“Syndrome in syndrome”: Wernicke syndrome due to afferent loop syndrome. Case report and review of the literature

Wernicke syndrome is a rare neurological pathology due to a deficit in vitamin B1. The syndrome is common among alcohol abusers, patients with malignant tumor or gastrointestinal diseases, those who undergo hemodialysis or long-term peritoneal dialysis, pregnant women with hyperemesis, women who breast-feed, patients with hyperthyroidism or anorexia nervosa or gastric or jejunal-ileal bypass surgery for obesity, patients submitted to gastric surgery or prolonged total parenteral nutrition or prolonged intravenous therapy. We report a case of Wernicke syndrome due to afferent loop syndrome characterized by incoercible vomiting.

Clinical practice guideline on diagnosis and treatment of hyponatraemia

Hyponatraemia, defined as a serum sodium concentration <135 mmol/l, is the most common disorder of body fuid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution-and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice.

Effect of Aging in the Perception of Health-Related Quality of Life in End-Stage Renal Disease Patients under Online-Hemodiafiltration

This work aimed to evaluate how aging could influence patients' perception of health quality of life (HRQOL), as well as, the effect of aging on dialysis adequacy and in hematological, iron status, inflammatory and nutritional markers. In this transversal study were enrolled 305 ESRD patients under online-hemodiafiltration (OL-HDF) (59.67% males; 64.9 ± 14.3 years old). Data about comorbidities, hematological data, iron status, dialysis adequacy, nutritional and inflammatory markers were collected from patient's records. Moreover, HRQOL score, by using the Kidney Disease Quality of Life-Short Form (KDQOL-SF), was assessed. Analyzing the results according to quartiles of age, significant differences were found for some parameters evaluated by the KDQOL-SF instrument, namely for work status, physical functioning and role-physical, which decreased with increasing age. We also found a higher proportion of diabetic patients, a decrease in creatinine, iron, albumin serum levels, transferrin saturation and nPCR, with increasing age. Moreover, significant negative correlations were found between age and mean cell hemoglobin concentration, iron, transferrin saturation, albumin, nPCR, work status, physical functioning and role-physical. In conclusion, our results showed that aging is associated with a decreased work status, physical functioning and role-physical, with a decreased dialysis adequacy, iron availability and nutritional status, and with an increased proportion of diabetic patients and of patients using central venous catheter, as the vascular access. The knowledge of these changes associated with aging, which have impact in the quality of life of the patients, could be useful in their management.

Alteration of cell-wall porosity is involved in osmotic stress-induced enhancement of aluminium resistance in common bean (Phaseolus vulgaris L.)

Aluminium (Al) toxicity and drought are the two major abiotic stress factors limiting common bean production in the tropics. Using hydroponics, the short-term effects of combined Al toxicity and drought stress on root growth and Al uptake into the root apex were investigated. In the presence of Al stress, PEG 6000 (polyethylene glycol)-induced osmotic (drought) stress led to the amelioration of Al-induced inhibition of root elongation in the Al-sensitive genotype VAX 1. PEG 6000 (>> PEG 1000) treatment greatly decreased Al accumulation in the 1 cm root apices even when the roots were physically separated from the PEG solution using dialysis membrane tubes. Upon removal of PEG from the treatment solution, the root tips recovered from osmotic stress and the Al accumulation capacity was quickly restored. The PEG-induced reduction of Al accumulation was not due to a lower phytotoxic Al concentration in the treatment solution, reduced negativity of the root apoplast, or to enhanced citrate exudation. Also cell-wall (CW) material isolated from PEG-treated roots showed a low Al-binding capacity which, however, was restored after destroying the physical structure of the CW. The comparison of the Al(3+), La(3+), Sr(2+), and Rb(+) binding capacity of the intact root tips and the isolated CW revealed the specificity of the PEG 6000 effect for Al. This could be due to the higher hydrated ionic radius of Al(3+) compared with other cations (Al(3+) >> La(3+) > Sr(2+) > Rb(+)). In conclusion, the results provide circumstantial evidence that the osmotic stress-inhibited Al accumulation in root apices and thus reduced Al-induced inhibition of root elongation in the Al-sensitive genotype VAX 1 is related to the alteration of CW porosity resulting from PEG 6000-induced dehydration of the root apoplast.

Why badly treat what you can well prevent?

Transplantation is one of the medical activities with more expectation of success. For patients with end stage renal disease, kidney transplantation provides a better quality of life compared with those on dialysis, even for those with advanced age or co-morbidities. Greater access to food since the Second World War, high exposure to chemical and toxic, associated with changes in lifestyles, increased diabetes, hypertension, obesity, cardiovascular disease, chronic renal failure and transplantation demands. The dream of replacing damaged parts in the human body materialized with the transplants, but the hope in transplantation reached much higher levels than the actual results deserve. The transplant was used as flags of technical and scientific differentiation and success. Nonetheless transplantation was faced with shortage of organs and increased demand. The claim to the right to treatment quickly was confused and understood as the right to transplantation.

Population-E

Social inequalities in health are a major public concern. Some of theseinequalities are currently not well documented, and are thus largely absentfrom debate. One important health issue is renal disease and access tothe corresponding therapies (dialysis and renal transplant). These twotherapeutic options have very different consequences in terms of labourmarket participation and physical well-being. Renal transplants offerpatients an enhanced quality of daily life and a longer life expectancy, butthis option is limited by organ availability. Here, drawing on two recentsurveys, Christian Baudelot, Yvanie Caillé, Olivier Godechot and SylvieMercier examine socially differentiated access to these two therapiesand explore the underlying mechanisms. At each stage in the diseaseand its treatment, a cumulative process puts the least educated patientsat a disadvantage in terms of access to a kidney transplant.

Study of salinity gradients in the Persian Gulf and an experimental model for electric energy extraction from them using nano-membranes

Salinity gradient power (SGP) is the energy that can be obtained from the mixing entropy of two solutions with a different salt concentration. River estuary, as a place for mixing salt water and fresh water, has a huge potential of this renewable energy. In this study, this potential in the estuaries of rivers leading to the Persian Gulf and the factors affecting it are analysis and assessment. Since most of the full water rivers are in the Asia, this continent with the potential power of 338GW is a second major source of energy from the salinity gradient power in the world (Wetsus institute, 2009). Persian Gulf, with the proper salinity gradient in its river estuaries, has Particular importance for extraction of this energy. Considering the total river flow into the Persian Gulf, which is approximately equal to 3486 m3/s, the amount of theoretical extractable power from salinity gradient in this region is 5.2GW. Iran, with its numerous rivers along the coast of the Persian Gulf, has a great share of this energy source. For example, with study calculations done on data from three hydrometery stations located on the Arvand River, Khorramshahr Station with releasing 1.91M/ energy which is obtained by combining 1.26m3 river water with 0.74 m3 sea water, is devoted to itself extracting the maximum amount of extractable energy. Considering the average of annual discharge of Arvand River in Khorramshahr hydrometery station, the amount of theoretical extractable power is 955 MW. Another part of parameters that are studied in this research, are the intrusion length of salt water and its flushing time in the estuary that have a significant influence on the salinity gradient power. According to the calculation done in conditions HWS and the average discharge of rivers, the maximum of salinity intrusion length in to the estuary of the river by 41km is related to Arvand River and the lowest with 8km is for Helle River. Also the highest rate of salt water flushing time in the estuary with 9.8 days is related to the Arvand River and the lowest with 3.3 days is for Helle River. Influence of these two parameters on reduces the amount of extractable energy from salinity gradient power as well as can be seen in the estuaries of the rivers studied. For example, at the estuary of the Arvand River in the interval 8.9 days, salinity gradient power decreases 9.2%. But another part of this research focuses on the design of a suitable system for extracting electrical energy from the salinity gradient. So far, five methods have been proposed to convert this energy to electricity that among them, reverse electro-dialysis (RED) method and pressure-retarded osmosis (PRO) method have special importance in practical terms. In theory both techniques generate the same amount of energy from given volumes of sea and river water with specified salinity; in practice the RED technique seems to be more attractive for power generation using sea water and river water. Because it is less necessity of salinity gradient to PRO method. In addition to this, in RED method, it does not need to use turbine to change energy and the electricity generation is started when two solutions are mixed. In this research, the power density and the efficiency of generated energy was assessment by designing a physical method. The physical designed model is an unicellular reverse electro-dialysis battery with nano heterogenic membrane has 20cmx20cm dimension, which produced power density 0.58 W/m2 by using river water (1 g NaCl/lit) and sea water (30 g NaCl/lit) in laboratorial condition. This value was obtained because of nano method used on the membrane of this system and suitable design of the cell which led to increase the yield of the system efficiency 11% more than non nano ones.

Aplicación de los criterios RIFLE (Risk, Injury, Failure, Loss y End) para determinar la falla renal aguda en pacientes de 1 a 5 años hospitalizados en la unidad de cuidados intensivos del Hospital de Niños Benjamín Bloom en el año 2013.

La Falla Renal Aguda (FRA) es un síndrome multifactorial de etiología variada e incidencia que difiere según países y poblaciones de estudio. A nivel mundial no existe un consenso en cuanto a una definición universal. Últimamente se ha reconocido la importancia que tiene la reducción leve a moderada de la función renal en la morbimortalidad especialmente en los pacientes críticos. En 2004, la Acute Dialysis Quality Initiative, realizó un consenso para definir la falla renal aguda, a través del criterio de RIFLE (Riesgo, Injuria, Falla, Pérdida y Estado final de la falla), el cual utilizó los criterios de los adultos y lo extrapoló hacia los pacientes pediátricos. Objetivo: diagnosticar falla renal aguda de acuerdo con los criterios RIFLE en los pacientes de 1 a 5 años hospitalizados en la Unidad de Cuidados Intensivos Pediátricos del Hospital Bloom en el año 2013, identificación de la prevalencia y de las principales causas etiológicas en las cuales se presenta. Muestra: pacientes de 1 a 5 años hospitalizados en la Unidad de Cuidados Intensivos del Hospital Nacional de Niños Benjamín Bloom, los cuales no fueron sometidos a procedimientos quirúrgicos o presentaron insuficiencia renal crónica. Método: se realizó un estudio retrospectivo, descriptivo, desarrollado en la unidad de cuidados intensivos de dicho hospital, haciendo el diagnóstico de falla renal aguda mediante la aplicación los criterios RIFLE para demostrar la utilidad de ésta metodología en el diagnóstico temprano de FRA. Se analizaron los datos epidemiológicos, clínicos y analíticos de todos los pacientes con falla renal aguda. Consideraciones éticas: el presente estudio se evaluó y aprobó por el comité de ética del HNNBB considerándolo adecuado y de bajo riesgo para los pacientes. Resultados: hubo 27 episodios de FRA en 43 pacientes con edad de 1 a 5 años lo cual corresponde al 62.7% de los casos estudiados, el 52% sexo femenino. La patología primaria más frecuente fueron las patologías de origen infeccioso, más común en las neumonías; la media de edad de presentación son los 26 meses. Mediante la aplicación de los criterios RIFLE se permitió diagnosticar de forma más temprana la FRA.

Studies on terpenes solubility in water and deep eutectic solvents diagrams for biomedical applications

The main objectives of this work are the measurement of terpenes solubility in water at different temperatures, and the formulation of Deep Eutectic Solvents based on choline chloride and polycarboxylic acids, that can be used as hydrotropes of aqueous solutions in terpenes, replacing conventional organic solvents. In this work a new experimental methodology was implemented, using dialysis membranes, for the measurement of terpenes solubility in water. Concerning the deep eutectic diagrams formulation, the determination of the melting points of the eutectic mixtures was performed using a visual method. The method used for determining solubilities was previously validated using a well-studied model compound, toluene. The experimental results of terpenes solubilities in water resulted in a very satisfactory coefficients of variation, always below 6%. The experimental solubility data were analysed and the temperature dependence is also studied in a thermodynamic perspective. The compound with the largest solubility dependence with the temperature is geraniol, while thymol presents the smallest. The phase diagrams of DES formulated were quite satisfactory, presenting always eutectic points below to 373.15 K. For some compositions, the systems composed by choline chloride and lactic, or malonic, or myristic acid were liquid at room temperature. In the case of monocarboxylic acids, eutectic is formed at 60% mol of the acid, to dicarboxylic acid is formed at 50% mol of the acid and for tricarboxylic acid these point is formed at 30% mol of the acid. In the future, it will be important to study the effect of DES as hydrotropes in aqueous solutions of terpenes. Furthermore, it would be interesting to study more terpenes in order to assess the effect of the size of the alkyl chain and the structures of the compounds.

Deficiencies in education and experience in the management of acute kidney injury among Malawian healthcare workers

Background Acute kidney injury (AKI) is a common but under-recognised disease process, which carries a high risk of mortality or chronic complications, such as chronic kidney disease and other organ dysfunction. Management of AKI, however, is suboptimal, both in developed settings and in Malawi. This is partly because of deficiencies in AKI education and training. Aim To establish current levels of AKI education in a range of healthcare workers in Malawi. Methods An AKI symposium was held in Blantyre in March 2015. Delegates were asked to complete a survey at the start of the symposium to assess their clinical experience and education in the management of AKI. Results From 100 delegates, 89 nurses, clinical officers, and physicians, originating from 11 different districts, responded to the survey. Twenty-two percent of healthcare workers (including 28% of district workers of the various cadres and 31% of nurses) had never received teaching on any aspect of renal disease, and 50% (including 63% of district workers and 61% of nurses) had never received teaching specifically on AKI. Forty-four percent did not feel confident managing AKI, and 98% wanted more support managing patients with renal disease. Thirty-four percent (including 55% of district workers) were unaware that haemodialysis was available at Queen Elizabeth Central Hospital (QECH) for the treatment of AKI and 53% (74% of district workers) were unaware that peritoneal dialysis was available for the treatment of AKI in children. Only 33% had ever referred a patient with AKI to QECH. Conclusions There are deficiencies in education about, and clinical experience in, the management of AKI among Malawian healthcare workers, in addition to limited awareness of the renal service available at QECH. Urgent action is required to address these issues in order to prevent morbidity and mortality from AKI in Malawi.

Desenvolvimento de uma nanoformulação autoemulsificante contendo o alcaloide epiisopiloturina para melhorar sua biodisponibilidade plasmática após administração via oral

Dissertação (mestrado)—Universidade de Brasília, Instituto de Ciências Biológicas, Programa de Pós-Graduação em Nanociência e Nanobiotecnologia, 2016.

Effects of an intradialytic resistance training programme on physical function: a prospective stepped-wedge randomized controlled trial

BACKGROUND: Intradialytic exercise programmes are important because of the deterioration in physical function that occurs in people receiving haemodialysis. Unfortunately, exercise programmes are rarely sustained in haemodialysis clinics. The aim of this study was to determine the efficacy of a sustainable resistance exercise programme on the physical function of people receiving haemodialysis. METHODS: A total of 171 participants from 15 community satellite haemodialysis clinics performed progressive resistance training using resistance elastic bands in a seated position during the first hour of haemodialysis treatment. We used a stepped-wedge design of three groups, each containing five randomly allocated cluster units allocated to an intervention of 12, 24 or 36 weeks. The primary outcome measure was objective physical function measured by the 30-s sit-to-stand (STS) test, the 8-foot timed up and go (TUG) test and the four-square step test. Secondary outcome measures included quality of life, involvement in community activity, blood pressure and self-reported falls. RESULTS: Exercise training led to significant improvements in physical function as measured by STS and TUG. There was a significant average downward change (β = -1.59, P < 0.01) before the intervention and a significant upward change after the intervention (β = 0.38, P < 0.01) for the 30-s STS with a similar pattern noted for the TUG. CONCLUSION: Intradialytic resistance training can improve the physical function of people receiving dialysis.

Asymptomatic intradialytic hypotension: the need for pre-emptive intervention

Intradialytic hypotension (IDH) remains the most common severe side effect of hemodialysis despite numerous technological advancements. Recent evidence emphasises the significance of asymptomatic hypotensive episodes, as well as the hypoperfusive consequences of both relative blood pressure drops and repetitive, symptomatic events. This article reviews the physiological importance of rapid blood pressure decrease during hemodialysis, and highlights the pathological consequences of repeated asymptomatic and symptomatic hypoperfusive episodes. In proposing a view concerned with asymptomatic IDH, a practicalpre-emptive intervention is offered to improve the long-term outcomes of patients on hemodialysis. Ongoing monitoring of individual patient's mean arterial pressure (MAP) throughout the dialysis treatment can facilitate the identification of an asymptomatic hypotensive episode. A brief pause in ultrafiltration enables vascular refill and subsequent increase in MAP, allowing resumption of safe fluid removal. Such enhanced assessment results in a reduction off patient risk, allowing safe and optimal fluid removal.

Stressors and coping resources of Australian kidney transplant recipients related to medication taking: a qualitative study

AIM: To understand the stressors related to life post-kidney transplantation, with a focus on medication adherence, and the coping resources people use to deal with these stressors. BACKGROUND: Although kidney transplantation offers enhanced quality and years of life for patients, the management of a kidney transplant post-surgery is a complex process. DESIGN: A descriptive exploratory study. METHOD: Participants were recruited from five kidney transplant units in Victoria, Australia. From March to May 2014, patients who had either maintained their kidney transplant for ≥ 8 months or had experienced a kidney graft loss due to medication non-adherence were interviewed. All audio-recordings of interviews were transcribed verbatim and underwent Ritchie and Spencer's framework analysis. RESULTS: Participants consisted of fifteen men and ten women aged 26 - 72 years old. All identified themes were categorised into: 1) Causes of distress and 2) Coping resources. Post-kidney transplantation, causes of distress included the regimented routine necessary for graft maintenance, and the everlasting fear of potential graft rejection, contracting infections and developing cancer. Coping resources utilised to manage the stressors were firstly, a shift in perspective about how easy it was to manage a kidney transplant than to be dialysis-dependent and secondly, receiving external help from fellow patients, family members and healthcare professionals in addition to utilising electronic reminders. CONCLUSION: An individual well-equipped with coping resources is able to deal with stressors better. It is recommended that changes, such as providing regular reminders about the lifestyle benefits of kidney transplantation, creating opportunities for patients to share their experiences and promoting the utilisation of a reminder alarm to take medications, will reduce the stress of managing a kidney transplant.

Identifying and integrating patient and caregiver perspectives for clinical practice guidelines on the screening and management of infectious microorganisms in hemodialysis units

Introduction: The integration of patient and caregiver input into guideline development can help to ensure that clinical care addresses patient expectations, priorities, and needs. We aimed to identify topics and outcomes salient to patients and caregivers for inclusion in the Kidney Health Australia Caring for Australasians with Renal Impairment (KHA-CARI) clinical practice guideline on the screening and management of infectious microorganisms in hemodialysis units.

Methods: A facilitated workshop was conducted with 11 participants (patients [n = 8], caregivers [n = 3]). Participants identified and discussed potential topics for inclusion in the guidelines, which were compared to those developed by the guideline working group. The workshop transcript was thematically analyzed to identify and describe the reasons underpinning their priorities.

Findings: Patients and caregivers identified a range of topics already covered by the scope of the proposed guidelines and also suggested additional topics: privacy and confidentiality, psychosocial care during/after disease notification, quality of transportation, psychosocial treatment of patients in isolation, patient/caregiver education and engagement, and patient advocacy. Five themes characterized discussion and underpinned their choices: shock and vulnerability, burden of isolation, fear of infection, respect for privacy and confidentiality, and confusion over procedural inconsistencies.

Discussion: Patients and caregivers emphasized the need for guidelines to address patient education and engagement, and the psychosocial implications of communication and provision of care in the context of infectious microorganisms in hemodialysis units. Integrating patient and caregiver perspectives can help to improve the relevance of guidelines to enhance quality of care, patient experiences, and health and psychosocial outcomes.