Current status of the kidney-pancreas transplant

El trasplante de páncreas es un tratamiento alternativo para la diabetes. Sus modalidades e indicaciones son: 1) trasplante de páncreas simultáneo con riñón para pacientes con diabetes mellitus tipo 1 o con nefropatía diabética en estadio terminal en tratamiento sustitutivo o próximo al mismo; 2) trasplante de páncreas después de riñón para pacientes con diabetes mellitus tipo 1 con un trasplante renal funcionante; 3) trasplante de páncreas aislado para pacientes con diabetes mellitus tipo 1 con hipoglucemias aperceptivas que requieren internaciones o rescate de terceros. Algunos pacientes con diabetes mellitus tipo 2 seleccionados pueden ser candidatos a trasplante de páncreas. La selección de donantes es muy importante, el donante ideal es fallecido por traumatismo craneoencefálico, menor de 45 años, con un peso entre 30 y 90 kg, con un IMC menor a 30kg/m2, hemodinámicamente estable y sin antecedentes de paro cardiorespiratorio ni hipotensión sostenida. Hay varias estrategias de derivación de la función endócrina (sistémica y portal) y exócrina (entérica o vesical), la más utilizada es la derivación sistémica y entérica. En el manejo perioperatorio se destacan estrategias para mantener una buena presión de perfusión tisular, un control estricto de glucemia, para prevenir la trombosis del injerto debe implementarse un plan de antiagregación y anticoagulación, todo lo anterior junto a una profilaxis antibiótica, antifúngica y antiviral. Los esquemas clásicos de inmunosupresión incluyen una inducción con esteroides y anticuerpos deplecionantes de linfocitos T y un mantenimiento con un triple esquema con esteroides, tacrolimus y micofenolato. La clasificación de Banff distingue rechazos celulares y humorales. La base del tratamiento del rechazo celular incluye pulsos de esteroides y anticuerpos deplecionantes de linfocitos T, mientras que los rechazos humorales requieren de plasmaféresis e inmunoglobulina endovenosa. Las principales complicaciones postoperatorias son el sangrado, la pancreatitis, la trombosis del injerto y las fístulas anastomóticas. En cuanto a los resultados, el trasplante de páncreas presenta, a cinco años, una supervivencia del paciente del 90% y un 77% del injerto pancreático. Las modalidades de trasplante solitario presentan menor supervivencia alejada del injerto. En Argentina hay una actividad de trasplante de páncreas de entre 60 y 80 trasplantes anuales. La reglamentación del INCUCAI prevé la inscripción anticipada en lista de espera de pacientes con nefropatía terminal con depuración de creatinina menor a 30 ml/min.Pancreas transplantation is an alternative treatment for diabetes. Its modalities and indications are the following: 1) simultaneous pancreas and kidney transplantation: type 1 diabetes mellitus patients with end-stage diabetic nephropathy (in replacement treatment or close to it); 2) pancreas transplantation after kidney: type 1 diabetes mellitus patients with a functioning kidney transplant; 3) isolated pancreas transplantation: type 1 diabetes mellitus patients with unperceived hypoglycemia requiring hospitalization or rescue by third parties. Some of the screened type 2 diabetes mellitus patients may be pancreas transplantation candidates. Choosing a donor is very important: the ideal donor should be a deceased one who died due to intracranial injury, under 45 years of age, weighing between 30 and 90 kg, with a BMI below 30kg/m2 , hemodynamically stable and having no history of cardiopulmonary arrest or sustained hypotension. There exist various strategies to divert the endocrine function (systemic and portal) and the exocrine function (vesical or enteric), systemic and enteric diversion being the most commonly used. Among the techniques which stand out during perioperative management, we could mention maintaining a good tissue perfusion, a strict glycemic control, an antiaggregation/anticoagulation plan to prevent graft thrombosis and antibiotic, antifungal and antiviral prophylactic treatment. Classic immunosuppression schemes consist of induction with T cell depleting steroids and antibodies and keeping a three-drug treatment including steroids, tacrolimus and mycophenolate. Banff classification draws a distinction between cellular and humoral rejection. The basis for cellular rejection treatment includes steroid-pulse therapy and T-cell depleting antibodies, while humoral rejection requires plasmapheresis and endovenous immunoglobulin. The main postoperative complications are bleeding, pancreatitis, graft thrombosis and anastomosis fistula. As for the results, the survival rate 5 years after pancreas transplantation is 90% for patients and 77% for pancreatic grafts. Isolated transplantation presents a lower long-term survival of the graft. In Argentina, between 60 and 80 pancreas transplants are performed every year. INCUCAI regulations provide for early registration on the waiting list for patients suffering from end-stage nephropathy with a creatinine clearance lower than 30 mL/min.Fil: Uva, Pablo Daniel. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Centro de Estudios Farmacológicos y Botánicos. Universidad de Buenos Aires. Facultad de Medicina. Centro de Estudios Farmacológicos y Botánicos; Argentina. Instituto de Trasplantes y Alta Complejidad; ArgentinaFil: Quevedo, Alejandra. Instituto de Trasplantes y Alta Complejidad; ArgentinaFil: Rosés, Josefina. Instituto de Trasplantes y Alta Complejidad; ArgentinaFil: Toniolo, María Fernanda. Instituto de Trasplantes y Alta Complejidad; ArgentinaFil: Pilotti, Roxana. Instituto de Trasplantes y Alta Complejidad; ArgentinaFil: Chuluyan, Hector Eduardo. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Centro de Estudios Farmacológicos y Botánicos. Universidad de Buenos Aires. Facultad de Medicina. Centro de Estudios Farmacológicos y Botánicos; Argentina. Instituto de Trasplantes y Alta Complejidad; ArgentinaFil: Ré, Luis. Instituto de Trasplantes y Alta Complejidad; Argentin

Estudo da postura corporal em crianças com respiração predominantemente oral e escolares em geral

Objective: to evaluate the posture of children with predominant oral breathing and to compare these findings to the described ones in the literature related to the general school-age children. Methods: 30 school-age children with oral breathing were submitted to subjective postural evaluation, with analysis of the positioning symmetry of the structures in the anterior, posterior and lateral views. The obtained results were compared to those described in the literature related to the general school-age body posture. Results: in the anterior view, the elevation of the right shoulder, elbow and fingers flexion prevailed. In the posterior view, it was observed abduction and elevation of the scapulas and rotation of the knees. And, in the lateral view, it was observed forward head posture and protrusion and medial rotation of shoulders. In the literature findings it was observed semiflexion of the knees, shoulder protrusion and lumbar hyperlordosis. Conclusion: the breathing mode is essential for the postural balance of children in school- age. It was also evidenced that some alterations are peculiar of the normal postural development, once they were present in both groups.Objetivo: avaliar a postura de respiradores predominantemente orais e comparar com achados, descritos na literatura, de escolares em geral. Métodos: a amostra foi composta por 30 escolares, respiradores orais, que foram submetidos à avaliação postural subjetiva com análise da simetria e do posicionamento das estruturas, nas vistas anterior, posterior e lateral. Os achados obtidos foram comparados aos descritos na literatura sobre a postura corporal de escolares em geral. Resultados: na vista anterior predominou a elevação do ombro direito, flexão de cotovelo e dedos. Na vista posterior, observou-se abdução e elevação das escápulas e rotação dos joelhos. E, na vista lateral, anteriorização da cabeça, protrusão e rotação interna de ombros. Na literatura revisada predominaram: semiflexão de joelhos, protrusão de ombros, hiperlordose lombar. Conclusão: o modo respiratório é essencial no equilíbrio postural de crianças em idade escolar. Algumas alterações são próprias do desenvolvimento postural normal, pois apareceram em ambos os grupos

Estudo da postura corporal em crianças com respiração predominantemente oral e escolares em geral

Objective: to evaluate the posture of children with predominant oral breathing and to compare these findings to the described ones in the literature related to the general school-age children. Methods: 30 school-age children with oral breathing were submitted to subjective postural evaluation, with analysis of the positioning symmetry of the structures in the anterior, posterior and lateral views. The obtained results were compared to those described in the literature related to the general school-age body posture. Results: in the anterior view, the elevation of the right shoulder, elbow and fingers flexion prevailed. In the posterior view, it was observed abduction and elevation of the scapulas and rotation of the knees. And, in the lateral view, it was observed forward head posture and protrusion and medial rotation of shoulders. In the literature findings it was observed semiflexion of the knees, shoulder protrusion and lumbar hyperlordosis. Conclusion: the breathing mode is essential for the postural balance of children in school- age. It was also evidenced that some alterations are peculiar of the normal postural development, once they were present in both groups.Objetivo: avaliar a postura de respiradores predominantemente orais e comparar com achados, descritos na literatura, de escolares em geral. Métodos: a amostra foi composta por 30 escolares, respiradores orais, que foram submetidos à avaliação postural subjetiva com análise da simetria e do posicionamento das estruturas, nas vistas anterior, posterior e lateral. Os achados obtidos foram comparados aos descritos na literatura sobre a postura corporal de escolares em geral. Resultados: na vista anterior predominou a elevação do ombro direito, flexão de cotovelo e dedos. Na vista posterior, observou-se abdução e elevação das escápulas e rotação dos joelhos. E, na vista lateral, anteriorização da cabeça, protrusão e rotação interna de ombros. Na literatura revisada predominaram: semiflexão de joelhos, protrusão de ombros, hiperlordose lombar. Conclusão: o modo respiratório é essencial no equilíbrio postural de crianças em idade escolar. Algumas alterações são próprias do desenvolvimento postural normal, pois apareceram em ambos os grupos

Delphi:A Democratic and Cost-Effective Method of Consensus Generation in Transplantation

The Thrombotic Microangiopathy Banff Working Group (TMA-BWG) was formed in 2015 to survey current practices and develop minimum diagnostic criteria (MDC) for renal transplant TMA (Tx-TMA). To generate consensus among pathologists and nephrologists, the TMA BWG designed a 3-Phase study. Phase I of the study is presented here. Using the Delphi methodology, 23 panelists with &gt;3 years of diagnostic experience with Tx-TMA pathology listed their MDC suggesting light, immunofluorescence, and electron microscopy lesions, clinical and laboratory information, and differential diagnoses. Nine rounds (R) of consensus resulted in MDC validated during two Rs using online evaluation of whole slide digital images of 37 biopsies (28 TMA, 9 non-TMA). Starting with 338 criteria the process resulted in 24 criteria and 8 differential diagnoses including 18 pathologic, 2 clinical, and 4 laboratory criteria. Results show that 3/4 of the panelists agreed on the diagnosis of 3/4 of cases. The process also allowed definition refinement for 4 light and 4 electron microscopy lesions. For the first time in Banff classification, the Delphi methodology was used to generate consensus. The study shows that Delphi is a democratic and cost-effective method allowing rapid consensus generation among numerous physicians dealing with large number of criteria in transplantation.</p

Thrombotic Microangiopathy in the Renal Allograft:Results of the TMA Banff Working Group Consensus on Pathologic Diagnostic Criteria

The Banff community summoned the TMA Banff Working Group to develop minimum diagnostic criteria (MDC) and recommendations for renal transplant TMA (Tx-TMA) diagnosis, which currently lacks standardized criteria. Using the Delphi method for consensus generation, 23 nephropathologists (panelists) with &gt;3 years of diagnostic experience with Tx-TMA were asked to list light, immunofluorescence, and electron microscopic, clinical and laboratory criteria and differential diagnoses for Tx-TMA. Delphi was modified to include 2 validations rounds with histological evaluation of whole slide images of 37 transplant biopsies (28 TMA and 9 non-TMA). Starting with 338 criteria in R1, MDC were narrowed down to 24 in R8 generating 18 pathological, 2 clinical, 4 laboratory criteria, and 8 differential diagnoses. The panelists reached a good level of agreement (70%) on 76% of the validated cases. For the first time in Banff classification, Delphi was used to reach consensus on MDC for Tx-TMA. Phase I of the study (pathology phase) will be used as a model for Phase II (nephrology phase) for consensus regarding clinical and laboratory criteria. Eventually in Phase III (consensus of the consensus groups) and the final MDC for Tx-TMA will be reported to the transplantation community.</p

Na arena da leitura: políticas corporativas para formação de leitores

This article aims to understand some voices of discourse of corporate reading incentive policies in Brazil, more specifically the Project "Read to a child", launched by the banking institution. Based in discursive studies, we analyze how to build, the speeches, the directions for the training of players; understand the presence of global hegemonic interests in reading incentive speeches in Brazil; besides knowing other aspects of the role of private business projects in relation to reading. To make the study of selected speeches, we rely on theoretical assumptions of Mikhail Bakhtin regarding the use of speech and authors that dialogue with these assumptions to understand the reading practices, as John Wanderley Geraldi and Paulo Freire. We seek to understand, analyze and discuss the applied project through corporate policies, its influence and competition for space in the formation of readers.Este artigo tem como objetivo compreender algumas vozes de discursos que sustentam políticas corporativas de incentivo à leitura no Brasil, mais especificamente do Projeto “Leia para uma criança”, lançado pela Instituição bancária. Fundamentado nos estudos discursivos, buscamos analisar como se constroem, pelos discursos, os sentidos em relação à formação de leitores; compreender a presença de interesses hegemônicos globais nos discursos de incentivos à leitura no Brasil; além de conhecer outras faces do papel de projetos de empresas privadas em relação à leitura. Para fazer o estudo dos discursos selecionados, baseamo-nos nos pressupostos teóricos de Mikhail Bakhtin no que diz respeito ao uso do discurso e de autores que dialogam com esses pressupostos para compreender as práticas de leitura, como João Wanderley Geraldi e Paulo Freire. Buscamos compreender, analisar e discutir o projeto aplicado através de políticas corporativas, sua influência e a disputa por espaço na formação de leitores