Lung ultrasound to detect and monitor pulmonary congestion in patients with acute kidney injury in nephrology wards: a pilot study.

INTRODUCTION: Lung congestion and frank pulmonary edema are established complications of acute kidney injury (AKI) and early detection and monitoring of lung congestion may be useful for the clinical management of AKI patients. METHODS: We compared standardized clinical criteria (including lung crackles and peripheral edema grading) and simultaneous chest ultrasound (US) to detect lung congestion in a series of 39 inpatients with AKI. RESULTS: At baseline, twelve patients (31%) were clinically euvolemic and twelve presented clear-cur cardiovascular congestion (31%) by clinical criteria. Fifteen patients (38%) were hypovolemic. The median number of US-B lines in patients with cardiovascular congestion was much higher (50, inter-quartile range 27-99) than in euvolemic (14, IQR 11-37) and hypovolemic patients (7, IQR 3-16, P < 0.001). Remarkably, a substantial proportion of asymptomatic euvolemic (66%) and hypovolemic (46%) patients had lung congestion of moderate to severe degree (> 15 US-B lines) by lung US. Crackles severity and the number of US-B lines over time were inter-related (Spearman's ρ = 0.38, P < 0.01) but the agreement (Cohen k statistics) between the two metrics was unsatisfactory. Forty-eight percent of patients had lung congestion of moderate to severe degree by lung US and this estimate by far exceeded that by clinical criteria (32%). CONCLUSIONS: This pilot study shows that chest US has potential for the detection of lung congestion at a pre-clinical stage in AKI. The results of this pilot study form the basis for a clinical trial testing the usefulness of this technique for guiding lung congestion treatment in patients with AKI.

Herpes Virus, Oral Clinical Signs and QoL: Systematic Review of Recent Data.

This manuscript aims to highlight all the clinical features of the herpes virus, with a particular focus on oral manifestations and in the maxillofacial district about Herpes Simplex Virus-1 (HSV-1) and Herpes Simplex Virus-2 (HSV-2). Oral herpes virus is a very common and often debilitating infectious disease for patients, affecting oral health and having important psychological implications. The collection of relevant data comes from the scientific databases Pubmed, Embase; initially this collection obtained an extremely high number of results, 1415. After applying the inclusion and exclusion criteria, as well as a manual screening, the results included in this review were limited to 14. The results were expressed by evaluating all the signs and symptoms that this pathology entails during the study, paying attention to the characteristics linked to the quality of life and the psychological implications. This pathology has numerous therapies, which often make the healing phase of the manifestations of this viral pathology more comfortable. The therapies currently used for the treatment of this viral infection are pharmacological, topical, systemic, or instrumental, for example with laser devices.

Diabetes: Oral Health Related Quality of Life and Oral Alterations.

BACKGROUND AND OBJECTIVES: About 5% of the world's population is affected by diabetes; these patients must be further treated during medical and surgical treatments. These patients, due to the glycemic conditions, realize during their life multiorgan changes, in different body districts. Moreover, this condition obliges them to undertake hypoglycemic therapies. Diabetes is a risk factor for many diseases, including those concerning the oral district with immunological implications. MATERIALS AND METHODS: A comprehensive review of the literature was conducted according to PRISMA guidelines accessing the NCBI PubMed database. Authors conducted the search of articles in English language. The results of the last 10 years have been considered, which present useful information regarding the oral conditions. A total of 17 relevant studies were included in the review. The study evaluated only papers with specific inclusion criteria regarding oral health. The works initially taken into consideration were 782; subsequently applying the inclusion and exclusion criteria, there were 42 works. After a careful analysis of the work obtained by two academics who have worked separately, there have been 17 studies. All data from the studies were compared and many of these confirmed alteration in the oral district. RESULTS: The studies taken into consideration evaluated different factors, such as OHRQoL, QoL, and oral alterations, involving soft tissue, dental structures, and postrehabilitative complications, as well as immunological alterations. CONCLUSIONS: We can affirm, in conclusion, that this study has brought to light those that are complications due to diabetic pathology, from different points of view. The psychological and psychosocial alterations, certainly present in these patients, are probably due to local and systemic alterations; this is confirmed by the correlation between oral health and quality of life reported by the patients.

A novel human aquaporin-4 splice variant exhibits a dominant-negative activity: a new mechanism to regulate water permeability.

Two major isoforms of aquaporin-4 (AQP4) have been described in human tissue. Here we report the identification and functional analysis of an alternatively spliced transcript of human AQP4, AQP4-Δ4, that lacks exon 4. In transfected cells AQP4-Δ4 is mainly retained in the endoplasmic reticulum and shows no water transport properties. When AQP4-Δ4 is transfected into cells stably expressing functional AQP4, the surface expression of the full-length protein is reduced. Furthermore, the water transport activity of the cotransfectants is diminished in comparison to transfectants expressing only AQP4. The observed down-regulation of both the expression and water channel activity of AQP4 is likely to originate from a dominant-negative effect caused by heterodimerization between AQP4 and AQP4-Δ4, which was detected in coimmunoprecipitation studies. In skeletal muscles, AQP4-Δ4 mRNA expression inversely correlates with the level of AQP4 protein and is physiologically associated with different types of skeletal muscles. The expression of AQP4-Δ4 may represent a new regulatory mechanism through which the cell-surface expression and therefore the activity of AQP4 can be physiologically modulated.

Ultrafiltration intensification in hemodialysis patients improves hypertension but increases AV fistula complications and cardiovascular events.

INTRODUCTION: Hypertension remains a major problem in hemodialysis (HD) patients. METHODS: We performed a pragmatic trial (Pragmatic Clinical Intervention on Blood Pressure Driven by Audit [CLINIDEA]) testing the effectiveness and safety of a 6-month multimodal intervention in hypertensive HD patients regarding the application of higher ultrafiltration (UF) rates or longer or more frequent dialyses in UF-intolerant patients, and an educational intervention to encourage patients to lower their salt and fluid intake. RESULTS: Blood pressure (BP) in hypertensive patients (n=32) fell from 156.8 ± 13.3 / 81.1 ± 8.9 mm Hg to 147.9 ± 18.8 / 77.5 ± 11.1 mm Hg. UF intensification was well tolerated, and the BP goal was achieved without resorting to longer or more frequent dialyses. BP changes were paralleled by a consistent (p<0.01) fall in dry body weight. The trial largely failed at increasing compliance with salt prescription (salt intake: baseline: 156.9 ± 64 mEq/day, 6-month: 150.7 ± 60.3 mEq/day). During the 12 months preceding the trial, the hospitalization rates for arteriovenous (AV) fistula complications and cardiovascular (CV) events were identical in hypertensive and in normotensive patients. However, these complications selectively increased (AV complications: relative risk [RR] = 7.6; CV complication: RR=8.4) in hypertensive patients coinciding with UF intensification during the trial. Increasing the UF rate is an effective BP-lowering intervention in HD patients. However, this intervention is associated with a higher risk for AV complications and CV events. CONCLUSION: Longer and/or more frequent dialyses and better efforts to increase compliance to low salt diets than those put in place in this study are needed to reduce the high prevalence of hypertension in the HD population.

Combining an external fixator and an artificial nerve-guide for the treatment of a complex digital injury.

A complex digital injury, with tendon, nerve and bone losses, may pose the problem of which structure deserves the highest priority. Authors were able to treat tendon, nerve and bone lesions with the same level of priority thanks to the combined use of an external fixator and a nerve-guide.

Combining back scattered and secondary emission scanning electron microscopy to study articular cartilage morphology on undecalcified unstained samples A descriptive study / 中国组织工程研究

BACKGROUND: The use of undecalcified and unstained samples for articular cartilage's study (as Authors suggest) will enable to better preserve its three-dimensional structure. Feasibility of such approach will reduce time and complexity when analyzing a great number of specimens.OBJECTIVE: To test the possibility of studying articular cartilage morphology on the undecalcified inclusion blocks, avoiding cutting and staining thin sections.METHODS: Femoral condyles were obtained from White New Zealand rabbits and from Sardinian sheep, fixed in paraformaldehyde, dehydrated in ethyl alcohol, and embedded into poly-methylmethacrylate. Blocks were cut and ground,sputter-coated with gold-palladium and analyzed by a Jeol JSM 6310 electron microscope, operated between 20 and 25 kV. Data from secondary emission scanning electron microscopy were combined with data from back scattered electron microscopy (BSEM), performed sequentially over the same area.RESULTS AND CONCLUSION: In the rabbit, it was easy to discern the passage between uncalcified and calcified cartilage but it was difficult to highlight the small chondrocytic lacunae in zones Ⅱ and Ⅲ. The sheep proved to be more suitable for easily discerning all the zones of articular cartilage and its cellularity; BSEM excelled in defining the structure of calcified cartilage and the "tidemark" front. Large canals could be demarcated, digged through subchondral bone and calcified cartilage, topped by non-calcified cartilage. The results suggested that the possibility of describing articular cartilage morphology on undecalcified and unstained embedding blocks, by avoiding the cutting of thin sections, was illustrated. This provides an obvious advantage in terms of less time needed and tess complexity required in comparison with classical histomorphology. It may be an opportunity when a relevant number of samples must be analyzed.

Articular ganglia of the volar aspect of the wrist: arthroscopic resection compared with open excision. A prospective randomised study.

Our aim was to compare two methods of treatment of ganglia on the volar aspect of the wrist (the open excision done through a longitudinal volar skin incision and the arthroscopic resection through two or three dorsal ports), to see if arthroscopy could reduce the risks of operating in this area and the time to healing. Twenty radiocarpal and five midcarpal volar ganglia were operated on by open approach and an equivalent group was treated by arthroscopy. Fifteen radiocarpal and five midcarpal ganglia were treated with good results in the open group and 18 radiocarpal and one midcarpal ganglia in the arthroscopic group (no visible or palpable ganglion, a full range of active wrist movement, grip strength equal to preoperatively, no pain, and a cosmetically acceptable scar). In the open group there were four injuries to a branch of the radial artery, two cases of partial stiffness of the wrist associated with a painful scar, one case of neuropraxia, and one recurrence (all of which were among the 20 radiocarpal ganglia). In the arthroscopic group there was one case of neuropraxia, one injury to a branch of the radial artery, and three recurrences (three of the complications were among the five midcarpal ganglia). The mean functional recovery time was equal to 15 (6) days in the open group and 6 (2) days in the arthroscopic group. The mean time lost from work was equal to 23 (11) days in the open group and 10 (5) days in the arthroscopic group. Our results suggest that arthroscopic resection is a reasonable alternative to open excision in treating radiocarpal volar ganglia because it has less postoperative morbidity and a better cosmetic result. Midcarpal volar ganglia, however, should still be treated by open operation.

Flexor tendon injuries of the hand treated with TenoFix: mid-term results.

BACKGROUND: Recently, the Teno Fix device has been detailed in the literature. Conventional stranded cruciate repair requires splinting to protect the sutures from excessive loading, and then, active motion is strongly limited leading to a possible incomplete functional recovery. MATERIALS AND METHODS: The authors report on their experience in treating 21 patients presenting primary flexor tendon injuries within the digital sheath in zone 2, in all fingers (including the thumb), at an average follow-up of 16 (range: 6-26) months. RESULTS: There were, according to Strickland and Glogovac criteria: 12 excellent; 6 good; 3 fair. CONCLUSIONS: This new device is practical clinically and can effect strong tendon repairs that withstand early active finger motion, but the best indication is to treat only selected cases of sharp flexor tendon lesions in zone 2. Using this technique it is possible to achieve a quick functional recovery and early return to work.

Adipose tissue cytokines, insulin sensitivity, inflammation, and cardiovascular outcomes in end-stage renal disease patients.

From an evolutionary perspective, Darwinian selection has favored insulin-resistant individuals, ie, those with a trait ensuring brain functioning in situations of extreme fuel deprivation. The ability to mount a powerful inflammatory response to infection was another survival advantage in our ancestors, and we now have solid evidence showing that these 2 traits, insulin resistance and inflammation (as measured by serum C-reactive protein [CRP]), are associated in modern human beings. In an analysis of 192 nondiabetic hemodialysis patients, leptin and adiponectin were related in an opposite fashion with insulin sensitivity in end-stage renal disease (ESRD) and interacted in determining insulin resistance in these patients. The risk of insulin resistance was about 6 times higher in ESRD patients with an unfavorable combination of the 2 adipokines (high leptin and low adiponectin) than in those with a favorable combination (low leptin and high adiponectin). Low adiponectin but not high leptin predicted incident cardiovascular events in this cohort. Neither leptin nor adiponectin were associated with CRP in a cross-sectional analysis, but they were linked in an opposite fashion to CRP in a longitudinal study in 21 patients with acute inflammation secondary to infection. High sympathetic activity predicts adverse cardiovascular outcomes in ESRD. Of note, we found that the risk for cardiovascular events is more than 3 times higher in patients with high sympathetic activity and low adiponectin than in those with high adiponectin and low sympathetic activity. The adipocyte hormones leptin and adiponectin are associated in an opposite fashion to insulin sensitivity and inflammation in ESRD patients. Relatively lower plasma adiponectin levels are associated with a higher rate of incident cardiovascular events. Finally, low adiponectin and high norepinephrine seem to be interacting factors in the dismal cardiovascular outcomes with ESRD.

Adiponectin is markedly increased in patients with nephrotic syndrome and is related to metabolic risk factors.

BACKGROUND: Adiponectin (ADPN), the gene product of apM1, is the most abundant secretory protein of the adipose tissue in human plasma. Altered regulation (reduced synthesis) of this substance may be relevant to endothelial dysfunction and cardiovascular complications in patients with ESRD. METHODS: We investigated the relationship between plasma ADPN, glomerular filtration rate (GFR) (plasma iohexol clearance), and metabolic risk factors in 16 patients with nephrotic syndrome, in 25 patients with chronic nephropathies without nephrotic syndrome, and in 31 healthy subjects. RESULTS: Plasma ADPN was much higher (P < 0.01) in patients with nephrotic syndrome (24.4 +/- 14.9 microg/mL) than in patients with chronic nephropathies without nephrotic syndrome (12.3 +/- 7.2 microg/mL) and healthy subjects (5.9 +/- 2.6 microg/mL). In the aggregate 24-hour, proteinuria (r = 0.53, P < 0.01) and serum cholesterol (r = 0.53, P < 0.01) were strong and direct correlates of plasma ADPN, while serum albumin correlated inversely (r = -0.46, P < 0.01) with this protein. Proteinuria appeared to be an important confounder of the relationship between ADPN and the GFR because in the whole patient population (with and without nephrotic syndrome), this relationship emerged only after data adjustment for 24-hour proteinuria (partial r = -0.31, P = 0.05), while no such relationship was demonstrable on crude data analysis (r = 0.03, P = 0.87). CONCLUSIONS: ADPN is markedly increased in patients with nephrotic syndrome, and proteinuria is strongly related to circulating ADPN in patients with nephrotic and non-nephrotic renal diseases. The relationships between plasma ADPN, serum cholesterol, and serum albumin suggest that this adipocyte protein may serve to mitigate endothelial damage triggered by dyslipidemia and other risk factors in patients with chronic renal diseases.