Risk Assessment in High- and Low-MELD Liver Transplantation.

Allocation of liver grafts triggers emotional debates, as those patients, not receiving an organ, are prone to death. We analyzed a high-Model of End-stage Liver Disease (MELD) cohort (laboratory MELD score ≥30, n = 100, median laboratory MELD score of 35; interquartile range 31-37) of liver transplant recipients at our center during the past 10 years and compared results with a low-MELD group, matched by propensity scoring for donor age, recipient age, and cold ischemia time. End points of our study were cumulative posttransplantation morbidity, cost, and survival. Six different prediction models, including donor age x recipient MELD (D-MELD), Difference between listing MELD and MELD at transplant (Delta MELD), donor-risk index (DRI), Survival Outcomes Following Liver Transplant (SOFT), balance-of-risk (BAR), and University of California Los Angeles-Futility Risk Score (UCLA-FRS), were applied in both cohorts to identify risk for poor outcome and high cost. All score models were compared with a clinical-oriented decision, based on the combination of hemofiltration plus ventilation. Median intensive care unit and hospital stays were 8 and 26 days, respectively, after liver transplantation of high-MELD patients, with a significantly increased morbidity compared with low-MELD patients (median comprehensive complication index 56 vs. 36 points [maximum points 100] and double cost [median US$179 631 vs. US$80 229]). Five-year survival, however, was only 8% less than that of low-MELD patients (70% vs. 78%). Most prediction scores showed disappointing low positive predictive values for posttransplantation mortality, such as mortality above thresholds, despite good specificity. The clinical observation of hemofiltration plus ventilation in high-MELD patients was even superior in this respect compared with D-MELD, DRI, Delta MELD, and UCLA-FRS but inferior to SOFT and BAR models. Of all models tested, only the BAR score was linearly associated with complications. In conclusion, the BAR score was most useful for risk classification in liver transplantation, based on expected posttransplantation mortality and morbidity. Difficult decisions to accept liver grafts in high-risk recipients may thus be guided by additional BAR score calculation, to increase the safe use of scarce organs.

Reasons for family refusal of ocular tissue donation.

INTRODUCTION: Corneal donations do not fill the transplant demand. The waiting list had 5512 individuals in Brazil and 143 in Rio Grande do Sul in December 2012. The aim of this study was to identify the reasons for family refusal of ocular tissues donation. METHODS: This retrospective study analyzed interview records for ocular tissue procurement performed in a general, public university hospital located in Southern Brazil between January 2008 and December 2012. It identified the reasons of family refusal for ocular tissue donation. RESULTS: A total of 1010 interviews for ocular tissues procurement were performed. From these, 513 (50.79%) refused donation with the following reasons: 60 (11.69%) family members were unaware of the desire of the potential donor, 153 (29.82%) of potential donors spoke against donation in life, 113 (22.02%) family members were undecided about the donation, 156 (30.40%) family members were against donation, 3 (0.58%) family members were unhappy with the service, 11 (2.14%) family members were afraid of body release delay, 6 (1.16%) families expressed religious convictions against donation, and 11 (2.14%) family members wanted to keep the body intact. CONCLUSION: There are many reasons for ocular tissues donation refusal, and the knowledge provides better strategies for family interviews. In this study, most of the reasons, around 90%, can be related to lack of information or communication about the subject. Greater awareness of the population about the subject can be a good way to increase ocular tissue procurement indexes.

Causes of organ donation failure in Brazil.

INTRODUCTION: There has been a great improvement in transplantation medicine in Brazil in the last 2 decades. However, there remain several barriers regarding notification of brain and cardiac death as well as completion of the donation process. METHODS: This retrospective study was performed between January 2008 and December 2010. We reviewed all deaths in a University Hospital, observing the causes of non-notification to the State Transplantation Authority and non-donations. RESULTS: There were 41 notifications of brain death resulting in donation in only 19.5% of those cases. Cardiac death was diagnosed in 21 patients, resulting in 52.4% donations. The main cause for non-donation were family refusal (37.2%), infectious diseases (30.2%), and clinical contraindications (32.6%). Most of the missed possible donors occurred during the night (54.8%) and in the emergency room (80.9%). CONCLUSION: There is an urgent need for better education of the Brazilian population about organ donation and brain death definitions. Other identified problems include lack of uniformity in brain death determinations among hospitals, rigid contraindications to donation in the State of Parana, physician unawareness or disbelief about brain death diagnostic criteria, and lack of structure of our Hospital.

Transmission of Citrus leprosis virus C by Brevipalpus phoenicis (Geijskes) to Alternative Host Plants Found in Citrus Orchards.

The equivalent of US$75 million is spent each year in Brazil to control Brevipalpus phoenicis, a mite vector of Citrus leprosis virus C (CiLV-C). In this study, we investigated the possibility that hedgerows and windbreaks normally found in citrus orchards could host CiLV-C. Mites confined by an adhesive barrier were reared on sweet orange fruit with leprosis symptoms then were transferred to leaves of Hibiscus rosa-sinensis, Malvaviscus arboreus, Grevilea robusta, Bixa orellana, and Citrus sinensis. Ninety days post infestation, the descendant mites were transferred to Pera sweet orange plants to verify the transmissibility of the virus back to citrus. Nonviruliferous mites which had no feeding access to diseased tissue were used as controls. Local chlorotic or necrotic spots and ringspots, symptoms of leprosis disease, appeared in most plants tested. Results generated by reversetranscription polymerase chain reaction with primers specific for CiLV-C and by electron microscope analyses confirmed the susceptibility of these plants to CiLV-C.

Accuracy of routine diagnostic tests used in paracoccidioidomycosis patients at a university hospital.

The identification of appropriate laboratory measures to confirm clinical hypotheses is important in routine paracoccidioidomycosis medical care. The clinical records and laboratory reports of 401 paracoccidioidomycosis patients attended at the Tropical Diseases Area, Faculdade de Medicina de Botucatu, from 1974 to 2008 were reviewed. Direct mycological (DM), cell block (CB), histopathological (HP), and double immunodiffusion (DID) tests were evaluated before treatment. Typical Paracoccidioides brasiliensis yeast forms were observed in clinical specimens of 86% of the patients, but 14% were detected only by serological test. DM of 51 different tissue specimens produced 74.5% sensitivity, and 62.5% sensitivity was observed in 112 sputum samples. CB in 483 sputum samples generated 55.3% sensitivity. HP performed in 239 samples from different tissues revealed 96.7% sensitivity. Serology carried out in 351 patients and 200 healthy controls provided 90.0% sensitivity, 100.0% specificity, 100.0% positive predictive value, 85.1% negative predictive value and 93.6% accuracy. Comparisons of laboratory measurements performed in the same patient showed that sensitivity decreases from HP to DID to CB and DM, with the last two assays providing similar sensitivities. This study demonstrated that P. brasiliensis identification by HP, CB, and/or DM associated with DID is sufficient to establish the laboratorial diagnosis of paracoccidioidomycosis in practically all cases.

Uric acid changes in urine and plasma: an effective tool in screening for purine inborn errors of metabolism and other pathological conditions.

Purine inborn errors of metabolism (IEM) are serious hereditary disorders, which should be suspected in any case of neonatal fitting, failure to thrive, recurrent infections, neurological deficit, renal disease, self-mutilation and other manifestations. Investigation usually starts with uric acid (UA) determination in urine and plasma. UA, the final product of purine metabolism in humans, may be altered not only in purine IEM, but also in other related pathologies and clinical conditions. However, data and information about abnormal UA levels are scattered in the literature, often being controversial and confusing. A comprehensive overview has been elaborated, according to abnormal UA levels in urine and plasma, which associates these alterations with purine IEM. Other possible diseases, clinical conditions, diet and drug intake, related to the metabolism of uric acid, are also presented. The article includes tables that classify the disorders according to different patterns of UA alterations, with pertinent enzymes, clinical symptoms, inheritance and comments. Additionally, summarized pathophysiological mechanisms of important disorders are described. The overview is intended to assist in the interpretation of the results of UA analyses. It demonstrates that variation of UA concentrations in urine and plasma may constitute an effective tool in screening for purine IEM and other related pathological conditions.

Control of attention by a peripheral visual cue depends on whether the target is difficult to discriminate.

The influence of a peripheral cue represented by a gray ring on responsivity to a subsequent target varies. When a vertical line inside a ring was a go target and a white small ring inside a ring was a no-go target, reaction time was shorter at the same location relative to a different location. However, no reaction time difference between the two locations occurred when a white cross inside the ring, instead of the white vertical line inside the ring, was the go target. We investigated whether this last finding was due to a forward masking influence of the cue, a requirement of low attention for the discrimination or a lack of attention mobilization by the cue. In Experiment 1, the intensity of the cue was reduced in an attempt to reduce forward masking. In Experiment 2, the vertical line and the cross were presented in the same block of trials so as to be dealt with a common attentional strategy. In Experiments 3 and 4, the no-go target was a 45 masculine rotated cross inside a ring to increase the difficulty of the discrimination. No evidence was obtained that the cross was forward masked by the cue nor that it demanded less attention to be discriminated from the small ring. There was a facilitation of responsivity by the cue when the small ring was replaced by the rotated cross. The results suggest that when the discrimination to be performed is too easy the cue does not mobilize attention.

Control of attention by a peripheral visual cue depends on whether the target is difficult to discriminate

The influence of a peripheral cue represented by a gray ring on responsivity to a subsequent target varies. When a vertical line inside a ring was a go target and a white small ring inside a ring was a no-go target, reaction time was shorter at the same location relative to a different location. However, no reaction time difference between the two locations occurred when a white cross inside the ring, instead of the white vertical line inside the ring, was the go target. We investigated whether this last finding was due to a forward masking influence of the cue, a requirement of low attention for the discrimination or a lack of attention mobilization by the cue. In Experiment 1, the intensity of the cue was reduced in an attempt to reduce forward masking. In Experiment 2, the vertical line and the cross were presented in the same block of trials so as to be dealt with a common attentional strategy. In Experiments 3 and 4, the no-go target was a 45° rotated cross inside a ring to increase the difficulty of the discrimination. No evidence was obtained that the cross was forward masked by the cue nor that it demanded less attention to be discriminated from the small ring. There was a facilitation of responsivity by the cue when the small ring was replaced by the rotated cross. The results suggest that when the discrimination to be performed is too easy the cue does not mobilize attention.

Single-cell gel (comet) assay detects primary DNA damage in nonneoplastic urothelial cells of smokers and ex-smokers.

A protocol for DNA damage assessment by the single-cell gel (SCG)/comet assay in human urinary bladder washing cells was established. Modifications of the standard alkaline protocol included an increase to 2% of sodium sarcosinate in the lysis solution, a reduction in the glass-slide area for comet analysis, and a cutoff value for comet head diameter of at least 30 microm, to exclude contaminating leukocytes. Distinguishing cell populations is crucial, because significant differential migration was demonstrated for transitional and nontransitional cells, phenomena that may confound the results. When applying the modified protocol to urinary bladder cells from smokers without urinary bladder neoplasia, it was possible to detect a significant (P = 0.03) increase in DNA damage as depicted by the tail moment (6.39 +/- 3.23; mean +/- 95% confidence interval; n = 18) when compared with nonsmokers (1.94 +/- 1.41; n = 12). No significant differences were observed between ex-smokers and current smokers regarding comet parameters. Inflammation was not a confounding factor, but DNA migration increased significantly with age in nonsmokers (r = 0.68; P = 0.014). Thus, age matching should be a concern when transitional cells are analyzed in the SCG assay. As it is well known, DNA damage may trigger genomic instability, a crucial step in carcinogenesis. Therefore, the present data directly support the classification of individuals with smoking history as patients at high risk for urinary bladder cancer.

[Ethical behavior in the daily professional practice of nurses]. / O agir ético na prática profissional cotidiana das enfermeiras.

The daily practice of nurses is full of situations that demand a close analysis of the sociocultural context, so that the appropriate decisions are made. These decisions can either be of technical or ethical nature. In the present study, the authors reflect about the professional practice of nurses, focusing especially on the process of ethic decision making. They also relate these decisions to some of the ethic theoretical frameworks in order to indicate the references that guide the nurse's practices in the different professional situations.

Clinical and histological evaluation of granuloma gravidarum: case report.

Granuloma gravidarum is a benign lesion of the oral mucosa which occurs during pregnancy. This case report presents the clinical and histological evaluation and treatment of a granuloma gravidarum in a patient in the 9th month of pregnancy.

[Ethics committees: research with human beings in Brazil]. / Comitês de ética: pesquisa em seres humanos no Brasil.

The objective of this article is therefore to present the National Resolutions which regulate the research field on human beings. Stimulate reflection on the need for control over the research, provide guidance for the creation of ethics committees, to indicate course of action to researchers on how to register their researches and to stress the importance of registering a research with Committees.

Hand, foot, and mouth disease: a case report.

Hand, foot, and mouth disease is a viral infection related to coxsackieviruses A5, A6, A9, and A10, coxsackieviruses B2 and B5, and echovirus 11. It generally affects children, but this article presents a clinical case of a young woman with hand, foot, and mouth disease. Patients with this disease have oral and skin lesions that may be confused with other diseases. The differential diagnosis is very important because both dental and medical professionals may misdiagnose the disease and sometimes prescribe an inappropriate medication.

Screening for inborn errors of metabolism in high-risk children from Rio de Janeiro, Brazil.

From 1988 to 1995, our laboratory at the Institute of Chemistry of the Federal University of Rio de Janeiro, in Rio de Janeiro, screened 2650 samples from 2000 high-risk patients (mostly children) for Inborn Errors of Metabolism (IEM). Chemical tests, various chromatographic techniques and enzyme assays were performed on urine, plasma and in some cases, cerebrospinal fluid (CSF). A total of 145 cases of IEM (7.2%) was identified. These were related to: the metabolism of amino acids (41) and carbohydrates (17), organic acids (7), lysosomal enzymes (61), membrane transport system (16), metals (2), intestinal disaccharidases (1) and porphyrin metabolism (3). Furthermore, a relevant number of patients with abnormal findings is still under investigation. Biochemical results and clinical symptoms are presented and the importance of reference laboratories for the detection of IEM is stressed.

Frequent p53 mutations and occasional loss of chromosome 4 in invasive bladder carcinoma induced by N-butyl-N-(4-hydroxybutyl)nitrosamine in B6D2F1 mice.

B6D2F1 mice (45/group) were treated with N-butyl-N-(4-hydroxybutyl)nitrosamine (BBN) or uracil as follows: Group 1 received 0.05% BBN in drinking water for the entire experiment, Group 2 received 5 mg of BBN by gastric gavage in 0.1 mL of 20% ethanol twice per week for 10 wk, Group 3 received a 2.5% uracil-containing diet for the entire experiment, and Group 4 was controls (received 0.1 ml of 20% ethanol by gavage twice per week for 10 wk). The surviving mice in Group 1 were killed after week 26 and those in the other groups after week 30. By week 15, three of 11 Group 1 and one of 15 Group 2 mice had bladder carcinoma. By 26 and 30 wk, respectively, invasive carcinomas were observed in 33 of 34 and six of 21 mice in Groups 1 and 2 and renal pelvic carcinomas in 11 of 34 and three of 21 mice in Groups 1 and 2. Four of 19 uracil-treated mice had bladder nodular hyperplasia. By polymerase chain reaction-single-strand conformation polymorphism and sequence analyses, 16 of 20 and two of five bladder carcinomas from Groups 1 and 2, respectively, showed mutations in the p53 gene. Ha-ras mutation was present in one case. Loss of heterozygosity analysis with simple-sequence length polymorphism markers for chromosome 4 showed that 10 of 21, two of 15, and nine of 13 mice in Groups 1-3, respectively, had heterozygous or homozygous deletions. B6D2F1 mice are therefore susceptible to the urothelial carcinogenic effects of BBN and develop frequent p53 mutations and chromosome 4 deletions. Chromosome 4 deletions were also seen with uracil.

[Determination of HIV protein 24 in feces of Triatoma infestans fed with blood from AIDS patients]. / Pesquisa da proteína 24 do vírus da imunodeficiência humana (HIV) nas fezes de triatomíneos alimentados em pacientes com AIDS.

OBJECTIVE: To verify any possibility of the elimination of p24 in feces of Triatoma infestans, p24 being an antigen and one of the markers of HIV infection. The purpose of the study was the evaluation of any risk of contamination by laboratory staff who work with activities related to this particular insect, and also investigate any mechanism that might thus lead to the dissemination of HIV. METHOD: Triatoma infestans were fed with p24-marked blood from 23 AIDS patients. Twenty-four and 48 hours later, their feces were examined in order to verify the presence of the antigen. The search for p24 was performed by means of the immunoenzymatic technique. RESULT AND CONCLUSION: No protein 24 was detected in any of the samples. In accordance with the applied methodology, the purpose of showing that the elimination of p24 does not occur, was obtained. Were this question approached in other ways different results might reveal new information in terms of risks of HIV dissemination.

The first two cases of Cyclospora in dogs, São Paulo, Brazil.

Cyclospora cayetanensis is a coccidium which has been identified in diarrheal feces or immunocompetent individuals or in AIDS patients. The main aspects related to its epidemiology and pathogeny have not been solved so far, as well as the possibility of human infection by this protozoan being a zoonosis. We describe in this work the first case identifying the Cyclospora in dogs. Our findings, notwithstanding their preliminary characteristics, could suggest that besides untreated water, other transmission means, along with contact with dogs, there could be important factors in the human diarrhea associated with Cyclospora.

[Hepatopulmonary syndrome]. / Síndrome hepatopulmonar.

Hepatopulmonary Syndrome is an uncommon clinical situation of unknown cause. It remains the focus of intense investigation and ongoing debate. The authors present a case of a 77 year old man with chronic liver disease known for 5 years, who developed central cyanoses, digital clubbing and hypoxemia. On searching for the cause of these clinical features, the diagnosis of Hepatopulmonary Syndrome was admitted and confirmed by contrast enhanced echocardiography using agitated saline, and also by technetium 99m-labelled macroaggregated albumin scanning.

[Evaluation of theoretical knowledge of diabetics in an interdisciplinary program]. / Avaliação dos conhecimentos teóricos dos diabéticos de um programa interdisciplinar.

Using an instrument of evaluation of theoretical knowledge, the authors have assessed the capacity of understanding and memorizing often groups of diabetes' carriers, that were being followed by a multiprofessional team from the ambulatory of the HURNP. The evaluation included the discussion of a variety of subjects which were part of the activities of an Educational Program. Only one group of patients showed a satisfactory performance. Individual analysis showed that young diabetes' carriers, that were motivated and had good level of understanding, had a better performance. It was concluded that the evaluation allows the selection of patients that need specific reinforcement and that a plan of activities can be elaborated according to the tested subjects.