Carlos Fischer de Toledo

Serum hyaluronic acid as a comprehensive marker to assess severity of liver disease in schistosomiasis.

Schistosomiasis mansoni is a non-cirrhotic fibrogenic disease model. The mild form shows normal liver function with slight or no liver fibrosis whereas in the periportal fibrosis form the manifestations of portal hypertension prevail over hepatocellular failure. We assessed serum hyaluronic acid as a marker of the course of the disease. We studied 24 patients presenting with pure chronic forms of schistosomiasis and seven with cirrhosis. In order to measure serum hyaluronic acid we developed a sandwich fluorescent ELISA-like assay. alpha2-Macroglobulin, prothrombin index, gamma-glutamyltransferase, platelets and ultrasound parameters were also assessed. The 20 micro g/l (ROC plot) hyaluronic acid level differentiated patients with the mild form (with no portal hypertension) from those with the severe form of schistosomiasis with 78% diagnostic efficacy. The 80 micro g/l cut-off value differentiated patients with the severe form of schistosomiasis from the cirrhotic group with similar diagnostic efficacy. alpha2-Macroglobulin provided no distinction between the groups studied. The hyaluronic acid serum concentration correlated positively with the splenic vein diameter (P=0.004) and marginally with alpha2-macroglobulin (P=0.059). Serum hyaluronic acid is a good marker for the initial phase of hepatic fibrosis and it was able to assess severity of liver disease in schistosomiasis.

Thrombocytemia as a predictor of portal hypertension in schistosomiasis.

Sufferers of schistosomiasis mansoni can evolve a clinical form of the disease associated with portal hypertension. To differentiate this form, routine clinical tests and biological indices were evaluated. In all, 54 HBsAg- and HCV-negative patients were studied, 42 with schistosomiasis and 12 normal volunteers. Using clinical criteria, ultrasonography, and endoscopy, the schistosomiasis patients were classified into two groups: mild chronic form (MS, N = 14) and chronic form associated with portal hypertension (PH, N = 28). The laboratory parameters of the MS group did not differ from the controls. The PH group differed from the others in prothrombin index, thrombocytemia, γ-glutamyltransferase, serum α2-macroglobulin, and the calculated indices. ROC plot cutoff levels verified that isolated thrombocytemia was the most efficient marker for discrimination of the PH and MS forms. Thrombocytemia of 130 × 109 platelets/liter discriminated the groups with an 86% accuracy when all patients were analyzed and 96% when only schistosomiasis patients who did not consume alcohol were included.

Elevação da gama-glutamiltransferase sérica na hepatopatia esquistossomótica não se correlaciona com a carga parasitária e precede alterações ultra-sonográficas

BACKGROUND Liver disorders are the major manifestations of schistosomiasis mansoni. Factors that account for increased concentrations of cholestasis-indicating enzymes in the hepatosplenic form of the disease are unknown. OBJECTIVE To assess the correlation between increased gamma-glutamyltransferase serum levels and both the parasitic load and ultrasound alterations in patients with schistosomiasis. PATIENTS AND METHODS Twenty-five patients with the chronic form of schistosomiasis were assessed for the presence or absence of increased enzymatic levels, for the parasitic load (low x medium/high) and for ultrasound parameters. Furthermore, analysis of prothrombin time and a platelet count were performed. RESULTS Of the 25 patients, 13 showed increased gamma-glutamyltransferase plasma levels. No significant correlation was found between increased gamma-glutamyltransferase levels and the parasitic load, or between increased enzyme levels and ultrasound alterations. Nor did the prothrombin index or the platelet count differ between the two groups (normal gamma-glutamyltransferase levels and increased gamma-glutamyltransferase levels). CONCLUSION The parasitic load explains no rise in gamma-glutamyltransferase plasma levels in patients with the chronic form of schistosomiasis, and conventional ultrasound is not a sensitive method to detect the alteration suggested by the increased enzyme level in those patients.Background - Liver disorders are the major manifestations of schistosomiasis mansoni. Factors that account for increased concentrations of cholestasis-indicating enzymes in the hepatosplenic form of the disease are unknown. Objective - To assess the correlation between increased g-glutamyltransferase serum levels and both the parasitic load and ultrasound alterations in patients with schistosomiasis. Patients and methods - Twenty-five patients with the chronic form of schistosomiasis were assessed for the presence or absence of increased enzymatic levels, for the parasitic load (low x medium/high) and for ultrasound parameters. Furthermore, analysis of prothrombin time and a platelet count were performed. Results - Of the 25 patients, 13 showed increased g-glutamyltransferase plasma levels. No significant correlation was found between increased g-glutamyltransferase levels and the parasitic load, or between increased enzyme levels and ultrasound alterations. Nor did the prothrombin index or the platelet count differ between the two groups (normal g-glutamyltransferase levels and increased g-glutamyltransferase levels). Conclusion - The parasitic load explains no rise in g-glutamyltransferase plasma levels in patients with the chronic form of schistosomiasis, and conventional ultrasound is not a sensitive method to detect the alteration suggested by the increased enzyme level in those patients.

Malignant melanoma with liver and spleen metastases: case report

CONTEXT The diagnosis of primary melanoma is easily confirmed after histological analysis of the lesion, whereas it is rarely diagnosed when the patient even has distant metastases. DESIGN Case report CASE REPORT Malignant melanoma is responsible for about 1% of all deaths caused by cancer in the USA and only 3% of all malignant skin diseases. Malignant melanoma is a rare disease, although it corresponds to 65% of all deaths caused by skin cancer. The liver and spleen are rarely the first sites of melanoma metastases. This paper reports on the clinical picture of a patient with fatal malignant melanoma and hepatic and spleen metastases. As this was an un-usual presentation, the melanoma diagnosis could only be made after pathological analysis of the skin and hepatic lesions.

Plasma kallikrein clearance by the liver of chronic carbon tetrachloride-treated rats

Abstract We have previously reported that the endocytosis of rat plasma kallikrein (RPK) by hepatocytes is a calcium‐independent and beta‐galactoside‐dependent mechanism. We now report the clearance of RPK by the liver of four groups of rats: normal, inflamed (48 h ex‐turpentine) and two groups chronically treated with CCl4 (52 mg/kg per week, intragastrically, for 9‐12 weeks). Each liver was isolated, exsanguinated and perfused at 37°C with 30 mL of BSA‐Krebs‐Henseleit‐bicarbonate medium containing 10 nmol/L RPK. Although all rats received the same mild CCl4 treatment, the liver histology showed that they evolved either to severe hepatitis (serum alanine aminotransferase [ALT] 4852 ± 885 U/L, parenchymatous necrosis in the perivenous region) or to compensated cirrhosis (serum ALT 209 ± 42 U/L, vigorous fibrous encircling regeneration nodules); neither jaundice nor ascites was noted. The results show that serum albumin was not altered among the groups and that: the acute‐phase response by itself (inflamed group) increased RPK clearance rate (3.01 ± 0.59 mL/min) as compared with the normal group (1.85 ± 0.14 mL/min); the CCl4 treatment, although induced an acute‐phase response, decreased (P < 0.01) RPK clearance rates (0.80 ± 0.11 mL/min hepatitis group and 0.98 ± 0.10 mL/min cirrhosis group). These findings suggest that the hepatic clearance rate of plasma kallikrein is an early indicator of liver injury.

Plasma-kallikrein clearance by the liver of acetaminophen-intoxicated rats.

The liver synthesizes prokallikrein and is the main organ to clear the active enzyme (plasma-kallikrein) from circulation. This clearance, a receptor-mediated endocytosis, is calcium-independent and not affected by the blockade of Kupffer cells. The effects of endothelial cells blockade and of acetaminophen intoxication on the clearance of 10 nM rat plasma-kallikrein (RPK) by the isolated, exsanguinated and perfused rat liver are now reported. Endothelial cells blockade obtained by the addition of large excess (30 uM) of formaldehyde-treated serum albumin to the perfusion fluid does not affect the hepatic clearance of RPK (the half-lives of hepatic uptake were 15.5 +/- 1.0 min in the absence versus 16.5 +/- 1.4 min in the presence of the treated protein, p > 0.05). Some livers were perfused 24 hours after acetaminophen intoxication: 6.6 mmol/kg given i.p. after a 42-hour period of fast. Hepatocyte injury suggested by elevated aminotransferase activity (ALT 10 times control value, AST 30 times control value), acute phase inflammatory response (serum alpha 2-macroglobulin increase) and reduced synthetic function (serum albumin decrease), was confirmed histologically and only zone 3 hepatocytes were necrotic. A 66-hour period of fast does not affect by itself the hepatic clearance of RPK (16.9 +/- 1.3 min of half-life of hepatic uptake) when compared with the control group (15.5 +/- 1.0 min, p > 0.05). On the other hand the RPK clearance by the livers of rats previously intoxicated with acetaminophen was markedly deficient (the half-life of hepatic uptake was 39.2 +/- 3.2 min). These findings suggest that RPK is internalized by hepatocytes, preferentially by those of the perivenular zone of the hepatic acinus.

Construção e implementação de ações de enfermagem em ambulatório de gastroenterologia

The reorganization of the Schistosomiasis Sector of Gastroenterology at UNIFESP started in 1998, when the Nursing Service was implanted. Objective: to develop administrative nursing actions, systematization of care and orientation program for the schistosomic patient. Method: a descriptive study carried out at the Gastroenterology Outclinic, which attends schistosomic patients of different clinical types. Results and Discussion: the reorganization of activities in this Sector resulted in the creation of an organizational structure and the implantation of the nursing visit; creation and distribution of explanatory leaflets and development of the Schistosomiasis Education Program; beginning of the database pilot project with all outpatients and an electronic register of the collection of biologic material. Conclusion: this initiative opens up a new opportunity for nursing actions and contributes to quality improvement in ambulatory care.UNLABELLED The reorganization of the Schistosomiasis Sector of Gastroenterology at UNIFESP started in 1998, when the Nursing Service was implanted. OBJECTIVE to develop administrative nursing actions, systematization of care and orientation program for the schistosomic patient. METHOD a descriptive study carried out at the Gastroenterology Outclinic, which attends schistosomic patients of different clinical types. RESULTS AND DISCUSSION the reorganization of activities in this Sector resulted in the creation of an organizational structure and the implantation of the nursing visit; creation and distribution of explanatory leaflets and development of the Schistosomiasis Education Program; beginning of the database pilot project with all outpatients and an electronic register of the collection of biologic material. CONCLUSION this initiative opens up a new opportunity for nursing actions and contributes to quality improvement in ambulatory care.

Uso de concentrado de antitrombina III em cirróticos com distúrbios de coagulaçäo

BACKGROUND Patients with severe hepatic failure present acquired deficiency of antithrombin III (ATIII) owing to reduced synthesis associated with intravascular activation of blood coagulation, which may be corrected by ATIII infusion. OBJECTIVE The aim of this uncontrolled trial was to verify the effect of a standard dose of ATIII concentrate (Kybernin), that is, 50 U/kg of body weight per day, every 2 days, on ATIII levels in patients with severe hepatic failure and hemostatic imbalance. PATIENTS AND METHODS Six cirrhotic patients were studied: mean age of 44 years (14 to 63 years), who presented at least 2 abnormal coagulation tests (PT > 1.40, APTT > 1.25, Fibrinogen < 1.5 g/dL, Platelet count < 80,000/mm3). Mean serum albumin was 2.6 g/dL (1.9 to 3.8 g/dL). Blood was drawn before infusion, 4 h after the first infusion, and just before the next infusion. ATIII levels were measured by amidolytic method. RESULTS Mean ATIII levels were: initial = 35.8%, 4th h = 56.2%*, 2nd d = 48.7%*, 4th d = 45.7%*, and 8th d = 42.3%. ATIII levels increased significantly after infusion of this standard dose in all patients, although they have not been fully corrected (Friedman test, * p < 0.02), which has been sustained till the 4th day. There was no improvement on the clinical outcome. CONCLUSIONS These findings suggest that doses of ATIII concentrate higher than 50 U/kg/infusion must be administered to patients with severe hepatic failure, to guarantee normal levels of the inhibitor, in order to verify its influence on the hemostatic mechanism.BACKGROUND. Patients with severe hepatic failure present acquired deficiency of antithrombin III (ATIII) owing to reduced synthesis associated with intravascular activation of blood coagulation, which may be corrected by ATIII infusion. OBJECTIVE. The aim of this uncontrolled trial was to verify the effect of a standard dose of ATIII concentrate (Kybernin™ ), that is, 50U/kg of body weight per day, every 2 days, on ATIII levels in patients with severe hepatic failure and hemostatic imbalance. PATIENTS AND METHODS. Six cirrhotic patients were studied: mean age of 44 years (14 to 63 years), who presented at least 2 abnormal coagulation tests (PT > 1.40, APTT > 1.25, Fibrinogen < 1.5g/dL, Platelet count < 80,000/mm3). Mean serum albumin was 2.6g/dL (1.9 to 3.8g/dL). Blood was drawn before infusion, 4h after the first infusion, and just before the next infusion. ATIII levels were measured by amidolytic method. RESULTS. Mean ATIII levels were: initial = 35.8%, 4th h = 56.2%*, 2th d = 48.7%*, 4 dth = 45.7%*, and 8th d = 42.3%. ATIII levels increased significantly after infusion of this standard dose in all patients, although they have not been fully corrected (Friedman test, * p < 0.02), which has been sustained till the 4th day. There was no improvement on the clinical outcome. CONCLUSIONS. These findings suggest that doses of ATIII concentrate higher than 50U/kg/infusion must be administered to patients with severe hepatic failure, to guarantee normal levels of the inhibitor, in order to verify its influence on the hemostatic mechanism.A deficiencia de antitrombina III (ATIII) e observada na hepatopatia grave e pode ser decorrente da reducao de sintese ou de consumo aumentado, o que poderia ser compensado com o uso de concentrado de ATIII. OBJETIVO. Avaliar a eficiencia da administracao de uma dose fixa de concentrado de ATIII, em pacientes com hepatopatia descompensada com disturbio da hemostasia. CASUISTICA E METODO. Foram avaliados seis pacientes, com idade media de 44 anos, variando de 14 a 63 anos, portadores de cirrose (quatro de etiologia alcoolica, um viral e um doenca de Wilson), com alteracao de pelo menos dois dos parâmetros da hemostasia (TP > 1,40, TTPA > 1,25, fibrinogenio < 1,5g/L, plaquetas < 80.000/mm3). A media do nivel de albumina foi de 2,6g/dL (1,9 a 3,8g/dL). O concentrado de ATIII (Kybernin®) foi administrado na dose de 50U/kg, em dias alternados. Foi colhido sangue antes da primeira infusao, 4 horas apos e, depois, diariamente, antes da infusao do dia, para medida da ATIII plasmatica (amidolitico). Nenhum paciente recebeu hemoderivados. RESULTADOS.As medias da dosagem de ATIII foram: inicial = 35,8%, 4 horas = 56,2%*, 2 dias = 48,7%*, 4 dias = 45,7%* e 8 dias = 42,3%. Apos a infusao houve elevacao significante dos niveis de ATIII (* = p < 0,02, teste de Friedman), que se manteve ate o 4o dia. Nao houve alteracao dos demais parâmetros de coagulacao. CONCLUSOES. O uso de concentrado de ATIII na dose utilizada e suficiente para elevar os niveis desse inibidor na hepatopatia; entretanto, com essa dose nao se obteve normalizacao de seus niveis. Esses dados sugerem que doses mais elevadas devem ser usadas em pacientes com hepatopatias graves, que apresentam nao apenas reducao de sintese, mas aumento de consumo dos fatores da coagulacao e de seus inibidores.

Construyendo y implementando acciones de enfermería en la consulta externa de gastroenterología

The reorganization of the Schistosomiasis Sector of Gastroenterology at UNIFESP started in 1998, when the Nursing Service was implanted. Objective: to develop administrative nursing actions, systematization of care and orientation program for the schistosomic patient. Method: a descriptive study carried out at the Gastroenterology Outclinic, which attends schistosomic patients of different clinical types. Results and Discussion: the reorganization of activities in this Sector resulted in the creation of an organizational structure and the implantation of the nursing visit; creation and distribution of explanatory leaflets and development of the Schistosomiasis Education Program; beginning of the database pilot project with all outpatients and an electronic register of the collection of biologic material. Conclusion: this initiative opens up a new opportunity for nursing actions and contributes to quality improvement in ambulatory care.UNLABELLED The reorganization of the Schistosomiasis Sector of Gastroenterology at UNIFESP started in 1998, when the Nursing Service was implanted. OBJECTIVE to develop administrative nursing actions, systematization of care and orientation program for the schistosomic patient. METHOD a descriptive study carried out at the Gastroenterology Outclinic, which attends schistosomic patients of different clinical types. RESULTS AND DISCUSSION the reorganization of activities in this Sector resulted in the creation of an organizational structure and the implantation of the nursing visit; creation and distribution of explanatory leaflets and development of the Schistosomiasis Education Program; beginning of the database pilot project with all outpatients and an electronic register of the collection of biologic material. CONCLUSION this initiative opens up a new opportunity for nursing actions and contributes to quality improvement in ambulatory care.

Construction and implementation of nursing actions in the gastroenterology outclinic

The reorganization of the Schistosomiasis Sector of Gastroenterology at UNIFESP started in 1998, when the Nursing Service was implanted. Objective: to develop administrative nursing actions, systematization of care and orientation program for the schistosomic patient. Method: a descriptive study carried out at the Gastroenterology Outclinic, which attends schistosomic patients of different clinical types. Results and Discussion: the reorganization of activities in this Sector resulted in the creation of an organizational structure and the implantation of the nursing visit; creation and distribution of explanatory leaflets and development of the Schistosomiasis Education Program; beginning of the database pilot project with all outpatients and an electronic register of the collection of biologic material. Conclusion: this initiative opens up a new opportunity for nursing actions and contributes to quality improvement in ambulatory care.UNLABELLED The reorganization of the Schistosomiasis Sector of Gastroenterology at UNIFESP started in 1998, when the Nursing Service was implanted. OBJECTIVE to develop administrative nursing actions, systematization of care and orientation program for the schistosomic patient. METHOD a descriptive study carried out at the Gastroenterology Outclinic, which attends schistosomic patients of different clinical types. RESULTS AND DISCUSSION the reorganization of activities in this Sector resulted in the creation of an organizational structure and the implantation of the nursing visit; creation and distribution of explanatory leaflets and development of the Schistosomiasis Education Program; beginning of the database pilot project with all outpatients and an electronic register of the collection of biologic material. CONCLUSION this initiative opens up a new opportunity for nursing actions and contributes to quality improvement in ambulatory care.