High blood pressure represents a major public health problem. Worldwide, approximately one-fourth of the adult population has hypertension. Epidemiological and experimental studies suggest a link ...between hyperuricemia and hypertension. Hyperuricemia affects 25% to 40 % of individuals with untreated hypertension; a much lower prevalence has been reported in normotensives or in the general population. However, whether lowering serum uric acid (UA) might lower blood pressure (BP) is an unanswered question.
To determine whether UA-lowering agents reduce BP in patients with primary hypertension or prehypertension compared with placebo.
The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to February 2016: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 2), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also searched LILACS up to March 2016 and contacted authors of relevant papers regarding further published and unpublished work.
To be included in this review, the studies had to meet the following criteria: 1) randomized or quasi-randomized, with a group assigned to receive a UA-lowering agent and another group assigned to receive placebo; 2) double-blind, single-blind or open-label; 3) parallel or cross-over trial; 4) cross-over trials had to have a washout period of at least two weeks; 5) minimum treatment duration of four weeks; 6) participants had to have a diagnosis of essential hypertension or prehypertension, and hyperuricemia (serum UA greater than 6 mg/dL in women, 7 mg/dL in men and 5.5 mg/dL in children/adolescents); 7) outcome measures assessed included change in clinic systolic, diastolic or 24-hour ambulatory BP.
The two review authors independently collected the data using a data extraction form, and resolved any disagreements via discussion. We assessed risk of bias using the Cochrane Collaboration' Risk of bias' tool.
In this review update, we examined the abstracts of 349 identified papers and selected 21 for evaluation. We also identified three ongoing studies, the results of which are not yet available. Three other randomized controlled trials (RCTs) (two new), enrolling individuals with hypertension or prehypertension, and hyperuricemia, met the inclusion criteria for the review and were included in the meta-analysis. Low quality of evidence from three RCTs indicate no reduction in systolic (MD -6.2 mmHg, 95% CI -12.8 to 0.5) or diastolic (-3.9 mmHg, 95% CI -9.2 to 1.4) 24-hour ambulatory BP with UA-lowering drugs compared with placebo. Low quality of evidence from two RCTs reveal a reduction of systolic clinic BP (-8.43 mmHg, 95% CI -15.24 to -1.62) but not diastolic clinic BP (-6.45 mmHg, 95% CI -13.60 to 0.70). High quality of evidence from three RCTs indicates that serum UA levels were reduced by 3.1 mg/dL (95% CI 2.4 to 3.8) in the participants that received UA-lowering drugs. Very low quality of evidence from three RCTs suggests that withdrawals due to adverse effects were not increased with UA-lowering therapy (RR 1.86, 95% CI 0.43 to 8.10).
In this updated systematic review, the RCT data available at present are insufficient to know whether UA-lowering therapy also lowers BP. More studies are needed.
•The intensive care unit can use indicators that measure the nursing workload.•The nursing workload is high in the first 24 hours after liver transplantation.•The increase in nursing workload is ...related to patient severity.•Nursing workload after liver transplantation gradually decreases until discharge.•Nursing workload assessment in patients post liver transplant is a strategy in care.
Liver transplantation is a complex treatment that demands a high workload from the nursing team. This study evaluated the nursing workload and its relationship with the severity of patients after liver transplantation.
A retrospective cohort study, with a review of 286 medical records of liver transplant patients from January 2014 to June 2018 in a hospital in southern Brazil was performed. Demographic and clinical characteristics were analyzed, as well as the outcome and the scores Model for End-Stage Liver Disease (MELD), Nursing Activity Score (NAS), and Acute Physiology and Chronic Health Evaluation IV (APACHE IV).
Men represented 68.9% of the sample, the mean age was 57.6 years (±10), and the MELD and APACHE IV scores respectively showed means of 24.3 (±5.6) and 58.9 (±23.7). The length of stay in the intensive care unit was 5 days (range, 3-7) and mortality was 9.1%. There was a gradual reduction in the mean NAS in 24 hours (94.9 ± 18.5), 48 hours (87.2 ± 17.0), 72 hours (83.3 ± 19.6) and at discharge (82.3 ± 18.0). Associations of NAS with MELD (P ˂ .05), APACHE IV (P ˂ .001), length of stay in the intensive care unit (P ˂ .001), and death outcome (P ˂ .001) were observed. The greatest workload was in checking vital signs, water balance, and administrative tasks (P ˂ .001).
The nursing workload in the postoperative period of liver transplantation exceeds what is recommended and is related to the severity of the patients.
Self-medication and the belief that herbal products are free of health risks are common in Brazil. The kava (Piper methysticum), known for its anxiolytic action, has a widespread popular use. ...Hepatotoxicity of kava is reported, including cases of liver transplantation and death. The kava had its use prohibited or restricted in countries like Germany, France, among others. Toxicity may be related to overdosage; however, factors such as botanical characteristics of the plant, the harvesting, storage, and production process may be associated with the development of hepatotoxic substances, such as triggering idiosyncratic reactions.
In this case, there is a suspicion that the toxicide is intrinsic to the drug; however, the possibility of adulterants and contaminants must be ruled out.
This study reports the case of a patient who, after using the herbal kava for 52 days, evolved into acute liver failure and liver transplantation.
The data were collected directly with the patient and compared with their clinical records. Causality was determined through the RUCAM algorithm. In addition, a phytochemical analysis of the drug used was performed.
According to the patient's report, there is no evidence of overdosage. Results from RUCAM algorithm infer causality between liver damage and the use of kava. The analysis chemical constituents did not find any possible contaminants and major changes in the active compounds. Seven months after transplantation, the patient is well and continues to be followed up by a medical team.
Our investigation indicates that there was kava-induced hepatotoxicity at standard dosages. In Brazil, self-medication by herbal medicines is frequent and many patients and health professionals do not know the risks associated with their use. Diagnosing and notifying cases in which plants and herbal medicine induce liver damage is of paramount importance to increase the knowledge about DILI and to prevent or treat similar cases quickly.
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ObjectivesCarbapenemase-producing Klebsiella pneumoniae (CP-Kp) is a major cause of infections in transplanted patients and has been associated with high mortality rates in this group. There is a ...lack of information about the Brazilian structure population of CP-Kp isolated from transplanted patients. By whole-genome sequencing (WGS), we analyzed phylogeny, resistome, virulome of CP-Kp isolates, and the structure of plasmids encoding blaKPC–2 and blaNDM–1 genes.MethodsOne K. pneumoniae isolated from each selected transplanted patient colonized or infected by CP-Kp over a 16-month period in a hospital complex in Porto Alegre (Brazil) was submitted for WGS. The total number of strains sequenced was 80. The hospital complex in Porto Alegre comprised seven different hospitals. High-resolution SNP typing, core genome multilocus sequence typing (cgMLST), resistance and virulence genes inference, and plasmid reconstruction were performed in 80 CP-Kp.ResultsThe mortality rate of CP-Kp colonized or infected transplanted inpatients was 21.3% (17/80). Four CP-Kp epidemic clones were described: ST11/KPC-2, ST16/KPC-2, and ST15/NDM-1, all responsible for interhospital outbreaks; and ST437/KPC-2 affecting a single hospital. The average number of acquired resistance and virulence genes was 9 (range = 2–14) and 27 (range = 6–36), respectively. Two plasmids carrying the blaKPC–2 were constructed and belonged to IncN and IncM types. Additionally, an IncFIB plasmid carrying the blaNDM–1 was described.ConclusionWe detected intrahospital and interhospital spread of mobile structures and international K. pneumoniae clones as ST11, ST16, and ST15 among transplanted patients, which carry a significant range of acquired resistance and virulence genes and keep spreading across the world.
To customize and externally validate the recently proposed Simplified Mortality Score for the ICU (SMS-ICU, a simple score for 90-day mortality that has no need for ancillary testing results) for ...in-hospital mortality and to compare its performance to SAPS 3.
We used data from two distinct large cohorts of adult Brazilian patients with unplanned ICU admissions to perform a first-level customization (43,017 patients admitted to 78 ICUs) of the original SMS-ICU score for in-hospital mortality and, sequentially, externally validate it (313,365 patients admitted to 99 ICUs). Performance of SMS-ICU was assessed through measurements of discrimination and calibration and compared with SAPS 3.
In the validation cohort, median SMS-ICU was 13 (IQR 8–16) points and median SAPS 3 was 44 (IQR 36–51). Discrimination of SMS-ICU was good (AUC 0.817; 95% CI 0.814–0.819) but slightly lower than of SAPS 3 (AUC 0.845; 95% CI 0.843–0.848;). The customized SMS-ICU predictions were comparable to SAPS 3 in terms of calibration.
In this external validation of the SMS-ICU in a large Brazilian cohort, we observed good discrimination of SMS-ICU and acceptable calibration after first-level customization. SMS-ICU can be used as a measure of illness severity for acutely admitted ICU patients in clinical studies.
•Severity scores usually require laboratory data, which may result in missing values and increase burden of data collection•A simple illness severity score of seven variables (SMS-ICU) has good discrimination and acceptable calibration in a large cohort of critically ill patients•SMS-ICU could be used as an alternative to traditional illness severity scores specially in the context of clinical studies
Os médicos que atuam em unidades críticas são propensos a exaustão emocional, manifestações de despersonalização e insatisfação profissional. Essas três manifestações compõem o que foi identificado ...como burnout e são motivo de crescente preocupação. Neste artigo, os autores revisam a literatura disponível sobre o burnout entre os médicos intensivistas, mas discutem-no sob uma ótica que inclui o problema em uma manifestação mais ampla, relacionada ao culto do desempenho e à subsunção da vida ao capital, entendendo esse fenômeno como relacionado com a sociedade do burnout. Também se discutem iniciativas para combater esse quadro na perspectiva de uma visão ampliada do conceito de biopolítica, especialmente a psicopolítica.
The philosophy of organ allocation is the result of two seemingly irreconcilable principles: utilitarianism and distributive justice. The process of organ donation and transplantation in Brazil ...reveals large inequalities between regions and units of the Federation, from the harvesting of organs to their implantation. In this context, lung transplantation is performed in only a few centers in the country and is still a treatment with limited long-term results. The allocation of the few organs harvested for the few procedures performed is defined mainly by chronology, a criterion that is not linked to necessity, which is a criterion of distributive justice, and neither to utility, a criterion of utilitarianism. This article reviews the organ allocation philosophy focusing on the case of lung transplantations in Brazil.
Resumo: O processo de doação e transplante hepático no Brasil revela grandes desigualdades entre regiões e Unidades da Federação, desde a captação de órgãos até o implante do fígado. Em 2006, o ...escore MELD (Model for End-stage Liver Disease), inspirado no modelo estadunidense e baseado no princípio da necessidade, foi introduzido no Brasil para a alocação de fígado. Porém, as desigualdades no nosso país têm comprometido, parcialmente, o sucesso dessa iniciativa. Em outros países, já se presencia uma crescente discussão sobre o benefício de modelos que tentam harmonizar utilitarismo e necessidade. O presente artigo revisa a literatura pertinente com um foco especial na realidade brasileira.
Abstract: The process of liver donations and transplants in Brazil reveals major inequalities between regions and states of the country, ranging from uptake of the organs to their transplantation. In 2006, the MELD score (Model for End-stage Liver Disease), inspired by the U.S. model and based on the principle of need, was introduced in Brazil for liver transplant allocation. However, Brazil’s inequalities have partially undermined the initiative’s success. Other countries have already benefited from growing discussion on the benefits of models that seek to harmonize utilitarianism and need. The current article reviews the relevant literature with a special focus on the Brazilian reality.
Resumen: El proceso de donación y trasplante hepático en Brasil revela grandes desigualdades entre regiones y unidades de la federación, desde la captación del órgano hasta el implante del mismo. En 2006, el marcador MELD (Model for End-stage Liver Disease), inspirado en el modelo estadounidense, y basado en el principio de necesidad, fue incorporado en Brasil para la asignación en trasplantes de hígado. No obstante, las desigualdades en nuestro país han comprometido, parcialmente, el éxito de esta iniciativa. En otros países, ya se vive una creciente discusión sobre el beneficio de modelos que intentan armonizar utilitarismo y necesidad. Este artículo revisa la literatura pertinente, centrándose especialmente en la realidad brasileña.
Acute liver failure is a rare syndrome with high mortality and is often diagnosed
late. Intensivist physicians play fundamental roles in the diagnostic suspicion
and the management of the ...multiple-organic dysfunctions characteristic of this
entity. Immune reconstitution inflammatory syndrome is an entity that is
characterized by the paradoxical worsening of the patient's previous condition,
after the initiation of antiretrovirals, triggered against either pathogens
present in the host or autoantigens. Autoimmune hepatitis has recently been
described as one of these autoimmune manifestations. The authors report the
first case with evolution to acute liver failure and death within a few days
after the development of encephalopathy, review the cases of autoimmune
hepatitis described and comment on the therapeutic possibilities in this
context.
Liver transplantation is the only curative therapeutic modality available for individuals at end-stage liver disease. There is no reliable method of predicting the early postoperative outcome of ...these patients. The Acute Physiology and Chronic Health Evaluation (APACHE) is a widely used model for predicting hospital survival and benchmarking in critically ill patients. This study evaluated the calibration and discrimination of APACHE IV in the postoperative period of elective liver transplantation in the southern Brazil.
This was a clinical prospective and unicentric cohort study that included 371 adult patients in the immediate postoperative period of elective liver transplantation from January 1, 2012 to December 31, 2016.
In this study, liver transplant patients who evolved to hospital death had a significantly higher APACHE IV score (82.7±5.1 vs. 51.0±15.8; p<0.001) and higher predicted mortality (6.5% 4.4–20.2% vs. 2.3% 1.4–3.5%; p<0.001). The APACHE IV score showed an adequate calibration (Hosmer-Lemeshow – H-L=11.37; p=0.181) and good discrimination (Receiver Operator Curve – ROC of 0.797; Confidence Interval 95% – 95% CI 0.713–0.881; p<0.0001), although Standardized Mortality Ratio (SMR=2.63), (95% CI 1.66–4.27; p<0.001) underestimate mortality.
In summary, the APACHE IV score showed an acceptable performance for predicting a hospital outcome in the postoperative period of elective liver transplant recipients.
O transplante de fígado é a única modalidade terapêutica curativa disponível para indivíduos com doença hepática terminal. Não há método confiável de prever o resultado pós-operatório imediato desses pacientes. A Avaliação da Gravidade da Doença Crônica e Aguda com bases Fisiológicas (APACHE) é um modelo amplamente utilizado para prever a sobrevida hospitalar e fazer a avaliação comparativa de pacientes criticamente enfermos. Este estudo avaliou a calibração e discriminação do APACHE IV no pós-operatório de transplante hepático eletivo no sul do Brasil.
Estudo clínico prospectivo de coorte em centro único que incluiu 371 pacientes adultos no pós-operatório imediato de transplante hepático eletivo de 1 de janeiro de 2012 a 31 de dezembro de 2016.
Neste estudo, pacientes com transplante hepático que evoluíram para óbito hospitalar obtiveram escore APACHE IV significativamente maior (82,7±5,1 vs. 51,0±15,8; p<0,001) e mortalidade prevista mais alta (6,5% 4,4% –20,2% vs 2,3% 1,4% –3,5%, p<0,001). O escore APACHE IV mostrou uma calibração adequada (Hosmer-Lemeshow – H-L=11,37; p=0,181) e boa discriminação (Receiver Operator Curve – ROC de 0,797; intervalo de confiança de 95% – IC 95% 0,713-0,881; p<0,0001), embora a taxa de mortalidade padronizada (Standardized Mortality Ratio – SMR=2,63), (IC 95% 1,66-4,27; p<0,001) subestime a mortalidade.
Em resumo, o escore APACHE IV mostrou um desempenho aceitável para predizer um desfecho hospitalar no período pós-operatório de receptores eletivos de transplante hepático.
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