule-associated proteins (MAPs). A family of these proteins, MAP2, which is very abundant in the mammalian nervous system, has been associated with the formation of neurites at early developmental stages and with the dendritic scaffold upon maturation. The function of MAP2 is regulated by its phosphorylation state. One of the phosphorylation sites that has been described is located in the proline-rich region of the protein. It comprises of the residues 1616-1626 and is specifically recognized by the antibody 305. However, little is known about the functional consequences of its modification in vivo. To gain insight into this, we have analysed the expression levels and intracellular distribution of MAP2 phosphorylated at this site (MAP2-P), in primary cultures of rat hippocampal neurons at different developmental stages. Western blot analysis of hippocampal neuron protein extracts revealed that the ratio of MAP2-P:MAP2 was 4:1 at early developmental stages and became 1:4 at later developmental stages, suggesting a role of such phosphorylated forms of the protein in neuritogenesis. Consistent with this view, immunofluorescence microscopy analysis showed that the ratio MAP2-P:MAP2 was 2 in the neurite growth cones, sites where net elongation takes place. A higher presence of phosphorylated MAP2 was observed in growth regions with higher levels of microfilaments, which may be related with the growth region stability. Indeed, when growth-cone collapse was induced in hippocampal neurons after cytochalasin D treatment, which depolymerizes microfilaments, the ratio MAP2-P:MAP2 in these growing regions decreased down to 1. Finally, acceleration of neuronal maturation induced by the activation of glutamate-receptors triggered a dramatic decrease in the phosphorylation of MAP2 at the site recognized by antibody 305. From these results we suggest that the phosphorylation of MAP2 at its proline-rich region is an important event during neuritogenesis.

Repair of a saccular aortic aneurysm with superficial femoral-popliteal vein in the presence of a pancreatic abscess.

When one is faced with impending rupture, repair of an aortic aneurysm cannot be delayed. In the presence of coexisting intra-abdominal sepsis, traditional therapy would call for aneurysm exclusion and axillofemoral bypass grafting. Consequences of this choice of treatment include limited long-term graft patency and recurrent prosthetic infection. Autogenous deep veins from the lower extremities have demonstrated exceptional patency and resilience to infection when used to replace infected aortic grafts. We now report a case of concomitant open drainage of a pancreatic abscess and repair of a saccular abdominal aortic aneurysm using the superficial femoral-popliteal vein as a conduit.

[Giant-cell arteritis: a descriptive study in southwestern Spain]. / Arteritis de células gigantes: un estudio descriptivo en el suroeste de España.

OBJECTIVE: To study the clinical and laboratory features of a series of patients with giant cell arteritis (GCA) or temporal arteritis in south-western Spain (Extremadura). PATIENTS AND METHODS: Retrospective study of 25 patients with GCA diagnosed by temporal artery biopsy between 1990 and 1998. RESULTS: Nine patients were males and 16 (64%) females. Sixteen cases (64%) presented polymyalgia rheumatica (PMR). Other clinical findings were: fever/febricula (64%), constitutional syndrome (64%), new headache (96%), visual symptoms (48%), jaw claudication (17%) and abnormal temporal arteries (17%). All patients had an ESR of more than 50 mm/hour and a raised C-reactive protein. Thirteen patients (52%) had anemia (hemoglobin level < 12 g/dl). Eleven cases (44%) presented a platelet count higher than 400,000/mm3. Four patients (16%) had an elevated AST and/or ALT levels and 8 patients (32%) had an elevated GGT and/or alkaline phosphatase levels. In patients with PMR, there was a higher frequency of constitutional syndrome (81 vs 33%, p = 0.02). In females, there was a higher frequency of anemia (75 vs 11%, p < 0.01), platelet count higher than 400,000/mm3 (75 vs 0%, p < 0.01) and elevated AST and/or ALT (25 vs 0%, p < 0.01) and elevated GGT and/or alkaline phosphatase (50 vs 0%, p < 0.01) levels. CONCLUSIONS: The clinical and laboratory features of GCA in our series of patients in south-western Spain are similar to that described in other spanish populations, with the exception of a slightly higher frequency of PMR and a lower frequency of jaw claudication and abnormal temporal arteries. In our study, the clinical picture of GCA was more severe in patients with PMR and in females.

Arteritis de células gigantes: un estudio descriptivo en el suroeste de España / Giant-cell arteritis: a descriptive study in southwestern Spain

Objetivo: Estudiar las características clínicas y analíticas de la arteritis de células gigantes (ACG) o arteritis temporal en una serie en el suroeste de España (Extremadura). Pacientes y métodos: Estudio retrospectivo de 25 pacientes diagnosticados de ACG mediante biopsia de la arteria temporal entre 1990 y 1998. Resultados: Nueve pacientes fueron varones y 16 (64 porciento) mujeres. Dieciséis casos (64 porciento) presentaron polimialgia reumática (PMR). Otras manifestaciones clínicas fueron: fiebre/febrícula (64porciento), síndrome constitucional (64 porciento), cefalea de reciente inicio (96 porciento), síntomas visuales (48 porciento), claudicación mandibular (17porciento) y arterias temporales anormales a la exploración (17 porciento). Todos los pacientes tuvieron una VSG >50 mm/hora y una proteína C reactiva elevada. Trece casos (52 porciento) presentaron anemia (hemoglobina <12 g/dl). Once casos (44 porciento) tuvieron un recuento plaquetario superior a 400.000/mm3. Cuatro casos (16 porciento) mostraron una elevación de la AST y/o ALT, y 8 casos (32 porciento) una elevación de la GGT y/o fosfatasa alcalina. En los pacientes con PMR, encontramos una mayor frecuencia de síndrome constitucional (81 vs 33 porciento, p= 0,02). En las mujeres, encontramos una mayor frecuencia de anemia (75 vs 11 porciento, p <0,01), de un recuento plaquetario superior a 400.000/mm3 (75 vs 0 porciento, p <0,01) y de elevación de la AST y/o ALT (25 vs 0 porciento, p <0,01) y de la GGT y/o fosfatasa alcalina (50 vs 0 porciento, p <0,01). Conclusiones: Las características clínicas y analíticas de la ACG en nuestra serie del suroeste de España son similares a las de otras zonas de España, salvo por una frecuencia algo mayor de PMR y una frecuencia menor de claudicación mandibular y unas arterias temporales anormales a la exploración. En nuestro estudio, el cuadro clínico de la ACG fue más severo en los pacientes con PMR y en las mujeres (AU)