Accidental Diagnosis of Isolated Persistent Left Superior Vena Cava After an Elective Central Venous Access Procedure for Chronic Hemodialysis: Clinical Implications and Precautions From a Case Report.

Persistent left superior vena cava (PLSVC) is the most frequent thoracic venous anatomical variant in the general population. Isolated PLSVC, without formation of the right superior vena cava, is described in 10% of cases of PLSVC only. While it can be associated with congenital heart disease, arrhythmias, and premature death, adult patients with PLSVC are mostly asymptomatic, and the diagnosis is usually accidental. We present the case of a 72-year-old male with end-stage renal disease who was started on urgent hemodialysis through a temporary non-tunneled femoral central venous catheter (CVC) in the SLED (slow low-efficiency dialysis) modality and later remained dependent on hemodialysis. At this stage, placement of a tunneled CVC in the right internal jugular vein was necessary and fluoroscopy guidance was not available. There were no complications during the procedure, but postoperative conventional chest radiography revealed an inadequate positioning of the CVC tip in the left hemithorax, crossing the midline. Subsequently, the diagnosis of PLSVC was obtained by performing a thoracic angio-CT scan, confirming CVC tip positioning inside the PLSVC, and also excluded the presence of cardiac defects or additional anatomical variations of the great vessels of the thorax. Early evaluation for the creation of autologous vascular access was started under our care, and there were no mechanical or other complications associated with hemodialysis sessions during early follow-up after discharge.

Fatal Budd-Chiari syndrome associated with Hemodialysis Reliable Outflow (HeRO) graft.

Population aging and prolonged time on dialysis pose challenges to vascular access for nephrologists and vascular surgeons. HeRO grafts are an option used for patients with central venous obstruction and without the possibility of other vascular access on upper limbs. Some long-term complications, namely access thrombosis, infection, and limb ischemia, have already been reported. There are few data on thromboembolic complications associated with this device. We report the first case in the literature of Budd-Chiari Syndrome associated with the HeRO graft.

Corrigendum: The significance of cephalopod beaks as a research tool: An update.

[This corrects the article DOI: 10.3389/fphys.2022.1038064.].

Antarctic toothfish Dissostichus mawsoni as a bioindicator of trace and rare earth elements in the Southern Ocean.

The Antarctic toothfish Dissostichus mawsoni is a Southern Ocean long-lived top predator which is regularly captured on an annual fishery operating in the region. By its biological and ecological characteristics, it is a potential bioindicator for the concentrations of trace and rare earth elements in the Antarctic. As these elements are mainly transferred through the diet and a deficiency or excess of these elements can lead to diverse health problems, it is important to measure their concentrations on the organisms. This study provides, for the first time, the concentration of 27 trace (major essential, minor essential and non-essential) and rare earth elements in the muscle of D. mawsoni captured in three areas of the Amundsen and Dumont D'Urville Seas (Antarctica). Major essential elements had the highest concentrations, with potassium (K) as the most concentrated, and rare earth elements the lowest. Significant differences between areas were found for most of the studied elements. No bioaccumulation nor biomagnification potential was found for the studied elements, with several elements decreasing concentrations towards larger individuals. Decreasing trends are related with the different habitats occupied by D. mawsoni through their life, suggesting that elements' concentrations in the water is determinant for the concentrations in this top predator, and/or there is a dilution effect as the fish grows. Our results also support that Se presents a detoxification potential for Hg in D. mawsoni, but only when Hg concentrations are higher to unhealthy levels. This study supports D. mawsoni as a potential bioindicator for the concentrations of the different trace and rare earth elements in the Southern Ocean, though only when comparing individuals of similar size/age, but also to evaluate annual changes on their concentrations. Furthermore, D. mawsoni can be a good source of major essential elements to humans with concentrations of major essential elements above some of other marine fish worldwide.

The significance of cephalopod beaks as a research tool: An update.

The use of cephalopod beaks in ecological and population dynamics studies has allowed major advances of our knowledge on the role of cephalopods in marine ecosystems in the last 60 years. Since the 1960's, with the pioneering research by Malcolm Clarke and colleagues, cephalopod beaks (also named jaws or mandibles) have been described to species level and their measurements have been shown to be related to cephalopod body size and mass, which permitted important information to be obtained on numerous biological and ecological aspects of cephalopods in marine ecosystems. In the last decade, a range of new techniques has been applied to cephalopod beaks, permitting new kinds of insight into cephalopod biology and ecology. The workshop on cephalopod beaks of the Cephalopod International Advisory Council Conference (Sesimbra, Portugal) in 2022 aimed to review the most recent scientific developments in this field and to identify future challenges, particularly in relation to taxonomy, age, growth, chemical composition (i.e., DNA, proteomics, stable isotopes, trace elements) and physical (i.e., structural) analyses. In terms of taxonomy, new techniques (e.g., 3D geometric morphometrics) for identifying cephalopods from their beaks are being developed with promising results, although the need for experts and reference collections of cephalopod beaks will continue. The use of beak microstructure for age and growth studies has been validated. Stable isotope analyses on beaks have proven to be an excellent technique to get valuable information on the ecology of cephalopods (namely habitat and trophic position). Trace element analyses is also possible using beaks, where concentrations are significantly lower than in other tissues (e.g., muscle, digestive gland, gills). Extracting DNA from beaks was only possible in one study so far. Protein analyses can also be made using cephalopod beaks. Future challenges in research using cephalopod beaks are also discussed.

Life History of the Arctic Squid Gonatus fabricii (Cephalopoda: Oegopsida) Reconstructed by Analysis of Individual Ontogenetic Stable Isotopic Trajectories.

Cephalopods are important in Arctic marine ecosystems as predators and prey, but knowledge of their life cycles is poor. Consequently, they are under-represented in the Arctic ecosystems assessment models. One important parameter is the change in ecological role (habitat and diet) associated with individual ontogenies. Here, the life history of Gonatus fabricii, the most abundant Arctic cephalopod, is reconstructed by the analysis of individual ontogenetic trajectories of stable isotopes (δ13C and δ15N) in archival hard body structures. This approach allows the prediction of the exact mantle length (ML) and mass when the species changes its ecological role. Our results show that the life history of G. fabricii is divided into four stages, each having a distinct ecology: (1) epipelagic squid (ML < 20 mm), preying mostly on copepods; (2) epi- and occasionally mesopelagic squid (ML 20−50 mm), preying on larger crustaceans, fish, and cephalopods; (3) meso- and bathypelagic squid (ML > 50 mm), preying mainly on fish and cephalopods; and (4) non-feeding bathypelagic gelatinous females (ML > 200 mm). Existing Arctic ecosystem models do not reflect the different ecological roles of G. fabricii correctly, and the novel data provided here are a necessary baseline for Arctic ecosystem modelling and forecasting.

Arterial percutaneous angioplasty in hemodialysis access: Endovascular treatment of hand ischemia.

BACKGROUND: Hemodialysis access-induced distal ischemia consists of symptomatic extremity malperfusion after vascular access creation. It is usually caused by discordant vascular resistance, with arteriovenous shunting of a high blood volume from arterial into venous system and subsequent hand hypoperfusion. Less often, hemodialysis access-induced distal ischemia is caused by arterial stenosis. In these cases, access frequently has normal/low flow, radial pulse is usually absent and not recoverable with vascular access digital compression, diabetes is often present, and percutaneous transluminal angioplasty can be critical for access and limb salvage. METHODS: Retrospective study conducted between June 2011 and February 2018 of patients with vascular access submitted to arterial percutaneous transluminal angioplasty for limb-threatening ischemia. RESULTS: Twenty-nine patients were referred for arterial angiography after hemodialysis access-induced distal ischemia diagnosis and physical examination or ultrasound findings suggestive of arterial disease. In 11 patients, percutaneous transluminal angioplasty was not technically feasible. Among 18 treated patients, 83.3% had diabetes and 60% had skin ulcerations. Target arteries were radial (11), brachial (7), axillar (2), ulnar (2), and subclavian (1). Clinical success, defined as arteriovenous maintenance and wound healing/pain resolution, was observed in 12 patients (66.7%). Concomitant procedures included adjuvant banding (n = 2) and finger amputation (n = 1), and one reintervention was performed. No intra- or postoperative complications were reported. CONCLUSION: Hemodialysis access-induced distal ischemia is a serious complication of hemodialysis vascular access, with multifactorial etiology. Correct and timely diagnosis is crucial for maintaining access and limb salvage. Percutaneous transluminal angioplasty is a minimally invasive procedure that may be effective and long-lasting in carefully selected patients with ischemic complaints.

Cephalopod beak sections used to trace mercury levels throughout the life of cephalopods: The giant warty squid Moroteuthopsis longimana as a case study.

Cephalopods represent an important pathway for mercury transfer through food webs. Due to the general difficulties in capturing oceanic squid, beaks found in the diet of top predators can be used to study their life-cycles and ecological role. Using upper beaks of the giant warty squid Moroteuthopsis longimana (major prey in the Southern Ocean), we describe a method to assess mercury concentrations along the life of cephalopods through the segmentary analysis of beak sections (i.e. tip of the rostrum and subsections along the hood). Distinct total mercury concentrations in the different subsections support that beaks can be used to study mercury levels in different periods of cephalopods' life-cycle. Mercury values in the anterior (1.3-7.9 µg kg-1 dw) and posterior (7.8-12.5 µg kg-1 dw) subsections of the hood reflect juvenile and adult stages, respectively. Furthermore, these results confirm that mercury bioaccumulates continuously throughout the individuals' life, with adults doubling their mercury concentrations to juveniles.

High mercury levels in Antarctic toothfish Dissostichus mawsoni from the Southwest Pacific sector of the Southern Ocean.

Mercury is a bioaccumulating toxic pollutant which can reach humans through the consumption of contaminated food (e.g. marine fish). Although the Southern Ocean is often portrayed as a pristine ecosystem, its fishery products are not immune to mercury contamination. We analysed mercury concentration (organic and inorganic forms - T-Hg) in the muscle of Antarctic toothfish, Dissostichus mawsoni, a long-lived top predator which supports a highly profitable fishery. Our samples were collected in three fishing areas (one seamount and two on the continental slope) in the Southwest Pacific Sector of the Southern Ocean during the 2016/2017 fishing season. Mercury levels and the size range of fish varied between fishing areas, with the highest levels (0.68 ± 0.45 mg kg-1 wwt) occurring on the Amundsen Sea seamount where catches were dominated by larger, older fish. The most parsimonious model of mercury concentration included both age and habitat (seamount vs continental slope) as explanatory variables. Mean mercury levels for each fishing area were higher than those in all previous studies of D. mawsoni, with mean values for the Amundsen Sea seamount exceeding the 0.5 mg kg-1 food safety threshold for the first time. It might therefore be appropriate to add D. mawsoni to the list of taxa, such as swordfish and sharks, which are known to exceed this threshold. This apparent increase in mercury levels suggests a recent contamination event which affected the Southwest Pacific sector, including both the Amundsen and Dumont D'Urville seas.

Refractory ascites and graft dysfunction in early renal transplantation / Ascite refratária e disfunção do enxerto no pós-transplante renal precoce

Abstract The occurrence of ascites after Renal Transplant (RT) is infrequent, and may be a consequence of surgical or medical complications. Case report: 61 year-old, male, history of arterial hypertension, tongue carcinoma and alcoholic habits 12-20g/day. He had chronic kidney disease secondary to autosomal dominant polycystic kidney disease, without hepatic polycystic disease. He underwent cadaver donor RT in September 2017. He had delayed graft function by surgically corrected renal artery stenosis. He was admitted in January 2018 for ascites de novo, with no response to diuretics. HE had visible abdominal collateral circulation. Graft dysfunction, adequate tacrolinemia, Innocent urinary sediment, mild anemia, without thrombocytopenia. Serum albumin 4.0g / dL. Normal hepatic biochemistry. Peritoneal fluid with transudate characteristics and serum albumin gradient > 1.1. Ultrasound showed hepatomegaly, permeable vascular axes, without splenomegaly. Mycophenolate mofetil was suspended, with reduced remaining immunosuppression. He maintained refractory ascites: excluded infectious, metabolic, autoimmune and neoplastic etiologies. No nephrotic proteinuria and no heart failure. MRI: micronodules compatible with bile cysts. Upper Digestive Tract Endoscopy did not show gastroesophageal varicose veins. Normal abdominal lymphoscintigraphy. He underwent exploratory laparoscopy with liver biopsy: incomplete septal cirrhosis of probable vascular etiology some dilated bile ducts. He maintained progressive RT dysfunction and restarted hemodialysis. The proposed direct measurement of portal pressure was delayed by ascites resolution. There was further recovery of the graft function. Discussion: Incomplete septal cirrhosis is an uncommon cause of non-cirrhotic portal hypertension. Its definition is not well known, morphological and pathophysiological. We have not found published cases of post-RT ascites secondary to this pathology, described as possibly associated with drugs, immune alterations, infections, hypercoagulability and genetic predisposition.

Resumo A ocorrência de ascite no pós-Transplante Renal (TR) é infrequente, podendo ser consequência de complicações cirúrgicas ou médicas. Caso clínico: 61 anos, masculino, antecedentes de hipertensão arterial, carcinoma da língua e hábitos alcoólicos 12-20g/dia. Doença renal crônica secundária à doença renal poliquística autossômica dominante, sem poliquistose hepática. Submetido a TR de doador cadáver em setembro de 2017. Atraso na função de enxerto por estenose da artéria renal, corrigida cirurgicamente. Internado em janeiro de 2018 por ascite de novo, sem resposta a diuréticos. Circulação colateral abdominal visível. Disfunção do enxerto, tacrolinemia adequada. Sedimento urinário inocente. Anemia ligeira, sem trombocitopenia. Albumina sérica 4,0g/dL. Bioquímica hepática normal. Líquido peritoneal com características de transudado e gradiente sero-ascítico de albumina > 1,1. Ecografia com hepatomegalia, eixos vasculares permeáveis, sem esplenomegalia. Suspendeu micofenolato mofetil, reduziu restante imunossupressão. Manteve ascite refratária: excluídas etiologias infecciosas, metabólicas, autoimunes e neoplásicas. Sem proteinúria nefrótica e sem insuficiência cardíaca. RM: micronódulos compatíveis com quistos biliares. EDA sem varizes gastroesofágicas. Linfocintigrafia abdominal normal. Submetido a laparoscopia exploradora com biópsia hepática: cirrose septal incompleta de provável etiologia vascular, alguns ductos biliares dilatados. Manteve disfunção progressiva do TR, reiniciou hemodiálise. Proposta medição direta da pressão portal, protelada por resolução da ascite. Recuperação posterior da função de enxerto. Discussão: A cirrose septal incompleta é uma causa incomum de hipertensão portal não cirrótica. A sua definição é morfológica e a fisiopatologia, pouco conhecida. Não encontramos publicados casos de ascite pós-TR secundária a esta patologia, descrita como possivelmente associada a fármacos, alterações imunitárias, infecções, hipercoagulabilidade e predisposição genética.

Refractory ascites and graft dysfunction in early renal transplantation.

The occurrence of ascites after Renal Transplant (RT) is infrequent, and may be a consequence of surgical or medical complications. Case report: 61 year-old, male, history of arterial hypertension, tongue carcinoma and alcoholic habits 12-20g/day. He had chronic kidney disease secondary to autosomal dominant polycystic kidney disease, without hepatic polycystic disease. He underwent cadaver donor RT in September 2017. He had delayed graft function by surgically corrected renal artery stenosis. He was admitted in January 2018 for ascites de novo, with no response to diuretics. HE had visible abdominal collateral circulation. Graft dysfunction, adequate tacrolinemia, Innocent urinary sediment, mild anemia, without thrombocytopenia. Serum albumin 4.0g / dL. Normal hepatic biochemistry. Peritoneal fluid with transudate characteristics and serum albumin gradient > 1.1. Ultrasound showed hepatomegaly, permeable vascular axes, without splenomegaly. Mycophenolate mofetil was suspended, with reduced remaining immunosuppression. He maintained refractory ascites: excluded infectious, metabolic, autoimmune and neoplastic etiologies. No nephrotic proteinuria and no heart failure. MRI: micronodules compatible with bile cysts. Upper Digestive Tract Endoscopy did not show gastroesophageal varicose veins. Normal abdominal lymphoscintigraphy. He underwent exploratory laparoscopy with liver biopsy: incomplete septal cirrhosis of probable vascular etiology some dilated bile ducts. He maintained progressive RT dysfunction and restarted hemodialysis. The proposed direct measurement of portal pressure was delayed by ascites resolution. There was further recovery of the graft function. Discussion: Incomplete septal cirrhosis is an uncommon cause of non-cirrhotic portal hypertension. Its definition is not well known, morphological and pathophysiological. We have not found published cases of post-RT ascites secondary to this pathology, described as possibly associated with drugs, immune alterations, infections, hypercoagulability and genetic predisposition.

Stenosis and thrombosis-unveiled complications of buttonhole cannulation.

The vascular access is the mainstay of hemodialysis. Arteriovenous fistula has been prioritized as the first choice of long-term vascular access for its inferior rate of complications and improved patient survival. Rope ladder and buttonhole venipuncture are the most common techniques for arteriovenous fistulae cannulation. Much of the concern regarding buttonhole cannulation is the increased risk for potentially severe systemic infections. Increased risk for stenosis and thrombosis has been addressed but not confirmed. We discuss two cases of stenosis and thrombosis related to buttonhole puncture which heralded angiography intervention, raising awareness for the demand of close surveillance of arteriovenous fistulae when using buttonhole cannulation.

Lipoprotein apheresis in the management of severe hypercholesterolemia and hyperlipoproteinemia(a)-The Portuguese experience.

BACKGROUND: Low-density lipoprotein cholesterol (LDL-C) and lipoprotein(a) (Lp(a)) are established causal risk factors for cardiovascular disease (CVD). Lipoprotein apheresis is often required for treatment of patients with a high risk for CVD due to hypercholesterolemia and/or hyperlipoproteinemia(a). AIM: To describe our experience with lipoprotein apheresis in patients with severe hypercholesterolemia or with hyperlipoproteinemia(a). METHODS: We retrospectively investigated patients treated with Lipoprotein apheresis using direct adsorption of lipoproteins (DALI) technique, between December 2008 and March 2018, in our center. Adverse events, acute and long term reductions in lipid parameters were analyzed. RESULTS: Between December 2008 and March 2018, a total of 950 treatments were performed in five patients, four with heterozygous familial hypercholesterolemia (HeFH), all on maximally tolerated cholesterol-lowering drug therapy and in one patient with hyperlipoproteinemia(a) and progressive CVD. In the four patients with HeFH we obtained mean acute reductions in LDL-C and non-high-density lipoprotein cholesterol (non-HDL-C) of 62.0 ± 7.8% and 60.4 ± 6.8%, respectively. Regarding long-term efficacy we achieved a mean reduction of 43.1% in LDL-C and of 41.2% in non-HDL-C. In the patient with hyperlipoproteinemia(a) we attained mean acute reductions of 60.4 ± 6.4% in Lp(a) and of 75.4 ± 7.3% in LDL-C per session and long term reductions in Lp(a) and LDL-C of 67.4% and 40.5%, respectively. Adverse events were recorded in only 1.2% of treatments. CONCLUSION: Lipoprotein apheresis is an efficient and safe treatment in severely hypercholesterolemic patients who are refractory to conservative lipid-lowering therapy or with hyperlipoproteinemia(a) and progressive CVD.

The Role of Doppler Ultrassonography in Significant and Borderline Stenosis Definition.

BACKGROUND: The definition of significant stenosis (SS) remains controversial. METHODS: We retrospectively reviewed 1,040 consultations. SS was defined in the presence of clinical and echo-Doppler (DDU) criteria: Qa <500 mL/min or Qa decrease >25%; RI >0.7 in the feeding artery or absolute minimal luminal stenosis diameter <2.0 mm. Stenosis without any additional criteria were considered borderline stenosis (BS). RESULTS: Two hundred twenty-one arteriovenous fistulas (AVFs) were included: 58.8% had SS, 18.6% had BS, and 22.6% had no dysfunctional access (ND). SS had a significantly higher thrombotic events than BS and ND (13.1 vs. 4.4%, p = 0.018). The annual thrombosis rate was 0.007, 0.037, and 0.004 in the ND, SS, and BS, respectively. AVF cumulative survival at 5 years was significantly lower in SS (89.5%) compared to BS (100%) and ND (97.4%; p = 0.03). BS had an HR for AVF failure of 1.1, p = 0.955, while the SS presented an HR of 5.9, p = 0.09. CONCLUSION: AVF clinical monitoring with additional DDU criteria appear to be appropriate for therapeutic referral.

Two-Stage Basilic Vein Transposition: Second Stage Results.

The increasing survival of hemodialysis patients results in the depletion of superficial venous capital justifying the use of the basilic vein. Many groups still prefer an arteriovenous graft due to transposition complexity and the time needed to achieve maturation. In this work we review the results of our series of basilic vein transpositions (BVT). BVTs were performed in two stages: first, creation of the fistula; second, transposition of the vein using three small incisions in the arm. All patients had to have direct arterialization of the basilic vein, therefore, patients with previous ipsilateral wrist fistulas also followed a two-stage protocol. Data were retrospectively revised from all transposition procedures made between September 2005 and November 2012. Patency and complication rates were the primary outcomes evaluated. A total of 276 basilic veins were transposed. Usage rate was 82.2%. 8% (N = 22) of the fistulas were never used due to thrombosis. Secondary patency rates at 1 and 2 years were, respectively, 84% and 66.3%. Complications occurred in 61.6% (N = 170) of fistulas and 65.9% (N = 112) of which had to undergo surgical or endovascular revision. The most frequent complication was vein stenosis (39.7% of late complications, N = 92). Albeit its greater technical complexity, the transposed basilic vein represents a hemodialysis access with good patency rates. Complication rates, although high, are less than those of CVC or prosthetic grafts. These results support the use of the transposed basilic vein as hemodialysis access after the brachiocephalic fistula.

Brachio-Brachial Arteriovenous Fistula Superficialization with Short Skip Incisions.

The exhaustion of superficial venous patrimony or reduced diameter of superficial veins usually prevents patients from having an arteriovenous fistula created. In such cases, using deep vessels can be a more viable option as opposed to an arteriovenous graft. We describe a new approach for the brachio-brachial arteriovenous fistula creation technique. It consists of 3 small incisions, thus causing minimal surgical damage. We have found it to be better tolerated by the patients and well received by dialysis nurses. This procedure also allows improved access for cannulation and more available puncture sites.

Preoperative vessel mapping in chronic kidney disease patients - a center experience.

PURPOSE: Hemodialysis (HD) is the main treatment modality in stage 5 chronic kidney disease, and vascular access planning is a crucial step in the path to dialysis treatment. Beyond detailed patient history and physical examination, duplex ultrasound (DU) evaluation is essential in preoperative vascular mapping. METHODS: A retrospective descriptive nonrandomized study was performed and included 108 end-stage kidney disease patients referred from eight HD centers to be assessed for creation of an arteriovenous (AV) access (AV fistula or AV graft). We assessed primary failure, primary unassisted patency (PP) and primary assisted patency (PAP) rates and cumulative survival of AV accesses at 6 and 12 months. RESULTS: We created 86 AV accesses of which 79 (91.9%) were AV fistulas (AVFs) (29 distal AVFs, 49 proximal AVFs and 1 femorofemoral AVF) and 7 (8.1%) arteriovenous grafts (AVGs). Fifteen percent (15%) (n = 12) of primary failure occurred in the AVF group. Any case of primary failure was observed between AVGs.In the AVF group, PP at 6 months was 63.8 % and at 12 months was 48.3%, PAP was 80.7% at 6 and 12 months. PP excluding primary failures was 73.0% and 55.3% at 6 and 12 months, respectively. The cumulative survival at 6 and 12 months was 80.7%.In the AVG group, PP at 6 months and 12 months was 66.7%, PAP and cumulative survival at 6 and 12 months were of 100%. CONCLUSIONS: This study demonstrates that preoperative vascular mapping with a patient-centered approach may be critical to achieve good outcomes allowing the increase in AVF access.

LDL apheresis in the treatment of familial hypercholesterolemia: experience of Hospital Santo António, Porto.

INTRODUCTION: High plasma levels of low-density lipoprotein (LDL) cholesterol are a risk factor for the development of premature atherosclerosis. Direct adsorption of lipoproteins (DALI) is an apheresis technique by which LDL cholesterol is selectively removed from whole blood. OBJECTIVE: The present study describes our experience with DALI LDL apheresis in severely hypercholesterolemic patients. METHODS: Three hypercholesterolemic patients suffering from atherosclerotic complications were treated fortnightly by DALI apheresis, in a total of 308 sessions between December 2008 and January 2013. All patients were on the highest tolerated dose of statins and other lipid-lowering drugs. RESULTS: The sessions were essentially uneventful, adverse events being recorded in only 3.6% of them. A mean 63.3% acute reduction in LDL cholesterol was obtained. CONCLUSION: DALI apheresis proved to be a simple, safe and efficient method of lipid apheresis in hypercholesterolemic patients refractory to conservative lipid-lowering therapy.

Predictors of steal syndrome in hemodialysis patients.

Steal syndrome is a feared complication of dialysis vascular access in a population becoming older and frailer. The aim of this study was to determine the predictor factors of steal syndrome. All proximal arteriovenous fistulas (AVFs), patent at day 30, inserted between January 2008 and December 2009 were studied. Data on age, gender, diabetes mellitus (DM) status, presence of coronary or peripheral artery disease, date of initiation of renal replacement therapy, date of access construction, localization, type of anastomosis, previous interventions, and outcome for AVF and patients were analyzed. There were 324 AVFs placed into 309 individual patients. The mean age was 66.7 ± 15.3 years, and the majority (53.7%) of the patients was male. Mean follow-up of all 324 fistulas was 18.6 ± 8.5 months. During follow-up, steal syndrome occurred in 26 (8%) of the AVFs. Univariate analysis revealed correlations between steal syndrome and DM (P = 0.002), brachiomedian fistulas (P = 0.016), and side-to-side (STS) anastomosis (P = 0.003). However, in multivariate analysis, the presence of DM, STS anastomosis, and female gender were found to be the independent risk factors. The strongest predictive factor was DM (odds ratio: 6.7; 95% confidence interval: 2.5-17.9). Being diabetic is the factor most predictive of having steal syndrome. In diabetic women, with a proximal access, it seems preferable to construct fistulas with end-to-side anastomosis to minimize the risk.

Intercessão social enquanto prática cotidiana: uma experiência de psicodrama público com a população em situação de rua / Social intercession as a daily practice: a public psychodrama experiment with the street population

Este artigo relata a participação dos profissionais da área de assistência social da Prefeitura de São Paulo no psicodrama público com a população em situação de rua e seus reflexos no estabelecimento da política de gestão de pessoas, nas ações de capacitação e formação de pessoal. A estratégia utilizada foi a realização do curso "Interseção social enquanto prática cotidiana" dirigido a 210 participantes organizados em grupos divididos por regiões, que discutiram temas como a relação de cada um com a cidade, a diferença entre ética e moral, formas de abordagem junto à criança, ao adolescente e ao adulto, mitos, medos, preconceitos e surpresas, a violência e o resgate profissional dos servidores e trabalhadores das ONGs que atuam na área de assistência social. O resultado desse trabalho foi a definição das informações e conteúdos necessários para ações de capacitação e formação de pessoal, bem como a adoção da formação como suporte às mudanças da cultura organizadonal, concepções e práticas de trabalho utilizadas.