Leg Amputation for an Extensive, Severe and Intractable Sickle Cell Anemia Ulcer in a Brazilian Patient

A 35-year-old African Brazilian patient had sickle cell anemia complicated with recurrent vasoocclusive (VOC) crises and refractory painful leg ulcers for 16 years. The ulcers started over both medial malleoli and expanded gradually. The ulcer on the left leg spread from the foot to the knee circumferentially and was refractory to all forms of therapy within the frame work of multi-disciplinary care. The patient agreed to a below the knee amputation of the left leg. He felt much better after the amputation but developed severe neuropathic phantom pain that was well controlled medically. He could differentiate the sickle cell anemia and ulcer pain from the neuropathic pain. About 6 months after the amputation he had dengue fever with fatal outcome. This is the first report of treatment of refractory sickle cell anemia leg ulcer with amputation and probably the first report of a Brazilian patient with sickle cell anemia and dengue fever.

Crises cambiais e fragilidade financeira externa: uma interpretação minskyana aplicada à economia brasileira entre 1999 e 2013

Pós-graduação em Economia - FCLAR

Crises de fronteira e estruturas complexas no espaço de parâmetros em um mapeamento dissipativo bidimensional

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Phenotypic expression of homozygous hemoglobin S in relation to β-globin haplotypes, glutathione S-transferase polymorphisms and detoxification enzymes

Sickle cell anemia (SCA) shows a pathophysiology that involves multiple changes in sickle cell erythrocytes, vaso-occlusive episodes, hemolysis, activation of inflammatory mediators, endothelial cell dysfunction, and oxidative stress. These events complicate treatment and culminate in the development of manifestations such as anemia, pain crises and multiorgan dysfunction. The aim of this study was to evaluate, in SCA patients, oxidative stress and antioxidant capacity markers, correlating them to treatment with hydroxyurea (HU), β-globin haplotypes and glutathione S-transferase polymorphisms (GSTT1, GSTM1 and GSTP1), in comparison to a control group (CG). The study groups were composed of 48 individuals without hemoglobinopathies (CG), SCA patients treated with HU [AF (+HU), N = 13] and untreated SCA patients [AF (-HU), N = 15], after informed consent. The groups were analyzed using cytological, electrophoretic, chromatographic and molecular methods and information from medical records. The GSTM1 and GSTT1 polymorphisms were determined by multiplex PCR, while the GSTP1 polymorphism by PCR-RFLP. Biochemical parameters were measured using spectrophotometric methods [TBARS, TEAC and catalase (CAT) and GST activities] and a chromatographic method [glutathione (GSH)]. The fetal Hb (Hb F) levels observed in the SCA (+HU) group (10.9%) confirmed the already well-described pharmacological effect of HU, but the SCA (-HU) group also had high Hb F levels (6.1%), which may have been influenced by genetic factors not targeted in this study. We found a higher frequency of the Bantu haplotype (48.2%), followed by the Benin (32.1%) and also Cameroon haplotypes, rare in our population, and 19.7% of atypical haplotypes. The presence of Bantu haplotype was related to higher lipid peroxidation levels in patients, but also, it conferred a differential response to HU treatment, raising Hb F levels in 52.6% (P = 0.03). The protective effect of Hb F was confirmed, because the increase in their levels resulted in a 41.3% decrease in lipid peroxidation levels (r = -0.74, P = 0.0156). The genotypic frequency of the GST polymorphisms observed was similar to that of other studies in the Brazilian population, and its association with biochemical markers revealed a significant difference only for the GSTP1 polymorphism, where patients with genotype V/V showed higher GSH and TEAC levels (P = 0.04 and P = 0.03, respectively) compared to patients with genotype I/I. The TBARS levels were about five to eight times higher in the SCA (+HU) and SCA (-HU) groups, respectively, compared to controls, and HU produced a 35.2% decrease in lipid peroxidation levels in the SCA (+HU) group (P < 0.0001). Moreover, the SCA (+HU) group showed higher TEAC levels when compared to CG (P = 0.002). We did not find any significant difference in GST activity between the groups studied (P = 0.76), but CAT activity was about 17 and 30% lower in SCA (+HU) and SCA (-HU) groups, respectively (P < 0.00001). Plasma GSH levels were ~2 times higher in SCA patients than in the control group (P = 0.0005) and showed a positive correlation with TBARS levels, confirming its antioxidant function. HU treatment contributed to higher CAT activity and TEAC levels and lower lipid peroxidation, and its pharmacological effect showed a “haplotype-dependent” response. These findings may contribute to elucidating the potential of HU in ameliorating oxidative stress in SCA subjects.

The mean corpuscular volume and hydroxyurea in brazilian patients with sickle cell anemia: a surrogate marker of compliance

The suppression of erythropoiesis by Hydroxyurea (HU) therapy is associated with increase in mean corpuscular volume, in addition to the increase in Hb F. Monitoring the mean corpuscular volume values and the presence of macrocytosis are effective tools of adherence to the treatment with HU in patients with sickle cell anemia. The aim of this study is to monitor the mean corpuscular volume values after starting treatment with HU to determine if macrocytosis can be used as a surrogate marker of compliance with therapy. We conducted a prospective cohort study over one year with measurements of blood counts and mean corpuscular volume after starting therapy with HU in 95 patients with sickle cell anemia who were regularly followed in our ambulatory outpatient unit. In one-year of successful use of HU the mean value of the mean corpuscular volume increased significantly. The Andersen and Gill model demonstrated that the increase of one unit of MCV implies a 5% reduction in the risk of visiting the emergency room. Monitoring mean corpuscular volume values after prescribing HU alerts the provider of noncompliance in order to counsel the patient in question for better adherence to the use of HU that could improve the quality of care and to reduce morbidity and the frequency of acute pain crises and associated healthcare costs.

Hydroxyurea in the sickle cell anemia: toxicity and effectiveness

Objective: to evaluate the use of hydroxyurea with regard to effectiveness and toxicity in people with sickle cell anemia. Method: this is a retrospective descriptive study, developed with 57 medical records of patients with sickle cell anemia, treated at the University Hospital Center of Campo Grande (Mato Grosso do Sul, Brazil), from 1993 to 2005. Inclusion criteria: electrophoresis of hemoglobin in medical record; regular use of drugs, for an average of 196 weeks; dosage; and hematological analyses before starting treatment. Exclusion criteria: living with other hemoglobinopathies. The variables evaluated were: neutrophils count; platelets; leukocytes; hemoglobin; time using hydroxyurea; drug response to the optimal dosage; and number and type of episodes of hospitalization. The research protocol was approved by the Ethics Committee of Universidade Federal de Mato Grosso do Sul, under the Protocol 645. Results: of the 57 medical records, 3 cases were evaluated. Comparing the hematological values, according to Portaria 872, enacted on 11/12/2002, it was found that: cases A, B, and C present an use of hydroxyurea (500 mg/day) for four years, with an average of 196 weeks. Case A, female, decreased painful episodes and frequency of hospitalization, keeping hematological values with no toxicity. In Case B, female, there was one hospitalization due to pain crises and important hemolysis. It stood out, in case C, male, neutropenia with hematological values < 2,000/mm3 . Conclusion: in the cases analyzed, we observed a drop in the number of hospitalizations with the decrease in painful crises from three to one a year, and there was no toxicity with regard to the dosage and time using hydroxyurea, in all three cases. For more comprehensive results, one suggests further study on this therapy with significant samples of this clientele.

The current financial and economic crisis: empirical and methodological issues

In this paper we describe the main causes of the recent financial crisis as a result of many theoretical, methodological, and practical shortcomings mostly according to heterodox, but also including some important orthodox economists. At theoretical level, there are problems concerning teaching and using economic models with overly unrealistic assumptions. In the methodological front, we find the unsuspected shadow of Milton Friedman’s ‘unrealisticism of assumptions’ thesis lurking behind the construction of this kind of models and the widespread neglect of methodological issues. Of course, the most evident shortcomings are at the practical level: (i) huge interests of the participants in the financial markets (banks, central bankers, regulators, rating agencies mortgage brokers, politicians, governments, executives, economists, etc. mainly in the US, Canada and Europe, but also in Japan and the rest of the world), (ii) in an almost completely free financial and economic market, that is, one (almost) without any regulation or supervision, (iii) decision-taking upon some not well regarded qualities, like irresponsibility, ignorance, and inertia; and (iv) difficulties to understand the current crisis as well as some biases directing economic rescues by governments. Following many others, we propose that we take this episode as an opportunity to reflect on, and hopefully redirect, economic theory and practice.

Sobre a idade das crises: as inter-relações sujeito-identidade-feminismo na pós-modernidade

This essay intends to think critically and theoretically on the interrelations among subject, identity, and Feminism in the context of Postmodernity, a context which will be herein denominated ―Age of Crises. These three aspects will be approached under a Historical perspective and put into question in a philosophical sight guided by Post-structuralistic theories, especially Derridian Deconstruction. In general, the main objective is to reach into a discussion about the undecidable inter-relation between Feminist thinking and Postmodernity, which is one of the configurations of the many contemporary crises. In order to do so, it will be necessary a previous discussion on the postmodern subject and its identity. This discussion will open up the possibility of contextualizing and discussing Feminism inside the intended objective. This discussion will be structured around the word ―crises which, in a compositional relation to the word ―age, will be taken as a synonym for ―Postmodernity and ―contemporary. ―Age of Crises, ―Postmodernity, ―contemporary, and ―Feminism will be words haunted by the phármakon phenomenon, a key aspect for Derridian Deconstruction, which will be the gravitational force that approximates and separates, in an undecidable relation, those signs.

CARBON MARKET AND INSTITUTIONS: OPPORTUNITIES IN THE SEARCH OF A NEW MODEL FOR DEVELOPMENT

Seeking alternatives for the economic system to face the several crises it has gone through lately (electrical power, cultural, financing and technological) brought about a new market involving the Kyoto Protocol signatory countries: the carbon market. The present article aims at assessing the carbon market institutional issue in Brazil by identifying the risks and opportunities inherent to the institutional agent characteristics and to that market rules. The research methodology was bibliographic and based on the analysis of the Securities and Exchange Commission of Brazil (Comissao de Valores Mobiliarios and Bolsa Mercantil de Valores) contents. Its theoretical basis rests on concepts of the institution and the new institutional economy. The results show that in spite of the risks and institutional problems it involves, the carbon market is promising due to the opportunities create by new technologies and energies developed to achieve and sustain the capitalist system new cycle, addressed to produce a clean development.

On The Timing of Default Losses: When and Why?

At the light of what happened in 2010 and 2011, a lot of European countries founded themselves in a difficult position where all the credit rating agencies were downgrading debt states. Problem of solvency and guarantees on the states' bond were perceived as too risky for a Monetary Union as Europe is. Fear of a contagion from Greece as well was threatening the other countries as Italy, Spain, Portugal and Ireland; while Germany and France asked for a division between risky and riskless bond in order to feel more safe. Our paper gets inspiration by Roch and Uhlig (2011), it refers to the Argentinian case examined by Arellano (2008) and examine possible interventions as monetization or bailout as proposed by Cole and Kehoe (2000). We propose a model in which a state defaults and cannot repay a fraction of the old bond; but contrary to Roch and Uhlig that where considering a one-time cost of default we consider default as an accumulation of losses, perceived as unpaid fractions of the old debts. Our contributions to literature is that default immediately imply that economy faces a bad period and, accumulating losses, government will be worse-off. We studied a function for this accumulation of debt period by period, in order to get an idea of the magnitude of this waste of resources that economy will face when experiences a default. Our thesis is that bailouts just postpone the day of reckoning (Roch, Uhlig); so it's better to default before accumulate a lot of debts. What Europe need now is the introduction of new reforms in a controlled default where the Eurozone will be saved in its whole integrity and a state could fail with the future promise of a resurrection. As experience show us, governments are not interested into reducing debts since there are ECB interventions. That clearly create a distortion between countries in the same monetary union, giving to the states just an illusion about their future debtor position.

Gold and the Stock Market: 3 Essays on Gold Investments

This thesis gives an overview of the history of gold per se, of gold as an investment good and offers some institutional details about gold and other precious metal markets. The goal of this study is to investigate the role of gold as a store of value and hedge against negative market movements in turbulent times. I investigate gold’s ability to act as a safe haven during periods of financial stress by employing instrumental variable techniques that allow for time varying conditional covariance. I find broad evidence supporting the view that gold acts as an anchor of stability during market downturns. During periods of high uncertainty and low stock market returns, gold tends to have higher than average excess returns. The effectiveness of gold as a safe haven is enhanced during periods of extreme crises: the largest peaks are observed during the global financial crises of 2007-2009 and, in particular, during the Lehman default (October 2008). A further goal of this thesis is to investigate whether gold provides protection from tail risk. I address the issue of asymmetric precious metal behavior conditioned to stock market performance and provide empirical evidence about the contribution of gold to a portfolio’s systematic skewness and kurtosis. I find that gold has positive coskewness with the market portfolio when the market is skewed to the left. Moreover, gold shows low cokurtosis with the market returns during volatile periods. I therefore show that gold is a desirable investment good to risk averse investors, since it tends to decrease the probability of experiencing extreme bad outcomes, and the magnitude of losses in case such events occur. Gold thus bears very important and under-researched characteristics as an asset class per se, which this thesis contributed to address and unveil.

Risk factors promoting hypertensive crises: evidence from a longitudinal study

Background Current knowledge about risk factors promoting hypertensive crisis originates from retrospective data. Therefore, potential risk factors of hypertensive crisis were assessed in a prospective longitudinal study. Methods Eighty-nine patients of the medical outpatient unit at the University Hospital of Bern (Bern, Switzerland) with previously diagnosed hypertension participated in this study. At baseline, 33 potential risk factors were assessed. All patients were followed-up for the outcome of hypertensive crisis. Cox regression models were used to detect relationships between risk factors and hypertensive crisis (defined as acute rise of systolic blood pressure (BP) ≥200mmHg and/or diastolic BP ≥120mmHg). Results The mean duration of follow-up was 1.6 ± 0.3 years (range 1.0–2.4 years). Four patients (4.5%) were lost to follow-up. Thirteen patients (15.3%) experienced hypertensive crisis during follow-up. Several potential risk factors were significantly associated with hypertensive crisis: female sex, higher grades of obesity, the presence of a hypertensive or coronary heart disease, the presence of a somatoform disorder, a higher number of antihypertensive drugs, and nonadherence to medication. As measured by the hazard ratio, nonadherence was the most important factor associated with hypertensive crisis (hazard ratio 5.88, 95% confidence interval 1.59–21.77, P < 0.01). Conclusions This study identified several potential risk factors of hypertensive crisis. Results of this study are consistent with the hypothesis that improvement of medical adherence in antihypertensive therapy would help to prevent hypertensive crises. However, larger studies are needed to assess potential confounding, other risk factors and the possibility of interaction between predictors.

Full Cups, Full Coffers: Tax Strategies and Consumer Culture in the Early Modern German Cities

During the sixteenth and seventeenth centuries, the excise taxes (Ungeld) paid by town residents on the consumption of beer, wine, mead and brandy represented the single most important source of civic revenue for many German cities. In a crisis, these taxes could spike to 70-80% of civic income. This paper examines civic budgets and 'behind-the-scenes' deliberations in a sample of towns in southern Germany in order to illuminate how decisions affecting consumer taxes were made. Even during the sobriety movements of the Reformation and post-Reformation period, tax income from drinkers remained attractive to city leaders because the bulk of the excise tax burden could easily be shifted away from privileged members of society and placed on the population at large. At the same time, governments had to maintain a careful balance between what they needed in order to govern and what the consumer market could bear, for high taxes on drinks were also targeted in many popular revolts. This led to nimble politicking by those responsible for tax decisions. Drink taxes were introduced, raised, lowered and otherwise manipulated based not only on shifting fashions and tastes but also on the degree of economic stress faced by the community. Where civic rulers were successful in striking the right balance, the rewards were considerable. The income from drink sales was a major factor in how the cities of the Empire survived the wars and other crises of the early modern period without going into so much debt that they lost their independence.