ACUTE KIDNEY INJURY CAUSED BY Crotalus AND Bothrops SNAKE VENOM: A REVIEW OF EPIDEMIOLOGY, CLINICAL MANIFESTATIONS AND TREATMENT

SUMMARY Ophidic accidents are an important public health problem due to their incidence, morbidity and mortality. An increasing number of cases have been registered in Brazil in the last few years. Several studies point to the importance of knowing the clinical complications and adequate approach in these accidents. However, knowledge about the risk factors is not enough and there are an increasing number of deaths due to these accidents in Brazil. In this context, acute kidney injury (AKI) appears as one of the main causes of death and consequences for these victims, which are mainly young males working in rural areas. Snakes of the Bothrops and Crotalus genera are the main responsible for renal involvement in ophidic accidents in South America. The present study is a literature review of AKI caused by Bothrops and Crotalus snake venom regarding diverse characteristics, emphasizing the most appropriate therapeutic approach for these cases. Recent studies have been carried out searching for complementary therapies for the treatment of ophidic accidents, including the use of lipoic acid, simvastatin and allopurinol. Some plants, such as Apocynaceae, Lamiaceae and Rubiaceae seem to have a beneficial role in the treatment of this type of envenomation. Future studies will certainly find new therapeutic measures for ophidic accidents.

BIOPSY PROVEN ACUTE TUBULAR NECROSIS DUE TO RHABDOMYOLYSIS IN A DENGUE FEVER PATIENT: A CASE REPORT AND REVIEW OF LITERATURE

Renal histology results are very scarce in dengue-associated rhabdomyolysis patients developing acute kidney injury (AKI). We report a case of dengue fever-induced AKI associated to rhabdomyolysis with a renal biopsy showing acute tubular necrosis (ATN) and renal deposition of myoglobin. A 28-year-old patient who presented dengue fever (DF) complicated by severe AKI and rhabdomyolysis is described. The patient required hemodialysis for three weeks. A renal biopsy revealed ATN with positive staining for myoglobin in the renal tubuli. The patient was discharged with recovered renal function. In conclusion, this case report described a biopsy proven ATN associated to DF-induced rhabdomyolysis, in which renal deposition of myoglobin was demonstrated. We suggest that serum creatine phosphokinase should be monitored in DF patients to allow for an early diagnosis of rhabdomyolysis and the institution of renal protective measures.

Prophylactic Use of Liposomal Amphotericin B in Preventing Fungal Infections Early After Liver Transplantation: a Retrospective, Single-Center Study

In this study the authors evaluated the efficacy of prophylaxis with liposomal amphotericin B (L-AmB) in the incidence of fungal infections (FI) during the first 3 months after liver transplant (LT). The study was retrospective and accessed a 4-year period from 2008 to 2011. All patients who died in the first 48 hours after LT were excluded. Patients were divided by the risk groups for FI: Group 1, high-risk (at least 1 of the following conditions: urgent LT; serum creatinine >2 mg/dL; early acute kidney injury [AKI] after LT; retransplantation; surgical exploration early post-LT; transfused cellular blood components [>40 U]); and Group 2, low-risk patients. Group 1 patients were further separated into those who received antifungal prophylaxis with L-AmB and those who did not. Prophylaxis with L-AmB consisted of intravenous administration of L-AmB, 100 mg daily for 14 days. Four hundred ninety-two patients underwent LT; 31 died in the first 48 hours after LT. From the remaining 461 patients, 104 presented with high-risk factors for FI (Group 1); of these, 66 patients received antifungal prophylaxis and 38 did not. In this group 8 FI were observed, 5 in patients without antifungal prophylaxis (P = .011). Three more FI were identified in Group 2. By logistic regression analysis, the categorical variable high-risk group was independently related to the occurrence of invasive FI (P = .006). We conclude that prophylaxis with L-AmB after LT was effective in reducing the incidence of FI. No influence on mortality was detected.

Liver Depurative Techniques: A Single Liver Transplantation Center Experience

In a liver transplant (LT) center, treatments with Prometheus were evaluated. The main outcome considered was 1 and 6 months survival. Methods. During the study period, 74 patients underwent treatment with Prometheus; 64 were enrolled,with a mean age of 51 13 years; 47men underwent 212 treatments (mean, 3.02 per patient). The parameters evaluated were age, sex, laboratorial (liver enzymes, ammonia) and clinical (model for end-stage liver disease and Child-Turcotte-Pugh score) data. Results. Death was verified in 23 patients (35.9%) during the hospitalization period, 20 patients (31.3%) were submitted to liver transplantation, and 21 were discharged. LT was performed in 4 patients with acute liver failure (ALF, 23.7%), in 7 patients with acute on chronic liver failure (AoCLF, 43.7%), and in 6 patients with liver disease after LT (30%). Seven patients who underwent LT died (35%). In the multivariate analysis, older age (P ¼ .015), higher international normalized ratio (INR) (P ¼ .019), and acute liver failure (P ¼ .039) were independently associated with an adverse 1-month clinical outcome. On the other hand, older age (P ¼ .011) and acute kidney injury (P ¼ .031) at presentation were both related to worse 6-month outcome. For patients with ALF and AoCLF we did not observe the same differences. Conclusions. In this cohort, older age was the most important parameter defining 1- and 6-month survival, although higher INR and presence of ALF were important for 1-month survival and AKI for 6-month survival. No difference was observed between patients who underwent LT or did not have LT.

Acute Kidney Injury after Pediatric Cardiac Surgery: Risk Factors and Outcomes. Proposal for a Predictive Model

Objectives: To characterize the epidemiology and risk factors for acute kidney injury (AKI) after pediatric cardiac surgery in our center, to determine its association with poor short-term outcomes, and to develop a logistic regression model that will predict the risk of AKI for the study population. Methods: This single-center, retrospective study included consecutive pediatric patients with congenital heart disease who underwent cardiac surgery between January 2010 and December 2012. Exclusion criteria were a history of renal disease, dialysis or renal transplantation. Results: Of the 325 patients included, median age three years (1 day---18 years), AKI occurred in 40 (12.3%) on the first postoperative day. Overall mortality was 13 (4%), nine of whom were in the AKI group. AKI was significantly associated with length of intensive care unit stay, length of mechanical ventilation and in-hospital death (p<0.01). Patients’ age and postoperative serum creatinine, blood urea nitrogen and lactate levels were included in the logistic regression model as predictor variables. The model accurately predicted AKI in this population, with a maximum combined sensitivity of 82.1% and specificity of 75.4%. Conclusions: AKI is common and is associated with poor short-term outcomes in this setting. Younger age and higher postoperative serum creatinine, blood urea nitrogen and lactate levels were powerful predictors of renal injury in this population. The proposed model could be a useful tool for risk stratification of these patients.

Acute kidney injury in a tropical country: a cohort study of 253 patients in an infectious diseases intensive care unit

Introduction: Acute kidney injury (AKI) is a frequent and potentially fatal complication in infectious diseases. The aim of this study was to investigate the clinical aspects of AKI associated with infectious diseases and the factors associated with mortality. Methods: This retrospective study was conducted in patients with AKI who were admitted to the intensive care unit (ICU) of a tertiary infectious diseases hospital from January 2003 to January 2012. The major underlying diseases and clinical and laboratory findings were evaluated. Results: A total of 253 cases were included. The mean age was 46±16 years, and 72% of the patients were male. The main diseases were human immunodeficiency virus (HIV) infection, HIV/acquired immunodeficiency syndrome (AIDS) (30%), tuberculosis (12%), leptospirosis (11%) and dengue (4%). Dialysis was performed in 70 cases (27.6%). The patients were classified as risk (4.4%), injury (63.6%) or failure (32%). The time between AKI diagnosis and dialysis was 3.6±4.7 days. Oliguria was observed in 112 cases (45.7%). The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher in patients with HIV/AIDS (57±20, p-value=0.01) and dengue (68±11, p-value=0.01). Death occurred in 159 cases (62.8%). Mortality was higher in patients with HIV/AIDS (76.6%, p-value=0.02). A multivariate analysis identified the following independent risk factors for death: oliguria, metabolic acidosis, sepsis, hypovolemia, the need for vasoactive drugs, the need for mechanical ventilation and the APACHE II score. Conclusions: AKI is a common complication in infectious diseases, with high mortality. Mortality was higher in patients with HIV/AIDS, most likely due to the severity of immunosuppression and opportunistic diseases.

The absence of the human platelet antigen polymorphism effect on fibrosis progression in human immunodeficiency virus-1/hepatitis C virus coinfected patients

AbstractINTRODUCTION:Hepatic fibrosis progression in patients with chronic hepatitis C virus infections has been associated with viral and host factors, including genetic polymorphisms. Human platelet antigen polymorphisms are associated with the rapid development of fibrosis in HCV-monoinfected patients. This study aimed to determine whether such an association exists in human immunodeficiency virus-1/hepatitis C virus-coinfected patients.METHODS:Genomic deoxyribonucleic acid from 36 human immunodeficiency virus-1/hepatitis C virus-coinfected patients was genotyped to determine the presence of human platelet antigens-1, -3, or -5 polymorphisms. Fibrosis progression was evaluated using the Metavir scoring system, and the patients were assigned to two groups, namely, G1 that comprised patients with F1, portal fibrosis without septa, or F2, few septa (n = 23) and G2 that comprised patients with F3, numerous septa, or F4, cirrhosis (n = 13). Fisher's exact test was utilized to determine possible associations between the human platelet antigen polymorphisms and fibrosis progression.RESULTS:There were no deviations from the Hardy-Weinberg equilibrium in the human platelet antigen systems evaluated. Statistically significant differences were not observed between G1 and G2 with respect to the distributions of the allelic and genotypic frequencies of the human platelet antigen systems.CONCLUSION:The greater stimulation of hepatic stellate cells by the human immunodeficiency virus and, consequently, the increased expression of transforming growth factor beta can offset the effect of human platelet antigen polymorphism on the progression of fibrosis in patients coinfected with the human immunodeficiency virus-1 and the hepatitis C virus.

A systematic study of the structural and magnetic properties of Mn-, Co-, and Ni-Doped Colloidal Fe3O4 nanoparticles

A series of colloidal MxFe3-xO4 (M = Mn, Co, Ni; x = 0–1) nanoparticles with diameters ranging from 6.8 to 11.6 nm was synthesized by hydrothermal reaction in aqueous medium at low temperature (200 °C). Energy-dispersive X-ray microa-nalysis and inductively coupled plasma spectrometry confirms that the actual elemental compositions agree well with the nominal ones. The structural properties of obtained nanoparticles were investigated by using powder X-ray diffraction, Raman scattering, Mössbauer spectroscopy, and electron microscopy. The results demonstrate that our synthesis technique leads to the formation of chemically uniform single-phase solid solution nanoparticles with cubic spinel structure, confirming the intrinsic doping. Magnetic studies showed that, in comparison to Fe3O4, the saturation magnetization of MxFe3-xO4 (M = Mn, Ni) decreases with increasing dopant concentration, while Co-doped samples showed similar saturation magnetizations. On other hand, whereas Mn- and Ni-doped nanoparticles exhibits superparamagnetic behavior at room temperature, ferromagnetism emerges for CoxFe3-xO4 nanoparticles, which can be tuned by the level of Co doping.

A genome-wide association study of resistance to HIV infection in highly exposed uninfected individuals with hemophilia A.

Human genetic variation contributes to differences in susceptibility to HIV-1 infection. To search for novel host resistance factors, we performed a genome-wide association study (GWAS) in hemophilia patients highly exposed to potentially contaminated factor VIII infusions. Individuals with hemophilia A and a documented history of factor VIII infusions before the introduction of viral inactivation procedures (1979-1984) were recruited from 36 hemophilia treatment centers (HTCs), and their genome-wide genetic variants were compared with those from matched HIV-infected individuals. Homozygous carriers of known CCR5 resistance mutations were excluded. Single nucleotide polymorphisms (SNPs) and inferred copy number variants (CNVs) were tested using logistic regression. In addition, we performed a pathway enrichment analysis, a heritability analysis, and a search for epistatic interactions with CCR5 Δ32 heterozygosity. A total of 560 HIV-uninfected cases were recruited: 36 (6.4%) were homozygous for CCR5 Δ32 or m303. After quality control and SNP imputation, we tested 1 081 435 SNPs and 3686 CNVs for association with HIV-1 serostatus in 431 cases and 765 HIV-infected controls. No SNP or CNV reached genome-wide significance. The additional analyses did not reveal any strong genetic effect. Highly exposed, yet uninfected hemophiliacs form an ideal study group to investigate host resistance factors. Using a genome-wide approach, we did not detect any significant associations between SNPs and HIV-1 susceptibility, indicating that common genetic variants of major effect are unlikely to explain the observed resistance phenotype in this population.

Referral patterns and outcomes in noncritically ill patients with hospital-acquired acute kidney injury.

Background and objectives Despite modern treatment, the case fatality rate of hospital-acquired acute kidney injury (HA-AKI) is still high. We retrospectively described the prevalence and the outcome of HA-AKI without nephrology referral (nrHA-AKI) and late referred HA-AKI patients to nephrologists (lrHA-AKI) compared with early referral patients (erHA-AKI) with respect to renal function recovery, renal replacement therapy (RRT) requirement, and in-hospital mortality of HA-AKI. Design, setting, participants, & measurements Noncritically ill patients admitted to the tertiary care academic center of Lausanne, Switzerland, between 2004 and 2008 in the medical and surgical services were included. Acute kidney injury was defined using the Acute Kidney Injury Network (AKIN) classification. Results During 5 years, 4296 patients (4.12% of admissions) experienced 4727 episodes of HA-AKI during their hospital stay. The mean ± SD age of the patients was 61 ± 15 years with a 55% male predominance. There were 958 patients with nrHA-AKI (22.3%) and 2504 patients with lrHA-AKI (58.3%). RRT was required in 31% of the patients with lrHA-AKI compared with 24% of the patients with erHA-AKI. In the multiple risk factor analysis, compared with erHA-AKI, nrHA-AKI and lrHA-AKI were significantly associated with worse renal outcome and higher in-hospital mortality. Conclusions These data suggest that HA-AKI is frequent and the patients with nrHA-AKI or lrHA-AKI are at increased risk for in-hospital morbidity and mortality.

Sisäilma- ja kosteusteknisten asantuntijapalvelujen käyttö rakennuttamisprosessissa

Tämä insinöörityö tehtiin HKR-Rakennuttajan Taloteknisen toimiston Kiinteistöjen elinkaaripalvelut- yksikölle. Työ on osa HKR-Rakennuttajan laatujärjestelmän uudistusta ja selkeytystä. Tavoitteena oli selvittää millaisiin asioihin tulisi kiinnittää huomiota kosteusteknisessä mielessä HKR-Rakennuttajan hankkeissa. Samoin Kiinteistöjen elinkaaripalvelut -yksikön asiantuntijapalveluiden käyttö rakennuttamisprosessissa ei ollut selvästi dokumentoituna HKR-Rakennuttajan laatujärjestelmään, joten tähän pyrittiin saamaan selkeytys. Lisäksi käynnissä on kuntotutkimustoiminnan uudistus, jossa kosteusteknisten asiantuntijapalvelujen konsulttitoiminnan käytössä tapahtuu muutoksia. Omalta osaltaan tämä insinöörityö pyrki selvittämään konsultin toimia hankkeen eri vaiheissa. Insinöörityössä kartoitettiin yksikön omat toimintakuvaukset kosteus- ja sisäilmateknisissä asioissa. Tämän jälkeen käydään läpi kaksi eri HKR-Rakennuttajan kohdetta, jossa oli kosteusteknisesti ongelmia. Kohteet valittiin ohjaajien toimesta, sillä näin saatiin esille työn kannalta oleellisia puutteita. Lisäksi kartoitettiin HKR-Rakennuttajan hankkeiden eri vaiheissa eri osapuolien tehtävät kosteus- ja sisäilmatekniseltä kannalta. Kartoitusten ja toimintakuvausten perusteella tehtiin ohje, joka liitettiin HKR-Rakennuttajan laatujärjestelmään. Lisäksi tehtiin urakkarajaliitteeseen velvoite, jossa määritellään kosteudenhallintasuunnitelman sisältö. Tietolähteinä tässä insinöörityössä oli alan kirjallisuus, HKR-Rakennuttajan Taloteknisen toimiston henkilökunnalta saatu suullinen informaatio ja internet.

Haasteena J. S. Bachin 2. luuttusarja BWV 997 : oppimisprosessi

Tämä opinnäytetyö käsittelee Johann Sebastian Bachin toista luuttusarjaa Bwv 997 kokonaisvaltaisena oppimisprosessina. Tässä opinnäytetyössä reflektoin omaa tulkintaani kyseisestä teoksesta ja kerron kuinka tulkinta on saatettu muotoonsa ja miten olen onnistunut siinä. Pohdinnan kohteena ovat mm. se, miten rakennetta voidaan lähestyä, sekä mitkä seikat ovat esimerkiksi vaikuttaneet tempojen valintoihin, koristeluun sekä fraseeraukseen. Olen koonnut tähän työhön tarpeelliseksi kokemiani lainauksia barokkimusiikkia käsittelevästä kirjallisuudesta kuten Johann Matthesonin Der vollkommene Capellmeister vuodelta 1739, sekä C.P.E. Bachin Versuch über die Wahre Arts das Clavier zu spielen vuosilta 1753/1762. Jälkimmäinen teos on kuitenkin tulkittavissa aikakauden ulkopuoliseksi teokseksi. Kyseisen teoksen käyttöä perustellaan tämän työn kuluessa. Toivon että tätä työtä voidaan myös pitää johdantona barokkimusiikin esittämiskäytäntöön, sekä käyttää apuvälineenä esimerkiksi opetuksessa edistyneillä oppilailla. Työn kieli ja ulkoasu sekä käsiteltävät asiat on yritetty esittää mahdollisimman selkeästi ja ymmärrettävästi, jotta myös sen pedagoginen käyttö esimerkiksi musiikkiopistotasolla olisi mahdollista. Valitessani opinnäytetyön aihetta päädyin tekemään tämän työn siitä syystä, että en ollut aikaisemmin juurikaan perehtynyt barokkimusiikkiin. Tämän opinnäytetyön tekeminen tarjosi sopivat puitteet "päästä kiinni" sekä barokkimusiikin soittamiseen että tiedon hakuun. Koska kyseinen teos on haastava, on työn määrä ollut suuri ja olen joutunut todella pohtimaan asioita. Työ on avannut silmiä uusille asioille ja opettanut paljon sekä soittamisesta että tiedon hakemisesta kyseisestä aiheesta sekä yleensä. Työni koostuu kahdesta osiosta, äänitteestä ja kirjallisesta työstä. Työn äänitysvaihe ja sen jälkityöstö tehtiin yhteistyössä Sibelius-Akatemian musiikkiteknologian opiskelijoiden kanssa.

Maahanmuuttajat työntekijöinä Palmian catering-palveluissa

Opinnäytetyössä selvitettiin Palmian catering-palveluissa työskentelevien maahanmuuttajien taustoja ja heidän vaikutuksiaan työpaikkojensa toimintaan. Tavoitteena oli saada tietoa maahanmuuttajien koulutuksen kehittämiseksi. Saadun tiedon toivottiin auttavan niin Palmiaa kuin muitakin yrityksiä henkilöstövalinnoissaan. Kyselytutkimus osoitettiin Palmian catering-palveluiden esimiehille sähköpostitse. Maahanmuuttajien vaikutukset työpaikoilla perustuivat heidän näkemyksiinsä. Palmiaa kysyttiin yhteistyöhön, koska se toimi pääosin Helsingissä, missä asuu lähes puolet maamme maahanmuuttajista. Palmia oli myös riittävän suuri yritys tarpeellisen vastausmäärän saamiseksi. Vastausten analysoinnissa merkittävimmiksi tekijöiksi muodostuivat kielitaito ja koulutus, joiden osuutta peilattiin työsuhteen pituuteen, maahanmuuttajan motivaatioon, työpaikan ilmapiiriin ym. työhön vaikuttaviin tekijöihin. Maahanmuuttajien vaikutukset työpaikoilla olivat suurimmaksi osaksi myönteisiä ja he olivat pidettyjä työntekijöitä. Tutkimuksen maahanmuuttajista lähes 80 prosenttia työskenteli ruokapalvelutyöntekijöinä. Suurimpana yksittäisenä ongelmana tuli esille heikko suomen kielen osaaminen. Maahanmuuttajat, joilla oli huono kielitaito ja joilla ei ollut aikaisempaa alan koulutusta tai työkokemusta, työllistyivät kuitenkin parhaiten pysyviin työsuhteisiin. Koulutettujen ja kielitaitoisten maahanmuuttajien huomattiin vaikuttavan kaikkein myönteisimmin työpaikoilla. Tutkimus osoitti, että yritysten kannattaisi palkata kielitaitoisia ja koulutettuja maahanmuuttajia ennakkoluulottomasti, sillä heidän vaikutuksensa työpaikoilla olivat hyvin myönteisiä. Maahanmuuttajien kielitaidon kehittämiseen ja koulutukseen olisi panostettava uudella tavalla. Tutkimuksen mukaan ruokapalvelutyöntekijöiksi voidaan palkata heikosti suomea osaavia ihmisiä vailla aikaisempaa alan kokemusta. Heille olisi hyödyllistä opiskella kieltä rinnakkain työn kanssa, koska silloin heidän kommunikointi- ja yhteistyötaidot sekä edellytykset kouluttautua paranisivat. Olisi ilmeistä, että maahanmuuttajan usko parempaan huomiseen vaikuttaisi myönteisesti työpaikoilla. Kielenopiskelun ja työnteon yhdistäminen kannustavalla tavalla vaatisi uusia koulutuksellisia päätöksiä asian mahdollistamiseksi. Tehtävä voitaisiin antaa tutkimuksen valmistumisen kanssa samaan aikaan järjestäytyvän Suomen hallituksen uudelle opetusministerille työryhmineen.

Tohtori Seppo Laakso 15/4 1975

Kirje 15.4.1975