Negative pressure and nanocrystalline silver dressings for nonhealing ulcer: A randomized pilot study.

Chronic wounds have a high prevalence and wound care, treatment, and prevention consume large quantities of resources. Chronic wounds are a growing challenge for clinicians. A prospective randomized pilot study was conducted to assess the effectiveness in terms of reduction in area and safety of the combined use of negative-pressure wound therapy and nanocrystalline silver dressings as compared to negative pressure wound therapy (NPWT) alone in the management of outpatients with chronic wounds. A total of 17 patients were included in the study, 10 were treated with the combined method and 7 with NPWT. Patients were followed for 6 weeks, with a final assessment at 3 months. Clinical improvement, microbiologic data, and toxicity of silver were evaluated. The antibacterial effects of ionic silver together with the development of granulation tissue promoted by NPWT reduced significantly the median extension of the wound between weeks 3 and 6 of treatment. The combination with silver also reduced bacterial colonization with Pseudomonas aeruginosa and the bacterial load on the surface of the wound. The silver levels correlated positively with the extension of the wound, although in none of the patients' toxic levels were reached. The combination of NPWT with nanocrystalline silver dressings was safe and as effective as NPWT alone.

Pleiotropic effects of statins may improve outcomes in atherosclerotic renovascular disease.

BACKGROUND: Atherosclerotic renovascular disease (ARD) coexists with arterial obstructive disease in the coronary, cerebral, and peripheral arteries that may remain underdiagnosed and untreated. METHODS: This retrospective study compares overall survival and renal survival (i.e., time to doubling of serum creatinine or end-stage renal disease (ESRD)) over an 11-year period in 104 ARD patients of whom 68 received statin therapy (group S) because of elevated lipid levels and 36 had no statin (group NS) because of normal lipid profile at entry. RESULTS: Atherosclerosis in another vascular bed was documented in 84%. Lipid profiles at end point were virtually identical in both the groups. Group S had mean survival 123months (confidence interval (CI) 113-134) with four deaths, and mean renal survival 122months (CI 113-131). Group NS had mean survival 33 months (CI 23-42) with 13 deaths, and mean renal survival 27 months (CI 17-37). CONCLUSIONS: Statin therapy was associated with lesser rate of progression of renal insufficiency (with 7.4% of S patients reaching renal end points vs. 38.9% of NS patients) and lower overall mortality (5.9 % in S vs. 36.1% in NS patients), P < 0.001 for both. Although both groups received what was deemed optimal therapy, they did have other differences that may have affected the outcomes (a limitation addressed by Cox multiple regression analysis). These results suggest the need for prospective randomized controlled studies in ARD patients in order to explore potential benefits of statins that may not be attributable solely to lipid lowering.

Piperacillin/tazobactam-induced neurotoxicity in a hemodialysis patient: a case report.

Antibiotics are potentially a cause of neurotoxicity in dialysis patients, the most common are the beta-lactams as ceftazidime and cefepime, and few cases have been reported after piperacillin/tazobactam use. This report presents a case of a hypertensive and diabetic 67-year-old woman in regular hemodialysis, which previously had a stroke. She was hospitalized presenting pneumonia, which was initially treated with cefepime. Two days after treatment, she presented dysarthria, left hemiparesis, ataxia, and IX and X cranial nerves paresis. Computed tomography showed no acute lesions and cefepime neurotoxicity was hypothesized, and the antibiotic was replaced by piperacillin/tazobactam. The neurologic signs disappeared; however, 4 days after with piperacillin/tazobactam treatment, the neurological manifestations returned. A new computed tomography showed no new lesions, and the second antibiotic regimen withdrawn. After two hemodialysis sessions, the patient completely recovered from neurological manifestations. The patient presented sequentially neurotoxicity caused by two beta-lactams antibiotics. This report meant to alert clinicians that these antibiotics have dangerous neurological effects in chronic kidney disease patients.

Novel predictors of peritonitis-related outcomes in the BRAZPD cohort.

INTRODUCTION: Peritonitis remains the main cause of peritoneal dialysis (PD) technique failure worldwide, despite significant reductions in infection rates observed over the past decades. Several studies have described risk factors for peritonitis, technique failure and mortality. However, there are scarce data regarding predictors of complications during and after a peritonitis episode. The aim of our study was to analyze predictors of peritonitis-related outcome in the Brazilian Peritoneal Dialysis study (BRAZPD) cohort. METHODS: All adult incident patients recruited in the BRAZPD Study between December 2004 and October 2007, who remained at least 90 days on PD and presented their first peritonitis episode (n = 474 patients) were included in the study. The endpoints analyzed were non-resolution, death due to a peritonitis episode and long-term technique survival after a peritonitis episode. RESULTS: In the multivariable regression, non-resolution was independently associated with older age (odds ratio (OR) 1.02; p < 0.01), collagenosis as the primary renal disease (OR 4.6; p < 0.05) and Pseudomonas spp as etiological agent (OR 2.9; p < 0.05). Patients who were transferred from APD to CAPD during peritonitis therapy presented a higher risk of non-response (OR 2.5; p < 0.05). The only factor associated with death during a peritonitis episode was older age (OR 1.04; p < 0.05). Exposure to vancomycin and male gender were the independent predictors of long-term technique failure (OR 2.2; p < 0.01). CONCLUSION: Apart from confirming previous observations of the negative impact of older age and Pseudomonas spp peritonitis on outcomes, we observed that collagenosis may negatively impact response to treatment and exposure to vancomycin may possibly reduce long-term technique survival. It is important to emphasize that the association of vancomycin with technique failure does not prove causality. These findings shed light on new factors predicting outcome when peritonitis is diagnosed.

Validity of malnutrition scores for predicting mortality in chronic hemodialysis patients.

PURPOSE: Malnutrition is a strong predictor of mortality in hemodialysis patients. Several scoring systems for evaluating nutritional status have been proposed. However, they rely on different sets of anthropometric and laboratory markers to make a diagnosis of malnutrition and assess its impact on prognosis. To validate them, nutritional scores should be compared with clinical outcomes. Thus, the purpose of this study was to assess malnutrition by three different nutrition scoring systems and determine which best predicts mortality in hemodialysis patients. METHODS: This prospective study included 106 adult chronic hemodialysis patients. Their mean age was 56.3 ± 14.9 years and mean body mass index 24.8 (21.8-28.9); 52 % were men and they had been on dialysis for 24 (5-55) months. Nutritional status was classified according to the diagnostic systems proposed by Wolfson et al. (Am J Clin Nutr 39(4):547-555, 1984), International Society of Renal Nutrition and Metabolism (ISRNM) (Fouque et al. in Kidney Int 73(4):391-398, 2008), and Beberashvili et al. (Nephrol Dial Transplant 25(8):2662-2671, 2010). During about 2 years of follow-up, mortality was assessed by Kaplan-Meier curves, log-rank, and Cox's models adjusted for diabetes, sex, C-reactive protein, time on dialysis, age, and fractional urea clearance. RESULTS: Twenty-three deaths (21.5 %) occurred during the study period. According to the systems of Wolfson, Beberashvili, and the ISRNM, 54, 32, and 20 % of patients, respectively, had malnutrition. Both univariate and multivariate analyses showed that the ISRNM system was the only one that predicted poorer survival (fourfold higher death risk) in malnourished patients. CONCLUSIONS: The scoring system proposed by the ISRNM most accurately identifies patients at higher risk of death.

Geographic and educational factors and risk of the first peritonitis episode in Brazilian Peritoneal Dialysis study (BRAZPD) patients.

BACKGROUND AND OBJECTIVES: Peritonitis remains as the most frequent cause of peritoneal dialysis (PD) failure, impairing patient's outcome. No large multicenter study has addressed socioeconomic, educational, and geographic issues as peritonitis risk factors in countries with a large geographic area and diverse socioeconomic conditions, such as Brazil. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Incident PD patients recruited from 114 dialysis centers and reporting to BRAZPD, a multicenter observational study, from December 2004 through October 2007 were included. Clinical, dialysis-related, demographic, and socioeconomic variables were analyzed. Patients were followed up until their first peritonitis. Cox proportional model was used to determine independent factors associated with peritonitis. RESULTS: In a cumulative follow-up of 2032 patients during 22.026 patient-months, 474 (23.3%) presented a first peritonitis episode. In contrast to earlier findings, PD modality, previous hemodialysis, diabetes, gender, age, and family income were not risk predictors. Factors independently associated with increased hazard risk were lower educational level, non-white race, region where patients live, shorter distance from dialysis center, and lower number of patients per center. CONCLUSIONS: Educational level and geographic factors as well as race and center size are associated with risk for the first peritonitis, independent of socioeconomic status, PD modality, and comorbidities.

Associations between nutritional markers and inflammation in hemodialysis patients.

The purpose of this study is to evaluate associations between clinical, laboratory, demographic, and nutritional markers with inflammatory state and malnutrition in hemodialysis (HD) patients. Fifty-two patients on regular HD were evaluated by clinical, demographic, laboratory, and nutritional parameters (food intake, anthropometric measurements, bioelectric impedance, subjective global assessment--SGA and appetite characteristics). Inflammation (serum C-reactive protein >or= 0.9 mg/dl) was present in 13 (25%) and malnutrition (SGA) in 16 (30.7%) patients. Body mass index (BMI), total lymphocytes count, and phase angle were negative and independently associated with malnutrition. Values of BMI >or= 25 kg/m2 were associated with diabetes, positively associated with adipose tissue percentage (BIA) and negatively associated with diastolic blood pressure. Phase angle was positively associated with hematocrit, total lymphocytes count and serum creatinine, and was negatively associated with age. A negative and independent association between muscle mass percentage (BIA) and inflammation was observed. These results suggested that inflammatory state induces muscle mass depletion, while high BMI is associated with diabetes and with lower diastolic blood pressure, a recognized cardiovascular risk factor in uremic patients. Phase angle and SGA were associated with traditional nutritional markers, reinforcing their validity for HD patients.

Estudo aberto comparativo captopril + hidroclorotiazida versus clortalidona para tratamento da hipertensäo primária leve e moderada / An open comparative study of captopril + hydrochlorothiazide versus chlorthalidone for the treatment of mild and moderate primary hypertension

Objetivo - Comparar o efeito anti-hipertensivo e alterações metabólicas da associação captopril + hidroclorotiazida (C+HCTZ) contra clortalidona (CT) para tratamento de hipertensão arterial primária leve e moderada. Métodos - cinqüenta e cinco pacientes que tiveram a sua medicação anti-hipertensiva suspensa por 15 dias ou sem tratamento prévio, foram randomizados para tratamentos com a associação captopril 50mg + hidroclorotiazida 25mg (n=29) ou clortalidona 50mg (n=26). A avaliação clínica foi realizada previamente à medicação e mensalmente durante 3 meses e os exames laboratoriais foram feitos no início e ao final do estudo. Resultados - A pressão arterial (PA) no período placebo não foi diferente entre os grupos (C+CHTZ: 161 ± 25/102 ± 6 - CT: 155 ± 18/101 ± 6 mmHg), porém a diminuição da pressão diastólica já no 1° mês foi estatisticamente significante no grupo C+HCTZ (89±8 mmHg) comparado ao grupo CT (94±8 mmHg, p<0,05). O perceptual de queda da PA diastólica em média, de 12% no grupo C+HCTZ e no grupo CT variou de 7 (1° e 2° mês) a 11% (3° mês). Embora sem diferença estatística, obteve-se normalização pressórica em 69% dos pacientes com captopril associado ao diurético e, em 50%, com clortalidona. Observou-se uma redução significativa da potassemia com clortalidona (4,2±0,7 para 3,7±0,4 mEq/L, p<0,01) e manutenção dos níveis de potássio com associação captopril e tiazídico. Este último tratamento também reduziu significativamente os níveis de colesterol (219±39 mg/dl para 202±39 mg/dl, p<0,04). Conclusão - Os resultados mostraram que a associação de captopril com dose baixa de tiazídico normaliza a PA em 69% de pacientes portadores de hipertensão arterial primária leve e moderada e age mais rapidamente que a clortalidona no controle pressórico, apresentando efeito metabólico benéfico de reduzir os níveis de colesterol sem alterar a potassemia

Purpose - To compara the antihypertensive and metabolic effects of captopril combined with hydrochlorothiazide (C+HCTZ) versus chlorthalidone (CT) in mild and moderate primary hypertensive patients. Methods - Fifty five patients, whithout treatment or treated with 15 days placebo were randomized for treatment with the combination of captopril 50mg and hydrochlorothiazide 25mg (n=29) against chlorthalidone (n=26). The clinical evaluation was done during placebo and monthly throughout three months, and the laboratory tests were done before and at the end of the study. Results - The blood pressure were similar between groups during placebo period (C+HCTZ: 161±25/102±6 - CT: 155±18/101±6 mmHg); the diastolic blood pressure decreases significantly at first month already in the group C+HCTZ (89±8 mmHg) comparad to group CT (94±8 mmHg, p<0,05). The percentile diastolic and mean blood pressure dropped, in average, 12% in C+HCTZ group and in CT varied between 7 (1st and 2nd month) to 11% (3rd month). Without statistical difference, the blood pressure normalization was obtained in 69% of the patients with the association captopril and diuretic and in 50% of the patients in the chlorthalidone group. It was observed a significant reduction of potassium in patients treated with chlorthalidone (4,2±0,7 to 3,7±0,4 mEq/L, p<0,01) that was not observed with the captopril and the thyazide associated. The last treatment also significantly reduced the cholesterol levels (219±39mg/dl to 202±39mg/dl, p<0,04). Conclusion - Our results indicate that captopril combined with low diuretic dose normalize the blood pressure in 69% mild to moderate primary hypertensive patients, and acts faster than chlorthalidone in this control. In addition has metabolic benefits reducing cholesterol levels with no alteration in potassium levels

Avaliaçäo da eficácia da lercanidipina comparada à nifedipina oros no tratamento da hipertensäo arterial primária leve e moderada pela monitorizaçäo ambulatorial de 24 horas (MAPA) / Evaluation of efficacy of lercanidipine compared to nifedipine oros in treatment of mild and moderate primary arterial hypertension by ambulatorial 24 hours monitoring

A eficácia anti-hipertensiva da lercanidipina foi avaliada de forma comparativa e simples-cega com a nifedipina oros no tratamento da hipertensão primária leve a moderada nas 24 horas. Empregou-se a monitorização ambulatorial da pressão arterial nas 24 horas (MAPA) em 18 pacientes hipertensos leves a moderados, de ambos os sexos, sendo que a metade recebeu lercanidipina 10 mg/dia e os demais nifedipina oros 30 mg por 4 semanas. Os pacientes que não apresentaram a pressão arterial (PA) normalizada, sendo o critério PAS > 140 mmHg e/ou PAD > 90 mmHg, tiveram a dose duplicada; nos demais pacientes foi mantida e todos foram acompanhados por mais 4 semanas. Foi realizada a MAPA de 24 horas antes e após a primeira dose de cada medicação, ao final das 8 semanas do estudo e após 48 horas da administração da última dose da lercanidipina ou nifedipina oros. Foram observadas reduções semelhantes da PA nos dois grupos em todos os momentos durante a MAPA após a primeira dose e ao final das 8 semanas de tratamento durante as 48 horas após a última tomada. A persistência do efeito anti-hipertensivo 48 horas após a última dose foi mantida sem diferença quando se comparou os dois fármacos. A eficácia anti-hipertensiva da lercanidipina foi semelhante à da nifedipina oros nos hipertensos primários leves a moderados nas 24 horas, havendo persistência do efeito anti-hipertensivo, verificado com ambas as drogas durante o tratamento crônico, por um período de até 48 horas após a última tomada.