Evaluación de la enfermedad de Alzheimer en etapa temprana: biomarcadores y pruebas neuropsicológicas / Early evaluation of Alzheimer's disease: biomarkers and neuropsychological tests

Background: Alzheimer disease is a neurodegenerative condition that affects cognitive, behavioral and global functioning of patients. Currently and due to the lack of conclusive biological testing, Alzheimer's disease diagnosis is based primarily on clinical criteria. Since its early diagnosis allows clinical interventions when neurological damage is relatively mild, the development of early detection tools has become a major topic of interest. In this article, we review the main neuro-biological and neuropsychological features of Alzheimer's disease, analyzing the use of biomarkers and neuropsychological testing for early detection.

Hipnosis clínica y psicoterapia: una propuesta integrativa para el tratamiento de la depresión unipolar / Clinical hypnosis and psychotherapy: an integrative proposal for the treatment of unijpolar depression

Introduction: Hypnosis consists in a load of consciousness phenomena whose historical development is saturated of controversies and misunderstandings. Nevertheless, the Society of Psychological Hypnosis have achieved to reach a consensus for an academic definition. Development: In respect to it historical development, hypnosis have oriented through varied stages, in function of the theories that were set out to explain it. Between them we find the animal magnetism, the theory of neurosis and the theory of suggestion. However, it scientific exploration was scant until the end of nineteenth-century. Without a doubt, the course of the XX Century marked definitely the Entrance of hypnosis to the experimental psychology laboratories and to the massive use in clinical psychology. Nowdays exists extended empirical evidence in respect to its neurobiological correlates and efficacy in clinical psychology. Besides, exists therapeutic models, as Yapko’s, which attach hypnosis as a tool for the integrative treatment for unipolar depression. Conclusions: Nevertheless the controversies that have caused the popularization and masification of hypnosis, it have manage to come in the topics of interest of neurophysiology, cognitive neuroscience, medical science and clinical psychology. However, scientifics suggest that hypnosis research is still poor. Between the varied integrative psychotherapeutic models the attach hypnosis as a tool we find Yapko’s model for treatment for unipolar depression

Introducción: La hipnosis consiste en un cúmulo de fenómenos de la conciencia cuyo desarrollo histórico se encuentra saturado de controversias y malos entendidos. No obstante, la Sociedad de Hipnosis Psicológica ha logrado consensuar una definición académica. Desarrollo: Respecto a su desarrollo histórico, la hipnosis se ha encaminado por diversas etapas, en función de las teorías que se plantearon para explicarla. Entre ellas encontramos el magnetismo animal, la teoría de la neurosis y la teoría de la sugestión. Sin embargo, su exploración científica fue escasa hasta finales de los tiempos decimonónicos. Sin duda el transcurso del siglo XX marcó definitivamente el ingreso de la hipnosis a los laboratorios de psicología experimental y a su uso masivo en la clínica psicológica. Actualmente se cuenta con amplia evidencia empírica respecto de sus correlatos neurobiológicos y eficacia en clínica psicológica. Además existen modelos terapéuticos, como el de Yapko, que la utilizan como coadyuvante para el tratamiento de la depresión unipolar. Conclusiones. No obstante las controversias que ha suscitado la popularización y masificación de la hipnosis, ésta ha logrado introducirse en los temas de interés de la neurofisiología, neurociencia cognitiva, ciencia médica y psicología clínica. Sin embargo, los investigadores sugieren que la investigación de la hipnosis aún es escasa. Entre los diversos modelos psicoterapéuticos integrativos que adjuntan hipnosis como coadyuvante encontramos el modelo de Yapko para tratar la depresión unipolar

Human polyomavirus BK in patients with lupus nephritis: clinical and histological correlations.

Polyomavirus BK (BKV) reactivation can occur in immunodeficient patients. Few studies on BKV infection in patients with systemic lupus erytematosus (SLE) nephritis are available. Aim of this study was to analyse the prevalence of BKV infection by quantifying viral load and to investigate the association with clinical and histological parameters indicating duration, type and activity of SLE.BKV-DNA was evaluated by polymerase chain reaction in serum (sBKV) and urine (uBKV) specimens from 40 patients with SLE nephritis and 29 healthy controls. Renal function, urinary activity, clinical index of SLE activity [SLE Disease Activity Index (SLEDAI) score], CD4+/CD8+ ratio, histological classes and duration of SLE nephritis were compared according to the BKV-DNA-positivity.sBKV was present in 15% of SLE patients and in 13.8% of controls; uBKV in 32% of SLE patients and in 17.2% of controls. There was no significant difference in terms of kidney function, urinary activity, SLEDAI score, presence of anti-dsDNA antibodies, CD4+/CD8+ ratio and BKV viremia and/viruria, as well as there was no significant correlation between SLEDAI score, anti-dsDNA antibodies titers and median viral load. Duration of nephropathy tended to be shorter in patients with BKV viremia and/or viruria; proteinuria/creatininuria ratio tended to be higher in patients with positive sBKV and uBKV. BKV-DNA-positivity tended to be more frequent in patients treated with an immunosuppressive agent versus those on steroid treatment. Reactivation of BKV infection can occur in patients with SLE, although prevalence data do not significantly differ from those obtained in the control group. The trend toward an association between BKV infection and degree of proteinuria and less duration of SLE nephritis could indicate a major susceptibility to develop BKV infection in more active phases of the disease. The role of BKV reactivation in terms of clinical parameters and histological pattern, as well as the role of therapeutic protocols in the onset of BKV reactivation and, conversely, the therapeutic implication of BKV reactivation in SLE patients remain to be defined and should be addressed in further studies on a larger number of patients.

[Urinalysis in Italy in 2006]. / Dalla Mailing List Soci-SIN (ML-SIN): L'esame urine in Nefrologia. Stato dell'arte nel 2006.

Urinalysis and proteinuria testing represent fundamental tests for the clinician, even though they too often lack standardization. Through the Italian Society of Nephrology Mailing List we sent a questionnaire to 282 centers, in order to assess the state of the art in Italy in the year 2006. 82% of the questionnaires were completed (nephrology laboratories: 64%, general laboratories: 36%). The questionnaire dealt with the main steps of preparation, analysis and report of urinalysis, and proteinuria / microalbuminuria measurement. 85% of the centers use first morning urine, and 7% second morning urine; only 57% of the centers supply with written instructions, 189 laboratories (82%) have only one bright field microscope, rate and time of centrifugation are very varied among centers, different units of measurement are used in reports. Few laboratories measure routinely the proteinuria / creatininuria ratio, there is no agreement on the urine sample type for microalbuminuria assay, total urinary proteins are measured through different methods. 92% of the centers is endowed with an internal quality control system, but only 47% participate in an external quality control program. These data confirm the lack of standardization for urine analysis methods and procedures.

Comparison between 24-h proteinuria, urinary protein/creatinine ratio and dipstick test in patients with nephropathy: patterns of proteinuria in dipstick-negative patients.

OBJECTIVE: Three main tests are commonly employed for the measurement of proteinuria: the dipstick test, the urinary protein/creatinine ratio (P/C) and the 24-h urine collection. The aim of this study was to evaluate the correlation between these methods, comparing linear regression and ROC curve data. MATERIAL AND METHODS: A total of 297 consecutive outpatients with different renal diseases were included in the study. Twenty-four-hour proteinuria was considered the reference test. RESULTS: A high degree of correlation was observed between all the tests (p<0.0001), the highest regression coefficient being between 24-h proteinuria and P/C (R=0.82), and the lowest between P/C and the dipstick test (R=0.72). The dipstick test failed to detect pathological proteinuria in 94 patients (31.6%). Therefore, in these subjects, the patterns of proteinuria were assessed by immunofixation and sodium dodecyl sulphate (SDS) electrophoresis. CONCLUSIONS: Our data strongly support the use of urinary P/C for the detection of proteinuria, at least in nephrology units, where the prevalence of proteinuria is likely to be high.

"Decoy cells" in urine.

BK virus-associated nephropathy is an emerging cause of kidney transplant loss. Tapering immunosuppressive drugs and antiviral agents are the only therapy. The diagnosis is based on immunohistochemical findings or polymerase chain reaction on renal biopsy. Phase-contrast microscopy without staining is a simple test to screen the urine of transplant recipients for BK nephritis. Any kidney transplant unit should have the ability to detect decoy cells by phase-contrast microscopy on a spot urine.

Maintenance of residual renal function 10 years after the start of hemodialysis: the advantage of tailored schedules?

Maintenance of residual renal clearance is a clinical advantage, protecting against the long-term effects of uremia: although demonstrated in peritoneal dialysis, the strategies in hemodialysis are less clear. This case suggests that dialysis schedules individualized on the basis of renal clearances may help preserve residual function. SB is a 58 year-old male who started dialysis in emergency (creatinine 30.7 mg/dL) in 1993. He had a history of gout, small shrunken kidneys and moderate hypertension. The clinical diagnosis was vasculointerstitial nephropathy. Eighteen months after starting hemodialysis on a conventional thrice weekly schedule, the patient was switched to 2 sessions/week (creatinine clearance increased to 6 ml/min). Thereafter, clearances were checked in alternate months and treatment was tailored to an equivalent renal clearance > or =12 ml/min (1-2 sessions, 2-3.30 hours/week). Ten years after beginning dialysis, he is on a twice weekly schedule (3.30 hours), is normotensive, works full-time and does not want to go on a transplant waiting list.

Complete reversal of the nephrotic syndrome after preemptive pancreas-kidney transplantation: a case report.

BACKGROUND: Nephrotic syndrome due to diabetic nephropathy is presently considered an indication for pancreas-kidney transplantation even in the absence of severe renal failure. Reversal of the nephrotic syndrome has been reported, but the mechanisms of this effect are unclear. AIM: To describe the renal morphofunctional pattern and the pattern of proteinuria before and after preemptive pancreas-kidney transplantation. METHODS: Methods included quantitative and qualitative assessment of proteinuria as well as renal ultrasound and scintiscan. CASE REPORT: A 42-year-old woman with type 1 diabetes since age 24 had widespread end-organ damage. Renal biopsy (2001) showed a mainly nodular pattern of diabetic nephropathy. Following referral (1999), her serum creatinine ranged from 1.6 to 2.2 mg/dL, with nephrotic range proteinuria (glomerular nonselective, tubular complete). Renal scintiscan revealed bilateral, symmetric, well-perfused kidneys. The functional data before pancreas-kidney graft (February 2003) were: serum creatinine 1.6 mg/dL, creatinine clearance 58 mL/min, serum albumin 2.6 g/dL, proteinuria 9.1 g/d. At hospital discharge (March 2003), the creatinine was 1.2 mg/dL, the creatinine clearance 97 mL/min, the proteinuria 0.676 g/d. Two months later, the creatinine was 1.2 mg/dL and proteinuria 0.421 g/d. A renal scintiscan demonstrated the functional prevalence of the grafted kidney (77% of total function), with vital, almost completely excluded native kidneys (functional contribution, 11.5% each). Proteinuria, ranging from 0.3 to 0.6 g/d, showed a physiological pattern. CONCLUSIONS: Functional exclusion of the native kidneys by renal scintiscan gives morphological support to reversal of the nephrotic syndrome.

[Contribution to the study of innervation of the pancreas with a view to its relevance to neoplasm surgery]. / Contributo allo studio sull'innervazione del pancreas finalizzato alla chirurgia neoplastica.

Pancreaticoduodenal resection yields poor results, mainly because of cancer spread into retropancreatic nervous tissue. The aim of this study was to evaluate the feasibility of dissection capable of sparing a portion of retropancreatic nervous tissue in order to lessen, if not prevent, postoperative diarrhoea and severe malabsorption. From April 2000 to June 2001 20 dissections were carried out on 18 fresh cadavers (15 male) within 24 hours of death and on 2 frozen trunks. In all dissections the splanchnic nerves, coeliac plexuses, capital pancreatic plexus and superior mesenteric plexus were identified and traced. The capital pancreatic plexus is composed of two bundles, the first originating in the right coeliac plexus, the second in the superior mesenteric plexus. These two bundles join together just behind the head of the pancreas. The superior mesenteric plexus is composed of two preganglionic bundles, one ganglion, and another two postganglionic bundles. These latter two bundles receive fibres from both the right and left coeliac plexuses. In pancreaticoduodenal resection for cancer, the capital pancreatic plexus has to be completely removed, like the superior mesenteric plexus, as they are very often infiltrated and constitute a route for cancer spread. In small cancers, a thin layer of nervous tissue around the superior mesenteric artery might be spared in order to avoid diarrhoea due to intestinal denervation. The results of this study show that there is anatomical evidence that a thin layer of superior mesenteric plexus receiving fibres from both the left and right coeliac plexuses maintains adequate intestinal innervation.

Contribution to the surgical anatomy of the ligaments of the rectum.

PURPOSE: Many authors have discussed the presence and the importance of the lateral ligaments of the rectum. Our contribution aims at clarifying some aspects of surgical anatomy that help in the preservation of the urogenital functions and may influence the surgical practice. METHODS: From 1994 to 1998 we examined 27 fresh cadavers and five embalmed pelves. We performed all dissections with a technique similar to that used for the surgical mobilization of the rectum. RESULTS: The lateral ligaments of the rectum are trapezoid structures originating from mesorectum and are anchored to the endopelvic fascia; as lateral extensions of the mesorectum, they must be included in the surgical specimen. According to our results, three main structures can be recognized laterally to the rectum: 1) the lateral ligament, which does not contain important structures; 2) the inferior hypogastric plexus and the urogenital bundle; and 3) the lateral neurovascular pedicle of the rectum that comprises the nervi recti and the middle rectal artery, both running under the lateral ligament, although at different angles. CONCLUSION: At the point of insertion into the endopelvic fascia, the lateral ligaments run close to the urogenital bundle. Nevertheless, the dissection at its attachment is safe if the urogenital bundle is kept under visual control.

The lateral ligaments of the rectum: myth or reality?

The modern approach to rectal surgery aims at preserving the nerves to the urogenital system. The relationships between the lateral aspects of the rectum and the surrounding structures represent one of the most controversial points in the surgical anatomy of this area. This study was conducted on 27 fresh cadavers and 5 frozen pelvises. All dissections were performed with a technique similar to that used for the surgical mobilisation of the rectum. The lateral ligaments can be considered extensions of the mesorectum; they originate laterally to the middle portion of the rectum and descend posterolaterally to anchor to the endopelvic fascia. The lateral neurovascular pedicle of the rectum, comprising the middle rectal artery and the transverse autonomic nervous fibres, courses partially beneath the lateral ligament. The urogenital nervous bundle runs close to the point of insertion of the lateral ligaments in the endopelvic fascia, but is not covered with the same layer that forms the ligament itself. Anatomical dissection of cadavers is of invaluable help to the surgeon as it represents the basis for easy recognition of all the various structures in the rectal area.

[The nutrition of the elderly surgical patient]. / La nutrizione nel paziente anziano operato.

The key concepts regarding nutrition of elderly patients prior to surgery are outlined. The main metabolic changes that occur during surgical stress, paying special attention to the characteristics of elderly patients, are described. Lastly, the caloric-energy intake required by postoperative geriatric patients is evaluated and the methods of food intake compared to the benefits obtained are analysed.

Prognostic implications of detection of troponin I in patients with unstable angina pectoris.

In our study, troponin I was not a predictor of cardiac events and a negative troponin I test did not exclude the presence of severe coronary artery disease. A positive troponin I test in patients with unstable angina identified a subgroup with probable, more active coronary disease (with higher levels of C-reactive protein).

Observations on surgical anatomy for rectal cancer surgery.

BACKGROUND/AIMS: The investigators studied the surgical anatomy of the main structures involved in the mobilization of the rectum (Denonvilliers' fascia, mesorectum, middle rectal artery, superior and inferior hypogastric plexuses). METHODOLOGY: The study was carried out on 20 cadavers (17 unembalmed and 3 embalmed). To study Denonvilliers' fascia, ten embryos and fetuses (11 mm to 80 mm CRL) were also examined. RESULTS: Denonvilliers' fascia originates from the fusion of the primary pouch of Douglas. The two leaves making up this structure are easily separated. The mesorectum surrounds the rectum on three sides; it is easily separated from the presacral fascia and its connective tissue is bordered by a thin membrane. The middle rectal artery varies in appearance rate, origin, size, distribution and anastomosis. It runs under the lateral ligament and also sends branches to the genital apparatus. Of the two hypogastric plexuses, the inferior is the most difficult one to identify. Its superior branches extend to the rectum, and the inferior ones to the genital apparatus. Because the anterior part contains the parasympathetic nerves and the middle rectal artery, this region is at major risk during surgical dissection. CONCLUSIONS: A sound understanding of the surgical anatomy of the rectum enables the surgeon to perform a more correct and reasonable procedure in terms of both the extent of surgical treatment and the preservation of important anatomical structures.

[Venous ulcers of the lower limbs in the aged. Indications for bandages]. / Le ulcere venose degli arti inferiori negli anziani. Indicazioni al bendaggio.

BACKGROUND: There are many causes of ulcer of the lower limb. In the elderly, venous ulcers and arteriosclerosis often coexist; for this reason pressure bandages might be contraindicated for the risk of precipitating a potentially critical arterial flow. In this work, the conditions which allow a safely treatment with pressure bandage in the elderly are evaluated. MATERIAL AND METHOD: Eleven self-sufficient elderly, with venous ulcerations to one leg only, and ankle pressure/omeral pressure between 0.92 and 0.86 were treated with elastic bandaging of the leg. RESULTS: All patients completed the treatment, with healing of the ulcer obtained in 3-8 months time. So far none of them relapsed. CONCLUSIONS: In the elderly, in selected cases, when Pc/Po > 0.86, pressure bandages can be safely applied to heal the ulcer, without running the risk of endangering arterial circulation.

Reperfusion damage to the bile canaliculi in transplanted human liver.

In 19 patients who have undergone orthotopic liver transplantation (OLT), the trend and degree of cholestasis was statistically monitored in terms of plasma levels of L-gamma-glutamyl transferase (GGT) and total bilirubin. In addition, the ultrastructure of the bile canaliculus was examined during the entire OLT procedure, i.e., during explantation, cold ischemia, and after 60 to 90 minutes of organ reperfusion. Cholestasis was evident from the second day after surgery, with a peak after approximately 10 to 16 days. Defined, small changes in the functional state of actin filaments were noted in the bile canalicular area after prolonged ischemia. But the morphological status of the bile canaliculi changed dramatically after reperfusion. In fact, the mean area and perimeter of the canaliculi had increased significantly, and there was a marked loss in the number of bile microvilli per unit of canalicular area. The bile canaliculus appears to be one of the liver structures most susceptible to ischemia-reperfusion damage. A series of biochemical changes occurring during ischemia and after reoxygenation of the transplanted liver, especially, would provide a reason for the observed early morphological damage of the bile canaliculus, which, in turn, would explain the cholestasis of these patients in the first posttransplantation period.

[Acute suppurative thyroiditis. Report of a case and review of the literature]. / La tiroidite acuta suppurativa. Presentazione di un caso e revisione della letteratura.

The authors present a case of acute suppurative thyroiditis complicated by acute dyspnoea with asphyxia in a patient of geriatric age. In this patient there were present possible infectious focuses like multiple dental abscesses and contamination of the urinary tract. Histological examination highlighted a focus of papillifer carcinoma in the context of the gland. We have a review of the literature on this observation and description. Acute suppurative thyroiditis is currently a pathology of rare observation. This rarity is due, apart from the availability of antibiotic therapy, to an intrinsic resistance of the thyroid gland to contamination. In most cases we are talking of bacterial infections, but in immunodepressed subjects fungal etiology is noteworthy. The infection could arise from primitive focuses present in any bodily district with propagation to the thyroid across different ways. Expressive is the anamnestic observation of preexisting thyroid dysfunction. After an attentive evaluation of the clinical findings, usually characteristic, it is important to complete the diagnostic course with some instrumental investigations. In particular cervical sonography, possibly associated with agobiopsy is fundamental. Initially therapy is medical (basically antibiotic). The surgical resolution foresees the drainage of the purulent abscess or the thyroidectomy if it is associated with a struma.

[General surgery after lung transplantation]. / La chirurgia generale dopo trapianto polmonare.

The authors report the case of correction of a large laparocele after lung transplant. Paradoxical respiration interfered with patient breathing. Three overlapping meshes were used to surgically correct the wound. Excellent results were achieved. Cortisone and immunosuppression therapy was not discontinued; infection risk was minimized by implementing rigorous asepsis and a wide spectrum antibiotic therapy.