Machado Joseph-Disease Is Rare in the Peruvian Population

Spinocerebellar ataxia type 3 or Machado-Joseph disease (MJD/SCA3) is the most prevalent autosomal dominant cerebellar ataxia worldwide, but its frequency varies by geographic region. We describe MJD/SCA3 patients diagnosed in a tertiary healthcare institution in Peru. In a cohort of 341 individuals (253 probands) with clinical ataxia diagnosis, seven MJD/SCA3 probands were identified and their pedigrees extended, detecting a total of 18 MJD/SCA3 cases. Out of 506 alleles from all probands from this cohort, the 23-CAG repeat was the most common ATXN3 allele (31.8%), followed by the 14-CAG repeat allele (26.1%). Normal alleles ranged from 12 to 38 repeats while pathogenic alleles ranged from 64 to 75 repeats. We identified 80 large normal (LN) alleles (15.8%). Five out of seven families declared an affected family member traced back to foreign countries (England, Japan, China, and Trinidad and Tobago). MJD/SCA3 patients showed ataxia, accompanied by pyramidal signs, dysarthria, and dysphagia as well as abnormal oculomotor movements. In conclusion, ATXN3 allelic distribution in non-MJD/SCA3 patients with ataxia is similar to the distribution in normal individuals around the world, whereas LN allele frequency reinforces no correlation with the frequency of MJD/SCA3. Evidence of any atypical MJD/SCA3 phenotype was not found. Furthermore, haplotypes are required to confirm the foreign origin of MJD/SCA3 in the Peruvian population.

Characteristics and Therapeutic Needs of Older Patients with Oropharyngeal Dysphagia Admitted to a General Hospital

BACKGROUND

Oropharyngeal dysphagia (OD) is a prevalent geriatric syndrome causing severe nutritional and respiratory complications.

OBJECTIVE

We aimed to describe the characteristics and therapeutic needs of older patients with OD admitted to a general hospital.

DESIGN, PARTICIPANTS AND MEASUREMENTS

Prospective cohort study with patients (≥70 years) with OD consecutively admitted to a general hospital. OD was clinically assessed with the Volume-Viscosity Swallowing Test and nutritional status with the Mini Nutritional Assessment-short form. Oral health (OH) and periodontal diseases were evaluated by dentists. Functionality, frailty, sarcopenia, comorbidities, dehydration, quality of life (QoL) and mortality were also assessed.

RESULTS

We included 235 patients (87.3±5.5 years) with OD hospitalized for acute diseases (9.6±7.6 days). On admission, they had low functionality (Barthel: 51.3±25.1), frailty (Fried: 3.9±0.9; Edmonton: 10.3±2.7, 87.2-91.1% frail) and high comorbidities (Charlson: 3.7±2.0). Moreover, 85.1% presented signs of impaired safety and 84.7% efficacy of swallow. Up to 48% required fluid adaptation with a xanthan gum-based thickener (89.4% at 250 mPa·s; 10.6% at 800 mPa·s) and 93.2% a texture-modified diet (TMD) (74.4%, fork-mashable; 25.6%, pureed). A total of 98.7% had nutritional risk, 32.3% sarcopenia and 75.3% dehydration. OH was moderate (Oral Hygiene Index-simplified: 2.0±1.3) and 67.4% had periodontitis. QoL self-perception was 62.2% and 5.5% of patients died during hospitalization.

CONCLUSION

Hospitalized older OD patients have impaired safety of swallow, frailty, malnutrition, dehydration, low functional capacity and poor OH and high risk of respiratory infections. They need a multimodal intervention including fluid thickening, TMD, thickened oral nutritional supplementation and OH care to improve health status and reduce OD-associated complications.

Gastroparesis: An Important Cause of Hospitalization in Continuous Ambulatory Peritoneal Dialysis Patients and the Role of Erythromycin

Gastroparesls Is a disabling complication In diabetic patients. It has been reported as the second most frequent cause of hospitalization In diabetic patients on continuous ambulatory peritoneal dialysis (CAPD). We analyzed Infectious and noninfectious complications In our CAPD patients. We Included 31 patients (12 diabetics and 19 nondiabetics) with an average time on CAPD of 14±7 months. The Incidence of peritonitis was 1.68 episodes/patient/year In diabetics and 0.84 tn nondiabetics. Nine (75%) diabetic patients had peritonitis, 5 (42%) had vomiting, and 4 (33%) had Ischemic heart disease. The hospitalization Index (days/year) was greater In diabetics: 11.83± 11.36 versus 4.16±8.84 In nondiabetics (p<0.05). Vomiting was the first cause of admission in diabetics. We were unable to control severe gastroparesls with cisapride and metoclopramide in 4 patients. Erythromycin, 100 mg/2-L bag of dialysate, improved symptoms In all of them.

We concluded that gastroparesls Is an Important cause of morbidity In CAPD patients. Intraperitoneal erythromycin can Improve symptoms If other prokinetic drugs fail.

Effect of A Minimal-Massive Intervention in Hospitalized Older Patients with Oropharyngeal Dysphagia: A Proof of Concept Study

BACKGROUND

Oropharyngeal dysphagia (OD) is a newly defined geriatric syndrome that causes nutritional and respiratory complications in older hospitalized patients. Following hospital discharge, OD also causes hospital readmission and mortality in this population.

OBJECTIVE

Our aim was to assess the effect of a minimal-massive intervention (MMI) in reducing nutritional and respiratory complications in older hospitalized patients with OD.

DESIGN AND PARTICIPANTS

An open label trial was performed on 186 hospitalized older patients (>70y) with OD; 62 of these patients with OD were treated with the MMI and paired by sex, age, functionality, comorbidities and body mass index with two controls.

INTERVENTION

The MMI consisted of: a) fluid thickening and texture-modified foods, b) caloric and protein supplementation; and c) oral health and hygiene recommendations during hospitalization and following discharge. The control group followed the standard clinical practice without MMI.

MEASUREMENTS

Main study outcomes were hospital readmissions, respiratory infections, nutritional status and survival after 6 months follow up.

RESULTS

Both groups had similar advanced age (84.87±6.02MMI and 84.42±5.31 years), poor functionality (Barthel 59.51±26.76 MMI and 58.84±26.87), and high comorbidities (Charlson 3.00±1.60 MMI and 3.06±1.45). Main results showed that MMI improved nutritional status (MNA 9.84±2.05 pre-MMI vs. 11.31±2.21 post-MMI; p=0.0038) and functionality (Barthel 62.34±25.43 pre-MMI vs. 73.44±25.19 post-MMI; p=0.007). In addition MMI decreased hospital readmissions (68.8 readmissions/100 persons-year (28.1-109.38) MMI vs. 190.8 (156.0-225.7); p=0.001), respiratory infections (12.50 readmissions/100 persons-year (0-29.82) MMI vs. 74.68 (52.86-96.50); p=0.002), and increased 6-month survival (84.13% MMI vs. 70.96%; p=0.044).

CONCLUSIONS

Our results suggest that a MMI in hospitalized older patients with OD improves nutritional status and functionality and reduces hospital readmissions, respiratory infections and mortality. MMI might become a new simple and cost-effective strategy to avoid OD complications in the geriatric population admitted with an acute disease to a general hospital.

Videofluoroscopic assessment of the pathophysiology of chronic poststroke oropharyngeal dysphagia

BACKGROUND AND PURPOSE

Oropharyngeal dysphagia (OD) is a major complaint following stroke, associated with poor clinical outcome and high mortality rates. We aimed at characterizing the kinematics of swallow response associated with unsafe swallowing in chronic poststroke patients with OD.

PATIENTS AND METHODS

Consecutive poststroke patients with a positive volume-viscosity swallow test for OD 3 months following stroke were studied by videofluoroscopy (VFS). Demographical and clinical factors and kinematics of swallow response were compared between those poststroke patients with safe swallow (penetration-aspiration scale, PAS≤2) and those with unsafe swallow (PAS≥3). Receiver operating characteristic (ROC) curves were drawn for laryngeal vestibule closure (LVC) time which predicts unsafe swallow.

RESULTS

We studied 73 poststroke patients (76.7±9.3 years, 53.4% male) by VFS (60.4% with impaired safety, PAS=4.47±1.44, and 95.9% with impaired efficacy of swallow). Poststroke patients with unsafe swallow presented a poorer functional (Rankin 2.2±1.6 vs 1.2±1.0, P<.012) and nutritional status (MNA-sf≤11, 34.2% vs 7.4%, P<.05) than poststroke patients with safe swallow. Poststroke patients with unsafe swallow presented a significant delay in LVC time (406.4±99.5 ms vs 318.9±80.4 ms; P<.05) and weaker tongue bolus propulsion forces (0.771±0.450 mJ vs 1.638±3.212 mJ; P=.043). LVC time ≥340 ms predicts unsafe swallow in chronic poststroke patients with a diagnostic accuracy of 0.78.

CONCLUSIONS

Impaired safety of swallow in chronic poststroke patients is caused by specific impairments in swallow response including delayed timing of airway protection mechanisms and weak tongue propulsion forces. Treatments aiming to restore swallowing function in poststroke patients with OD should be targeted to improve these critical biomechanical events.

Spatiotemporal characteristics of the pharyngeal event-related potential in healthy subjects and older patients with oropharyngeal dysfunction

BACKGROUND

Oropharyngeal dysphagia (OD) is a highly prevalent symptom in older people. Appropriate oropharyngeal sensory feedback is essential for safe and efficient swallowing. However, pharyngeal sensitivity decreases with advancing age and could play a fundamental role in the physiopathology of swallowing dysfunction associated with aging. We aimed to characterize pharyngeal sensitivity and cortical response to a pharyngeal electrical stimulus in healthy volunteers (HV) and older patients with and without OD.

METHODS

Eight young HV, eight older HV without OD, and 14 older patients with OD were studied by electroencephalography through 32 scalp electrodes. Pharyngeal event-related potentials (ERP) were assessed following electrical stimulation of the pharynx. Sensory and tolerance thresholds to the electrical stimulus and latency, amplitude, and scalp current density of each ERP component were analyzed and compared. An ERP source localization study was also performed using the sLORETA software.

KEY RESULTS

Older participants (with and without OD) presented an increased sensory threshold to pharyngeal electrical stimulation (10.2 ± 1.7 mA and 11.5 ± 1.9 mA respectively), compared with young HV (6.0 ± 1.2 mA). The cortical activation of older HV in response to pharyngeal electrical stimulus was reduced compared with young HV (N2 amplitude: 0.22 ± 0.79 vs -3.10 ± 0.59, P<.05). Older patients with OD also presented disturbances to the pharyngo-cortical connection together with disrupted pattern of cortical activation.

CONCLUSIONS AND INFERENCES

Older people present a decline in pharyngeal sensory function, more severe in older patients with OD. This sensory impairment might be a critical pathophysiological element and a potential target for treatment of swallowing dysfunction in older patients.

The effect of levosulpiride on in vitro motor patterns in the human gastric fundus, antrum, and jejunum

BACKGROUND

Levosulpiride is a 5HT4 agonist/D2 antagonist prokinetic agent used to improve gastric emptying in patients with functional dyspepsia or gastroparesis. The aim of this study was to characterize its effect on the main in vitro motility patterns in the human fundus, antrum, and jejunum.

METHODS

Circular muscle strips from human stomach (antrum and fundus) and jejunum, obtained from 46 patients undergoing bariatric surgery, were studied using organ baths. Enteric motor neurons (EMNs) were stimulated by electrical field stimulation (EFS).

KEY RESULTS

Levosulpiride, caused an increase in the EFS-induced cholinergic contractions in the gastric antrum (+37 ± 15.18% at 100 μM, pEC50 = 4.46 ± 0.14; p < 0.05, n = 8) and jejunum (+45.4 ± 22.03% at 100 μM, pEC50 = 3.78 ± 6.81; p < 0.05, n = 5), but not in the gastric fundus. It also caused a slight decrease in tone and frequency of spontaneous contractions in the jejunum, but did not have any major effect on tone or spontaneous contractions in the stomach. It did not have any effect on EFS-induced relaxations mediated by nitric oxide (NO) in the stomach (antrum and fundus) and by NO and ATP in the jejunum.

CONCLUSIONS & INFERENCES

Our results suggest that the prokinetic effects of levosulpiride in humans are mainly due to the facilitation of the release of acetylcholine by enteric motor neurons in the gastric antrum and the jejunum.

Epidemiological and clinical profiles of hospitalized female patients in the psychiatric hospital “Nuestra Señora Del Pilar” between 1912 and 1915

Introduction

Hospitalization is fundamental in the treatment of severe psychiatric disorders, at present and in the past. The Psychiatric Hospital “Ntra. Sra. Del Pilar de Zaragoza”, established in 1425, is one of the most ancient hospitals and with longest history of the country, one of the first centers to start considering as demented persons as another sick patient. This paper describes the sociodemographic and clinical characteristics of the patients admitted to the psychiatric hospital between 1912 and 1915.

Method

We developed a descriptive research, using secondary information sources (clinical histories) of patients hospitalized between 1912 and 1915. For data analysis was used software SPSS 10.

Results

We reviewed 110 files and the most common diagnoses were senile dementia and manic-depressive psychosis. The mean of age was 42 years, and the predominant marital status was the single status (47%). We documented that in more than 60% of the cases, the precedence of the patients was from rural zone. El 75% of the patients had remained hospitalized during several years until their death. Only the 10% were discharged for improvement.

Conclusion

It is important to understand the socio-economic variables of the female patients from a century ago to be aware of the evolution of psychiatry and psychiatric treatment and consequently of the profile of current patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

High prevalence of colonization of oral cavity by respiratory pathogens in frail older patients with oropharyngeal dysphagia

BACKGROUND

Aspiration pneumonia (AP) is caused by dysfunctional swallowing resulting in aspiration of material colonized by respiratory pathogens. The aim of this study was to assess and compare the swallowing physiology, health status, oral health status, and oral/nasal microbiota in frail older patients (FOP) with oropharyngeal dysphagia (OD) and a control group.

METHODS

We studied 47 FOP (>70 year) with OD by videofluoroscopy (17 with acute pneumonia -APN-, 15 with prior pneumonia-PNP- and 15 without) and 14 older controls without OD (H). Oral/nasal colonization by five respiratory pathogens was evaluated by qPCR, whereas commensal microbiota composition was assessed by pyrosequencing.

KEY RESULTS

(i) Frail older patients with OD presented similar comorbidities, poor functionality, polymedication, and prevalent videofluoroscopic signs of impaired safety of swallow (33.3-61.5%). However, patients with OD-APN also presented malnutrition, delayed laryngeal vestibule closure (409.23 ± 115.6 ms; p < 0.05), and silent aspirations (15.6%). (ii) Oral health was poor in all groups, 90% presented periodontitis and 72%, caries. (iii) Total bacterial load was similar in all groups, but higher in the oropharynx (>10(8) CFU/mL) than in the nose (<10(6) CFU/mL) (p < 0.0001). Colonization by respiratory pathogens was very high: 93% in OD patients (p < 0.05 vs H); 93% in OD-PNP (p < 0.05 vs H); 88% in OD-APN (p = 0.07 vs H), and lower in controls (67%).

CONCLUSIONS & INFERENCES

Frail older patients with OD had impaired health status, poor oral health, high oral bacterial load, and prevalence of oral colonization by respiratory pathogens and VFS signs of impaired safety of swallow, and were therefore at risk for contracting AP.

Mast cell degranulation inhibits motor patterns of human ileum and sigmoid colon in vitro: relevance for postoperative ileus

BACKGROUND

Local release of mast cell proteases during gastrointestinal surgery is associated with the inhibition of motility and postoperative ileus (POI). We determined whether activation of intramuscular mast cell affects the motor patterns of the human ileum and colon and whether proteases are involved.

METHODS

Motor response of ileal and colonic circular muscle strips was measured in organ bath. Mast cell degranulation was induced by compound 48/80 (c48/80; 25-675 μg/mL). Motor response was quantified as tone, rhythmic phasic contractions (RPCs) and contractions to electric field stimulation (EFS; 40 Hz), and bethanechol-evoked contractions. Ketotifen (10(-6) mol/L) and a protease inhibitor cocktail (P8340) were used to evaluate the role of mast cell mediators.

KEY RESULTS

(a) c48/80 impaired the spontaneous and the electrically evoked motor response in small bowel and colonic strips (sigmoid colon EC50 : 460.0 μg/mL for RPCs and 8.9 μg/mL for electrically evoked contraction amplitudes) and bethanechol-evoked contractions. (b) Preincubation with ketotifen (10(-6) mol/L, 1 h) prevented the impairment of RPCs and EFS-evoked contractions in the sigmoid colon and ileum but not in the right colon. (c) Preincubation with P8340 also prevented the impairment of contractions in the sigmoid colon but not in the ileum or the right colon.

CONCLUSIONS & INFERENCES

Mast cell degranulation by c48/80 inhibits the spontaneous and the nerve-mediated motor response in the human ileum and colon. The effect is partially mediated by mast cell proteases and could be relevant in the pathophysiology of POI.

Clinical and Molecular Features of Late Onset Huntington Disease in a Peruvian Cohort

BACKGROUND

Late onset cases of Huntington disease (HD), with onset ≥60 years, account for up to 20% of HD cases worldwide. Clinical features include mild motor dysfunction with slow progression and cognitive impairment, frequent absence of family history and low number of CAG repeats. The clinical and molecular features of late onset HD is still understudied in Latin America.

OBJECTIVES

To describe the clinical and molecular characteristics of late onset HD in a Peruvian cohort.

METHODS

An observational study was carried out by reviewing the HD registry at the Neurogenetics Research Center-INCN from 2000 to 2014. Genotyping of HTT gene …was confirmed using standard PCR and PAGE in accordance to protocols previously established.

RESULTS

Thirty-one late onset HD cases from 27 pedigrees were identified (9.42% of total HD cases, n = 329), 51.61% were male. Mean age at onset was 64.1 ± 4.2 and CAG repeats mean was 42.5 ± 2.5. We did not find significant correlation between age at onset and CAG repeats. 33.3% of cases were traced back to Cañete valley. Twenty-two cases had a positive family history, 14 of them with paternal transmission. Choreic movements and cognitive impairment were the main existing manifestations reported in this cohort, with lower frequency of psychiatric disturbances.

CONCLUSIONS

This report of late onset HD affected individuals shows a mild phenotype expression of the disease, associated with low range of CAG repeats and up to 30% of cases with absence of clear family history. Cañete valley remains the region with more cases.

Nitrergic neuro-muscular transmission is up-regulated in patients with diverticulosis

BACKGROUND

Neuro-transmission impairment could be associated to motility changes observed in patients with diverticular disease. Therefore, the objective was to characterize the inhibitory neuro-muscular transmission and gene expression changes of the enteric inhibitory pathways in patients with diverticulosis (DS).

METHODS

Circular muscle strips from sigmoid colon of patients with DS and controls were studied using the organ bath technique to evaluate spontaneous contractility and enteric motor neurons stimulated by electrical field and qRT-PCR to assess the expression of nNOS, iNOS, P2Y1 R and PGP9.5.

KEY RESULTS

Patients with DS presented decreased spontaneous rhythmic contractions (SRC) that were significantly enhanced after incubation with L-NNA (1 mM) and TTX (1 μM), and unaffected by the P2Y1 antagonist MRS2500 (1 μM). Stimulation on enteric motor neurons caused an increased duration of the latency of OFF-contractions in DS group (p < 0.001), antagonized by L-NNA and slightly affected by MRS2500 (1 μM). No differences in the IC50 between controls and DS patients were observed on inhibition of SRC for the NO-donor sodium nitroprusside (SNP) and the preferential P2Y agonist ADPβS. Moreover, nNOS relative expression was also up-regulated 2.3-fold in the DS group (p < 0.05) whereas there was no significant difference in relative expression of iNOS, P2Y1 R and the neuronal marker PGP9.5 between groups.

CONCLUSIONS & INFERENCES

Patients with DS presented an over-expression of nNOS with increased endogenously NO-mediated responses suggesting enhanced NO-release. Up-regulation in the nitrergic pathway in early stages of the disease might play a role in colonic motor disorders associated to diverticular disease.

Asociación entre el polimorfismo genético de la apolipoproteína E (ApoE) y la enfermedad de Parkinson

En nuestro país, con el incremento en la esperanza de vida, existe una tendencia creciente de enfermedades neurodegenerativas, por lo que se hace necesario realizar estudios sobre factores de riesgo genético en personas afectadas con la enfermedad de Parkinson (EP), entre ellos el gen de la apolipoproteína E (ApoE), ya que esta asociación es desconocida en nuestra población. Objetivo: Determinar la asociación del polimorfismo en el gen ApoE con la EP. Diseño: Estudio asociativo, observacional tipo casos y controles. Lugar: Instituto Nacional de Ciencias Neurológicas, Lima, Perú. Participantes: Personas de ambos sexos, 163 pacientes con la EP y 176 controles. Intervenciones: Extracción de ADN genómico según metodología estándar. Análisis del gen APOE mediante técnica PCR-RFLP. Principales medidas de resultados: Frecuencias genotípicas y alélicas del gen ApoE en los casos y controles, medidas de asociación y de riesgo. Resultados: No se encontró diferencias significativas entre el grupo control y los pacientes según genotipo de ApoE. La frecuencia del alelo ε4 fue similar en pacientes y en controles. El odds ratio para el alelo ε4 de la ApoE fue 1,0852 (IC 95%: 0,5812 a 2,0266). La edad de inicio de la EP no tuvo relación con los genotipos ApoE. Conclusiones: El alelo ε4 de la ApoE no podría ser considerado un factor de riesgo para la EP, y los genotipos de la ApoE no se asociaron con la edad de inicio en esta muestra evaluada.

[Kennedy disease in Peru: first cases with molecular diagnosis]

Kennedy's disease is an X-linked recessive disorder with onset in adulthood, characterized by progressive degeneration of spinal motor neurons due to a dynamic mutation in the androgen receptor gene. We report three families (five cases) characterized by progressive weakness involving both limbs and bulbar muscles, atrophy, tremor, cramps and endocrinologic disturbances; the neurophysiological studies demonstrated second motor neuron impairment. The molecular analysis identified abnormal CAG repeats expansion in the androgen receptor gene (AR) in all cases. Clinical features were consistent with other previous reports. These are the first Peruvian cases of Kennedy's disease with confirmed molecular diagnosis.

[Genetic polymorphism of apolipoprotein E in a Peruvian population]

OBJECTIVES

To determine the allelic and genotypic frequencies of the APOE gene in a sample of a population group in Peru.

MATERIALS AND METHODS

Cross-sectional analytic study in 189 apparently healthy volunteers, workers of the Instituto Nacional de Ciencias Neurológicas in Lima, Perú, divided into 5 groups by birth department and two generations ancestry. Genomic DNA was amplified using PCR-RFLP. The resulting fragments were detected by 12 % polyacrylamide gel electrophoresis.

RESULTS

The ε3 allele is the most frequent in all the groups (93.9 %), with low ε4 (5 %) and ε2 (1.1 %) allele frequencies. The analysis of heterozygosity (H) for each group displays intermediate diversity between 10 and 20%. Population genetic diversity (Ht) and diversity within populations (Hs) are 14.43 % and 14.31% respectively, suggesting genetic proximity between the studied groups for the ApoE polymorphism.

CONCLUSIONS

Allele frequencies of the ApoE gene found show that allele ε3 has one of the highest frequencies and ε4 allele one of the lowest compared to other population groups in the world, with possible implications in the risk of neurological, cardiovascular and other diseases in our country.

Lrrk2 p.Q1111H substitution and Parkinson's disease in Latin America

Mutations in the LRRK2 gene are the most common genetic cause of Parkinson's disease, with frequencies displaying a high degree of population-specificity. Although more than 100 coding substitutions have been identified, only seven have been proven to be highly penetrant pathogenic mutations. Studies however are lacking in non-white populations. Recently, Lrrk2 p.Q1111H (rs78365431) was identified in two affected Hispanic brothers and absent in 386 non-Hispanic white healthy controls. We therefore screened this variant in 1460 individuals (1150 PD patients and 310 healthy controls) from 4 Latin American countries (Peru, Chile, Uruguay and Argentina). In our case-control series from Peru and Chile we observed an increased frequency of Lrrk2 p.Q1111H in patients (7.9%) compared to controls (5.4%) although the difference did not reach significance (OR 1.38; p = 0.10). In addition, the frequency of Lrrk2 p.Q1111H varied greatly between populations and further screening in a set of pure Amerindian and pure Spanish controls suggested that this variant likely originated in an Amerindian population. Further studies in other Latin American populations are warranted to assess its role as a risk factor for Parkinson's disease. Screening in Parkinson's disease patients from under-represented populations will increase our understanding of the role of LRRK2 variants in disease risk worldwide.

[Profile and professional expectations for nursing students]

The authors describe the profile corresponding to students enrolled in first, second and third year courses to become registered nurses in Catalonia, along with their professional and job expectations; the authors examine students' perceptions of the university environment. This information will be a great aid to, on the one hand, update the performances and initiatives taken by those responsible for nursing schools, and on the other hand, to obtain a preliminary view on future nursing professionals. At the same time, this information will provide useful elements for students themselves to reflect on their studies and their future as professionals.

Treatment of hirudin overdosage in a dialysis patient with heparin-induced thrombocytopenia with mixed hemodialysis and hemofiltration treatment

We report a patient who developed type II heparin-induced thrombocytopenia (HIT) and accidentally received a recombinant hirudin (r-hirudin) overdosage. Treatment with hemodialysis (HD) using high-flux polysulfone dialyzer and hemofiltration was performed. Length of treatment was adjusted, monitoring activated partial thromboplastin time (aPTT) to 1.5-2.5 times the mean of the normal range. She developed deep venous thrombosis and occlusion of vascular access. Only after cessation of heparin lock catheter, platelet count began to increase. After one year of treatment with acenocoumarol and additional low-dose r-hirudin, neither bleeding nor thrombotic episodes have been reported.

[Sclerosing encapsulating peritonitis: a latent threat. Changes of posture in surgery treatment]

Sclerosing Encapsulating Peritonitis (SEP) is a rare but serious complication of continuous ambulatory peritoneal dialysis (CAPD) with a high morbi-mortality. We describe our experience with patients was diagnostic of SEP, their characteristics in CAPD and their clinic evolution after diagnosis. 190 CAPD patients were follow-up during 17 years. Eight patients (4.2%) developed SEP. Average age 45+/-14 years (range 29-64 years), four was male. Time in CAPD was 72+/-29 months (range 24-120 months). All patients have peritonitis previously (mean 3+/-1). We observe a change in peritoneum characteristics (D/P Cr 4), with an average of 0.6+/-0.1 at one year of CAPD, versus 0.82+/-0.08 at the end of CAPD, with statistic significance (p<0.001). There are increases in use of hypertonic bags: 53%+/-28 at beginning versus 91%+/-27 at end, with statistic significance (p<0.009). All patients show tendency to hyperphosphoremia (mean 6.7+/-0.7 mg/dl), with product calcium-phosphorus 68.4+/-8.3. Five patients (62.5%) have a previous renal transplant, one lost due to early graft thrombosis and two lost due to acute rejection. Six patients (75%) have a previous abdominal surgery, although was extra peritoneal in all cases. The diagnosis of SEP was clinic suspicion in all cases, suggestive radiological data (intestinal handle group) and laparoscopy showing SEP (cocoon) with histological confirmation (fibrosis and peritoneal calcification) in four cases. The treatment was medical in six cases associated with surgery in four of them. The medical treatment was tamoxifen and/or corticosteroids, associated with total parenteral nutrition in two patients and enteral nutrition in one. Surgery in six patients: three as urgent surgery (all died) and three as programme surgery (two live still). Etiology of died was: three for sepsis, one for peritonitis after bowel perforation, one for severe problems of nutrition. The average survival of three patients alive was 38+/-17 months, two of them had programme surgery, and one with functioning transplant we opt for conservative treatment. The actuarial survival at 24 months was 51%.

CONCLUSION

The SEP is a serious entity with high mortality. Although our short experience doesn't can indicate a concrete treatment, our personal impression is that early surgery associated with corticosteroids treatment may improve the prognostic.

[Factors which influence phosphorus removal in hemodialysis]

BACKGROUND

The sustained elevation of phosphorous among patients with end-stage renal failure is associated with elevated mortality rates. Phosphate binding agents are usually necessary to control serum phosphate levels. Phosphate removal during dialysis is limited largely due to the intracellular location of most inorganic phosphorous. The membrane surface, the frequency and the duration of therapy have proved to be very important factors in the serum phosphate control. THE AIM of our work is to investigate the influence on phosphate removal of factors that normally participate in the haemodialysis session: Plasma phosphate level (Php), treatment duration, membrane surface, high or low-flux membranes, the vascular access, dialysate flux , the volume of blood passing through the dialyzer (L) in each dialysis session and the blood flow during the first hour of dialysis. On 16 patients, we also had the possibility of comparing phosphate removal with 1.8 m(2) high-flux haemodialysis, 1.8 m(2) on-line hemodiafiltration and the on-line technique with the new Helixone dialyzer Fresenius Fx100.

METHODS

108 haemodialysis patients, 62% men, 38% women aged 21-82 years (61+/-14;mean+/-sem),) were selected for the study. Mean treatment time 4.14+/-0.41 hours (range 3.5-5 hours). The vascular access was an arterio-venous fistula in eighty five (78%) and a double lumen tunnelled catheter 23 (22%). Patients were studied under their normal every day conditions. High-flux membrane was used by 31 (30%) patients and low-flux membrane by 77 (70%). Membrane surface was: 1.7 m2:17 (16%); 1.8 m2:77 (71%); 2,1 m2:14 (13%). Dialysate flux was: 500 ml/min. 55 patients; 700 ml/min: 53 patients. In 16 out of 108 patients we had the possibility of using on-line hemodiafiltration with ultrapure bicarbonate-buffered dialysate. Phosphate mass removal (MPO4) was calculated using the formula:MPO4=0.1 t-17+50 Cds 60+11Cb 60 (1), where t is treatment time in minutes, Cds60 and Cb60 are phosphate concentrations in dialysate and plasma measured at 60 min from the beginning of hemodialysis in mg/dl, and MPO4 is the estimated phosphate removed in mg/treatment.

RESULTS

We found a good correlation between phosphate removal and serum phosphate levels (p=0.01), but not with the membrane surface or treatment duration. Phosphate removal was 640+/-180 mg/session with low-flux membrane and 700+/-170 mg/session with high-flux membrane (p=0.280). The MPO4 was 720+/-190 mg/treatment in patients with a AV fistula and 620+/-180 in patients with a tunnelled catheter (p=0.023). We found a good correlation between phosphate removal and the volume of blood (L) that passed the dialyzer in each session (r=0.001) but we did not find a correlation between phosphate removal and KT/Vurea, the dialysate flux or the ultra filtration. On-line technique did not increased the MPO4(733+/-280 mg, p=0.383). The on-line technique with the new dialyzer (Fresenius Fx100), increased the phosphate removal to 759+/-199 mg/session (p=0.057).

CONCLUSION

Phosphate removal during dialysis is influenced by Plasma phosphate levels, the volume of blood that passed the dialyzer and the vascular access. Uniformity on time and membrane surface could explain the abs cense of influence in our case. The ultra filtration, dialysate flux, membrane permeability or on-line hemodiafiltration does not influence the phosphate removal. The new membrane helixone with 2,1 m2 (Fresenius Fx100) increases phosphate removal probably because the membrane surface is higher.

[Telemedicine and follow up of peritoneal dialysis patients]

Mean-term experience in the use of Telemedicine in Peritoneal Dialisis (PD) patients is limited as well as its cost-benefit. The main objective of this work is to evaluate Telemedicine utility in mean-long term control of stable PD patients, analyzing if the televisit (TV) could substitute 50% of the programed inhospital consults (HC) the time spent in both visit modalities, the quality of patient-personel contact as well as how image and sound have been perceived. Visit resolution was analyzed taking into account the need of HC after a TV; We also have studied if it would be possible to retrain patients in the dialisis technique with telemedicine, and we have checked the patient perceived quality and calculate the real and social costs.

METHODS

during 18 months, the system has been implanted to 19 patients with 7 +/- 4 follow up (range 3-17). A Falcon videoconference kit at patient's place was used, connected to the home television set. In the hospital there was a computer with a videoconference card, webcam and software meeting point which permits the control of patient's camera from the hospital. Both are connected by a 3RDSI line system. A monthly programmed HC or TV has been made. If more controls had been required, they have been made by TV Time spent was recorded on each TV and patients and staff questionary were inquired.

RESULTS

(a)

PATIENTS

mean age 44 +/- 8 years, 13 (68%) male. 12 (63%) had elemental educational level and 7 (37%) mean-superior. 17 (89%) were actively working. The PD technique was: CAPD 6 (32%) and APD13 (68%). (b) Televisits: 103 TV have been made. 22 +/- 9 minutes were spent on each TV less than in the HC, 33 +/- 8 minutes (p < 0.01). There were technical problems related with lines in 21 TV, but only in 4 the connection was not possible. 92 TV (89%) were made on time, 99 (96%) had a good image quality and 96 (93%) had a correct sound. 100% of patients perceived TV as close to HC. In 90 TV (87%) medical treatment was modified. Only in 4 cases (3.9%) patients needed an hospital visit. According to patient's valuation, TV replaced correctly to HC in 97 instances (94%) and in 97 (97%) in staff opinion. In all cases (100%) catheter exit site could be evaluated as well as edema presence. Retraining was possible in all cases. There was a save in nurse's time and patient's time and also, a save in physical hospital space. Initial investment apart, the daily cost increment was scarce (1.5 Euro) taking into account that there is a save in time for patients and personnel, save in physical space in hospital and in sanitary transport.

CONCLUSION

Telemedicine is useful from the clinical point of view in the mean-term for stable patients in PD. Daily cost increment is scarce and there is a save in time for patients and personnel, save in physical space in hospital and in sanitary transport.

Peritoneal sodium mass removal in continuous ambulatory peritoneal dialysis and automated peritoneal dialysis: influence on blood pressure control

BACKGROUND/AIM

Sodium and water retention is common in peritoneal dialysis patients and contributes to cardiovascular disease. As peritoneal sodium removal depends partly on dwell time, and automated peritoneal dialysis (APD) often uses short dwell time exchanges, the aim of this study was to compare the 24-hour peritoneal sodium removal in APD and standard continuous ambulatory peritoneal dialysis (CAPD) patients and to analyze its possible influence on blood pressure control.

METHODS

A total of 53 sodium balance studies (30 in APD and 23 in CAPD) were performed in 36 stable peritoneal dialysis patients. The 24-hour net removal of sodium was calculated as follows: M = ViCi - VdCd, where Vd is the 24-hour drained volume, Cd is the solute sodium concentration in Vd, Vi is the amount of solution used during a 24-hour period, and Ci is the sodium concentration in Vi. Peritoneal sodium removal was compared between APD and CAPD patients. Residual renal function, serum sodium concentration, daily urinary sodium losses, weekly peritoneal Kt/V and creatinine clearance, 4-hour dialysate/plasma creatinine ratio, proportion of hypertonic solutions, net ultrafiltration, systolic and diastolic blood pressures, and need for antihypertensive therapy were also compared between the groups.

RESULTS

Peritoneal sodium removal was higher (p < 0.001) in CAPD than in APD patients. There were no significant differences in residual renal function, serum sodium concentration, urinary sodium losses, peritoneal urea or creatinine clearances, 4-hour dialysate/plasma creatinine ratio, or proportion of hypertonic solutions between groups. The net ultrafiltration was higher in CAPD patients and correlated strongly (r = 0.82; p < 0.001) with peritoneal sodium removal. In APD patients, peritoneal sodium removal increased significantly only in those patients with a second daytime exchange. The systolic blood pressure was higher (p < 0.05) in APD patients, and the proportion of patients with antihypertensive therapy was also higher in APD patients, although no significant relationship between blood pressure values and amount of peritoneal sodium removal was found.

CONCLUSIONS

The 24-hour sodium removal is higher in CAPD than in APD patients, and there is a trend towards better hypertension control in CAPD patients. As hypertension control and volume status are important indices of peritoneal dialysis adequacy, our results have to be considered in the choice of the peritoneal dialysis modality.

[Influencing factors in the control of phosphorus in peritoneal dialysis. Therapeutic options]

Impaired phosphate excretion resulting in hyperphosphatemia is one of the earliest consequences of chronic renal failure. To control serum phosphate levels, we can use the following therapies: 1) Restriction of dietary phosphate (but on CAPD, obligatory protein losses via peritoneal fluid makes impractical any reduction of phosphate diet. 2) Reduction of phosphate absorption, using phosphate binders. 3) Peritoneal phosphate removal.

OBJECTIVE

1) To evaluate the factors affecting peritoneal phosphate removal such as plasma phosphate, peritoneal membrane transport type, peritoneal dialysis modality prescription (CAPD or APD) and daily dialysate volume. 2) To test the best calcium concentration in the peritoneal dialysis fluid (5, 6 or 7 mg/dl) in order to permit the use of calcium carbonate or acetate without the risk of hypercalcemia or hyperparathyroidism.

METHOD

Phosphate was measured in seventy 24-hour dialysate collections, 33 from patients on CAPD and 37 from patients on APD. 24-hour peritoneal phosphate removal (mg/24 hours) and weekly peritoneal phosphate clearance was calculated (L/week). The peritoneal membrane was studied by the peritoneal equilibrium test (PET), using a 2.27% glucose. We calculated also the peritoneal calcium balance in 25 daily peritoneal fluid collections from patients using a calcium dialysate concentration of 5, 6 or 7 mg/dl each one. IPTH levels and doses of vitamin D were compared at 6 months in patients using a calcium concentration of 5, 6 or 7 mg/dl from the beginning of peritoneal dialysis (5 patients of each calcium dialysate concentration).

RESULTS

Weekly peritoneal phosphate clearance (WPC) were higher or APD than on CAPD (51 +/- 21 vs 41 +/- 14, p < 0.005). Daily dialysate volume was also higher on APD (14 +/- 4 vs 7.8 +/- 1.8 L/day, p < 0.001). WPC was higher on APD when a mild-day exchange was done (61 +/- 23 vs 45 +/- 15, p < 0.005), instead an equal total daily volume of the dialysate. Peritoneal calcium balance was significantly more negative in patients using a calcium in the dialysis fluid of 5 than 6 or 7 mg/dl (-125 +/- 7 vs -18 +/- 41 vs -11 +/- 49, p < 0.001). At 6 months, patients using a calcium fluid concentration of 5 mg/dl increased iPTH levels (from 160 +/- 101 to 332 +/- 153, p < 0.001) and vitamin D needs (from 0 to 1.87 +/- 0.37 mcg/week, p < 0.001). In summary, peritoneal phosphate clearance depends on plasma phosphate levels, daily volume of dialysate prescribed and peritoneal membrane transport characteristics. It can be improved by increasing the total peritoneal fluid. On APD, a mild-day exchange may improve phosphate clearance, without total volume increase. The risk of secondary hyperparathyroidism can be decreased with a calcium fluid concentration of 6 mg/dl, which was shown to be better than 5 mg/dl when calcium phosphate binders are not correctly taken.

[Benign mediastinal opacity: Castleman disease, apropos of a case and review of the current literature]

We report a case of fortuitously observed Castleman's disease. An mediastinal opacity was observed on the chest x-ray. At surgery, the apparently benign tumor was well individualized. Pathology reported Castleman's disease. Pathogenesis is unknown. Recent data on localized and more diffuse forms of this disease are presented. Diffuse forms occur more readily in immunodepressed patients.