Use of Eculizumab in Pediatric Patients with High-Risk Transplantation-Associated Thrombotic Microangiopathy: Outcomes and Risk Factors Associated with Response and Survival. A Retrospective Study on Behalf of the Spanish Group for Hematopoietic Transplantation and Cellular Therapy (GETH-TC)

Transplantation-associated thrombotic microangiopathy (TA-TMA) is associated with high morbidity and mortality. Although survival has improved significantly with the introduction of eculizumab, the need for improvement remains, especially in high-risk patients. This study aimed to describe the results obtained with eculizumab in a pediatric cohort with the attempt to define which risk factors could determine the response to treatment. We designed a national multicenter retrospective study of children treated with eculizumab for high-risk TA-TMA. The study cohort comprised 29 patients who had undergone a first (n = 28) or second (n = 1) allogeneic hematopoietic stem cell transplantation (HSCT) for malignant (n = 17) or nonmalignant (n = 12) disease. The median time from HSCT to TA-TMA diagnosis was 154 days (interquartile range [IQR], 103 to 263 days). Eleven patients (38%) who were initially diagnosed with low- to intermediate-risk TA-TMA progressed to high-risk TA-TMA (hrTA-TMA), within a median time of 4 days (IQR, 1 to 33 days). SC5b-9 was increased in 90% of 20 patients in whom it was measured. Renal (n = 12), pulmonary (n = 1), and intestinal (n = 1) biopsy confirmed the diagnosis in 12 of 14 patients (85%). Seventeen patients (58%) had extrarenal involvement with serositis (n = 13; 44,8%), pulmonary (n = 12; 41,4%), gastrointestinal (n = 8; 27.6%), cardiovascular (n = 7; 24.1%), or central nervous system (CNS) (n = 2; 6.9%) involvement. The median time from hrTA-TMA diagnosis to the initiation of eculizumab was 7 days (IQR, 1 to 8 days). Overall, 19 patients (65.5%) responded to eculizumab, of whom 17 (58.6%) achieved a complete response and 2 (6.9%) achieved a partial response. The remaining 10 patients (34.5%) did not show any of response. The overall response rate to eculizumab for TA-TMA was 27.59% (95% confidence interval [CI], 14.87% to 47.66%) at 1 month, 55.17% (95% CI, 38.43% to 73.48%) at 3 months, and 62.07% (95% CI, 45.10% to 79.13%) at 6 months after eculizumab initiation. In multivariate analysis, the pulmonary involvement decreased the probability of response (hazard ratio [HR], .18; P = .0298). The 1-year overall survival (OS) was 55.2% (95% CI, 35.6% to 71.0%) for the whole cohort and 83.3% (95% CI, 56.7% to 94.3%) for patients who responded to eculizumab. Pulmonary involvement (HR, 14.93; P = .0043) and CNS involvement (HR, 8.63; P = .0497) were associated with a statistically significant decrease in survival. We found that patients diagnosed with hrTA-TMA with pulmonary involvement had a poor response to eculizumab, and that patients with pulmonary and CNS involvement had significantly decreased survival. Given these results, we hypothesize that providing eculizumab therapy at an early stage of the disease before organ damage is established might significantly improve the response and, consequently, survival.

Attitudes scale toward cancer-related cognitive changes - an initial Colombian validation

OBJECTIVE

The aim of this study was to develop an initial valid tool to measure attitudes toward cancer-related cognitive changes.

SUBJECTS AND METHODS

After revising the literature, three main dimensions were hypothesized. Eight judges were contacted to obtain content validity evidence. A robust Exploratory Factor Analysis (EFA) was performed via a parallel analysis with an Unweighted Least Squares (ULS) estimator and polychoric correlations. The results were crossed with sociodemographic variables to find possible statistical differences and estimate the size effect. Analysis was performed in the software Factor and the statistical package R.

RESULTS

A sample of 374 participants was obtained, involving oncology patients, their caregivers, and people from the general community. A statistical fit was found in two dimensions: Awareness and Judgments [root mean squared error of approximation (RMSEA) = 0.042, standardized root mean square residual (SRMR) = 0.02, comparative fit index (CFI) = 0.99, Tucker-Lewis index (TLI) = 0.98] with a moderate correlation between them (r = 0.612). Optimal reliability indices were obtained for the total scale and its dimensions. No real statistical difference was found between sociodemographic variables; the interpretation norms were established via the quartiles.

CONCLUSIONS

The first attempt to measure the construct of interest was developed with two primary validity evidence based on the content and its internal structure. This instrument could help strengthen the prevention of cancer-related cognitive changes. More research is needed to adhere more valid evidence to the scale.

Cross-cultural adaptation, validation and reliability of the Medication Safety Thermometer tool for use in Brazil

OBJECTIVES

to perform cross-cultural adaptation, face and content validation and reliability analysis of the Medication Safety Thermometer tool for use in Brazil.

METHODS

the process of cross-cultural adaptation and validation followed the stages of translation, synthesis of translations, back-translation, content validation performed by experts, and face validation through pre-testing. Reliability was determined by calculating the Kappa coefficient.

RESULTS

the two translated versions were synthesized into a single version, which was back-translated and showed no divergences. The expert committee judged the adapted tool as equivalent, reaching a Content Validity Index higher than 0.8. The mean global understanding was 1.82, demonstrating face validity. The assessed items had Kappa coefficient greater than 0.61, showing agreement between observers.

CONCLUSIONS

the cross-cultural adaptation of the tool was performed following an established methodology. The adapted tool showed inter-rater reliability and validity for use in Brazil.

Cuidado em saúde de pacientes insulinizados da Farmácia Municipal de um município da Região Metropolitana de Porto Alegre - RS

Este artigo objetivou estabelecer o perfil dos usuários com diabetes insulinizados e fatores associados ao autocuidado na sua terapêutica. Trata-se de um estudo quantitativo, descritivo, transversal, com amostra de 139 pessoas atendidas na Farmácia Municipal de São Leopoldo - RS. Utilizou-se a versão brasileira adaptada do "Questionário de Atividades de Autocuidado com o Diabetes”. Foram incluídas perguntas para avaliar o perfil sociodemográfico desses pacientes. O perfil dos usuários investigados foi: população idosa na faixa de 61 a 70 anos (29,5%), feminina (58,3%), com diabetes mellitus tipo 2 (64,0%), aposentados (39,6%) e com nível de escolaridade até o ensino médio incompleto (52,5%). Nas atividades de autocuidado, a menor adesão foi a realização de atividade física, dieta saudável e monitorização da glicemia capilar. A maior aderência foi no uso de insulina (média 6,56 ± 1,26). Conhecer o perfil dos usuários com diabetes insulinizados pode contribuir com o fortalecimento do autocuidado e contribuir na qualidade de vida destes pacientes.

Adaptação transcultural, validação e confiabilidade da ferramenta Medication Safety Thermometer para uso no Brasil

RESUMO Objetivos: realizar adaptação transcultural, validação de face e conteúdo e análise da confiabilidade da ferramenta Medication Safety Thermometer para uso no Brasil. Métodos: o processo de adaptação transcultural e validação seguiu as etapas de tradução, síntese das traduções, retrotradução, validação de conteúdo realizada por especialistas e validação de face mediante o pré teste. A confiabilidade foi determinada pelo cálculo do coeficiente de Kappa. Resultados: as duas versões traduzidas foram sintetizadas em uma única versão, que foi retrotraduzida e não demonstrou divergências. O comitê de experts julgou a ferramenta adaptada como equivalente, alcançando Índice de Validade de Conteúdo maior que 0,8. A média de compreensão global foi de 1,82, demonstrando validade de face. Os itens avaliados apresentaram coeficiente de Kappa maior que 0,61, evidenciando concordância entre observadores. Conclusões: a adaptação transcultural da ferramenta foi realizada seguindo metodologia estabelecida. A ferramenta adaptada mostrou confiabilidade entre observadores e validade para utilização no Brasil.

O ensino na saúde na pauta da formação dos profissionais de saúde

Este editorial apresenta o trabalho da Editora Rede Unida em 2021 com um breve relato sobre os livros publicados pela editora e os números regulares e suplementos da Revista Saúde em Rede. Em seguida, são discutidos conjuntamente os 33 artigos publicados neste número. Os autores fazem parte de Instituições de 13 Estados das cinco regiões do Brasil, evidenciando a abrangência territorial dos trabalhos publicados, que juntos traçam um panorama da diversidade de temas e contextos abordados na revista: a interface da educação com a saúde, seja na perspectiva da educação permanente em saúde, voltada para o trabalho, seja na perspectiva da promoção da saúde; o uso de tecnologias no campo da saúde; os cenários de cuidado nos diferentes níveis (atenção básica, vigilância em saúde, gestão do cuidado em hospitais); gestão em saúde; desigualdades em saúde; saúde mental.

Relatos de experiência e as articulações entre ensino, pesquisa e práticas profissionais

Este editorial discute a relevância da modalidade “Relatos de Experiência” nas publicações no campo da saúde coletiva. São identificados aspectos que marcam o campo da formação em saúde, da pesquisa em saúde e das práticas de cuidado que dialogam diretamente com as potencialidades da escrita criativa e das descrições etnográficas. Destaca-se que os Relatos de Experiência constroem pontes sobre os hiatos que desafiam o campo da saúde, tais como a relação entre ensino e serviço, pesquisa e intervenção, teoria e prática, e outros. Enfatizamos sua relação com os problemas de campo, métodos e teorias, recordando que é uma versão da história sobre algo que aconteceu, com embasamento teórico e habilidade de convidar à experimentação - mesmo que imaginativa, dos passados, como uma mostra de vivências, experiências e pesquisas realizadas, com a intencionalidade de relatar o que ocorreu, fomentando o pensamento e a ação do pesquisar. Finalizamos discutindo o perfil dos relatos publicados neste número, ressaltando a presença de autoras/es de 15 Estados, das 5 regiões do Brasil.

Compreensão de território nos serviços farmacêuticos da atenção básica à saúde: um estudo qualitativo

Objetivo: descrever a compreensão de território por farmacêuticos que atuam na Atenção Básica. Métodos: Foram realizadas entrevistas com farmacêuticos alocados nas farmácias públicas de um município do Sul do Brasil. A entrevistas foram transcritas e analisadas por meio de análise temática de conteúdo. Resultados: Entrevistou-se treze farmacêuticos. As categorias temáticas elaboradas foram: território aprisionante, território distante e território desconhecido. Os resultados evidenciaram a atuação predominante do profissional como responsável pela gestão dos serviços farmacêuticos. A atuação profissional é dependente de recursos humanos e materiais adequados e da priorização de políticas de gestão voltadas à área da assistência farmacêutica. Conclusão: A compreensão do território nos serviços farmacêuticos da Atenção Básica à Saúde estabelece formas de atuação adequadas para tais serviços, no contexto dos 5.570 municípios contemplados na Política Nacional de Assistência Farmacêutica, conforme o preconizado na Lei 8.080/90.

O ensino da saúde e orgulho de lutar por equidade e justiça: acenos para uma democracia como construção cotidiana

Este editorial discute a determinação do Supremo Tribunal Federal de que o Ministério da Saúde adote medidas para garantir o respeito à identidade de gênero no acesso à saúde, tomada em 28 de junho deste ano. Para tal, contextualiza esta medida por meio de um pequeno histórico da relação entre o estado e as ações e políticas públicas voltadas para as pessoas LGBTQIA+, que atualmente está marcada por retrocessos e pressões políticas de grupos fundamentalistas. O texto apresenta o histórico de luta e avanços da população LGBTQIA+, suas relações com a saúde, e defende o enfrentamento dos preconceitos que ainda impedem a efetivação de direitos, convidando autoras/es a submeterem trabalhos relacionados a esta temática. Além disso, também é discutido o contexto de pandemia que impõe à população brasileira uma situação de aumento da precarização de direitos básicos e aumento da pobreza. Diante disso, intensificam-se os movimentos populares que promovem a organização comunitária e articulam o processo coletivo e democrático de vigilância popular em saúde. Em seguida, são apresentadas as publicações deste número, que traz dezoito artigos e duas resenhas, que versam sobre temas centrais para o ensino da saúde, tais como a Educação Permanente em Saúde, a interprofissionalidade, a participação popular e o controle social e as Redes de Atenção do SUS. Nestes trabalhos estão representados 13 estados, das cinco regiões do Brasil, com pesquisadoras/es vinculados a 25 instituições diferentes, entre universidades, institutos e serviços de saúde. Este perfil expressa a capilaridade da Revista Saúde em Redes no território brasileiro, bem como a presença de estudos gestados na interface entre instituições de ensino e pesquisa e serviços de saúde.

Dinâmicas do ensino-aprendizagem na saúde para reengendrar a democracia e combater as desigualdades

Chegamos ao sétimo volume da revista Saúde em Redes, consolidando um trabalho editorial tecido por muitas mãos e que se entrelaça cada vez mais na pluralidade de perspectivas e autoras/es que compõem o campo da saúde coletiva, com ênfase especial nos temas do trabalho e do ensino na saúde. A diversidade das submissões que têm sido enviadas para a Revista Saúde em Redes, evidencia a capilarização do periódico nas diversas regiões do Brasil e em alguns países estrangeiros. Ao longo dos últimos seis anos, trabalhamos para qualificar o trabalho editorial, as estratégias de comunicação da revista e o alcance das publicações. Ainda temos muito trabalho pela frente, mas é gratificante constatarmos o amadurecimento da revista, sobretudo em um cenário de enormes desafios que os periódicos científicos brasileiros têm enfrentado, com a escassez de financiamento e a fragilidade das políticas editoriais que pouco reconhecem e legitimam o trabalho dos periódicos nacionais. É gratificante também identificar o reconhecimento do trabalho, com a expansão das submissões e a diversificação de pessoas que produzem os manuscritos da revista. Os impasses no estabelecimento de políticas de avaliação e as formas atuais de ranqueamento da produção científica nacional aprofundam a hierarquização entre periódicos, sobretudo se considerarmos o cenário internacional, que apresenta novos desafios. Temos visto periódicos bastante consolidados e bem avaliados sendo descontinuados, atrasando ou, até mesmo interrompendo a publicação. Nesse cenário de incertezas, a Saúde em Redes segue apostando em um trabalho editorial que investe cada vez mais na excelência e qualidade das publicações, intensificando o debate entre autoras/es e pareceristas, sem contudo, deixar de abrir espaço para autoras/es iniciantes e sustentar um fluxo editorial sem cobrança de taxas, e de acesso aberto. Um trabalho implicado que acredita na democratização e difusão científica como elemento fundamental para o exercício da cidadania e a transformação das relações de poder e saber entre academia, serviços e população.

Ensino da graduação em cenários da atenção primária: espaço para aprendizagem interprofissional

Resumo Neste estudo, investigou-se como o ensino da graduação em cenário de prática da Atenção Primária à Saúde pode constituir espaço de aprendizagem interprofissional, por meio da análise do significado de sua experiência na formação de futuros profissionais de saúde. Pesquisa desenvolvida em universidade pública do sul do Brasil, com dados qualitativos coletados por instrumento autoaplicado online com estudantes e egressos (n=186) de 15 profissões da saúde que participaram de uma experiência de educação interprofissional. Resultados mostraram que práticas de ensino compartilhadas com estudantes, professores, profissionais da saúde de diversas áreas e com usuários, promoveram momentos de escuta e de compartilhamento de experiências, percepções e diferentes saberes. A educação tutorial em pequenos grupos no cenário da Atenção Primária potencializou a experiência de educação interprofissional. Aprendizagens relacionadas ao reconhecimento e valorização dos papéis de cada profissão na equipe e ao desenvolvimento de habilidades de comunicação foram destacadas. O curto espaço de tempo da experiência foi um desafio reconhecido pelos participantes para promover a integração. Interações entre estudantes de diferentes profissões em atividades práticas de ensino na Atenção Primária promoveram aprendizagens compartilhadas na graduação, passíveis de apoiar habilidades de colaboração no trabalho em equipe e de atenção integral à saúde.

Percepção de Equipes de Saúde da Família sobre a notificação de eventos adversos a medicamentos

Objetivo: Avaliar se profissionais de saúde da equipe de saúde da família reconhecem a notificação de eventos adversos a medicamentos (EAM) como forma de promoção a Segurança do Paciente e as possíveis barreiras para execução da mesma. Método: Aplicação de questionário semiestruturado em 24 unidades de saúde de atenção primária em saúde (APS). Resultados: Foram 175 respondentes: 53 agentes comunitários de saúde, 7 agentes de saúde bucal, 25 enfermeiros, 18 médicos, 14 odontólogos, 58 técnicos de enfermagem. A falta de confiança, medo de exposição por má prática e o medo de perda da reputação foram as barreiras a notificação para os respondentes que possuem menor tempo de trabalho na unidade de saúde. Os profissionais com maior tempo de trabalho na unidade atribuem o tempo como barreira a notificação de EAM. Conclusão: As barreiras identificadas sinalizam a necessidade de intervenções na cultura da segurança do paciente na APS.A equipe da estratégia de saúde da família pode ser um elo de aproximação da APS com os Núcleos de Segurança do Paciente na prevenção de EAM.

Distribuição espacial de casos da Doença Falciforme em um estado do sul do Brasil com base no Componente Especializado da Assistência Farmacêutica

A doença falciforme é considerada a doença genética com maior prevalência mundial, configurando-se como um grave problema de saúde pública devido a sua relevância clínica e morbimortalidade da população acometida. Por ser associada a questões de vulnerabilidade social por vezes torna-se invisível no território, dificultando a gestão do cuidado em saúde de forma longitudinal. Este estudo objetivou identificar os pacientes com doença falciforme e verificar a sua distribuição espacial no Rio Grande do Sul. Estudo descritivo com desenho transversal, realizado por meio da coleta de dados do Componente Especializado da Assistência Farmacêutica do estado. Tendo por base os CIDs contemplados no protocolo clínico para a doença foi possível verificar os pacientes com cadastro ativo para acesso aos medicamentos deste componente utilizados no seu tratamento. Os dados coletados indicaram que 194 pacientes possuem cadastro ativo, sendo que 98% destes fazem uso do medicamento hidroxiureia. Em relação à frequência dos casos conforme o CID, 84% dos pacientes apresentam anemia falciforme e 11% talassemia beta. O sexo feminino foi prevalente no estudo (53%), bem como os pacientes na faixa etária de 10 a 19 anos. Ao todo, 69 municípios possuem um ou mais pacientes com a doença, com destaque para Porto Alegre que engloba 35% dos casos. A distribuição espacial se dá de forma heterogênea no estado, tendo um aglomerado relevante na região metropolitana. Percebendo-se que o geoprocessamento pode atuar de maneira estratégica para a identificação geográfica de pacientes com doença falciforme e que a assistência farmacêutica tem participação importante neste processo.

Medications used in pediatric cystic fibrosis population

Objective

To describe the drug utilization profile used by pediatric cystic fibrosis patients.

Methods

A transversal study comprising the analysis of records and interviews with caregivers of pediatric patient in a reference center of Southern Brazil. We collected information about patients’ clinical condition, medication used and household therapy.

Results

Out of 78 patients participating in the study, prevailing characteristics were: female, self-declared white color, mutation F508del and countryside resident. Forty-three patients had health monitoring exclusively in the hospital’s outpatient division. We analyzed 509 prescribed medication (6.5 medication/patient). The caregiver acknowledged the correct indication in 83% of cases. Patients with pulmonary complications and diseases and/or comorbities related to the cystic fibrosis had an increased quantity of prescribed medication. Vitamins, pancreatic enzymes, hypertonic saline solution, dornase alpha, acid ursodesoxicolic and inhalation antibiotics were most commonly prescribed. Out of the sum of medication, 265 (52.1%) were registered in the Relação Nacional de Medicamentos Essenciais , 26.7% were registered in the basic component and 25.4% were registered in the specialized component of pharmaceutical assistance. Seventy-four interviewees informed difficulty in the acquisition of at least one prescribed medication. Most of the reports acknowledge the State Health Department as the place to find and receive medication for cystic fibrosis.

Conclusion

This study allowed reaching a deeper understanding about therapy, caring needed with patients with cystic fibrosis, highlighting to implement strategies that might contribute to enhance life quality and to execute the patients’ therapy plan.

[The profile of caregivers to pediatric patients with cystic fibrosis]

The scope of this study was to establish the profile of caregivers of pediatric patients diagnosed with Cystic Fibrosis (CF). It was a cross-sectional, descriptive and prospective study in which the caregivers of fibrocystic patients were interviewed during pharmaceutical consultation in a reference center of a University Hospital in southern Brazil. General information was obtained about the caregivers and about their understanding of the disease, drug consumption and dynamics of treatment at home and at school. Seventy-five caregivers were interviewed. Most of them were female, 37.3 years old on average, mothers of the patients who did not work outside the home. Seventy-one caregivers declared difficulties in drug acquisition and patient support associations were highlighted as the main alternative to avoid the interruption of treatment. Another fact observed was the overload of the caregiving process on the shoulders of only one caregiver resulting in social and economic impacts and changes to the family's daily routine. This fact emphasizes the need of intervention by a qualified multidisciplinary team to identify and alleviate difficulties, investing in interpersonal relations and administering care.

Drug incompatibilities in the adult intensive care unit of a university hospital

Objectives

This study sought to identify the physical and chemical incompatibilities among the drugs administered intravenously to patients admitted to an adult intensive care unit. We also aimed to establish pharmaceutical guidelines for administering incompatible drugs.

Methods

This cross-sectional, prospective, and quantitative study was conducted from July to September 2015. Drug incompatibilities were identified based on an analysis of the patient prescriptions available in the hospital online management system. A pharmaceutical intervention was performed using the guidelines on the preparation and administration of incompatible drugs. Adherence to those guidelines was subsequently assessed among the nursing staff.

Results

A total of 100 prescriptions were analyzed; 68 were incompatible with the intravenous drugs prescribed. A total of 271 drug incompatibilities were found, averaging 4.0 ± 3.3 incompatibilities per prescription. The most commonly found drug incompatibilities were between midazolam and hydrocortisone (8.9%), between cefepime and midazolam (5.2%), and between hydrocortisone and vancomycin (5.2%). The drugs most commonly involved in incompatibilities were midazolam, hydrocortisone, and vancomycin. The most common incompatibilities occurred when a drug was administered via continuous infusion and another was administered intermittently (50%). Of the 68 prescriptions that led to pharmaceutical guidelines, 45 (66.2%) were fully adhered to by the nursing staff.

Conclusion

Patients under intensive care were subjected to a high rate of incompatibilities. Drug incompatibilities can be identified and eliminated by the pharmacist on the multidisciplinary team, thereby reducing undesirable effects among patients.

Establishment, Implementation, and Consolidation of Clinical Pharmacy Services in Community Pharmacies: Perceptions of a Group of Pharmacists

When pharmacists incorporate clinical practice into their routine, barriers and facilitators influence the implementation of patient care services. Three focus groups were conducted with 11 pharmacists who were working for the Farmácia Popular do Brasil program on the establishment, implementation, and consolidation of clinical pharmacy services. The perception of the pharmacists in Brazil about the program was that it facilitated access to health care and medication. The distance between neighboring cities made it difficult for patients to return for services. Lack of staff training created a lack of communication skills and knowledge. The pharmacists wanted to have increased technical support, skill development opportunities, and monitoring of researchers who assessed progress of the service. Pharmacists overcame many of their insecurities and felt more proactive and committed to quality service. Positive experiences in service implementations have shown that it is possible to develop a model of clinical services in community pharmacies.

The role of CDKN2A/B deletions in pediatric acute lymphoblastic leukemia

The CDKN2A/B genes in the 9p21 chromosomal region are frequently involved in human cancer, including pediatric acute lymphoblastic leukemia (ALL). These genes encode 3 proteins that belong to the RB1 and TP53 pathways and act as tumor suppressors by regulating the G1/S checkpoint of the cell cycle. The prognostic value of deletions in the CDKN2A/B locus in ALL is controversial in part due to the limitations of the methodologies used. Further studies with advanced technologies are needed for elucidation. Future studies would also highlight whether CDK4/CDK6 selective inhibitors might be useful therapies for children with these genetic aberrations.

[Therapeutic itineraries of users of medication in a unit of the Family Heatlh Strategy]

Therapeutic itineraries represent the trajectories taken by individuals in an attempt to resolve their health problems. The objective of this study was to analyze the trajectory when user prescription medication needs were not met in a Family Health Strategy Unit of the city of Porto Alegre. A database of users whose prescription needs were not fully met and the application of a questionnaire during home visits was performed. Users interviewed were between 53 and 85 years of age. The main problems reported were lack of money, physical difficulty in locomotion, side effects, illegible prescriptions, unavailability of medication in the local pharmacies of the city, fear of effects attributed to the medication, and "bureaucracy." When the medication is not available at the health unit, most users (60%) reported buying it. With respect to the communication of the family health team in the orientation of ways that the user can gain access to the medication, 25% of the respondents reported that the team did not provide necessary information about the alternate location for the acquisition of the medication that was lacking.

Cerebrospinal fluid control of neurogenesis induced by retinoic acid during early brain development

Embryonic-cerebrospinal fluid (E-CSF) plays crucial roles in early brain development including the control of neurogenesis. Although FGF2 and lipoproteins present in the E-CSF have previously been shown to be involved in neurogenesis, the main factor triggering this process remains unknown. E-CSF contains all-trans-retinol and retinol-binding protein involved in the synthesis of retinoic acid (RA), a neurogenesis inducer. In early chick embryo brain, only the mesencephalic-rombencephalic isthmus (IsO) is able to synthesize RA. Here we show that in chick embryo brain development: (1) E-CSF helps to control RA synthesis in the IsO by means of the RBP and all-trans-retinol it contains; (2) E-CSF has retinoic acid activity, which suggests it may act as a diffusion pathway for RA; and (3) the influence of E-CSF on embryonic brain neurogenesis is to a large extent due to its involvement in RA synthesis. These data help to understand neurogenesis from neural progenitor cells.

Observation of preparation and administration of drugs by nursing assistants in patients with enteral feeding tube

This study aimed to know the standard of preparation and administration of medicines to patients using probes of enteral nutrition (SNE) hospitalized in a university hospital in Porto Alegre. Were accompanied sixty nursing auxiliaries, in two units of hospital, in their routine work and observed their techniques. The practice was compared with procedures that are part of the rules for administration of medicines to patients on enteral therapy. The auxiliary held a grinding in 90% of cases of solid pharmaceutical preparation. For this procedure they used preferably the mortar and pistil (63.3%). The dilution of the drugs was made mainly with tap water (78.3%). Most professionals (91.1%) prepare and administer together all medications that were prescribed to the patient. Only four assistants performed the procedure separately. The washing of the SNE after administration of drugs was made for 75% of assistants. It was observed a great diversity of working methods used at the derivation, dilution and administration of medicines by nursing auxiliaries.

FGF2 plays a key role in embryonic cerebrospinal fluid trophic properties over chick embryo neuroepithelial stem cells

During early stages of brain development, neuroepithelial stem cells undergo intense proliferation as neurogenesis begins. Fibroblast growth factor 2 (FGF2) has been involved in the regulation of these processes, and although it has been suggested that they work in an autocrine-paracrine mode, there is no general agreement on this because the behavior of neuroepithelial cells is not self-sufficient in explants cultured in vitro. In this work, we show that during early stages of development in chick embryos there is another source of FGF2, besides that of the neuroepithelium, which affects the brain primordium, since the cerebrospinal fluid (E-CSF) contains several isoforms of this factor. We also demonstrate, both in vitro and in vivo, that the FGF2 from the E-CSF has an effect on the regulation of neuroepithelial cell behavior, including cell proliferation and neurogenesis. In order to clarify putative sources of FGF2 in embryonic tissues, we detected by in situ hybridization high levels of mRNA expression in notochord, mesonephros and hepatic primordia, and low levels in brain neuroectoderm, corroborated by semiquantitative PCR analysis. Furthermore, we show that the notochord segregates several FGF2 isoforms which modify the behavior of the neuroepithelial cells in vitro. In addition, we show that the FGF2 ligand is present in the embryonic serum; and, by means of labeled FGF2, we prove that this factor passes via the neuroepithelium from the embryonic serum to the E-CSF in vivo. Considering all these results, we propose that, in chick embryos, the behavior of brain neuroepithelial stem cells at the earliest stages of development is influenced by the action of the FGF2 contained within the E-CSF which could have an extraneural origin, thus suggesting a new and complementary way of regulating brain development.

Embryonic cerebrospinal fluid regulates neuroepithelial survival, proliferation, and neurogenesis in chick embryos

Early in development, the behavior of neuroepithelial cells is controlled by several factors, which act in a developmentally regulated manner. Diffusible factors are secreted locally by the neuroepithelium itself, although other nearby structures may also be involved. Evidence suggests a physiological role for the cerebrospinal fluid in the development of the brain. Here, using organotypic cultures of chick embryo neuroepithelial explants from the mesencephalon, we show that the neuroepithelium in vitro is not able to self-induce cell survival, replication, and neurogenesis. We also show that the embryonic cerebrospinal fluid (E-CSF) promotes neuroepithelial stem cell survival and induces proliferation and neurogenesis in mesencephalic explants. These data strongly suggest that E-CSF is involved in the regulation of neuroepithelial cells behavior, supporting the hypothesis that this fluid plays a key role during the early development of the central nervous system.

Disto-proximal regional determination and intercalary regeneration in planarians, revealed by retinoic acid induced disruption of regeneration

The mechanisms that define the body pattern during development and regeneration are the object of major concern in developmental biology. To understand the process and sequence of antero-posterior pattern formation of planarian body regions during regeneration, regenerating organisms were treated with exogenous retinoic acid, which affects development and regeneration in other systems, and the sequence of regional determination has been monitored by a specific molecular marker for the central region, which includes the pharynx. The sequence of gross regional specification have never been analysed in planarians using molecular regional markers or by direct disruption of the regeneration process. Exogenous retinoic acid administration on regenerating planarians disrupts anterior, but not posterior regeneration. The period of maximum sensitivity to exogenous retinoic acid is one day after amputation, during which time the determination of the head has been reported to occur. The data obtained allow us to suggest that gross regional specification during planarian regeneration is disto-proximal, from the regenerative blastema to the old stump, and thus takes place by intercalation of the central region between the anterior and posterior ones.

Extracorporeal treatment of thrombotic microangiopathy: a ten year experience

We reviewed 24 episodes of thrombotic microangiopathy (TMA) representing 22 patients from July 1989 to July 1998. Nine cases presented with a community acquired (CA group) thrombotic thrombocytopenic purpura or hemolytic uremic syndrome (TTP/HUS), 3 cases were related to pregnancy (P group), 10 cases were compatible with TMA after bone marrow transplantation or chemotherapy (BMT/C group), and 2 cases had a background of scleroderma (SC group). Twenty episodes were treated exclusively with therapeutic plasma exchange (TPE) using fresh frozen plasma (FFP) replacement. In the BMT/C group, 4 patients underwent immunoadsorption with the Prosorba protein A column in addition to TPE. The CA, P, and SC groups had favorable outcomes with 78% (7 of 9), 100% (3 of 3), and 100% (2 of 2) survival, respectively. Despite intensive therapy, there was only 1 survivor in the BMT/C group (1 of 10). Successful outcome required up to 57 TPE treatments. We could not document any benefit to immunoadsorption with the Prosorba protein A column.

Intercalary muscle cell renewal in planarian pharynx

Planarian cell renewal is achieved as a result of proliferation and differentiation of totipotent undifferentiated cells called neoblasts. The absence of mitosis within the planarian pharynx raises the question as to how cell renewal and growth occur within this organ. Two explanations have been advanced: one proposes that new cells remain close to the base of the pharynx, which then grows by distal displacement of older cells, and the other suggests that the new cells are intercalated between older cells throughout the pharynx. The second alternative, however, does not explain how new cells enter the pharynx or how they reach their final destination. In this study of myosin heavy-chain gene expression within planarian pharynx, a row of differentiating myocytes was detected all along the pharynx parenchyma. According to the hybridization pattern, all these myocytes appeared to be at early stages of differentiation. These data favour an intercalary model for muscle cell renewal within the pharynx. According to this model, neoblasts at the base of the pharynx would enter the pharynx, where they would start differentiation to myocytes, move to the subepithelial musculature and intercalate between the old muscle cells. The possible application of this intercalary model to other pharynx cell types is also discussed.

Characterization of platyhelminth POU domain genes: ubiquitous and specific anterior nerve cell expression of different epitopes of GtPOU-1

POU domain proteins are a large family of transcription factors that have been identified in a variety of metazoans, from freshwater sponges, planarians and nematodes to arthropods, echinoderms and vertebrates. Many of these proteins are implicated in the development and establishment of the nervous system. In this paper we describe the identification of the planarian genes GtPOU-1, GtPOU-3 and GtPOU-4, which belong to the subclasses III and IV of POU-domain genes. Their similarity with other members of the POU family is restricted to the POU and homeo domains, plus some peptide sequences scattered in the linker and flanking regions. As with other subclass III POU genes, GtPOU-1 is devoid of introns. Axial transcript distribution by RT-PCR and immunohistochemical assays, performed with a polyclonal antibody raised against the GtPOU-1 fusion protein, indicate that both the GtPOU-1 transcript and protein are continuously expressed along the antero-posterior axis. A monoclonal antibody raised against the same fusion protein indicates that a GtPOU-1-specific epitope, probably obtained by post-translational modification, is present in neural cells from both the central and peripheral nerve systems of the adult planarian's anterior third. Moreover, the GtPOU-1-specific epitope shows a dynamic expression pattern during regeneration, always marking the most anterior region of the planarian nervous system. Both the rapid and general GtPOU-1-specific epitope modification, during posterior regeneration, indicate that regeneration is a global process involving all planarian regions, including those that are far from the wound, by a combination of morphallactic and epimorphic mechanisms.

Cell-, tissue-, and position-specific monoclonal antibodies against the planarian Dugesia (Girardia) tigrina

To obtain specific immunological probes for studying molecular mechanisms involved in cell renewal, cell differentiation, and pattern formation in intact and regenerating planarians, we have produced a hybridoma library specific for the asexual race of the fresh-water planarian Dugesia (Girardia) tigrina. Among the 276 monoclonal antibodies showing tissue-, cell-, cell subtype-, subcellular- and position-specific staining, we have found monoclonal antibodies against all tissues and cell types with the exception of neoblasts, the undifferentiated totipotent stem-cells in planarians. We have also detected position-specific antigens that label anterior, central, and posterior regions. Patterns of expression uncovered an unexpected heterogeneity among previously thought single cell types, as well as interesting cross-reactivities that deserve further study. Characterization of some of these monoclonal antibodies suggests they may be extremely useful as molecular markers for studying cell renewal and cell differentiation in the intact and regenerating organism, tracing the origin, lineage, and differentiation of blastema cells, and characterizing the stages and mechanisms of early pattern formation. Moreover, two position-specific monoclonals, the first ones isolated in planarians, will be instrumental in describing in molecular terms how the new pattern unfolds during regeneration and in devising the pattern formation model that best fits classical data on regeneration in planarians.

Amino acid metabolism in rat hippocampus during the period of brain growth spurt

We studied protein synthesis, lipid synthesis and CO2 production by oxidation of glycine, alanine and leucine by slices of rat hippocampus during the period of brain growth spurt. The metabolism of the three amino acids decreased with the age of the animals. A major reduction was observed in protein synthesis, which was 4 times higher at 7 days of age than at 21 days of age for all amino acids studied. Glycine oxidation to CO2 was twice as high as alanine oxidation and ten times higher than leucine oxidation. The major pathway of leucine utilization was incorporation into proteins. Glycine was the amino acid that had the highest metabolic rate.

Spatial and temporal relationships between Shh, Fgf4, and Fgf8 gene expression at diverse signalling centers during mouse development

During limb outgrowth, Shh, Fgf4, and Fgf8 act as signals controlling limb growth and patterning. Because these genes are expressed in the limb bud and other known signalling centers, we have explored the relationships between the expression of these during mouse development using double in situ hybridization. Within the node and limb bud the expression domains of these genes contact each other, whereas in the floor plate the Fgf8 expression domain does not contact that of Shh. The relative temporal order of gene expression varies in different centers. The spatial and temporal expression of Fgf4, Fgf8, and Shh suggests that conservation of molecular mechanisms in different organizing centers as well as differences between them.

A central body region defined by a position-specific molecule in the planarian Dugesia (Girardia) tigrina: spatial and temporal variations during regeneration

We have isolated a monoclonal antibody, TCEN49, that displays position-specific binding to the central body region of the planarian Dugesia (Girardia) tigrina. TCEN49 binds to all cell types of the central area with the exception of epithelial cells. Labeled cells are more related by position than by lineage. In the intact organism, boundaries between labeled and unlabeled regions are very sharp and in a dynamic state as they shift in relative position along the body axis during growth and degrowth. During regeneration, TCEN49 antigen is present in the area which will form the central region before it is morphologically apparent. Moreover, when animals are cut through the central region, TCEN49 label fades quickly from those regions determined to become head or tail well before morphogenesis takes place. Taken together, these data suggest that expression of TCEN49 antigen is very sensitive to positional information changes and that it could be involved in the expression of central-body positional identity. TCEN49 antigen is a glycoprotein with an apparent molecular weight of 4.5 kDa, as determined by gel immunoblotting. Immunogold light and electron microscopy demonstrate that the main location of TCEN49 antigen is intracellular (granular components of secretory cells and, to a lesser extent, clear cytoplasmic vesicles and heterochromatin blocks), though it is also detected in the extracellular matrix. TCEN49 antigen represents the first position-specific molecule reported in planarians to date.