Fluid flow shear stress over podocytes is increased in the solitary kidney.

BACKGROUND: Glomerular hyperfiltration is emerging as the key risk factor for progression of chronic kidney disease (CKD). Podocytes are exposed to fluid flow shear stress (FFSS) caused by the flow of ultrafiltrate within Bowman's space. The mechanism of hyperfiltration-induced podocyte injury is not clear. We postulated that glomerular hyperfiltration in solitary kidney increases FFSS over podocytes. METHODS: Infant Sprague-Dawley rats at 5 days of age and C57BL/6J 14-week-old adult mice underwent unilateral nephrectomy. Micropuncture and morphological studies were then performed on 20- and 60-day-old rats. FFSS over podocytes in uninephrectomized rats and mice was calculated using the recently published equation by Friedrich et al. which includes the variables-single nephron glomerular filtration rate (SNGFR), filtration fraction (f), glomerular tuft diameter (2RT) and width of Bowman's space (s). RESULTS: Glomerular hypertrophy was observed in uninephrectomized rats and mice. Uninephrectomized rats on Day 20 showed a 2.0-fold increase in SNGFR, 1.0-fold increase in 2RT and 2.1-fold increase in FFSS, and on Day 60 showed a 1.9-fold increase in SNGFR, 1.3-fold increase in 2RT and 1.5-fold increase in FFSS, at all values of modeled 's'. Similarly, uninephrectomized mice showed a 2- to 3-fold increase in FFSS at all values of modeled SNGFR. CONCLUSIONS: FFSS over podocytes is increased in solitary kidneys in both infant rats and adult mice. This increase is a consequence of increased SNGFR. We speculate that increased FFSS caused by reduced nephron number contributes to podocyte injury and promotes the progression of CKD.

Tópicos y reflexiones sobre la reducción de ingresos hospitalarios: de la evidencia a la práctica / Topics and considerations on reducing hospital admission: From evidence to practice

Los cambios demográficos y la realidad económica de los últimos años han condicionado una reorientación de las políticas sanitarias priorizando la atención a la cronicidad. Dada la concentración de costes en la atención hospitalaria de los pacientes con enfermedades crónicas, la reducción de las hospitalizaciones ha pasado a ser un objetivo preferente. Mientras tanto, constatamos que entre el objetivo paradigmático de abordaje eminentemente comunitario propuesto para estos pacientes y la realidad asistencial vigente, queda aún un largo recorrido que valdría la pena realizar paso a paso. Con la evidencia científica de la que disponemos en el momento actual: ¿Es razonable dar por sentado que hay un nivel adecuado de ingresos o que reducir el número de ingresos es necesariamente mejor para los pacientes? ¿Es posible definir operativamente y con la suficiente fiabilidad cuáles de los ingresos hospitalarios son evitables? ¿Es perjudicial para un paciente y para el sistema que una persona con enfermedades crónicas con altas necesidades de atención ingrese en un hospital? ¿No serán los ingresos hospitalarios evitables y los reingresos, indicadores de fragmentación de los sistemas de salud? Ante esta situación, un abordaje razonable requiere en primer lugar de un análisis crítico de las distintas realidades asistenciales (microsistemas) y de la revisión sistemática de la evidencia científica –rompiendo algunos tópicos si es preciso–. En segundo lugar es indispensable llevar este conocimiento a la práctica asistencial, con la necesidad absoluta de conciliar el «qué» y el «cómo», la visión individual con la visión poblacional, la enfermedad única con la multimorbilidad y, finalmente, el abordaje clínico con la planificación sanitaria (AU)

Demographic changes and the economic situation of the recent years have conditioned a turning point in health policies, which have decided to progressively prioritize chronicity care programs. Given that hospital costs were concentrated in attention to patients with chronic diseases, reduction on admissions is now a priority target.Meanwhile, we state that among the obviously community handling paradigmatic aim for those patients and the current care situation, there is a long way to do that should be done gradually. According to the current scientific evidence: Is it sensible to assume that there is a proper level of admissions or is it better for the patients to reduce the number of admissions? Is it possible to operationally and reliably define which hospital admissions are avoidable? Is it harmful to a patient and to the health care system to admit a patient with multiple chronic disease? Maybe are hospital admissions are avoidable and readmissions are indicators of a fragmented health care system?Given that situation, a reasonable approach requires firstly a critical analysis of the various realities of care (microsystems) and a systematic review of the scientific evidence-breaking, and rejecting some topics if necessary. Secondly, we should bring all this knowledge to clinical practice, conciliating «what» and the know-how, individual and population view, sole disease and multimorbidity, and finally clinical approach and health planning (AU)

[Topics and considerations on reducing hospital admission: from evidence to practice]. / Tópicos y reflexiones sobre la reducción de ingresos hospitalarios: de la evidencia a la práctica.

Demographic changes and the economic situation of the recent years have conditioned a turning point in health policies, which have decided to progressively prioritize chronicity care programs. Given that hospital costs were concentrated in attention to patients with chronic diseases, reduction on admissions is now a priority target. Meanwhile, we state that among the obviously community handling paradigmatic aim for those patients and the current care situation, there is a long way to do that should be done gradually. According to the current scientific evidence: Is it sensible to assume that there is a proper level of admissions or is it better for the patients to reduce the number of admissions? Is it possible to operationally and reliably define which hospital admissions are avoidable? Is it harmful to a patient and to the health care system to admit a patient with multiple chronic disease? Maybe are hospital admissions are avoidable and readmissions are indicators of a fragmented health care system? Given that situation, a reasonable approach requires firstly a critical analysis of the various realities of care (microsystems) and a systematic review of the scientific evidence-breaking, and rejecting some topics if necessary. Secondly, we should bring all this knowledge to clinical practice, conciliating «what¼ and the know-how, individual and population view, sole disease and multimorbidity, and finally clinical approach and health planning.

Pneumocystis jiroveci pneumonia prophylaxis is not required with a CD4+ T-cell count < 200 cells/microl when viral replication is suppressed.

OBJECTIVE: To determine the safety of discontinuing Pneumocystis jiroveci pneumonia (PCP) prophylaxis, in patients on effective antiretroviral therapy with CD4+ T-cell counts that have plateaued at < 200 cells/microl. METHODS: We prospectively evaluated a cohort of HIV infected patients at a multidisciplinary HIV clinic with sustained HIV RNA levels < 50 copies/ml and CD4+ T-cell counts that have plateaued at < 200 cells/microl and who have discontinued PCP prophylaxis. RESULTS: Nineteen patients fulfilled the above criteria. Eleven had been taking daily trimethoprim-sulfamethoxazole, seven were receiving monthly aerosolized pentamidine, and one patient never received any prophylaxis. The median CD4+ T-cell count at the time of discontinuation and at the most recent determination were 120 (range, 34-184) and 138 (range, 6-201) cells/microl, respectively. To date, patients have been off PCP prophylaxis for a mean of 13.7 +/- 10.6 months and a median of 9.0 (range 3-39) months for a total of 261 patient-months. To date, no patient has developed PCP. This is significantly different from the risk of developing PCP with a CD4+ T-cell count of < 200 cells/microl in untreated HIV infection (rate difference 9.2%; 95% confidence interval, 5.7 to 12.8%; P < 0.05). CONCLUSION: With sustained suppression of viral replication, PCP prophylaxis may not be necessary, regardless of CD4+ T-cell count. This illustrates a degree of immune recovery that occurs with virologic suppression that is not reflected in absolute CD4+ T-cell count or percentage and suggests that guidelines for P. jiroveci pneumonia prophylaxis may need to be re-evaluated.

[Open wedge osteotomy of the distal femur in the valgus knee]. / Offnende Keilosteotomie des distalen Femurs beim Valgusknie.

This review presents a novel technique for open-wedge varus osteotomies of the distal femur in lateral compartment osteoarthritis in valgus knees. Indications and contraindications are discussed. The technique, its potential pitfalls, and postoperative management are presented. The authors' results with this technique are compared to the data of the literature.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) and inflammatory stimuli up-regulate secretion of the soluble GM-CSF receptor in human monocytes: evidence for ectodomain shedding of the cell surface GM-CSF receptor alpha subunit.

Soluble GM-CSF receptor alpha subunit (sGMRalpha) is a soluble isoform of the GMRalpha that is believed to arise exclusively through alternative splicing of the GMRalpha gene product. The sGMRalpha mRNA is expressed in a variety of tissues, but it is not clear which cells are capable of secreting the protein. We show here that normal human monocytes, but not lymphocytes, constitutively secrete sGMRalpha. Stimulation of monocytes with GM-CSF, LPS, PMA, or A23187 rapidly up-regulates the secretion of sGMRalpha in a dose-dependent manner, demonstrating that secretion is also regulated. To determine whether sGMRalpha arose exclusively through alternative splicing of the GMRalpha gene product, or whether it could also be generated through ectodomain shedding of GMRalpha, we engineered a murine pro-B cell line (Ba/F3) to express exclusively the cDNA for cell surface GMRalpha (Ba/F3.GMRalpha). The Ba/F3.GMRalpha cell line, but not the parental Ba/F3 cell line, constitutively shed a sGMRalpha-like protein that bound specifically to GM-CSF, was equivalent in size to recombinant alternatively spliced sGMRalpha (60 kDa), and was recognized specifically by a mAb raised against the ectodomain of GMRalpha. Furthermore, a broad-spectrum metalloprotease inhibitor (BB94) reduced constitutive and PMA-, A23187-, and LPS-induced secretion of sGMRalpha by monocytes, suggesting that shedding of GMRalpha by monocytes may be mediated in part through the activity of metalloproteases. Taken together, these observations demonstrate that sGMRalpha is constitutively secreted by monocytes, that GM-CSF and inflammatory mediators up-regulate sGMRalpha secretion, and that sGMRalpha arises not only through alternative splicing but also through ectodomain shedding of cell surface GMRalpha.

The axial view in evaluating tibial translation in cases of insufficiency of the posterior cruciate ligament.

The purpose of this report is to present a new radiological method of diagnosis and evaluation of posterior instability using the patellofemoral axial view. During a period of 22 months, we performed clinical and radiological assessments on 20 patients (6 acute and 14 chronic) with isolated posterior instability caused by posterior cruciate ligament (PCL) rupture and on 20 patients with normal knees. The radiological examination included stress radiographs using the Telos device (Telos, Griesheim, Germany) as well as a modification of the routine axial patellofemoral view. Both diagnosis and quantification of the posterior tibial translation was possible in all cases by measuring, on the axial view, the distance between the anterior edge of the tibial plateau and the center of the femoral groove (trochlea). Clinical examination, conventional radiography, KT-1000 arthrometry, stress radiography at 90 degrees and at 20 degrees of flexion, and magnetic resonance imaging all assist in diagnosing a PCL tear. This new radiographic technique is simple, fast, and consistently effective both in patients with acute and those with chronic PCL tears, as well as in those who have undergone PCL reconstruction.

[Primary headache and orthognathorhinodontia in childhood]. / Cefalee primarie e ortognatorinodonzia in età evolutiva.

The aim of the research was to study the interrelationship between the primary neurovascular headaches, the various levels dimension of nasal pyramid and the rapid palatal expansion. Twenty-five patients, of both sexes and on developmental age, were studied before and after the rapid palatal expansion. All patients showed palatal hypoplasia and were suffering from primary neurovascular headache. The research was based on the cephalometric and rhinomanometric data. The radiographic documentation of each patient consisted of three postero-anterior teleradiographic projection; the first before application of the disjunction device, the second immediately after disjunction and the third at the end of the contention period. The rhinomanometric evaluation studied the reduction of nasal resistance values before and after palatal expansion. In all patients a constant increase in the values relating both skeletal and dental structures was observed. The nasal septum, if deviated, appeared straightend. The nasal resistances were decreased. The concomitant headache symptomatology presented resolution or recovery in the 98% of treated patients. The results should confirm the hypothesis of the central-peripheral theory of "primary headaches" and the possibility to treat the primary headaches by rapid palatal disjunction in eliminating the stenosis at various levels of nasal pyramid.

Anterior cruciate ligament patellar tendon reconstruction: it is probably better to leave the tendon defect open!

The purpose of our prospective study was to establish whether or not in anterior cruciate ligament (ACL) patellar tendon reconstruction the tendon defect has to be closed. In 50 consecutive ACL patellar tendon reconstructions, the tendon defect was randomly closed (group I) or left open (group II). The following data were recorded from all patients on the 4th and 14th days post operation: range of motion (ROM), pain at rest, pain and validity at isometric contraction, ability of bent leg raising (at 4th day) and straight leg raising (at 14th day). All the patients underwent ultrasonographic examination after 3 months and X-ray scanning at 6 months post operation. Forty patients underwent a CT-scan examination at 6 months. Thirty patients underwent isokinetic testing between 10 and 12 months post operation. Evaluating the immediate post operation data, no statistically significant differences emerged between the two groups. Ultrasonography showed in 68% of the knees of group I (defect closed) a thickened patellar tendon (PT), while in 60% of group II it was of normal thickness. No patients of either group developed patella infera by X-ray evaluation 6 months post operation. CT scans at 6 months showed that 100% of the knees of group I had a thickened PT in toto (nearly twice as thick as normal). Scar tissue was present not only in its central third but also in more than half of the cases in the medial and lateral third. In group II 75% of the patients had a normal thickness PT and 25% presented with only a minimal thickening. Scar tissue was distinguished only at its central third.(ABSTRACT TRUNCATED AT 250 WORDS)

The double patella syndrome.

First described by A. Trillat, the double patella is an uncommon clinical feature following repetitive injuries of the extensor mechanism of the knee. The first injury is a tendo-periosteal avulsion of the suprapatellar or, less frequently, infrapatellar tendon from the corresponding patellar pole. Often these avulsions are misdiagnosed and therefore treated only with a cast or no immobilization at all. Subsequent giving-way episodes lead to extensive ossification which is adjacent to or separated from the patella. The peculiar shape of this ossification overriding or underlying the primary kneecap justifies the denomination of double patella. Surgical treatment consists of removal of the calcification and reattachment of the tendon to the patella by transosseous sutures.

Different patterns of meniscal tears in acute anterior cruciate ligament (ACL) ruptures and in chronic ACL-deficient knees. Classification, staging and timing of treatment.

Through the retrospective study of 1103 reconstructions of the anterior cruciate ligament (ACL) performed between 1984 and 1993, we try to outline the natural history of meniscal tears in acute lesions and in chronic insufficiency of the ACL. According to a more accurate evaluation of the clinical evolution, ACL-deficient knees can be classified into four different stages: acute, subacute, subchronic and properly chronic laxities. While acute injuries show a higher rate of lateral meniscus tears, chronic laxities are very frequently associated with severe medial meniscus lesions. Subacute and subchronic stages seem therefore to be the most favourable phases for ACL reconstruction, because of the lower percentage of severe associated meniscus tears and the minor risk of arthrofibrosis.

[Not Available]. / Cefalee primarie e ortognatorinodonzia in età evolutiva.

The aim of the research was to study the interrelationship between the primary neurovascular headaches, the various levels dimension of nasal pyramid and the rapid palatal expansion.Twenty-five patients, of both sexes and on developmental age, were studied before and after the rapid palatal expansion.All patients showed palatal hypoplasia and were suffering from primary neurovascular headache.The research was based on the cephalometric and rhinomanometric data.The radiographic documentation of each patient consisted of three posteroanterior teleradiographic projection; the first before application of the disjunction device, the second immediately after disjunction and the third at the end of the contention period. The rhinomanometric evaluation studied the reduction of nasal resistance values before and after palatal expansion.In all patients a constant increase in the values relating both skeletal and dental structures was observed.The nasal septum, if deviated, appeared straightend.The nasal resistances were decreased. The concomitant headache symptomatology presented resolution or recovery in the 98% of treated patients.The results should confirm the hypothesis of the central-peripheral theory of "primary headaches" and the possibility to treat the primary headaches by rapid palatal disjunction in eliminating the stenosis at various levels of nasal pyramid.

Anterior cruciate ligament reconstruction and augmentation with PDS graft.

The article briefly explains the biomechanical properties of the PDS and the most important ways of its use in anterior cruciate ligament (ACL) reconstruction. The different techniques of ACL reconstruction with gracilis and semitendinosus tendons are outlined. The authors explain their technique of ACL reconstruction with gracilis and semitendinosus plus PDS-band. The possible variations and pitfalls are pointed out. The results of this surgery are expounded.

Gianotti-Crosti syndrome: a retrospective analysis of 308 cases.

BACKGROUND: There is no agreement as to whether papular acrodermatitis of childhood caused by hepatitis B virus can be differentiated from other papulovesicular acrolocated syndromes. OBJECTIVE: We attempted to establish whether such differentiation is possible comparing histories, signs, and symptoms of all patients who have been previously diagnosed as having papular acrodermatitis of childhood or papulovesicular acrolocated syndromes. METHODS: Files of 308 patients hospitalized in the past three decades were studied. Photographs were examined by a panel of experts to determine whether it was possible to distinguish between papular acrodermatitis of childhood and papulovesicular acrolocated syndromes solely on the basis of cutaneous signs. RESULTS: The retrospective analysis confirmed a significant overlapping of the two types of the disease. The blind survey of photographs of the patients revealed that a distinction between the forms was not clinically possible. CONCLUSION: Acrodermatitis is a self-limiting cutaneous response to different viruses; clinical differences are probably due to individual characteristics of each patient rather than the causative virus.

[Acute postintervention cholecystitis]. / La colecistite acuta post-aggressiva.

A case of postoperative cholecystitis in a 64 years old man is reported. This is a nosological entity characterized by gallbladder distension without any patent obstacle in the cystic duct and constancy of necrosis involving all the parietal layers. Clinical signs and symptoms are aspecific. Mortality rate is high and diagnosis has to be done quickly because the gallbladder necrosis makes cholecystectomy compulsory on such patients.

Papular xanthoma in children.

Papular xanthoma is a normolipemic xanthomatosis that mainly affects adults. We describe the clinical, histologic, ultrastructural, and immunologic findings in 10 children with this disease. Papular xanthoma in children has the same clinical and histopathologic features as in adults, but it appears to be self-healing within 1 to 5 years.

[Hamartomatous polyps of Brunner's gland. Presentation of 2 cases. Review of the literature]. / I polipi amartomatosi delle ghiandole di Brunner. Presentazione di due casi. Review della letteratura.

Two uncommon cases of Brunner gland hyperplasia are reported. Both presented clinical symptoms simulating gastrointestinal disease caused by hyperacidity. In conjunction with clinical statistics, diagnosis based on aetiology was only formulated after a double-contrast radiological exam of the g-i tract. After treatment with antiacid and antisecretory drugs, remission of the clinical symptoms was obtained, and regression of the hamartomatous polypoid duodenal neoformation, thus confirming the hypothesis which states that hyperacidic gastric secretion is the main cause of Brunner gland hyperplasia.

[Infantile sclero-atrophic lichen and infection caused by Borrelia burgdorferi]. / Lichen sclero-atrofico infantile e infezione da Borrelia burgdorferi.

The authors describe a study of 8 girls suffering from genital and perianal lichen sclerosus et atrophicus. Following the most recent reports in literature, antibodies against Borrelia burgdorferi have been looked for, and the patients have been treated with propicillin. The results are discussed.

Cutaneous manifestations of tetrachlorodibenzo-p-dioxin in children and adolescents. Follow-up 10 years after the Seveso, Italy, accident.

After an accident in a chemical plant in Seveso, Italy, on July 10, 1976, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) spread over a populated area. The event was exceptional because children were also affected and because the contamination took place not only through direct exposure but also through inhalation and the ingestion of contaminated foods, especially fruits and vegetables. This paper illustrates the early dermatologic lesions, the late acneic (chloracne) lesions, and their evolution during a 10-year period. Peculiar cutaneous findings, histologic data, and a comparison with previously reported similar accidents are also included.