Renal involvement in sarcoidosis: histological patterns and prognosis, an Italian survey.

BACKGROUND: Granulomatous interstitial nephritis in sarcoidosis (sGIN) is generally clinically silent, but in <1% causes acute kidney injury (AKI). METHODS: This Italian multicentric retrospective study included 39 sarcoidosis-patients with renal involvement at renal biopsy: 31 sGIN-AKI, 5 with other patterns (No-sGIN-AKI), 3 with nephrotic proteinuria. We investigate the predictive value of clinical features, laboratory, radiological parameters and histological patterns regarding steroid response. Primary endpoint: incident chronic kidney disease (CKD) beyond the 1°follow-up (FU) year; secondary endpoint: response at 1°line steroid therapy; combined endpoint: the association of initial steroid response and outcome at the end of FU. RESULTS: Complete recovery in all 5 No-sGIN-AKI-patients, only in 45% (13/29) sGIN-AKI-patients (p=0.046) (one lost in follow-up, for another not available renal function after steroids). Nobody had not response. Primary endpoint of 22 sGIN-AKI subjects: 65% (13/20) starting with normal renal function developed CKD (2/22 had basal CKD; median FU 77 months, 15-300). Combined endpoint: 29% (6/21) had complete recovery and final normal renal function (one with renal relapse), 48% (10/21) had partial recovery and final CKD (3 with renal relapse, of whom one with basal CKD) (p=0.024). Acute onset and hypercalcaemia were associated to milder AKI and better recovery than subacute onset and patients without hypercalcaemia, women had better endpoints than men. Giant cells, severe interstitial infiltrate and interstitial fibrosis seemed negative predictors in terms of endpoints. CONCLUSIONS: sGIN-AKI-patients with no complete recovery at 1°line steroid should be treated with other immunosuppressive to avoid CKD, in particular if males with subacute onset and III stage-not hypercalcaemic AKI.

Mixed hemodiafiltration reduces erythropoiesis stimulating agents requirement in dialysis patients: a prospective randomized study.

BACKGROUND: Improved responsiveness to erythropoiesis stimulating agents (ESAs) in patients on on-line post-dilution hemodiafiltration (Post-HDF) compared with conventional hemodialysis (HD) was reported by some authors but challenged by others. This prospective, cross-over randomized study tested the hypothesis that an alternative infusion modality of HDF, mixed-dilution HDF (Mixed HDF), could further reduce ESAs requirement in dialysis patients compared to the traditional Post-HDF. METHODS: One-hundred-twenty prevalent patients from 6 Dialysis Centers were randomly assigned to two six-months treatment sequences: A-B and B-A (A, Mixed HDF; B, Post-HDF). Primary outcome was comparative evaluation of ESA (darbepoetin alfa) requirement and ESA resistance. Treatments efficiency, iron and vitamins status, inflammation and nutrition parameters were monitored. RESULTS: In sequence A, darbepoetin requirement decreased during Mixed HDF from 29.5 to 23.7 µg/month and increased significantly during Post-HDF (32.3 µg/month at 6th month) while, in sequence B, it increased during Post-HDF from 38.2 to 43.7 µg/month and decreased during Mixed HDF (23.9 µg/month at 6th month). Overall, EPO doses at 6 months on Mixed and Post-HDF were 23.8 and 38.4 µg/month, respectively, P < 0.01. A multiple linear model confirmed that Mixed HDF vs Post-HDF reduced significantly ESA requirement and ESA resistance (P < 0.0001), by a mean of 29% (CI 23-35%) in the last three months of the observation periods. CONCLUSIONS: Mixed HDF decreased darbepoetin-alfa requirement in dialysis patients. This might help preventing the untoward side effects of high ESA doses, besides having a remarkable economic impact. Additional evidence is needed to confirm this potential benefit of Mixed-HDF.

Modulating eIF6 levels unveils the role of translation in ecdysone biosynthesis during Drosophila development.

During development, ribosome biogenesis and translation reach peak activities, due to impetuous cell proliferation. Current models predict that protein synthesis elevation is controlled by transcription factors and signalling pathways. Developmental models addressing translation factors overexpression effects are lacking. Eukaryotic Initiation Factor 6 (eIF6) is necessary for ribosome biogenesis and efficient translation. eIF6 is a single gene, conserved from yeasts to mammals, suggesting a tight regulation need. We generated a Drosophila melanogaster model of eIF6 upregulation, leading to a boost in general translation and the shut-down of the ecdysone biosynthetic pathway. Indeed, translation modulation in S2 cells showed that translational rate and ecdysone biosynthesis are inversely correlated. In vivo, eIF6-driven alterations delayed Programmed Cell Death (PCD), resulting in aberrant phenotypes, partially rescued by ecdysone administration. Our data show that eIF6 triggers a translation program with far-reaching effects on metabolism and development, stressing the driving and central role of translation.

Translating the Game: Ribosomes as Active Players.

Ribosomes have been long considered as executors of the translational program. The fact that ribosomes can control the translation of specific mRNAs or entire cellular programs is often neglected. Ribosomopathies, inherited diseases with mutations in ribosomal factors, show tissue specific defects and cancer predisposition. Studies of ribosomopathies have paved the way to the concept that ribosomes may control translation of specific mRNAs. Studies in Drosophila and mice support the existence of heterogeneous ribosomes that differentially translate mRNAs to coordinate cellular programs. Recent studies have now shown that ribosomal activity is not only a critical regulator of growth but also of metabolism. For instance, glycolysis and mitochondrial function have been found to be affected by ribosomal availability. Also, ATP levels drop in models of ribosomopathies. We discuss findings highlighting the relevance of ribosome heterogeneity in physiological and pathological conditions, as well as the possibility that in rate-limiting situations, ribosomes may favor some translational programs. We discuss the effects of ribosome heterogeneity on cellular metabolism, tumorigenesis and aging. We speculate a scenario in which ribosomes are not only executors of a metabolic program but act as modulators.

Lanosterol Synthase Gene Polymorphisms and Changes in Endogenous Ouabain in the Response to Low Sodium Intake.

Circulating levels of endogenous ouabain (EO), a vasopressor hormone of adrenocortical origin, are increased by sodium depletion. Furthermore, lanosterol synthase, an enzyme involved in cholesterol biosynthesis, has a missense polymorphism (rs2254524 V642L) that affects EO biosynthesis in adrenocortical cells. Here, we investigated the hypothesis that lanosterol synthase rs2254524 alleles in vivo impact the blood pressure (BP) and EO responses evoked by a low dietary Na intake (<100 mEq/d, 2 weeks) among patients with mild essential hypertension. During the low salt diet, the declines in both systolic BP (SBP: -8.7±1.7 versus -3.0±1.5; P=0.013) and diastolic BP (DBP: -5.1±0.98 versus -1.4±0.94 mm Hg; P<0.05), and the slope of the long-term pressure-natriuresis relationship affected significantly the presence of the lanosterol synthase rs2254524 A variant (AA: 0.71±0.22, AC 0.09±0.13, and CC 0.04±0.11 mEq/mm Hg/24 h; P=0.028). In addition, BP rose in ≈25% of the patients in response to the low salt diet and this was associated with increased circulating EO. Lanosterol synthase gene polymorphisms influence both the salt sensitivity of BP and changes in circulating EO in response to a low salt diet. The response of BP and EO to the low salt diet is markedly heterogeneous. Approximately 25% of patients experienced adverse effects, that is, increased BP and EO when salt intake was reduced and may be at increased long-term risk. The augmented response of EO to the low salt diet further supports the view that adrenocortical function is abnormal in some essential hypertensives.

[Caroli's syndrome in a patient on hemodialysis: diagnostic and therapeutic difficulties]. / Sindrome di Caroli in paziente emodializzato: difficoltà diagnostiche e terapeutiche.

We present the case of a 65-year-old male patient without any family history of renal or hepatic disease. He had been on maintenance hemodialysis for 4 months because of autosomal recessive polycystic kidney disease. At the start of the hemodialysis session he reported general malaise, abdominal pain, fever and diarrhea occurring in the last two days. Laboratory workup showed neutrophilic leukocytosis and increased serum amylase and C-reactive protein. Abdominal contrast-enhanced CT scan and MRI cholangiography showed hepatic cysts with marked dilatation of the intra- and extrahepatic bile ducts. The patient underwent cholecystectomy with hepaticojejunal Rouxen- Y anastomosis and was discharged with oral ciprofloxacin. Histology confirmed marked cystic dilatation of the bile ducts. Because of persistent episodes of septic fever, administration of ciprofloxacin was continued. After 4 months retrograde endoscopic pancreatography was performed which led to a diagnosis of Caroli's syndrome associated with polycystic kidneys. Given the rarity of the disease and its difficult diagnosis, when patients with polycystic kidneys and liver cysts experience recurrent episodes of septic fever of unknown origin, Caroli's disease should be taken into account and the appropriate tests should be carried out to confirm the diagnosis.

Endogenous ouabain in renal Na(+) handling and related diseases.

The Na(+) pump and its Endogenous modulator Ouabain (EO) can be considered as an ancestral enzymatic system, conserved among species ranging from Drosophila to humans, related to Na handling. In this review, we examine how EO is linked with vascular function in hypertension and if it impacts the pathogenesis of heart and renal failure. Moreover, the molecular mechanism of endogenous ouabain-linked hypertension involves the sodium pump/sodium-calcium exchanger duet. Biosynthesis of EO occurs in adrenal glands and is under the control of angiotensin II, ACTH and epinephrine. Elevated concentrations of EO and in the sub-nanomolar concentration range were found to stimulate proliferation and differentiation of cardiac and smooth muscle cells. They may have a primary role in the development of cardiac dysfunction and failure. Experimental data suggest that the Na/K-ATPase α(2)-catalytic subunit causes EO-induced vasoconstriction. Finally, maneuvers that promote Na depletion, as diuretic therapy or reduced Na intake, raise the EO levels. Taken together, these findings suggest a key role for EO in body Na homeostasis.

Advanced age and sex as predictors of adverse outcomes following gastric bypass surgery.

OBJECTIVES: This study aimed to determine whether advanced age or sex was predictive of adverse outcomes after Roux-en-Y gastric bypass. METHODS: The Pennsylvania State Discharge Database was searched for records of morbidly obese patients who underwent Roux-en-Y gastric bypass. The SASs MIXED Procedure was used to test whether mortality alone or adverse outcomes (postoperative complications, nonroutine hospital transfer and mortality) were significantly related to sex or advanced age (>50 years). The presence of comorbidities was used as a blocking variable. RESULTS: Between 1999 and 2001, 4,685 patients underwent Roux-en-Y gastric bypass in Pennsylvania, of which 82% were female and 20% were older than 50 years of age. Comorbidities were present in 71% of patients. Twenty-eight deaths (0.6%) and 813 adverse outcomes (17.4%) occurred. Mortality was greater in males than in females (1.2% vs. 0.47%, P<0.05) without comorbid interaction. Mortality did not increase with age. Adverse outcomes were related to both sexes (24% male, 16% female, P<0.05) and age (< or = 50, 16% vs. > 50, 23%, P<0.05) with a small comorbid interaction. CONCLUSION: Adverse outcomes are more frequent among males and older patients and are influenced by comorbidities. Male patients have a higher mortality that was not affected by the presence of comorbidities.

Do physicians know when their diagnoses are correct? Implications for decision support and error reduction.

OBJECTIVE: This study explores the alignment between physicians' confidence in their diagnoses and the "correctness" of these diagnoses, as a function of clinical experience, and whether subjects were prone to over-or underconfidence. DESIGN: Prospective, counterbalanced experimental design. SETTING: Laboratory study conducted under controlled conditions at three academic medical centers. PARTICIPANTS: Seventy-two senior medical students, 72 senior medical residents, and 72 faculty internists. INTERVENTION: We created highly detailed, 2-to 4-page synopses of 36 diagnostically challenging medical cases, each with a definitive correct diagnosis. Subjects generated a differential diagnosis for each of 9 assigned cases, and indicated their level of confidence in each diagnosis. MEASUREMENTS AND MAIN RESULTS: A differential was considered "correct" if the clinically true diagnosis was listed in that subject's hypothesis list. To assess confidence, subjects rated the likelihood that they would, at the time they generated the differential, seek assistance in reaching a diagnosis. Subjects' confidence and correctness were "mildly" aligned (kappa=.314 for all subjects, .285 for faculty, .227 for residents, and .349 for students). Residents were overconfident in 41% of cases where their confidence and correctness were not aligned, whereas faculty were overconfident in 36% of such cases and students in 25%. CONCLUSIONS: Even experienced clinicians may be unaware of the correctness of their diagnoses at the time they make them. Medical decision support systems, and other interventions designed to reduce medical errors, cannot rely exclusively on clinicians' perceptions of their needs for such support.

The relationship of surgeon and hospital volume to outcome after gastric bypass surgery in Pennsylvania: a 3-year summary.

BACKGROUND: This study explores the volume-outcome relationship for gastric bypass surgery for obesity to determine whether higher-volume hospitals, higher-volume surgeons, or both are associated fewer adverse outcomes. METHODS: The Pennsylvania state discharge database was used to identify 4685 cases of gastric bypass surgery for obesity between 1999 and 2001. Statistical modeling analyses were used to determine whether mortality or adverse outcome rate was significantly related to hospital and surgeon volume; the data were controlled for risk factors such as age, gender, comorbidities, and others. RESULTS: There were 28 deaths (0.6%) and 813 adverse outcomes (17.4%). There was a significant risk-adjusted relationship between surgeon volume and adverse outcome, and the same trend was observed for deaths. Surgeons who performed fewer than 10 procedures per year had a 28% risk of adverse outcome and a 5% risk of death, compared with 14% (P<.05) and 0.3% (P=.06), respectively, for high-volume surgeons. Hospital volume did not reach significance, but there was a striking interaction between surgeon and hospital volume; surgeons who performed 10 to 50 cases per year operating in low-volume hospitals had a 55% risk of adverse outcome (P<.01). CONCLUSION: Risk-adjusted in-hospital adverse outcome is significantly lower when gastric bypass is performed by higher-volume surgeons.

Computer decision support as a source of interpretation error: the case of electrocardiograms.

OBJECTIVE: The aim of this study was to determine the effect that the computer interpretation (CI) of electrocardiograms (EKGs) has on the accuracy of resident (noncardiologist) physicians reading EKGs. DESIGN: A randomized, controlled trial was conducted in a laboratory setting from February through June 2001, using a two-period crossover design with matched pairs of subjects randomly assigned to sequencing groups. MEASUREMENTS: Subjects' interpretive accuracy of discrete, cardiologist-determined EKG findings were measured as judged by a board-certified internist. RESULTS: Without the CI, subjects interpreted 48.9% (95% confidence interval, 45.0% to 52.8%) of the findings correctly. With the CI, subjects interpreted 55.4% (51.9% to 58.9%) correctly (p < 0.0001). When the CIs that agreed with the gold standard (Correct CIs) were not included, 53.1% (47.7% to 58.5%) of the findings were interpreted correctly. When the correct CI was included, accuracy increased to 68.1% (63.2% to 72.7%; p < 0.0001). When computer advice that did not agree with the gold standard (Incorrect CI) was not provided to the subjects, 56.7% (48.5% to 64.5%) of findings were interpreted correctly. Accuracy dropped to 48.3% (40.4% to 56.4%) when the incorrect computer advice was provided (p = 0.131). Subjects erroneously agreed with the incorrect CI more often when it was presented with the EKG 67.7% (57.2% to 76.7%) than when it was not 34.6% (23.8% to 47.3%; p < 0.0001). CONCLUSIONS: Computer decision support systems can generally improve the interpretive accuracy of internal medicine residents in reading EKGs. However, subjects were influenced significantly by incorrect advice, which tempers the overall usefulness of computer-generated advice in this and perhaps other areas.

Exploring the boundaries of plausibility: empirical study of a key problem in the design of computer-based clinical simulations.

All clinical simulation designers face the problem of identifying the plausible diagnostic and management options to include in their simulation models. This study explores the number of plausible diagnoses that exist for a given case, and how many subjects must work up a case before all plausible diagnoses are identified. Data derive from 144 residents and faculty physicians from 3 medical centers, each of whom worked 9 diagnostically challenging cases selected from a set of 36. Each subject generated up to 6 diagnostic hypotheses for each case, and each hypothesis was rated for plausibility by a clinician panel. Of the 2091 diagnoses generated, 399 (19.1%), an average of 11 per case, were considered plausible by study criteria. The distribution of plausibility ratings was found to be statistically case dependent. Averaged across cases, the final plausible diagnosis was generated by the 28th clinician (sd = 8) who worked the case. The results illustrate the richness and diversity of human cognition and the challenges these pose for creation of realistic simulations in biomedical domains.