Environmental drivers of increased ecosystem respiration in a warming tundra.

Arctic and alpine tundra ecosystems are large reservoirs of organic carbon1,2. Climate warming may stimulate ecosystem respiration and release carbon into the atmosphere3,4. The magnitude and persistency of this stimulation and the environmental mechanisms that drive its variation remain uncertain5-7. This hampers the accuracy of global land carbon-climate feedback projections7,8. Here we synthesize 136 datasets from 56 open-top chamber in situ warming experiments located at 28 arctic and alpine tundra sites which have been running for less than 1 year up to 25 years. We show that a mean rise of 1.4 °C [confidence interval (CI) 0.9-2.0 °C] in air and 0.4 °C [CI 0.2-0.7 °C] in soil temperature results in an increase in growing season ecosystem respiration by 30% [CI 22-38%] (n = 136). Our findings indicate that the stimulation of ecosystem respiration was due to increases in both plant-related and microbial respiration (n = 9) and continued for at least 25 years (n = 136). The magnitude of the warming effects on respiration was driven by variation in warming-induced changes in local soil conditions, that is, changes in total nitrogen concentration and pH and by context-dependent spatial variation in these conditions, in particular total nitrogen concentration and the carbon:nitrogen ratio. Tundra sites with stronger nitrogen limitations and sites in which warming had stimulated plant and microbial nutrient turnover seemed particularly sensitive in their respiration response to warming. The results highlight the importance of local soil conditions and warming-induced changes therein for future climatic impacts on respiration.

Canopy physiology, vine performance and host-pathogen interaction in a fungi resistant cv. Sangiovese x Bianca accession vs. a susceptible clone.

The present study compares the physiological and cropping response of the new fungi-resistant grapevine Accession 72-096 ('Sangiovese' x 'Bianca' hybrid) against a susceptible 'Sangiovese' clone which was either fully (FS-SG) or partially sprayed (PS-SG). Data logged on Accession 72-096 indicate that while two early season sprays were enough to avoid major downy mildew (DM) and powdery mildew (PM) outbreaks, Accession 72-096 also showed concurrent desirable features such as moderate cropping, loose clusters, fast sugar accumulation coupled with sufficient acidity even at peak total soluble solids (TSS) concentration (around 24 °Brix), good color and higher flavonols prompting co-pigmentation. Conversely, FS-SG showed final lower acidity despite the notably lower sugar concentration (≅18 °Brix), as well as larger clusters and berries that resulted in more compact bunches. From a methodological viewpoint, end of season single-leaf readings appeared to overestimate the limitation of leaf function due to PM and DM infections in SG-PS vines which, when assessed via a whole-canopy approach, did not show significant differences vs. Accession 72-096, a result likely due to counteracting effects linked to a compensation mechanism by healthy tissues. Our data also suggest that a PM infection can lead to a decoupling in sugar-color accumulation patterns.

Advantages of multidetector-row CT with multiplanar reformation in guiding percutaneous lung biopsies.

PURPOSE: This study aimed to assess the usefulness of multiplanar reformations (MPR) during multidetector-row computed tomography (MDCT)-guided percutaneous needle biopsy of lung lesions difficult to access with the guidance of the native axial images alone owing to overlying bony structures, large vessels or pleural fissures. MATERIALS AND METHODS: MDCT-guided transthoracic needle biopsy (TNB) was performed on 84 patients (55 men and 29 women; mean age 65 years) with suspected lung neoplasm by using a spiral MDCT scanner with the simultaneous acquisition of six slices per rotation. We determined the site of entry of the 22-gauge Chiba needle on native axial images and coronal or sagittal MPR images. We took care to ensure the shortest needle path without overlying large vessels, main bronchi, pleural fissures or bony structures; access to the lung parenchyma as perpendicular as possible to the pleural plane; and sampling of highly attenuating areas of noncalcified tissue within the lesion. RESULTS: Diagnostic samples were obtained in 96% of cases. In 73 patients, lesions appeared as a solid noncalcified nodule <2 cm; 11 lesions were mass-like. In 22, the biopsy required MPR guidance owing to overlying ribs (18), fissures (2) or hilar-mediastinal location (2). CONCLUSIONS: MDCT MPR images allowed sampling of pulmonary lesions until now considered unreachable with axial MDCT guidance because of overlying bony structures (ribs, sternum and scapulae) or critical location (hilar-mediastinal, proximity to the heart or large vessels). Compared with the conventional procedure, the use of MPR images does not increase the rate of pneumothorax or the procedure time.

Intraperitoneal rupture of an infected urachal cyst: an unusual cause of acute abdomen in children. A case report and review of the literature.

Urachal cysts are rare and usually asymptomatic until they become infected. This is a report of a case of peritonitis due to intraperitoneal rupture of an infected urachal cyst in a 3-month-old girl. A review of the literature found 31 similar cases previously reported, only seven of which were described in children. The diagnosis and treatment of intraperitoneal perforation of an infected urachal cyst in a child are discussed.

Effectiveness of an uninterrupted procedure to transfer adolescents with Type 1 diabetes from the Paediatric to the Adult Clinic held in the same hospital: eight-year experience with the Parma protocol.

This paper reports an 8-yr retrospective study on the effects of an uninterrupted procedure of transition of 73 adolescents with Type 1 diabetes from the Paediatric to the Adult Clinic held in the same hospital. Interviewed patients had a mean age of 21.0+/-0.95 yr at transition. Patients were satisfied with the information received before transition (100%), and appreciated being introduced to the adult physician prior to being transferred (92%), and having found their paediatrician during the first visit at the Adult Clinic (100%). Consensus for transition was attained after 2-4 consultations in 66.6% of patients. Seventy-nine percent of patients considered 20 yr of age as an appropriate age to be transferred. Patients confirmed to have found at the Adult Clinic: privacy (85%), confidentiality (95%), short waiting times (78%), informal atmosphere (100%), and the same consultant (100%). Only 3% of patients tried to go back to the Paediatric Clinic but they were discouraged. Clinic attendance rate ranged between 92 and 100%. We consider that the key factors for a successful process of transition from a Paediatric to an Adult Clinic are: age at transfer around 20 yr, smooth movement within the same hospital, consensus of patients and their parents, prior personal contact with the adult physician, paediatrician attendance at the first visit at the adult service and his unambiguous role against all attempts to go back to the paediatric service and, finally, the availability of the same physician at out-patient clinic visits.

The direct measurement of 3-beta-hydroxy butyrate enhances the management of diabetic ketoacidosis in children and reduces time and costs of treatment.

In this study the effectiveness of a quantitative test of beta-hydroxybutyrate (beta-HBA) against a commercial test for urine ketone bodies (UKB) in monitoring diabetic ketoacidosis (DKA) was evaluated to verify whether this ketone-testing method was able to reduce the monitoring costs and professional burden of nurses and physicians. Thirty-three children with severe (arterial pH < or = 7.2) or moderate (7.2 < pH < or = 7.3) DKA were studied. Sixteen patients were randomly monitored with blood beta-HBA (group 1) and 17 by UKB (group 2). Contrary to UKB, beta-HBA levels appeared correlated with: HbA1c values on admission (r = 0.99; p = 0.0001); latent period before diagnosis of diabetes (r = 0.95; p = 0.0001); changes in arterial pH (r = -0.82; p = 0.0001) and blood bicarbonate values (r = -0.63; p = 0.001) during the treatment for DKA. Required time to achieve the resolution of ketosis in group 1 patients was related to the values of beta-HBA on admission (r = 0.84; p < 0.001). Determination of beta-HBA showed that ketosis in group 1 patients cleared 4 to 9.5 hours earlier than in group 2. Due to this early normalization, the patients of group 1 left the Intensive Care Unit 6.5 +/- 1.5 hr earlier than those of group 2. This led to 22 hr saved for clinical assessment and 375 laboratory investigations for a total saving of 2940 euros including costs for laboratory tests (29.8%) and clinical assessment (70.2%). Quantitative determination of beta-HBA levels seems to offer useful information for monitoring DKA in newly-diagnosed diabetic children and for reducing time and costs in an Intensive Care Unit.

[Diabetes and alternative medicine: diabetic patients experiences with Ayur-Ved, "clinical ecology" and "cellular nutrition" methods]. / Diabete e medicia alternativa. Tre esperienze di trattamento con metodi di "Ayur-Ved", "ecologia clinica" e "nutrizione cellulare."

In the last two years we discovered that three of our patients with type 1 diabetes mellitus (0.8%) suffered an unexpected worsening in their glycemic control due to a reduction of their insulin dosage in favour of some "alternative" diabetes treatments using herbs, vitamins, fantastic diets and trace elements prescribed by non-medical practitioners. The first patient, a 6.6 year old boy, was admitted to hospital because of a severe ketoacidosis with first degree coma as a result of his parents having reduced his insulin dosage by 77% and replacing the insulin with an ayurvedic herbal preparation (Bardana Actium Lapp). The second patient, a 10.4 year old boy, was admitted to hospital after his teachers noticed that he appeared tired, thinner and polyuric. During hospital admission for mild ketoacidosis the mother, reluctant at first, finally confessed that her son was under the care of a "clinical ecologist". Having identified several food allergies this "clinical ecologist" had placed the child on a spartan diet of bread, water and salt, and had reduced his insulin dosage by 68%. The third patient, a 21 year old male, upon transfer to the Adult Diabetic Center, reported that he had been under the care of a pranotherapist for several years. The pranotherapist had prescribed a cellular nutrition preparation (called "Madonna drops"), a meditation program and also a 50% reduction in his insulin dosage. During this period his HbAlc values had increased from 6.4% to 12%. Current orthodox diabetes treatments are considered unsatisfactory by many people and it is thus not surprising that they search for "miracle" cures. It is important, however, that hospital staff do not ridicule the patients or their parents for trying these alternative therapies. Nevertheless, it would be useful for staff to discuss in advance these "therapies" with patients, highlighting their ineffectiveness and strongly discouraging cures that call for a reduction or elimination of the insulin treatment.

Bilateral anterior pubic osteotomy in bladder exstrophy repair: report of increasing success.

Bilateral posterior iliac osteotomy is performed in most patients undergoing primary closure of an exstrophic bladder; the aims are to facilitate abdominal-wall closure, prevent postoperative wound dehiscene, and possibly, to achieve better urinary control in older age. A new technique, anterior pelvic osteotomy of the superior pubic ramus, seems to obtain tension-free symphysis approximation safely and quickly. We report our initial experience with this osteotomy. Five neonates, four males and one female from 1 to 4 days old, all underwent closure surgery for bladder exstrophy (BE) and subsequent bilateral osteotomy of the superior pubic ramus (SPRO). Postoperatively, Bryant's traction was applied. Tension-free, complete approximation of the symphysis and uncomplicated healing were achieved in all five cases without palsy of the obturator nerve or postoperative hemorrhage. Follow-up revealed partial rediastasis with a stable anterior pelvic ring. Tension-free closure and immobilization are important factors in both initial and subsequent closure of BE. Several osteotomy techniques are currently in use. SPRO presents numerous advantages, namely, ease and rapidity, minimal blood loss, and no requirement for an extra skin incision or need to turn the patient on the operating table. A certain degree of rediastasis with growth was subsequently observed: although undesirable, this complication is common to all osteotomy techniques. We believe that SPRO is a valid and uncomplicated method to facilitate BE closure.

Chronobiology of blood pressure.

The chronobiology of blood pressure is a useful tool for examining serial data to quantify the dynamics of variability. The implications and applications for diagnosis and therapy are discussed, with clinical examples. The chronobiological patterns of hypertension are described. Chronobiology can make a real contribution to the prevention of disease. Chronobiology helps diagnose circadian hyper-amplitude-tension (CHAT), a condition in which excessive circadian BP amplitude precedes chronic established hypertension.

Abdominoscrotal hydrocele in childhood: is it really a rare entity?

OBJECTIVES: Abdominoscrotal hydrocele (ASH) is an apparently highly uncommon clinical entity especially in childhood, with only about 80 pediatric cases reported in the modern literature. METHODS: The incidence, diagnosis, and treatment of ASH are discussed with reference to 9 cases observed at our institution and to cases in the literature. RESULTS: Surgical correction was successful in all our cases and no hydrocele or hernia recurrence was registered. CONCLUSIONS: ASH incidence appears to be higher than reported; undescended testis is a frequent association and surgical correction through an inguinal approach is always possible and curative. Ligation of the processus vaginalis may prevent recurrence.

[Practical considerations on screening for microalbuminuria in children and adolescents with type 1 diabetes]. / Considerazioni pratiche sullo screening per la microalbuminuria nei bambini e adolescenti con diabete di tipo 1.

Diabetic Nephropathy is one of the microvascular complications associated with type 1 diabetes mellitus with a major portion of the excess morbidity and mortality. In order to avoid or at least delay its onset we should detect a very small amount of proteins in the urine (between 15-20 and 200 micrograms/min.) that is a strong predictor of those likely to progress to overt nephropathy. This detection can be obtained evaluating an overnight sample of urine and suggest preventives interventions. such as intensive diabetes management and angiotensin converting enzyme inhibition (ACEi). Furthermore, associated risk factors should be prevented or treated (hypertension, retinopathy, hyperlipidemia and smoking).

[Neonatal diabetes, heterogeneous syndrome]. / Diabete neonatale, sindrome eterogenea.

Neonatal diabetes (ND) is a rare condition of hyperglycaemia which occurs, generally, within the first month of life, requires insulin therapy and lasts more than two weeks. The pathogenesis is uncertain and the different clinical variants are heterogeneous; both a "permanent" and a "transient" form of ND exist. We report the clinical history of three neonates (A.L., A.B. and V.I.) in which a tout-court diagnosis of ND was done; the follow-up allowed us to reevaluate the initial diagnoses and suppose different ethiopathogenic mechanisms. Clinical observations, insulin requirement and biochemical data obtained during the years of follow-up allowed to distinguish three different situations: a "permanent" ND (A.L.), a "transient-recurrent" ND (A.B.), and a Maturity Onset Diabetes of the Young (MODY) (V.I.).

Effectiveness of a prevention program for diabetic ketoacidosis in children. An 8-year study in schools and private practices.

OBJECTIVE: To shorten the period of carbohydrate intolerance preceding the diagnosis of IDDM in children. RESEARCH DESIGN AND METHODS: The incidence of diabetic ketoacidosis (DKA) was studied in newly diagnosed diabetic children aged 6-14 years, in the area of Parma, Italy, 8 years after an information program on DKA was introduced to teachers, students, parents, and pediatricians. Information was provided by displaying a poster with a few practical messages in 177 primary and secondary public schools. The pediatricians working in the same area were given equipment for the measurement of both glycosuria and blood glucose levels, as well as cards listing guidelines for the early diagnosis of diabetes, to be given to patients. A toll-free number was also provided. Clinical and laboratory features of 24 young diabetic patients diagnosed in the Parma area (group 1) were compared with those of 30 patients coming from two nearby areas in which no campaign for the prevention of DKA had been carried out (group 2). RESULTS: From 1 January 1991 to 31 December 1997, DKA was diagnosed in 3 children from group 1 (12.5%) and in 25 children from group 2 (83.0%) (chi 2 = 26.8; P = 0.0001). The three cases of DKA in group 1 were observed in 1991 (n = 1) and in 1992 (n = 2). No patients from the Parma area who had DKA were admitted to our unit after 1992. The duration of symptoms before diagnosis was 5.0 +/- 6.0 and 28.0 +/- 10.0 days (P < 0.0001), in groups 1 and 2, respectively, Metabolic derangements were less severe in patients of group 1 than in those of group 2. Hospitalization for the treatment of overt diabetes and for the teaching of self-management of the disease lasted 5.4 +/- 1.2 days in group 1 and 13.3 +/- 2.4 days in group 2 (P = 0.002). The total cost of the 8-year campaign was $23,470. CONCLUSIONS: The prevention program for DKA in diabetic children aged 6-14 years, carried out in the Parma area during the last 8 years, was successful. Thanks to this program, cumulative frequency of DKA in new-onset IDDM decreased from 78% during 1987-1991 to 12.5% during 1991-1997. None of the newly diagnosed diabetic children aged 6-14 years and from the Parma area were ever admitted to the hospital for DKA after 1992.

Metabolic control in children and adolescents with diabetes: experience of two Italian Regional Centers.

A survey on glycemic control in 201 diabetic children and adolescents, aged 0-18 years, was performed in two Italian Centers for Childhood Diabetes (Chieti and Parma). Mean HbA1c was 7.8+/-1.4 (range 4.8-13.3%; median 7.6%). With progression of diabetes duration, deterioration of glycemic control was observed (r=0.20; p< 0.002), more evident in girls than in boys, with peaks at 14 (8.9+/-2.0 vs 6.9+/-1.7%; p<0.05) and 16 years (9.5+/-1.4% vs 8.1+/-1.1; p<0.02). No differences were found in BMI values in boys or girls, or for insulin doses which were increased significantly in both sexes according to age (r= 0.33, p<0.04). The number of insulin injections did not influence glycemic control. Only one severe hypoglycemic episode was reported during the period of observation. This study demonstrates that modern management, continuous education and patient and family empowerment are effective in attaining excellent glycemic control without increasing the risk of hypoglycemia.

Ketoacidosis and hyperosmolarity as first symptoms of type 1 diabetes mellitus following ingestion of high-carbohydrate-containing fluids.

The concomitant occurrence of diabetic ketoacidosis and hyperosmolarity is reported in two children, as early symptoms of misdiagnosed type 1 diabetes mellitus. The precipitating factor for both severe metabolic abnormalities was the ingestion of a large amount of high-carbohydrate-containing fluids, a few days before admission. A similar situation has never been reported before in the literature. A successful therapeutic scheme is described.

Hypertensive vascular crisis secondary to chronic total renal artery occlusion.

We have reviewed thirty-three cases of accelerated hypertension associated with chronic total renal artery occlusion. During the process of progressive narrowing of the arterial lumen until complete occlusion, an exceptionally elevated blood pressure occurs when a critical reduction of renal blood flow is attained. Then the patient presents one or more of the following clinical manifestations: III-IV grade KWB retinal changes, hypertensive encephalopathy including convulsive attacks, stroke, heart failure, renal insufficiency. We have called this clinical event 'hypertensive vascular crisis'. Mostly in older patients an actual or anamnestic vascular crisis makes a diagnosis of chronic total renal artery occlusion highly probable.

Management of insulin-dependent diabetes mellitus in adolescents.

There are many reasons for a specific management plan for adolescents with insulin-dependent diabetes mellitus (IDDM). Although most new patients can be managed initially on an outpatient basis, as they reach their teenage years, blood glucose control deteriorates and insulin requirements increase. Eating disorders, missing insulin injections, excess of alcohol all contribute to poor glycaemic control. Teenagers who have had diabetes for a number of years may have developed microvascular complications and disturbances of growth can occur, more often in girls than in boys. The transition to adult care continues to be a significant problem both for paediatricians and patients. Diabetes management during adolescence requires a team effort involving nurse educator, dietitian, paediatric diabetologist and, possibly, a social worker, with referral to specialists if necessary. Organizing this type of care requires a Regional Paediatric Diabetes Centre.

Blood glucose normalization-induced haemolysis in three adolescents with type 1 diabetes mellitus at onset and unknown G-6-PD deficiency.

We present three adolescents unknown to be G-6-PD deficient who developed haemolytic anaemia after admission for diabetes at onset uncomplicated by ketoacidosis. These patients had no bacterial infections and had not ingested haemolytic drugs. The fall in glucose availability after the correction of hyperglycaemia is proposed as capable of inducing haemolysis in G-6-PD deficiency.