Recombinant C1 inhibitor in the prevention of severe COVID-19: a randomized, open-label, multi-center phase IIa trial

Background

Conestat alfa (ConA), a recombinant human C1 inhibitor, may prevent thromboinflammation.

Methods

We conducted a randomized, open-label, multi-national clinical trial in which hospitalized adults at risk for progression to severe COVID-19 were assigned in a 2:1 ratio to receive either 3 days of ConA plus standard of care (SOC) or SOC alone. Primary and secondary endpoints were day 7 disease severity on the WHO Ordinal Scale, time to clinical improvement within 14 days, and safety, respectively.

Results

The trial was prematurely terminated because of futility after randomization of 84 patients, 56 in the ConA and 28 in the control arm. At baseline, higher WHO Ordinal Scale scores were more frequently observed in the ConA than in the control arm. On day 7, no relevant differences in the primary outcome were noted between the two arms (p = 0.11). The median time to defervescence was 3 days, and the median time to clinical improvement was 7 days in both arms (p = 0.22 and 0.56, respectively). Activation of plasma cascades and endothelial cells over time was similar in both groups. The incidence of adverse events (AEs) was higher in the intervention arm (any AE, 30% with ConA vs. 19% with SOC alone; serious AE, 27% vs. 15%; death, 11% vs. 0%). None of these were judged as being related to the study drug.

Conclusion

The study results do not support the use of ConA to prevent COVID-19 progression.

Clinical trial registration

https://clinicaltrials.gov, identifier NCT04414631.

A systematic review of artificial intelligence algorithms for predicting acute kidney injury

OBJECTIVE

Acute kidney injury (AKI) increases mortality and costs in hospitalized patients. New methods for early AKI identification have been developed with targeted biomarkers and electronic health records data analysis. Machine learning (ML) use in diagnostics and health data analysis has recently increased. We performed a systematic review to analyze the use of ML for AKI prediction in hospitalized adults.

MATERIALS AND METHODS

Tubmed, EMBASE, Cochrane, and Web of Science databases were searched until 31st March of 2023. English-language studies using ML in adults for AKI prediction were included using predetermined eligibility search terms such as acute kidney injury, machine learning, and artificial intelligence. Two reviewers evaluated the publications' titles, abstracts, and full texts separately and obtained appropriate data. The main outcome was an area under the curve (AUC) result of at least 0.70.

RESULTS

Ten studies in 102 articles were included involving 242,251 patients. Deep learning (AUC 0.907 in critical care AKI; AUC 0.797 in hospitalized patients AKI) was similar to Logistic regression (AUC 0.877 in critical care AKI; AUC 0.789 in hospitalized patients). Decision tree constructions had similar AUC.

CONCLUSIONS

In this review, most ML models analyzed fulfilled the main outcome. AKI is multifactorial; however, ML performed well with different etiologies, such as cardiac-related AKI, drug-related AKI, and critical care patients. Overfitting data and constructing black box models are limitations that might jeopardize the generalization and comprehension of the results. Most studies were single-center, and three manuscripts used the same database with a predominantly Caucasian population, resulting in a lack of diversity and reducing external generalization. In conclusion, ML could effectively predict AKI in hospitalized adults. Future directions rely on including a more diverse population and completing prospective and controlled trials.

Ribavirin aerosol in hospitalized adults with respiratory distress and COVID-19: An open-label trial

There is an unmet medical need for effective treatments for hospitalized patients with coronavirus disease 2019 (COVID-19). Ribavirin is a broad-spectrum antiviral with demonstrated in vitro activity against multiple viruses, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This trial evaluated the potential of ribavirin inhalation solution (ribavirin aerosol) to reduce COVID-19 disease severity in adults with confirmed SARS-CoV-2 infection and a diagnosis of respiratory distress. This phase I, multicenter, open-label, nonrandomized trial was conducted from February 2021 through August 2021. Patients received ribavirin aerosol (100 mg/ml for 30 min or 50 mg/ml for 60 min) twice daily for up to 6 days. The primary end point was change from baseline in clinical status severity, rated on a 7-point scale (1 [death]; 7 [not hospitalized; no limitations on activities]), at day 7 (or end-of-treatment/early termination) and day 30 (follow-up). Fifty-one patients were treated with ribavirin aerosol (mean age, 51.5 years; 78.4% men); mean number of doses was 9.7 (range, 1-12). Improvement of ≥1 level in clinical status severity was observed in 31.4% (16/51) and 78.4% (40/51) of patients at end-of-treatment and day 30, respectively. Of 21 patients who required a ventilator, 16 (76.2%) were able to discontinue ventilator use. Five patients (9.8%) died between end-of-treatment and day 30. Three patients (5.9%) discontinued study treatment due to adverse events. No deaths were considered related to study treatment. These data provide preliminary evidence that ribavirin aerosol may be an efficacious treatment for respiratory distress in adults with COVID-19.

Safety and Efficacy of Vadadustat for Anemia in Patients Undergoing Dialysis

BACKGROUND

Vadadustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor, a class of compounds that stimulate endogenous erythropoietin production.

METHODS

We conducted two randomized, open-label, noninferiority phase 3 trials to evaluate the safety and efficacy of vadadustat, as compared with darbepoetin alfa, in patients with anemia and incident or prevalent dialysis-dependent chronic kidney disease (DD-CKD). The primary safety end point, assessed in a time-to-event analysis, was the first occurrence of a major adverse cardiovascular event (MACE, a composite of death from any cause, a nonfatal myocardial infarction, or a nonfatal stroke), pooled across the trials (noninferiority margin, 1.25). A key secondary safety end point was the first occurrence of a MACE plus hospitalization for either heart failure or a thromboembolic event. The primary and key secondary efficacy end points were the mean change in hemoglobin from baseline to weeks 24 to 36 and from baseline to weeks 40 to 52, respectively, in each trial (noninferiority margin, -0.75 g per deciliter).

RESULTS

A total of 3923 patients were randomly assigned in a 1:1 ratio to receive vadadustat or darbepoetin alfa: 369 in the incident DD-CKD trial and 3554 in the prevalent DD-CKD trial. In the pooled analysis, a first MACE occurred in 355 patients (18.2%) in the vadadustat group and in 377 patients (19.3%) in the darbepoetin alfa group (hazard ratio, 0.96; 95% confidence interval [CI], 0.83 to 1.11). The mean differences between the groups in the change in hemoglobin concentration were -0.31 g per deciliter (95% CI, -0.53 to -0.10) at weeks 24 to 36 and -0.07 g per deciliter (95% CI, -0.34 to 0.19) at weeks 40 to 52 in the incident DD-CKD trial and -0.17 g per deciliter (95% CI, -0.23 to -0.10) and -0.18 g per deciliter (95% CI, -0.25 to -0.12), respectively, in the prevalent DD-CKD trial. The incidence of serious adverse events in the vadadustat group was 49.7% in the incident DD-CKD trial and 55.0% in the prevalent DD-CKD trial, and the incidences in the darbepoetin alfa group were 56.5% and 58.3%, respectively.

CONCLUSIONS

Among patients with anemia and CKD who were undergoing dialysis, vadadustat was noninferior to darbepoetin alfa with respect to cardiovascular safety and correction and maintenance of hemoglobin concentrations. (Funded by Akebia Therapeutics and Otsuka Pharmaceutical; INNO₂VATE ClinicalTrials.gov numbers, NCT02865850 and NCT02892149.).

Recombinant human C1 esterase inhibitor (conestat alfa) in the prevention of severe SARS-CoV-2 infection in hospitalized patients with COVID-19: A structured summary of a study protocol for a randomized, parallel-group, open-label, multi-center pilot trial (PROTECT-COVID-19)

Objectives

Conestat alfa, a recombinant human C1 esterase inhibitor, is a multi-target inhibitor of inflammatory cascades including the complement, the kinin-kallikrein and the contact activation system. The study objective is to investigate the efficacy and safety of conestat alfa in improving disease severity and short-term outcome in COVID-19 patients with pulmonary disease.

Trial design

This study is an investigator-initiated, randomized (2:1 ratio), open-label, parallel-group, controlled, multi-center, phase 2a clinical trial.

Participants

This trial is conducted in 3 hospitals in Switzerland, 1 hospital in Brazil and 1 hospital in Mexico (academic and non-academic). All patients with confirmed SARS-CoV-2 infection requiring hospitalization for at least 3 calendar days for severe COVID-19 will be screened for study eligibility.

Inclusion criteria:

- Signed informed consent

- Age 18-85 years

- Evidence of pulmonary involvement on CT scan or X-ray of the chest

- Duration of symptoms associated with COVID-19 ≤ 10 days

- At least one of the following risk factors for progression to mechanical ventilation on the day of enrolment:

1) Arterial hypertension

2) ≥ 50 years

3) Obesity (BMI ≥ 30 kg/m2)

4) History of cardiovascular disease

5) Chronic pulmonary disease

6) Chronic renal disease

7) C-reactive protein > 35mg/L

8) Oxygen saturation at rest of ≤ 94% when breathing ambient air

Exclusion criteria:

- Incapacity or inability to provide informed consent

- Contraindications to the class of drugs under investigation (C1 esterase inhibitor)

- Treatment with tocilizumab or another IL-6R or IL-6 inhibitor before enrolment

- History or suspicion of allergy to rabbits

- Pregnancy or breast feeding

- Active or anticipated treatment with any other complement inhibitor

- Liver cirrhosis (any Child-Pugh score)

- Admission to an ICU on the day or anticipated within the next 24 hours of enrolment

- Invasive or non-invasive ventilation

- Participation in another study with any investigational drug within the 30 days prior to enrolment

- Enrolment of the study investigators, their family members, employees and other closely related or dependent persons

Intervention and comparator

Patients randomized to the experimental arm will receive conestat alfa in addition to standard of care (SOC). Conestat alfa (8400 U followed by 4200 U every 8 hours) will be administered as a slow intravenous injection (5-10 minutes) over a 72-hour period (i.e. 9 administrations in total). The first conestat alfa treatment will be administered on the day of enrolment. The control group will receive SOC only. SOC treatment will be administered according to local institutional guidelines, including supplemental oxygen, antibiotics, corticosteroids, remdesivir, and anticoagulation.

Main outcomes

The primary endpoint of this trial is disease severity on day 7 after enrolment assessed by an adapted WHO Ordinal Scale for Clinical Improvement (score 0 will be omitted and score 6 and 7 will be combined) from 1 (no limitation of activities) to 7 (death).

Secondary outcomes include (i) the time to clinical improvement (time from randomization to an improvement of two points on the WHO ordinal scale or discharge from hospital) within 14 days after enrolment, (ii) the proportion of participants alive and not having required invasive or non-invasive ventilation at 14 days after enrolment and (iii) the proportion of subjects without an acute lung injury (defined by PaO₂/FiO₂ ratio of ≤300mmHg) within 14 days after enrolment.

Exploratory outcomes include virological clearance, C1 esterase inhibitor pharmacokinetics and changes in routine laboratory parameters and inflammatory proteins.

Randomisation

Subjects will be randomised in a 2:1 ratio to treatment with conestat alfa in addition to SOC or SOC only. Randomization is performed via an interactive web response system (SecuTrial®).

Blinding (masking)

In this open-label trial, participants, caregivers and outcome assessors are not blinded to group assignment.

Numbers to be randomised (sample size)

We will randomise approximately 120 individuals (80 in the active treatment arm, 40 in the SOC group). Two interim analyses after 40 and 80 patients are planned according to the Pocock adjusted levels α_p = 0.0221. The results of the interim analysis will allow adjustment of the sample size (Lehmacher, Wassmer, 1999).

Trial Status

PROTECT-COVID-19 protocol version 3.0 (July 07 2020). Participant recruitment started on July 30 2020 in one center (Basel, Switzerland, first participant included on August 06 2020). In four of five study centers patients are actively recruited. Participation of the fifth study center (Mexico) is anticipated by mid December 2020. Completion of trial recruitment depends on the development of the SARS-CoV-2 pandemic.

Trial registration

Clinicaltrials.gov, number: NCT04414631, registered on 4 June 2020

Full protocol

The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest of expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-020-04976-x.

The Impact of Inflammatory Profile on Selenium Levels in Hemodialysis Patients

Introduction: Hemodialysis stands out as an eligible treatment for patients with chronic kidney disease. The subsequent inflammatory process resulting from this disease and hemodialysis per se is exacerbated in this therapy. Selenium (Se) is an essential trace element that can participate in the inhibition of pro-oxidant and pro-inflammatory processes and could be considered a measurement that indicates the progression of chronic kidney disease and inflammation.

Objectives: The present study investigated selenemia in hemodialysis patients of the ABC region of São Paulo and aimed to establish the correlation between an inflammatory marker and selenemia in this conditions disease.

Methods: This is an observational cross-sectional study of the Faculdade de Medicina do ABC in patients submitted to hemodialysis three times a week for at least six months. The eligible group composed of 21 patients, who filled out forms and underwent biochemical tests (colorimetric enzyme methods, flow cytometer, turbidimetric method and mass spectrometry).

Results: The study population showed, women (70%), men (30%) with a mean age of 47 ± 17 years, Caucasians (36%) and non-Caucasian (64%), hypertensive (68%), smokers (53%) and non-smokers (64%). There was a hegemonic prevalence of systolic arterial hypertension (SAH) 68.1% in relation to diabetes mellitus (DM) (50%). Pre and post hemodialysis (HD) selenemia showed statistical significance, which did not occur with C-reactive protein. There was a predominance of females in our sample; the pre- and post-HD selenemia were within the normal range of the reference values; there was a statistically significant correlation between pre and post-HD selenemia; there was no correlation with statistical significance between values of pre and post-HD C-reactive protein.

Conclusion: Our data showed that there was no direct relationship between pre- and post-HD inflammation and pre- and post-HD selenemia.

Uremic neuropathy: an overview of the current literature

INTRODUCTION

Peripheral neuropathy is a disorder that affects the cell body, axon or myelin of motor or peripheral sensory neurons and occurs in 60-100% of patients who are submitted to dialysis due to chronic kidney disease. Uremic neuropathy (UN) is attributed to the accumulation of organic waste, evident in patients with reduced glomerular filtration rate.

OBJECTIVES

This review aims to make clinical characteristics of uremic neuropathy evident enabling early diagnosis and treatment.

METHODS

This is a literature review of articles published on PubMed over the last 10 years using "Uremic Neuropathy" as "Title/Abstract".

RESULTS

A total of nine articles that met the inclusion criteria were included. UN is a distal symmetric sensorimotor polyneuropathy that occurs due to the accumulation of uremic toxins associated with an oxidative stress-related free radical activity. Hyperkalemia is thought to play an important role in its pathophysiology. Diagnosis depends on nerve conduction studies, and treatment includes dialysis or renal transplant.

CONCLUSION

Clinical presentations of UN are broad and non-specific; nonetheless, it is important to detect early changes in order to avoid its progression. The earlier UN is diagnosed and treated, the more successful are the clinical outcomes.

Uremic neuropathy: an overview of the current literature

INTRODUCTION

Peripheral neuropathy is a disorder that affects the cell body, axon or myelin of motor or peripheral sensory neurons and occurs in 60-100% of patients who are submitted to dialysis due to chronic kidney disease. Uremic neuropathy is attributed to the accumulation of organic waste, evident in patients with reduced glomerular filtration rate.

OBJECTIVES

This review aims to make clinical characteristics of uremic neuropathy evident enabling early diagnosis and treatment.

METHODS

This is a literature review of articles published on PubMed over the last 10 years using "Uremic Neuropathy" as "Title/Abstract".

RESULTS

A total of nine articles that met the inclusion criteria were included. UN is a distal symmetric sensorimotor polyneuropathy that occurs due to the accumulation of uremic toxins associated with an oxidative stress-related free radical activity. Hyperkalemia is thought to play an important role in its pathophysiology. Diagnosis depends on nerve conduction studies, and treatment includes dialysis or renal transplant.

CONCLUSION

Clinical presentations of UN are broad and non-specific; nonetheless, it is important to detect early changes in order to avoid its progression. The earlier UN is diagnosed and treated, the more successful are the clinical outcomes.

Remote ischemic preconditioning in myocardial protection in hemodialysis patients

Background

Remote ischemic preconditioning (RIPC) is a procedure that generates a brief period of ischemia followed by reperfusion. The role of RIPC in protecting myocardial ischemia during hemodialysis is not yet established. The aim of the study was to evaluate RIPC myocardial protection as evaluated by ultrasensitive I troponin in hemodialysis outpatients.

Patients and methods

A double-blind randomized trial with two groups: intervention submitted to RIPC and control group without RIPC. Intervention group received RIPC in three consecutive hemodialysis sessions. Blood samples were taken before and after each session. Blood urea nitrogen for calculation of single-pool Kt/v and ultrasensitive I troponin were measured to evaluate dialysis adequacy and myocardial injury.

Results

A total of 47 patients were randomized. About 60.8% were men and 54% were diabetic. The mean single-pool Kt/v was 1.51 in the intervention group and 1.49 in control. The ultrasensitive troponin I measured no significant change from the time of collection: before or after dialysis.

Conclusion

The RIPC applied in three consecutive sessions did not demonstrate superiority to control, therefore another study tested RIPC in 12 consecutive sessions with a positive result in myocardial protection. In our study, more than half of the patients were diabetic. Diabetic patients have a trend to show a lower response to RIPC because of the greater presence of collateral coronary circulation. In summary, in this model there was no interference of RIPC in ultrasensitive troponin I values, but troponin had a high negative predictive value for myocardial infarction in all tested models.

Quality of life on hemodialysis and inflammation: a descriptive analysis

Chronic kidney disease (CKD) is highly prevalent worldwide. Patients with CKD on hemodialysis are more likely to present behavioral changes and worse quality of life as a result of their routine and complications. They also have higher levels of cytokines. The aim of this study is to assess the relationship between the inflammatory profile and quality of life measured by KDOQL-SF36 in hemodialysis outpatients. Patients older than 21 years of age and on routine hemodialysis for at least 6 months with treatment on a regular weekly basis were included and their anthropometric parameters and serum inflammatory markers were evaluated. Thirty patients consented to participate. Homocysteine (Hcy) levels were correlated with worse glomerular filtration rate (GFR; P=0.003) and creatinine (P=0.002). IL-6 was not correlated with worse nutritional status taking into account body mass index (BMI; kg/m²; P=0.83). On the other hand, TNF-alpha was positively correlated with albumin (P=0.008), nutritional status by BMI (P=0.04), and nutritional status by arm circumference area (P=0.04). IL-6 was correlated with activity limitation (P=0.02) and Hcy with work status (P=0.04). Hcy was correlated with nutritional status and inflammatory markers. In this population, the majority of the sections in KDOQL-SF36 were not correlated with cytokines levels.

Serum NGAL and Cystatin C Comparison With Urinary Albumin-to-Creatinine Ratio and Inflammatory Biomarkers as Early Predictors of Renal Dysfunction in Patients With Type 2 Diabetes

Introduction

Diabetic nephropathy is associated with specific histological changes. Early detection of poor glomerular and tubular function can be achieved with biomarkers of diabetes. The aim of this study was to evaluate the accuracy of kidney dysfunction biomarkers in type 2 diabetes (T2D).

Methods

Patients with T2D were grouped according to their glycated hemoglobin level. Patients' urine and blood samples were taken to measure cystatin C (CysC), neutrophil gelatinase-associated lipocalin, beta-trace protein levels, and the first morning void albumin-to-creatinine ratio. Patients in the end stage of renal disease or receiving dialysis were not included. Receiver operating characteristic curves were generated, and the areas under the curve were compared with the performance of the biomarkers used to evaluate kidney dysfunction in T2D.

Results

Ninety patients with T2D were chosen. CysC was positively correlated with creatinine (P < 0.001), estimated glomerular filtration rate (P < 0.001), and urinary beta-trace protein (P = 0.01). The area under the curve was 0.635 for CysC, 0.621 for serum neutrophil gelatinase-associated lipocalin, and 0.660 for the albumin-to-creatinine ratio. A crude logistic regression model showed a positive association between serum CysC (P = 0.01) and serum neutrophil gelatinase-associated lipocalin (P < 0.001). A linear regression model showed a positive association between serum CysC, creatinine, and estimated glomerular filtration rate (P < 0.001) but did not show a positive association with glycated hemoglobin (P = 0.892).

Discussion

Neutrophil gelatinase-associated lipocalin and serum CysC were positively associated with the presence of renal dysfunction and had better performance on receiver operating characteristic analysis than the other markers evaluated in patients with T2D without kidney dysfunction.

Association between irisin and major chronic diseases: a review

OBJECTIVE

Irisin is a muscle-secreted protein released into the circulation by cleavage of fibronectin type III domain containing protein 5(FNDC5). Since its discovery in 2012, it has been the subject of many researches due to its physiological role. It is believed that understanding irisin's function may be the key to comprehend many diseases and their development. The aim of this study is to perform a systematic review in order to establish whether there is an association of irisin's levels with obesity, diabetes mellitus, non-alcoholic steatohepatitis, chronic kidney disease and cancer in terms of prognosis.

MATERIALS AND METHODS

The articles that support these findings were selected from Medline using the keyword "irisin" and filtered with "humans only". The selected articles were in English and with abstract.

RESULTS

Higher baseline irisin concentrations are associated with greater reductions in glycemia and insulinemia after weight loss in obese subjects. Besides, it was observed that macrovascular disease, a complication of diabetes, was developed when there were lower levels of irisin. In addition, although not statistically significant, high levels of irisin were associated with portal inflammation and severity of histological lesions. Its concentrations decreased with increasing chronic kidney disease stage, and they were not only independently and positively predicted by renal function and insulin resistance but also associated with sarcopenia and carotid atherosclerosis in patients undergoing peritoneal dialysis. Regarding cancer, irisin reduced the proliferation, viability and migration of malignant breast cells. Finally, it is also related to bone health once its concentration is associated with previous osteoporotic fractures.

CONCLUSIONS

In every condition studied, irisin's concentrations were related to the development of the disease.

Endothelial, renal and hepatic variables in Wistar rats treated with Vancomycin

Vancomycin (VCM) is indicated in combat against Gram-positive infections, but it is not considered a first-choice drug because of its adverse effects. It is believed that oxidative stress is the primary mechanism of endothelial injury and the consequent VCM toxicity, which varies from phlebitis to nephrotoxicity. Moreover, dose recommendations, dilution, rates and types of infusion are still controversial. The aim of this study was to determine the effect of different VCM dilutions in endothelial, liver and kidney injuries by biochemical parameters and histopathological analysis. Wistar rats were randomly divided into six groups and subjected to femoral vein cannulation for drug administration. Control groups received 0.9 ml of saline and the others received VCM (10mg/Kg/day) at dilutions of 5.0 and 10.0 mg/mL for 3 and 7 days. Homocysteine, hs-CRP, AST, ALT, GGT, urea, creatinine, lycopene, alpha-tocopherol, beta-carotene and retinol were analyzed. Kidney, liver and cannulated femoral vein fragments were collected.This study showed alterations in ALT which featured hepatotoxicity. However, drug dilutions were not able to show changes in other biochemical parameters. In contrast, kidney and endothelium pathological changes were observed. More studies are needed to characterize VCM induced kidney and endothelium toxicity and biochemical markers able to show such morphological modifications.

IL-6 and TNF-α serum levels are associated with early death in community-acquired pneumonia patients

Community-acquired pneumonia (CAP) is amongst the leading causes of death worldwide. As inflammatory markers, cytokines can predict outcomes, if interpreted together with clinical data and scoring systems such as CURB-65, CRB, and Acute Physiology and Chronic Health Evaluation II (APACHE II). The aim of this study was to determine the impact of inflammatory biomarkers on the early mortality of hospitalized CAP patients. Twenty-seven CAP patients needing hospitalization were enrolled for the study and samples of interleukin-1 (IL-1) and interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), C-reactive protein (CRP), and homocystein were collected at the time of admission (day 1) as well as on the seventh day of the treatment. There was a significant reduction in the levels of IL-6 between the first and the second collections. Median IL-6 values decreased from 24 pg/mL (day 1) to 8 pg/mL (day 7) (P=0.016). The median levels of TNF-α were higher in patients: i) with acute kidney injury (AKI) (P=0.045), ii) requiring mechanical ventilation (P=0.040), iii) with short hospital stays (P=0.009), iv) admitted to the intensive care unit (ICU) (P=0.040), v) who died early (P=0.003), and vi) with worse CRB scores (P=0.013). In summary, IL-6 and TNF-α levels were associated with early mortality of CAP patients. Longer admission levels demonstrated greater likelihood of early death and overall mortality, necessity of mechanical ventilation, and AKI.

The use of vancomycin with its therapeutic and adverse effects: a review

OBJECTIVE

Vancomycin (VCM) is a tricyclic glycopeptide antibiotic produced by Streptococcus orientalis. Widely used in hospitals, it is indicated to fight severe infections caused by Gram-positive bacteria, especially with the advent of MRSA (methicillin-resistant Staphylococcus aureus), penicillin-resistant pneumococci among others. Furthermore, it is indicated for the treatment of patients allergic to penicillins and cephalosporins. Dose recommendations, dilution rates and types of infusion are controversial and also result in toxic effects. Aim of this paper was to perform a literature review showing the therapeutic and adverse effects of vancomycin.

MATERIALS AND METHODS

This is a literature review of recent articles published on MEDLINE and SciELO databases in English, Portuguese and Spanish.

RESULTS

The main adverse effects of vancomycin are: hypotension, phlebitis, nephrotoxicity, ototoxicity, hypersensitivity reactions, red man syndrome, neutropenia, chills, fever, interstitial nephritis.

CONCLUSIONS

The use of vancomycin is still very common; however, inadequate doses and prolonged therapy pose a risk of increasing minimum inhibitory concentrations (MICs), resulting in subtherapeutic levels, treatment failures and toxicity. Therefore, further studies should be conducted to optimize the administration of vancomycin, monitoring treatments from the beginning in order to ensure a safe and effective use of the drug.

AIDS and the pancreas in the HAART era: a cross sectional study

BACKGROUNDS

The aim of this study is identify the main morphological patterns of the pancreas in AIDS patients in use of Higly Active Antiretorviral Therapy (HAART).

METHODS

We conducted a cross sectional study in the year of 2010. The inclusion criteria were patients older than 18 years who died of AIDS with the use of HAART (2006-2009) and underwent to autopsy . They were compared with a group of 109 patients who died of AIDS in 1995 before the HAART therapy. All the autopsies were made in the Death Verification Service of São Paulo.

RESULTS

The HAART group presented pancreas abnormalities lighter than no HAART users. In the HAART group, histology shows: reduction of zymogen granules in the acinar cells (ZG) higher percentage of cases, "dysplasia-like" presents lower and pancreatic acinar atrophy, presents higher percentage of cases compared to no HAART group. The exocrine pancreas in treated patients was distinguished by the high level of atrophy, sharp reduction of zymogen granules and high level of apoptosis, reflecting degeneration and lower level of protein-caloric malnutrition.

CONCLUSIONS

The islets of Langerhans in HAART group were increased in number and volume and with high level of nuclear dysplasia. The antiviral therapy and a longer survival resulted in a higher atrophy and reduction of enzymes, increasing the apoptosis and generated important changes in the pancreatic islets, probably resulting in clinical laboratory repercussion.We found no evidence of pancreatic histopathological lesions secondary to antiretroviral therapy.

Diagnosis of the infection by the Helicobacter pylori through stool examination: method standardization in adults

OBJECTIVES

Infection caused by Helicobacter pylori (H. pylori) is one of the most common causes of chronic infection in the world. The presence of the infection is strongly associated with the neoplasia of the gastrointestinal tract, and its diagnosis is easily made by means of invasive or non-invasive methods. Among such methods, the H. pylori antigen detection in stool through ELISA technique is easily performed and it is an alternative to endoscopy in children, since this exam is not usually indicated in this age group. The aim of the current study is to establish the standardization of the ELISA method for the detection of H. pylori in stool specimens in Brazil.

DESIGN AND METHODS

Patients between 18 and 70 years of age were randomly selected in the gastroenterology ambulatory center at Faculdade de Medicina do ABC between 2007 and 2009. They all answered a questionnaire to investigate possible dyspeptic symptoms and then underwent endoscopy and detection of H. pylori through no more than 4 methods. Besides the gastric biopsy, established as the gold standard test, the urease test, the stool ELISA test and serology were also methods applied.

RESULTS

The sensitivity and specificity of the exams in this sample were respectively 87.2% and 44% for the stool ELISA test, 41.9% and 64% for serology, 65.6% and 58.8% for the urease test and 100% and 80.8% for the clinical analysis.

CONCLUSIONS

The ROC curve showed a good correlation between the compared methods. In Brazil the standardization of the ELISA test for the detection of H. pylori in stool specimens constitutes a non-invasive diagnostic alternative.