Rabdomiólise em militares: uma missão de reconhecimento para prevenção

O treinamento físico regular faz parte do cotidiano militar, com intuito de aprimorar competências físicas essenciais para tarefas de combate. No entanto, quando executado de forma extenuante ou desenvolvido em condições climáticas adversas pode ocasionar o desenvolvimento da rabdomiólise por esforço físico. A rabdomiólise por esforço físico é definida como uma síndrome decorrente da necrose das células musculares, com sintomas variáveis, como dor muscular, fraqueza e aumento plasmático de enzimas musculares. A severidade da rabdomiólise por esforço físico varia individualmente, porém, pode se tornar clinicamente relevante, contribuindo para a hospitalização, insuficiência renal aguda, incapacidade permanente ou óbito. Sendo assim, o objetivo desta revisão narrativa é apresentar possíveis causas e fatores de risco para rabdomiólise, discutir sua fisiopatologia, seus possíveis diagnósticos e suas principais complicações, enfatizando o contexto militar.

Reporting quality and adherence of randomized controlled trials about statins and/or fibrates for diabetic retinopathy to the CONSORT checklist

BACKGROUND

A considerable amount of randomized controlled trials (RCTs) have been published on statins and/or fibrates for diabetic retinopathy, a clinical condition associated with high social and economic burden. Adherence to the CONSORT statement items is imperative to ensure transparency and reproducibility in clinical research. The aim of this study is to assess the reporting quality and the adherence to CONSORT of RCTs assessing statins and/or fibrates for diabetic retinopathy.

METHODS

We conducted a critical appraisal study at Discipline of Evidence-based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp). A sensitive literature search was performed to identify all relevant RCTs, with no time or language limits. Two authors independently evaluated the reporting quality of the selected RCTs using the CONSORT statement as a standard.

RESULTS

Thirteen reports of RCTs were included in this study. The adherence of the reports to CONSORT items ranged from 24% to 68%. The median score was 11 (interquartile range (IQR) 8 to 13). When analyzed separately, the methods sections of the reports had a median of three items (IQR 2 to 4) judged adherent to the methods items of CONSORT (items 3 to 12). The most underreported items were those related to trial design, title and abstract, allocation concealment, implementation of the randomization sequence, and blinding. Other important items, such as the one related to the description of the inclusion criteria, also had low adherence.

CONCLUSIONS

The overall adherence to the CONSORT checklist items was poor, especially in the items related to the methods section. RCT reports on statins and/or fibrates for diabetic retinopathy must be optimized to avoid reporting biases and to improve transparency and reproducibility.

Differences for T-Cell Subtypes in Aspiration Biopsies of Patients With Kidney Transplant Under Polyclonal and Monoclonal Immunosuppressive Treatments

Thymoglobulin, or antithymocyte globulin (ATG), and anti-interleukin 2α (IL-2α) chain receptor antibody (IL-2αRAb) achieve comparable good results in kidney transplantation notwithstanding different actions on immune cells. Previously, we reported the usefulness of flow cytometry (FC) analysis of lymphocyte subsets present in peripheral blood sample (PBL) and fine-needle aspiration biopsies (FNABs) for clinical surveillance, as, FC reaches very high predictive positive values for acute rejection diagnosis. Now we report an FC study on 2 kidney transplantation (KT) groups under ATG (n = 19) and IL-2αRAb (n = 24) treatment. Both groups were further treated with calcineurin inhibitors mycophenolate mofetil (MMF) and prednisone. PBL and FNAB samples were collected on day 7 post-KT, stained for several T- and B-lymphocyte subsets, and acquired using FACScan. Statistical analysis were done by Mann-Whitney U test. FNAB results showed a significant downregulation by ATG of CD3 (P < .001), CD4 (P = .009), CD4CD29 (P = .003), and CD2 (P ≤ .001) and significant upregulation of death receptor (DR) (P = .03), CD3CD69 (P < .001), and CD3CD25 (P < .0001) as compared to groups treated with IL-2αRAb. For PBL, the same trend was seen for CD3, CD4, CD2, CD3CD25, CD3CD69, CD4CD29, and DR plus a downregulation of CD45RO (P = .001) and an upregulation of CD4CD45RA (P < .0001) in IL-2αRAb. This study shows that among stable KTs, ATG as compared to IL-2αRAb induces a significant downregulation of a subset of T-memory (CD4CD29) cells but an upregulation of antigen-experienced cells (CD45RO). Further, ATG decreases CD2, CD3, CD4, and naïve (CD45RA) and stimulates T cells as translated by CD3CD69 and DR. As it should be expected from an IL-2αRAb agent, CD25 cells were virtually eliminated.

Carbapenem-resistant Enterobacteriaceae in patients admitted to the emergency department: prevalence, risk factors, and acquisition rate

BACKGROUND

Carbapenem-resistant Enterobacteriaceae (CRE) have been reported worldwide and are associated with high mortality rates. Intestinal colonization acts as a reservoir and fosters exchange of resistance mechanisms.

AIM

To investigate the prevalence of patients harbouring CRE on hospital admission, risk factors associated, and the acquisition rate within the emergency department (ED).

METHODS

This was a cross-sectional survey with 676 patients consecutively admitted to the ED study during the months of May to July 2016. A questionnaire was performed and rectal swabs were collected from patients on admission, for culture and for multiplex real-time polymerase chain reaction (PCR). If the patient was hospitalized for more than one week in the ED, samples were taken again to determine the acquisition rate of CRE.

FINDINGS

Forty-six patients were colonized; all positive PCR were Klebsiella pneumoniae carbapenemase. The acquisition rate was 18%. Previous exposure to healthcare in the last year, liver disease, and use of antibiotics in the last month were risk factors for colonization. Six patients with no previous exposure to healthcare were CRE-colonized on admission, suggesting transmission of CRE within the community.

CONCLUSION

Screening of high-risk patients on admission to the ED is a strategy to early identify CRE carriage and may contribute to control CRE dissemination.

Effect of calcium, bicarbonate, and albumin on capacitation-related events in equine sperm

Repeatable methods for IVF have not been established in the horse, reflecting the failure of standard capacitating media to induce changes required for fertilization capacity in equine sperm. One important step in capacitation is membrane cholesterol efflux, which in other species is triggered by cholesterol oxidation and is typically enhanced using albumin as a sterol acceptor. We incubated equine sperm in the presence of calcium, BSA, and bicarbonate, alone or in combination. Bicarbonate induced an increase in reactive oxygen species (ROS) that was abolished by the addition of calcium or BSA. Bicarbonate induced protein tyrosine phosphorylation (PY), even in the presence of calcium or BSA. Incubation at high pH enhanced PY but did not increase ROS production. Notably, no combination of these factors was associated with significant cholesterol efflux, as assessed by fluorescent quantitative cholesterol assay and confirmed by filipin staining. By contrast, sperm treated with methyl-β-cyclodextrin showed a significant reduction in cholesterol levels, but no significant increase in PY or ROS. Presence of BSA increased sperm binding to bovine zonae pellucidae in all three stallions. These results show that presence of serum albumin is not associated with a reduction in membrane cholesterol levels in equine sperm, highlighting the failure of equine sperm to exhibit core capacitation-related changes in a standard capacitating medium. These data indicate an atypical relationship among cholesterol efflux, ROS production, and PY in equine sperm. Our findings may help to elucidate factors affecting failure of equine IVF under standard conditions.

Colloid centrifugation of fresh stallion semen before cryopreservation decreased microorganism load of frozen-thawed semen without affecting seminal kinetics

Freezability of equine semen may be influenced by microorganism population of semen. The objective of this study was to verify the effect of single-layer density gradient centrifugation (SLC) of fresh semen before cryopreservation on semen's microbial load (ML) and sperm cells kinetics after freezing-thawing. For that, one ejaculate was collected from 20 healthy stallions and split into control (C) samples (cryopreserved without previous SLC) and SLC samples (subjected to SLC). Semen cryopreservation was performed according to the same protocol in both groups. Microbial load of each microorganism species and total microbial load (TML) expressed in colony-forming units (CFU/mL) as well as frozen-thawed sperm kinetics were assessed in both groups. Additional analysis of the TML was performed, subdividing the frozen-thawed samples in "suitable" (total motility ≥ 30%) and "unsuitable" (total motility < 30%) semen for freezing programs, and comparing the C and SLC groups within these subpopulations. After thawing, SLC samples had less (P < 0.05) TML (88.65 × 10(2) ± 83.8 × 10(2) CFU/mL) than C samples (155.69 × 10(2) ± 48.85 × 10(2) CFU/mL), mainly due to a reduction of Enterococcus spp. and Bacillus spp. A relationship between post-thaw motility and SLC effect on ML was noted, as only in samples with more than 30% total motility was ML reduced (P < 0.05) by SLC (from 51.33 × 10(2) ± 33.26 × 10(2) CFU/mL to 26.68 × 10(2) ± 12.39 × 10(2) CFU/mL in "suitable" frozen-thawed semen vs. 240.90 × 10(2) ± 498.20 × 10(2) to 139.30 × 10(2) ± 290.30 × 10(2) CFU/mL in "unsuitable" frozen-thawed semen). The effect of SLC on kinetics of frozen-thawed sperm cells was negligible.

Effect of breeding activity on the microflora of the external genitalia and in the semen of stallions, and the relationship between micro-organisms on the skin and on the external genitalia

A possible role of breeding activities in the composition of the microbial population in stallions' external genitalia (EG) and the relationship between micro-organisms colonizing the skin of the abdomen and the ones colonizing the EG have not been studied. In experiment 1, EG microbiological samples were collected from 41 stallions used for both natural cover and semen collection (BST) and from 18 non-breeding stallions (NBST). A higher (p < 0.05) frequency of isolation of potentially pathogenic species was found for BST. Age did not influence number of micro-organism species isolated both in BST and NBST. In experiment 2, the microbial content of the EG and semen was compared in 23 BST. Most micro-organisms isolated from the EG were present in semen, albeit with a numerically lower prevalence. In 7 stallions, six microbial species isolated from semen were absent from the EG cultures, suggesting contamination by the operator. In experiment 3, a numerically higher number of micro-organism species was isolated from the EG of 31 stallions, than from their skin of the ventral abdomen in contact with the penis or from the skin of the thorax. With the sole exception of Escherichia coli, potentially pathogenic bacteria were only isolated from the EG but not from the skin. Results suggest that breeding activity increased the number of species colonizing the EG; most species isolated from the EG were also found in semen even if with a lower frequency, and additional semen contamination seemed to occur during its manipulation. Many micro-organism species of the skin were also isolated from the penis, but independently of being or not in contact with the penis, skin did not seem to provide an adequate environment for the growth of potentially pathogenic bacteria that were isolated from EG, with the sole exception for E. coli.

Nosocomial outbreak of Pantoea agglomerans bacteraemia associated with contaminated anticoagulant citrate dextrose solution: new name, old bug?

We describe an outbreak investigation of Pantoea agglomerans bacteraemia associated with anticoagulant citrate-dextrose 46% (ACD) solution prepared in-house. A healthy man presented with septic shock during plasmapheresis for granulocyte donation. The solution used for priming and blood samples were sent for culture. Identification of the isolate to species level was performed by gyrB sequencing. Typing was performed by pulsed-field gel electrophoresis (PFGE). In total, eight cases were identified during a three-week period. P. agglomerans was also cultured from six ACD solution bags. Isolates from patients and ACD bags were identical by PFGE. All isolates were susceptible to ampicillin, cephazolin, gentamicin, ciprofloxacin, cefepime and imipenem.

Neovascularisation is a prognostic factor of early recurrence in T1/G2 urothelial bladder tumours

BACKGROUND

Of patients with superficial bladder cancer, a group are still at risk of disease recurrence, progression and death from their cancer after curative treatment. Angiogenesis is a crucial pathogenic mechanism for this type of urothelial cell carcinoma (UCC), and is a potential therapeutic target. However, the selection of the appropriate patients remains a dilemma.

PATIENTS AND METHODS

Vascular endothelial growth factor (VEGF) expression and the presence of angiogenesis and occurrence of CD31, CD34, endoglin and factor VIII immunoexpression, were evaluated in 66 superficial papillary UCCs of the bladder and were correlated with classical histopathological factors and disease outcome.

RESULTS

VEGF immunoreactivity was observed in 100% of cases, and more intensely in the luminal surface. The presence of microvessel clusters independently of a fibrovascular core was observed in 22.7% of cases. Of these, the T1/G2 subgroup had an independent and significantly lower recurrence-free survival (P = 0.0002).

CONCLUSIONS

These results indicate that the presence of angiogenesis in tumour urothelium is a potential prognostic factor in superficial UCC, particularly in T1/G2 tumours, and may be used to select patients for anti-angiogenic treatments.

Broncho-alveolar inflammation in cork worker's asthma

Suberosis is an occupational lung disease of cork workers associated with repeated exposure to mouldy cork dust in the cork industry, usually presenting as an interstitial lung disorder (Extrinsic Allergic Alveolitis). However, Occupational Asthma can also be associated with cork dust exposure and demonstrated by serial peak expiratory flow changes.

AIM

To investigate broncho-alveolar inflammation in patients with cork work-related occupational asthma, evaluated by Broncho-alveolar fluid cellular profiles and serial peak expiratory flow (PEF) rates monitoring.

RESULTS

We studied 14 patients with respiratory symptoms associated with occupational exposure in the cork industry. Positive PEF monitoring occurred in 7 cases (Occupational Asthma-OA), and in 7 (Non-occupational asthmatics-NOA) PEF records were negative. There were no differences in age, lung function (FEV1%, RV%), bronchial hyperresponsiveness, years of exposure, and atopy between the two patients groups. However, patients with work-related asthma had higher BAL eosinophil counts than NOA (1.9 +/- 2.6% versus 0.2 +/- 0.3%; p < 0.05, Wilcoxon test).

CONCLUSIONS

Cork worker's asthma, demonstrated by work related changes in serial PEF recordings, is associated with eosinophilic lung inflammation as described in other forms of occupational asthma.

High prevalence of hepatitis C infection in a Brazilian prison: identification of risk factors for infection

Hepatitis C virus (HCV) causes infectious hepatitis worldwide. It is transmitted mainly by blood products and sharing of intravenous paraphernalia during illicit drug use. High prevalence rates have been described among specific groups considered to be at higher risk for HCV infection, including prison inmates. The objectives of this study were: to determine the HCV seroprevalence among inmates of Casa de Detenção de São Paulo; to identify risk factors for HCV infection; and to compare the seroprevalence of HCV to other blood borne or sexually transmitted diseases. From December, 1993, to January, 1994, a total of 779 inmates were interviewed to collect information on sociodemographic status, sexual behavior, and past experience with illicit drugs. Blood samples were obtained from 756 inmates for serological tests. 310 (41%) blood samples were positive for anti-HCV, 425 (56.2%) were negative, and 21 (2.8%) showed indeterminate results. In this population, we found a seroprevalence of 13.7% for HIV, 3.3% for syphilis (VDRL), and 68.1% for hepatitis B virus previous infection. Four variables were each identified as associated with a positive anti-HCV serologic test: a positive VDRL (OR = 2.63 IC 95% 1.08 to 6.36); a time of current imprisonment longer than 130 months (OR = 2.44 IC 95% 1.04 to 5.71); previous incarceration at Casa de Detenção de São Paulo (OR = 1.73 IC 95% 1.19 to 2.52) and; illicit drug use before admission to the Casa de Detenção de São Paulo (OR = 1.64 IC 95% 1.15 to 2.33). The seroprevalence of HCV antibodies among the study population was high (41%), indeed, one of the highest clusters of HCV infection recorded until now. Four variables were each shown to be associated with HCV infection. The simultaneous presence of these 4 variables is associated with an 82% probability of being anti-HCV positive. Although risk factor analysis indicates most HCV infections occur prior to inprisonment, initiation of control measures to prevent continued transmission after incarceration should be done.

Monitoring of peak expiratory flow rates in cork workers' occupational asthma

Suberosis is an occupational lung disorder of cork industry workers usually presenting as an extrinsic allergic alveolitis, but airway involvement in some cases makes the diagnostic approach complex. We assessed peak expiratory flow rates (PEF) in 17 cork workers with asthma symptoms that worsened at work, comparing three methods of PEF graph analysis. Complete agreement (three observers) was found in 12 of 17 cases (70.6%) with the visual inspection of mean daily values and in 11 of 17 cases (64.7%) with the minimum, maximum, and mean daily values (without any consensus in two cases). According to the mean PEF graph, there were eight positive readings (47%), five negative readings (29%), and four dubious readings (24%); with the other graphic analysis, two of the dubious cases were reclassified as negative. When we analyzed daily variability >20%, we found only three positive results, one of which was in absolute disagreement with the visual analysis. Our results suggest that it is possible to demonstrate occupational asthma in cork work exposure. The visual inspection of PEF monitoring shows a greater number of positive results than the index of daily variability; however, the latter may help to sort out dubious cases.

A prospective study of gemcitabine and carboplatin as first-line therapy in advanced non-small cell lung cancer: toxicity of a three- versus a four-week schedule

We evaluated the toxicity and activity of gemcitabine (Gemzar; Eli Lilly and Company, Indianapolis, IN) and carboplatin on a 3-week (trial A) versus a 4-week (trial B) schedule in patients with advanced/metastatic non-small cell lung cancer. Chemotherapy-naive patients in trial A received gemcitabine 1,000 mg/m(2) on days 1 and 8 plus carboplatin area under the curve of 5 on day 1, every 3 weeks. In trial B, patients received gemcitabine 1,000 mg/m(2) on days 1, 8, and 15 and carboplatin area under the curve of 6 on day 1, every 4 weeks. Thirty patients were enrolled in trial A and 28 in trial B. Patients received a total of 142 cycles in trial A and 134 in trial B. Despite more frequent treatment delays (82 cycles in trial B and 20 cycles in trial A), and dose reductions/omissions (mainly on day 15), gemcitabine mean dose intensities of both schedules were similar. The principal dose-limiting toxicity was grade 3/4 thrombocytopenia. Objective response rates were 40% in trial A and 68% in trial B (no complete response). Gemcitabine and carboplatin administered on days 1 and 8 every 3 weeks is associated with lower myelotoxicity than that of a 4-week schedule, although both schedules were active against non-small cell lung cancer. Semin Oncol 28 (suppl 10):10-14.

Short report: evaluation of the potency and stability of a candidate vaccine against American cutaneous leishmaniasis

Availability of a safe, immunogenic, and affordable vaccine would represent the best strategy for control of cutaneous leishmaniasis (CL). Stability in field conditions is a essential property for any candidate vaccine. The stability and immunogenicity of three different preparations (thimerosal-preserved, autoclaved, and lyophilized) of a killed Leishmania amazonensis vaccine were assessed using fresh products and after 12 months of storage at 4 degrees C. Autoclaving was associated with a time-dependent decrease in the immunogenicity of the vaccine, as measured by the leishmanin skin test and production of interferon-gamma. These findings are of importance in the decision of which preparation of candidate killed CL vaccines should move to phase III trials.

Behçet's syndrome/AIDS/cerebral toxoplasmosis: an unusual association

Few cases of AIDS associated to manifestations suggesting Behçet's syndrome have been reported. This case is of a young married woman who presented, during a period of 7 years, clinical manifestations consistent with the late diagnosis of Behçet's syndrome, when she developed recurrent lymphomonocytic meningoencephalitis. At this time, she was found to be infected by HIV-1. Immunosuppressive doses of glucocorticoid produced an unsatisfactory response and she evolved to death due to CNS toxoplasmosis. The latter diagnosis was presumed on the basis of magnetic resonance imaging findings and proved by necropsy after her third hospital stay. One of the factors hindering the appropriate diagnosis was the low level of CD4 and the CD4/CD8 ratio, sometimes observed in active Behçet's syndrome and higher than those observed in patients with this severe opportunistic infection. No information about the exact period of time she had been infected with HIV-1 is available. So, we do not know whether both diseases were overlooked, if the patient, infected by HIV-1, developed an unusual clinical feature consistent with Behçet's Behçet's syndrome, and subsequently evolved to AIDS.