New-Onset Seizures 15 Years After Renal Transplant

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Oxalate Nephropathy Following Roux‑en‑Y Gastric Bypass Surgery – Mini‑Review

Oxalate Nephropathy is characterised by the presence of tubular crystalline deposits of calcium oxalate, which can lead to both acute and chronic tubular injury and progressive renal failure. Enteric hyperoxaluria is the most common cause of moderate hyperoxaluria; it occurs in conditions associated with fat or bile acid malabsorption, which include jejunoileal bypass and other bariatric procedures such as Roux‑en‑Y gastric bypass surgery. We present the clinical case of a 69‑year‑old man who was hospitalised for non‑oliguric renal dysfunction, with a serum creatinine of 10 mg/dl and normocytic normochromic anaemia. There was no prior history of renal disease. Twenty months before admission the patient was diagnosed with a gastro‑oesophageal junction adenocarcinoma and was treated with pre‑operative chemotherapy, followed by total gastrectomy, with a Roux‑en‑Y gastric bypass reconstruction. On discharge from gastric surgery, renal function was normal. On the first day of hospital stay haemodialysis was initiated. Over the following days, the rapid unexplained renal impairment was investigated, and this workup [2] included a kidney biopsy. Histological examination of the biopsy specimen revealed a predominantly interstitial nephropathy with tubular atrophy and interstitial fibrosis, with bright intra‑tubular calcium oxalate crystals in over 50% of the tubules and so the histological diagnosis was of oxalate nephropathy. Subsequently, no recovery of renal function was observed, so the patient is currently undergoing regular haemodialysis. Oxalate nephropathy is a rare but severe complication of Roux‑en‑Y gastric bypass surgery that can lead to a rapid progression to kidney failure. Although the treatment of obesity is the main indication for this surgery, this is also the preferred approach for gastrointestinal reconstruction after total gastrectomy for treatment of gastric carcinoma. Considering the rapid progression of oxalate nephropathy to kidney failure, patients who undergo Roux‑en‑Y gastric bypass surgery should have regular follow‑up of renal function.info:eu-repo/semantics/publishedVersio

Doença Hepática Crónica Agudizada: Revisão da Experiência de um Centro Português de Referenciação

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by an acute deterioration of a patient with cirrhosis, frequently associated with multi-organ failure and a high short-term mortality rate. We present a retrospective study that aims to characterize the presentation, evolution, and outcome of patients diagnosed with ACLF at our center over the last 3 years, with a comparative analysis between the group of patients that had ACLF precipitated by infectious insults of bacterial origin and the group of those with ACLF triggered by a nonbacterial infectious insult; the incidence of acute kidney injury and its impact on the prognosis of ACLF was also analyzed. Twenty-nine patients were enrolled, the majority of them being male (89.6%), and the mean age was 53 years. Fourteen patients (48.3%) developed ACLF due to a bacterial infectious event, and 9 of them died (64.2%, overall mortality rate 31%); however, no statistical significance was found (p < 0.7). Of the remaining 15 patients (51.7%) with noninfectious triggers, 11 died (73.3%, overall mortality rate 37.9%); again there was no statistical significance (p < 0.7). Twenty-four patients (83%) developed acute kidney injury (overall mortality rate 65.5%; p < 0.022) at the 28-day and 90-day follow-up. Twelve patients had acute kidney injury requiring renal replacement therapy (41.37%; overall mortality rate 37.9%; p < 0.043). Hepatic transplant was performed in 3 patients, with a 100% survival at the 28-day and 90-day follow-up (p < 0.023). Higher grades of ACLF were associated with increased mortality (p < 0.02; overall mortality 69%). CONCLUSIONS: ACLF is a heterogeneous syndrome with a variety of precipitant factors and different grades of extrahepatic involvement. Most cases will have some degree of renal dysfunction, with an increased risk of mortality. Hepatic transplant is an efficient form of therapy for this syndrome.info:eu-repo/semantics/publishedVersio

Impacto das Infeções Respiratórias Viricas Múltiplas na Evolução de Crianças Gravemente Doentes

Introdução: As infecções respiratórias baixas são a principal causa de mortalidade em crianças até aos 5 anos. A utilização do painel rápido multiplex por PCR melhora a identificação do diagnóstico etiológico. Objetivos: Comparar a evolução de infecções respiratórias víricas com um ou mais agente isolado em crianças admitidas por insuficiência respiratória aguda (IRA) em cuidados intensivos. Métodos: Estudo retrospetivo (39 meses, dezembro 2014 a fevereiro 2018) de doentes com IRA e identificação de pelo menos um vírus por PCR multiplex. Estudou-se a idade, género, PCR multiplex e evolução. Consideraram-se dois grupos: A um vírus e B mais do que um vírus. Utilizaram-se os testes Qui-quadrado ou Exato de Fisher para testar associações entre variáveis. Resultados: Obtiveram-se 54 IRA com agente identificado: grupo A=42 e B=12. Mediana de idade de 4 e 5 meses (A/B), género masculino 57% e 50% (A/B). No mesmo período, verificaram-se 1149 internamentos, com PRISM médio de 2,68 e mortalidade de 2,78%. No grupo A, o PRISM médio foi de 7,50 e no B de 5,17. Não se registaram óbitos. A doença crónica e a falência de órgão foram mais frequentes no grupo A (33% e 8%, p=0,088; 83% e 67%, p=0,206). Os vírus mais frequentes foram: A - Vírus Sincicial Respiratório (43%), B - Rhinovírus (58%), com coinfecção bacteriana em 21% e 8% (A/B, p=0,303). O grupo B necessitou mais de ventilação (A - 67%, B - 75%, p=0,512), sem diferença no modo (não invasiva p=0,571, invasiva p=0,571). Houve necessidade de acesso central em 24% e 25% (A/B, p=0,932) e vasopressores em 10% e 0% (A/B, p=0,564). A demora média foi 11 e 10 dias (A/B). Conclusão: O estudo sugere que a coexistência de vários vírus no mesmo doente não alterou significativamente a evolução e o prognóstico.info:eu-repo/semantics/publishedVersio

Confirmatory factor analysis of the Neuropsychological Assessment Battery of the LADIS study: a longitudinal analysis

WOS:000315985900004Age-related white matter changes have been associated with cognitive functioning, even though their role is not fully understood. This work aimed to test a 3-factor model of the neuropsychological assessment battery and evaluate how the model fit the data longitudinally. Confirmatory factor analysis (CFA) was used to investigate the dimensions of a structured set of neuropsychological tests administered to a multicenter, international sample of independent older adults (LADIS study). Six hundred and thirty-eight older adults completed baseline neuropsychological, clinical, functional and motor assessments, which were repeated each year for a 3-year follow-up. CFA provided support for a 3-factor model. These factors involve the dimensions of executive functions, memory functions, and speed and motor control abilities. Performance decreased in most neuropsychological measures. Results showed that executive functioning, memory and speed of motor abilities are valid latent variables of neuropsychological performance among older adults, and that this structure is relatively consistent longitudinally, even though performance decreases with time.info:eu-repo/semantics/acceptedVersio

A European Academy of Neurology guideline on medical management issues in dementia

BACKGROUND AND PURPOSE: Dementia is one of the most common disorders and is associated with increased morbidity, mortality and decreased quality of life. The present guideline addresses important medical management issues including systematic medical follow‐up, vascular risk factors in dementia, pain in dementia, use of antipsychotics in dementia and epilepsy in dementia. METHODS: A systematic review of the literature was carried out. Based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework, we developed a guideline. Where recommendations based on GRADE were not possible, a good practice statement was formulated. RESULTS: Systematic management of vascular risk factors should be performed in patients with mild to moderate dementia as prevention of cerebrovascular pathology may impact on the progression of dementia (Good Practice statement). Individuals with dementia (without previous stroke) and atrial fibrillation should be treated with anticoagulants (weak recommendation). Discontinuation of opioids should be considered in certain individuals with dementia (e.g. for whom there are no signs or symptoms of pain or no clear indication, or suspicion of side effects; Good Practice statement). Behavioral symptoms in persons with dementia should not be treated with mild analgesics (weak recommendation). In all patients with dementia treated with opioids, assessment of the individual risk–benefit ratio should be performed at regular intervals. Regular, preplanned medical follow‐up should be offered to all patients with dementia. The setting will depend on the organization of local health services and should, as a minimum, include general practitioners with easy access to dementia specialists (Good Practice statement). Individuals with dementia and agitation and/or aggression should be treated with atypical antipsychotics only after all non‐pharmacological measures have been proven to be without benefit or in the case of severe self‐harm or harm to others (weak recommendation). Antipsychotics should be discontinued after cessation of behavioral disturbances and in patients in whom there are side effects (Good Practice statement). For treatment of epilepsy in individuals with dementia, newer anticonvulsants should be considered as first‐line therapy (Good Practice statement). CONCLUSION: This GRADE‐based guideline offers recommendations on several important medical issues in patients with dementia, and thus adds important guidance for clinicians. For some issues, very little or no evidence was identified, highlighting the importance of further studies within these areas

Global burden of small vessel disease-related brain changes on MRI predicts cognitive and functional decline

Background and Purpose- Cerebral small vessel disease is characterized by a wide range of focal and global brain changes. We used a magnetic resonance imaging segmentation tool to quantify multiple types of small vessel disease-related brain changes and examined their individual and combined predictive value on cognitive and functional abilities. Methods- Magnetic resonance imaging scans of 560 older individuals from LADIS (Leukoaraiosis and Disability Study) were analyzed using automated atlas- and convolutional neural network-based segmentation methods yielding volumetric measures of white matter hyperintensities, lacunes, enlarged perivascular spaces, chronic cortical infarcts, and global and regional brain atrophy. The subjects were followed up with annual neuropsychological examinations for 3 years and evaluation of instrumental activities of daily living for 7 years. Results- The strongest predictors of cognitive performance and functional outcome over time were the total volumes of white matter hyperintensities, gray matter, and hippocampi (PPeer reviewe

Small vessel disease and general cognitive function in nondisabled elderly : The LADIS study

Background and Purpose - On cerebral magnetic resonance imaging (MRI), white matter hyperintensities (WMH) and lacunes are generally viewed as evidence of small vessel disease. The clinical significance of small vessel disease in terms of global cognitive function has as yet not been completely clarified. We investigated the independent contribution of WMH and lacunes to general cognitive function in a group of independently living elderly with varying degrees of small vessel disease. Methods - Data were drawn from the multicenter, multinational Leukokraurosis and Disability (LADIS) study. There were 633 independently living participants. General cognitive function was assessed using the Mini Mental State Examination (MMSE) and the modified Alzheimer Disease Assessment Scale (ADAS). On MRI, WMH was rated as mild, moderate, or severe. Lacunes were rated as none, few (1 to 3), or many (4 or more). Results - In the basic analysis, increasing severity of both WMH and lacunes was related to deteriorating score on the MMSE and ADAS. When WMH and lacunes were entered simultaneously, both MRI measures remained significantly associated with MMSE score. Increasing severity of WMH remained associated with ADAS score, whereas the association with lacunes became less prominent. These associations were independent of other risk factors for dementia, like education, depression, vascular risk factors, or stroke. Conclusion - We found WMH and lacunes to be independently associated with general cognitive function in a sample of independently living elderly. These results highlight the fact that WMH and lacunes should both be evaluated when assessing small vessel disease in relation to cognitive function

Adiponectin, leptin, and IGF-1 are useful diagnostic and stratification biomarkers of NAFLD

[EN] Background: Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease where liver biopsy remains the gold standard for diagnosis. Here we aimed to evaluate the role of circulating adiponectin, leptin, and insulin-like growth factor 1 (IGF-1) levels as non-invasive NAFLD biomarkers and assess their correlation with the metabolome. Materials and Methods: Leptin, adiponectin, and IGF-1 serum levels were measured by ELISA in two independent cohorts of biopsy-proven obese NAFLD patients and healthy-liver controls (discovery: 38 NAFLD, 13 controls; validation: 194 NAFLD, 31 controls) and correlated with clinical data, histology, genetic parameters, and serum metabolomics. Results: In both cohorts, leptin increased in NAFLD vs. controls (discovery: AUROC 0.88; validation: AUROC 0.83; p < 0.0001). The leptin levels were similar between obese and non-obese healthy controls, suggesting that obesity is not a confounding factor. In the discovery cohort, adiponectin was lower in non-alcoholic steatohepatitis (NASH) vs. non-alcoholic fatty liver (AUROC 0.87; p < 0.0001). For the validation cohort, significance was attained for homozygous for PNPLA3 allele c.444C (AUROC 0.63; p < 0.05). Combining adiponectin with specific serum lipids improved the assay performance (AUROC 0.80; p < 0.0001). For the validation cohort, IGF-1 was lower with advanced fibrosis (AUROC 0.67, p<0.05), but combination with international normalized ratio (INR) and ferritin increased the assay performance (AUROC 0.81; p < 0.01). Conclusion: Serum leptin discriminates NAFLD, and adiponectin combined with specific lipids stratifies NASH. IGF-1, INR, and ferritin distinguish advanced fibrosis.CR was funded by FEDER through the COMPETE program and by national funds through Fundação para a Ciência e a Tecnologia (PTDC/MED-FAR/29097/2017—LISBOA-01- 0145-FEDER-029097) and by European Horizon 2020 (H2020- MSCA-RISE-2016-734719). This work was also supported by Fundação para a Ciência e Tecnologia (PD/BD/135467/2017) and Portuguese Association for the Study of Liver/MSD 2017. JB was funded by Spanish Carlos III Health Institute (ISCIII) (PI15/01132, PI18/01075 and Miguel Servet Program CON14/00129 and CPII19/00008), co-financed by Fondo Europeo de Desarrollo Regional (FEDER), Instituto de Salud Carlos III (CIBERehd, Spain), La Caixa Scientific Foundation (HR17-00601), Fundación Científica de la Asociación Española Contra el Cáncer, and European Horizon 2020 (ESCALON project: H2020-SC1-BHC-2018-2020)