Alba Otoni

Inflammation, neoangiogenesis and fibrosis in peritoneal dialysis

Peritoneal dialysis (PD) is a form of renal replacement therapy used in patients with end stage renal disease (ESRD). It is based on using the peritoneum as a semipermeable membrane through which ultrafiltration (UF) and diffusion occur. Despite several benefits, PD has long-term complications, including inflammation, neoangiogenesis and fibrosis. Several inflammatory molecules can be found in the dialysate of PD patients including: interleukins (IL), tumor necrosis factor α (TNF-α) and C-reactive protein (CRP). Angiogenesis results in increased effective surface area exchange. Consequently, the glucose-driven osmotic pressure of the peritoneal dialysis fluid (PDF) is significantly reduced leading to UF failure (UFF). Several factors are implicated in the development of peritoneal fibrosis (PF) in PD patients. The most important factor is the conventional bio-incompatible PD solution, which contains high concentration of glucose and glucose degradation products (GDP). Although there are several studies elucidating the mechanisms leading to UFF in PD patients, more studies needed to be developed in this area and more research is required to find mechanisms to delay or to minimize the occurrence of many deleterious changes in peritoneal membrane (PM) during PD.

Peritoneal dialysis and inflammation

Peritoneal dialysis (PD) is a kidney replacement therapy for end stage renal disease (ESRD) patients. Despite being a lifesaving treatment, the rate of mortality in patients under PD is elevated, mainly due to the chronic peritoneal dysfunction which is characterized by inflammation, peritoneal fibrosis and neoangiogenesis. The inflammatory process is trigged and modulated by the type of the peritoneal dialysis solutions (PDSs) used during PD. Currently, different PDSs are commercially available: (i) the conventional solutions; (ii) solutions of neutral pH containing low concentration of glucose degradation products (GDPs); (iii) solutions with icodextrin; and (iv) solutions containing taurine. Therefore, the aim of this review is to describe the different types of peritoneal dialysis solutions used during PD and their relationship with systemic and intraperitoneal inflammation. Some studies suggested that solutions of neutral pH containing low concentration of GDPs, icodextrin and taurine have better biocompatibility and lower influence on the inflammatory process compared to the conventional one. On the other hand, the studies, in general, were performed with a small population and for a short period of time. Therefore, further well-designed and -controlled clinical trials with larger number of individuals are required in order to better understand the role of different peritoneal dialysis solution types in the development of inflammation in patients with chronic peritoneal dialysis. Accordingly, studies that are more well-designed, well-controlled and with a larger number of patients are needed to explain and define the role of different types of PDS in the inflammation development in patients with chronic peritoneal dialysis.

An Outbreak of Acute Schistosoma mansoni Schistosomiasis in a Nonendemic Area of Brazil: A Report on 50 Cases, Including 5 With Severe Clinical Manifestations

BACKGROUND Acute schistosomiasis is a systemic hypersensitivity reaction against the migrating schistosomula and eggs. In this report, we describe an atypical outbreak of the disease with severe cases. Transmission occurred in a nonendemic area of Brazil, which became a new focus of transmission due to the in-migration of infected workers. METHODS From December 2009 to March 2010, the 50 patients with acute schistosomiasis (group 1) bathed in a swimming pool supplied by a brook on a country estate in the outskirts of São João del Rei, Brazil. Thirty other subjects (group 2) living in the same area, who denied having contact with the swimming pool, volunteered to participate in the study. All participants were submitted to clinical, laboratory, and ultrasound examinations. RESULTS Five of 50 (10%) patients were admitted to the hospital: 1 with myeloradiculopathy, 1 with diffuse pulmonary micronodules, and 3 with diarrhea and dehydration. All 5 had hypereosinophilia and prolonged fever. Group 1 patients more frequently had cercarial dermatitis (P = .01), blood in the stool (P = .04), and intra-abdominal lymph nodes (P = .001). All group 1 patients were treated with praziquantel; 1 patient with myeloradiculopathy also received oral prednisone (60 mg/day) for 6 months with complete recovery. CONCLUSIONS This report describes the first time that patients from an outbreak of acute schistosomiasis have been compared to controls. Five subjects (10%) had severe manifestations of schistosomiasis. Diagnosis of the disease and its severity was delayed because physicians did not consider that an epidemic of schistosomiasis might emerge in a nonendemic area.

Oficina sobre projeto pedagógico de curso de enfermagem: refletindo sobre inovações, desafios e potencialidades

Framework: education in a higher education setting in nursing requires the establishment of educational resources to encourage students to acquire the skil...

Percepção dos enfermeiros gestores da atenção primária sobre o processo de enfermagem

OBJECTIVE this qualitative study aimed to analyze the perceptions of primary health care management nurses on the nursing process. METHOD data were collected through interviews and analyzed by the Content Analysis proposed by Bardins theoretical framework. RESULTS managers recognize the importance of the nursing process, although its implementation was not a priority at the time of the interviews. A conceptual difficulty and a lack of understanding that the implementation of the care methodology should be a cross-departmental action in the local healthcare management were clearly observed. CONCLUSION managers should have their perspectives broadened concerning the relevance of the nursing process and the professional training. The active participation of legislative nursing bodies, local healthcare management and the federal government may open the way for the effective implementation of the nursing process.

Perception of primary healthcare management nurses on the nursing process

OBJECTIVE this qualitative study aimed to analyze the perceptions of primary health care management nurses on the nursing process. METHOD data were collected through interviews and analyzed by the Content Analysis proposed by Bardins theoretical framework. RESULTS managers recognize the importance of the nursing process, although its implementation was not a priority at the time of the interviews. A conceptual difficulty and a lack of understanding that the implementation of the care methodology should be a cross-departmental action in the local healthcare management were clearly observed. CONCLUSION managers should have their perspectives broadened concerning the relevance of the nursing process and the professional training. The active participation of legislative nursing bodies, local healthcare management and the federal government may open the way for the effective implementation of the nursing process.

Prevalência da doença renal crônica em um município do sudeste doBrasil

INTRODUCTION Chronic kidney disease (CKD) is a worldwide public health alarming problem. OBJECTIVE This study investigated the estimated prevalence of kidney disease in diabetic and high-risk hypertensive patients to cardiovascular disease registered in Hiperdia program of a city of southeast of Brazil. METHODS It is a transversal study conducted between May 2014 and August 2015. The study has included randomly 243 diabetic and high-risk hypertensive patients to cardiovascular disease which were originally referred from primary health care to the Hiperdia. CKD was classified based on cause, Glomerular Filtration Rate (GFR), and albumin creatinine ratio (ACR). Were considered abnormalities GFR < 60 mL/min/1.73m2 and/or ACR ≥ 30 mg/g. RESULTS Of the 243 patients, 89 (36.6%) showed alterations in renal function markers in the first collection. Of these, 60 patients had a GFR < 60 mL/min/1.73 m2 and 25 the GFR was < 45 mL/min/1.73 m2. The ACR was ≥ 30 mg/g in 43 patients and eight of the values were > 1000 mg/g. In 15 patients studied were found both changes. Of the 89 participants with abnormal renal function markers in the first collection 63 held the second test and 42 kept the changes being diagnosed with CKD. None of these patients had prior knowledge of the diagnosis of kidney disease and the need for consultation with the nephrologist. CONCLUSION The prevalence of CKD was 17.3% of disease in the population studied.

Percepción de directores de la enfermera de salud primaria en el proceso de enfermería

OBJECTIVE this qualitative study aimed to analyze the perceptions of primary health care management nurses on the nursing process. METHOD data were collected through interviews and analyzed by the Content Analysis proposed by Bardins theoretical framework. RESULTS managers recognize the importance of the nursing process, although its implementation was not a priority at the time of the interviews. A conceptual difficulty and a lack of understanding that the implementation of the care methodology should be a cross-departmental action in the local healthcare management were clearly observed. CONCLUSION managers should have their perspectives broadened concerning the relevance of the nursing process and the professional training. The active participation of legislative nursing bodies, local healthcare management and the federal government may open the way for the effective implementation of the nursing process.

Reply to Soentjens et al

TO THE EDITOR—We thank Soentjens et al for their comments on our article [1, 2]. The authors ask whether all exposed individuals have been finally diagnosed with schistosomiasis, and to which extent additional exposed cases may have been missed. In fact, all exposed individuals were invited to come to the outpatient clinic and those who responded to the call had a diagnosis of acute schistosomiasis confirmed. We know that some did not come due to different reasons. The contact occurred during a private party and we do not expect that a large number of individuals were missed [2]. We called severe cases those patients who were hospitalized. All stayed in hospital for >30 days with a diagnosis of fever of undetermined origin [3]. Typhoid fever, liver abscess, AIDS, neoplasia, granulomatous diseases of the gut (ulcerative colitis, Crohn disease), autoimmune diseases (Wegener granulomatosis, Churg-Strauss syndrome), and tuberculosis were considered in the differential diagnosis of the 3 patients presenting with diarrhea [4–6]. Note that after a diagnosis of any disease has been confirmed, physicians tend to devaluate the difficulty that other physicians had to reach a diagnosis [7]. In addition, patients were not examined by the same physician in only 1 hospital, and we believe this was also a factor that impaired or delayed more rational clinical investigation. In their letter, Soentjens et al mention that report of pulmonary distress in acute schistosomiasis has been regularly described. We agree on that. However, there are different degrees of lung involvement in acute schistosomiasis [8, 9]. To be fair, this is a truism. Pulmonary manifestations depend on the worm burden and host response to parasite invasion. In our case, the computed tomographic scan showed scattered nodules on both lung fields, and the patient underwent lung biopsy to clarify the diagnosis; this is not a regular presentation of acute schistosomiasis. The same applies to neurological involvement: the severity of symptoms varies greatly [10]. Besides, only after the advent of magnetic resonance imaging did it become possible to strongly associate Schistosoma mansoni infection with neurological involvement [11–13]. In regard to Katayama fever or syndrome, some investigators, including us, prefer to use the term acute schistosomiasis when the infection is caused by S. mansoni, because Katayama is a syndrome described for those infected with Schistosoma japonicum. Moreover, the clinical presentation of both syndromes is quite different. Soentjens et al also suggest that realtime polymerase chain reaction (PCR) would be useful in diagnosing acute schistosomiasis; however, reading the articles Soentjens et al quoted on PCR, we found that the first PCR used seemed to diagnose infection by Schistosoma haematobium, but failed to diagnose 22 patients infected with S. mansoni. The second article found PCR for S. mansoni in 8 patients with acute schistosomiasis caused by S. mansoni, but PCR did not disappear from the serum even after 2 years posttreatment. This means that we still have much work to do before using PCR in our clinical laboratories. We wish to thank Soentjens et al again for their attention and comments. We enjoyed very much the opportunity to discuss a disease that has been considered neglected, but, actually, one whose presence has been largely underestimated even in developed countries.