Sodium-glucose linked transporter-2 inhibitors in chronic kidney disease.

SGLT2 inhibitors are new antihyperglycaemic agents whose ability to lower glucose is directly proportional to GFR. Therefore, in chronic kidney disease (CKD) the blood glucose lowering effect is reduced. Unlike many current therapies, the mechanism of action of SGLT2 inhibitors is independent of insulin action or beta-cell function. In addition, the mechanism of action of SGLT2 inhibitors is complementary and not alternative to other antidiabetic agents. SGLT2 inhibitors could be potentially effective in attenuating renal hyperfiltration and, consequently, the progression of CKD. Moreover, the reductions in intraglomerular pressure, systemic blood pressure, and uric acid levels induced by SGLT inhibition may potentially be of benefit in CKD subjects without diabetes. However, at present, only few clinical studies were designed to evaluate the effects of SGLT2 inhibitors in CKD. Consequently, safety and potential efficacy beyond blood glucose lowering should be better clarified in CKD. In this paper we provide an updated review of the use of SGLT2 inhibitors in clinical practice, with particular attention on subjects with CKD.

An unusual case of multiple and bilateral ovarian dermoid cysts. Case report.

OBJECTIVE: Multiple and bilateral ovarian dermoid cysts constitute a very unusual report. We report an rare case of a woman with three ovarian dermoid cyst, two localized in the same ovary, detected by US examination and removed by laparoscopy. CASE REPORT: A patient aged 29 years, para 0, gravida 0, was referred to our hospital with pain of the right adnexal region. Gynaecological examination showed an antiverted uterus with normal volume; on the right side a mobile mass approximately 7 cms in diameter was palpable, moreover the left ovary was normal. Ultrasound examination showed a normal uterus. The right ovary presented two complex masses of 7 and 3 cm in diameter, respectively; moreover, the left ovary showed a hyperechogenic complex mass of 3 cm in diameter. The ultrasound pattern was compatible with bilateral ovarian dermoid cysts. On laparoscopy abdominal cavity and uterus were normal, while the right ovary presented two masses and the left ovary a small mass which were enucleated and removed. The patient had an uncomplicated postoperative recovery and was discharged two day after laparoscopy. Pathologic examination confirmed the diagnosis of ovarian dermoid cysts. A one year follow-up showed no evidence of recurrence. CONCLUSION: The case reported shows that exceptionally multiple and bilateral dermoid cysts may be detected underlining the importance of an accurate preoperative diagnostic imaging. Some recurrence of ovarian dermoid cysts may be due to undiagnosed small dermoid cists during preoperative imaging and/or surgical exploration.

Complete excision with narrow margins provides equivalent local control to wider excision in breast conservation for invasive cancer.

Background: Society of Surgical Oncology and American Society for Radiation Oncology guidelines define clear margins in breast-conserving therapy (BCT) as 'no ink on tumour', in contrast to the attainment of margins of at least 1 mm widely practised in the UK. The primary aim of this study was to explore clinical, surgical and tumour-related factors associated with local recurrence after BCT, with a secondary aim of assessing the impact of margin re-excision on the risk of local recurrence. Methods: Patient demographics, surgical details, tumour characteristics and local recurrence were recorded for consecutive women with BCT undergoing surgery between January 1997 and January 2007. Margins were defined as clear (greater than 1 mm), close (less than 1 mm but no ink on tumour), reaches (ink on tumour) and clear after re-excision. Results: A total of 1045 women of median age 54 (range 18-86) years were studied. Median follow-up was 89 (range 4-196) months. Local recurrence occurred in 52 patients (5·0 per cent). Ink on tumour was associated with local recurrence (hazard ratio (HR) 4·86, 95 per cent c.i. 1·49 to 15·79; P = 0·009). Risk of local recurrence was the same for close and clear margins (HR 1·03, 0·40 to 2·62; P = 0·954). In women with involved margins, re-excision was still associated with an increased local recurrence risk (HR 2·50, 1·32 to 4·72; P = 0·005). Oestrogen receptor negativity increased risk (HR 2·28, 1·28 to 4·06; P = 0·005). Conclusion: Adequately excised margins, even when under 1 mm, provide equivalent outcomes to wider margins in BCT. Achieving complete excision at primary surgery achieves the lowest rates of local recurrence.

Development and validation of the mental health professional culture inventory.

AIMS: No instrument has been developed to explicitly assess the professional culture of mental health workers interacting with severely mentally ill people in publicly or privately run mental health care services. Because of theoretical and methodological concerns, we designed a self-administered questionnaire to assess the professional culture of mental health services workers. The study aims to validate this tool, named the Mental Health Professional Culture Inventory (MHPCI). The MHPCI adopts the notion of 'professional culture' as a hybrid construct between the individual and the organisational level that could be directly associated with the professional practices of mental health workers. METHODS: The MHPCI takes into consideration a multidimensional definition of professional culture and a discrete number of psychometrically derived dimensions related to meaningful professional behaviour. The questionnaire was created and developed by a conjoint Italian-Canadian research team with the purpose of obtaining a fully cross-cultural questionnaire and was pretested in a pilot study. Subsequently, a validation survey was conducted in northern Italy and in Canada (Montreal area, Quebec). Data analysis was conducted in different steps designed to maximise the cross-cultural adaptation of the questionnaire through a recursive procedure consisting of performing a principal component analysis (PCA) on the Italian sample (N = 221) and then testing the resulting factorial model on the Canadian sample (N = 237). Reliability was also assessed with a test-retest design. RESULTS: Four dimensions emerged in the PCA and were verified in the confirmatory factor analysis: family involvement, users' sexuality, therapeutic framework and management of aggression risk. All the scales displayed good internal consistency and reliability. CONCLUSIONS: This study suggests the MHPCI could be a valid and reliable instrument to measure the professional behaviour of mental health services workers. The content of the four scales is consistent with the literature on psychosocial rehabilitation, suggesting that the instrument could be used to evaluate staff behaviour regarding four crucial dimensions of mental health care.

Dialysis and kidney transplantation: similarities and differences in the psychological aspects of noncompliance.

BACKGROUND: Dialysis and kidney transplantation represent two effective strategies in treating chronic uremia, albeit with different results. Our study compared the psychological aspects of two categories of patients: patients who faced kidney transplantation and have been on dialysis, and noncompliant patients treated with these therapies. MATERIALS AND METHODS: On 170 patients (120 hemodialysis and 50 peritoneal dialysis) we used a personality analysis (MMPI2) and the COPE, which assessed the ability of patients to cope under certain conditions that can be perceived as stressful or, in any case, unusual. The screening succeeded in 11 cases among the first group and 9 in the second. Three of the 20 patients were considered to be partially noncompliant: 1 on peritoneal and the other 2 on hemodialysis. We also tested a control group of 300 people of different ages, sexes, social and cultural status, dates and kinds of transplantation (cadaveric or living donors). Of the 36 feedbacks received, only 30 were considered valuable. RESULTS: The results of the research showed that patients with less than 2 years of dialysis treatment and patients with more than 2 years survival after transplantation time were inclined to deny their disease and the possible emotions about their clinical status, drawing an inadequate attention to the difficulties. This behavior was clearer among noncompliant patients. Family problems and couple malaise in everyday life can push more and more of these patients to be noncompliant with therapeutic prescriptions, as they do not feel adequate support. The result is an excessive foreboding, poor disposition, and nervousness. CONCLUSIONS: Screening of patients' social and psychological status is useful as is psychological intervention for those who miss emotional support from the family. This psychological support is advisable for uremics who have to enter a waiting list and for those who are subject to postoperative treatment in order to promote compliant behavior.

Dielectric matrix and plasmon dispersion in strongly coupled electronic bilayer liquids.

We develop a dielectric matrix and analyze plasmon dispersion in strongly coupled charged-particle bilayers in the T = 0 quantum domain. The formulation is based on the classical quasilocalized charge approximation (QLCA) and extends the QLCA formalism into the quantum domain. Its development, which parallels that of the two-dimensional companion paper [Phys. Rev. E 70, 026406 (2004)] by three of the authors, generalizes the single-layer scalar formalism therein to a bilayer matrix formalism. Using pair correlation function data generated from diffusion Monte Carlo simulations, we calculate the dispersion of the in-phase and out-of-phase plasmon modes over a wide range of high- r(s) values and layer separations. The out-of-phase spectrum exhibits an exchange-correlation induced long-wavelength energy gap in contrast to earlier predictions of acoustic dispersion softened by exchange and correlations. The energy gap is similar to what has been previously predicted for classical charged-particle bilayers and subsequently confirmed by recent molecular dynamics computer simulations.

Circulating natriuretic peptide concentrations in patients with end-stage renal disease: role of brain natriuretic peptide as a biomarker for ventricular remodeling.

OBJECTIVES: To determine levels of natriuretic peptides (NPs) in patients with end-stage renal disease (ESRD) and to examine the relationship of these cardiovascular peptides to left ventricular hypertrophy (LVH) and to cardiac mortality. PATIENTS AND METHODS: One hundred twelve dialysis patients without clinical evidence of congestive heart failure underwent plasma measurement of NP concentrations and echocardiographic investigation for left ventricular mass index (LVMI). RESULTS: Plasma atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) concentrations correlated positively with LVMI and inversely with left ventricular ejection fraction, whereas C-type NP and Dendroaspis NP levels did not correlate with LVMI. In dialysis patients with LVH (LVMI >125 g/m2), plasma ANP and BNP concentrations were increased compared with those in dialysis patients without LVH (both P<001). In a subset of 15 dialysis patients without LVH or other concomitant diseases, plasma BNP concentrations were not significantly increased compared with those in 35 controls (mean +/- SD, 20.1+/-13.4 vs 13.5+/-9.6 pg/mL; P=.06), demonstrating that the BNP concentration was not increased by renal dysfunction alone. Furthermore, the BNP level was significantly higher in the 16 patients who died from cardiovascular causes compared with survivors (mean +/- SD, 129+/-13 vs 57+/-7 pg/mL; P<.003) and was significantly associated with greater risk of cardiovascular death in Cox regression analysis (P<.001), as was the ANP level (P=.002). CONCLUSIONS: Elevation of the plasma BNP concentration is more specifically related to LVH compared with the other NP levels in patients with ESRD independent of congestive heart failure. Thus, BNP serves as an important plasma biomarker for ventricular hypertrophy in dialysis patients with ESRD.

Smoking, blood pressure and serum albumin are major determinants of carotid atherosclerosis in dialysis patients. CREED Investigators. Cardiovascular Risk Extended Evaluation in Dialysis patients.

AIM: To investigate the relationship between carotid atherosclerosis and some major cardiovascular risk factors in uremic patients on chronic dialysis. METHODS: A cross-sectional study was carried out in 119 unselected dialysis patients (89 on hemodialysis and 30 on chronic ambulatory peritoneal dialysis, CAPD). Fasting blood sampling for serum lipids, albumin, hemoglobin, and echo-colour-Doppler evaluation of common carotid arteries were performed in all patients (during the non-dialysis day in hemodialysis patients). In hemodialysis patients BP was measured before and after dialysis; in CAPD patients home BP values were recorded during the month before the study day. RESULTS: Ninety-five patients had at least one plaque and 57 had at least four plaques. Thirty-eight had mild and eleven severe carotid stenosis. In multiple regression models, the mean internal diameter of carotid arteries was explained (R=0.52, P=0.0001) by systolic pressure (r=0.39), serum cholesterol (r=-0.28), age (r=0.27) and smoking (r=0.24) while the degree of carotid stenosis was predicted (R=0.39, P=0.0001) by age (r=0.36) and smoking (r=0.25). The number of atherosclerotic plaques was explained (R=0.51, P=0.0001) by age (r=0.36), smoking (r=0.25) and pulse pressure (r=0.20), serum albumin just failing to reach statistical significance (P = 0.06). However, serum albumin was a significant and independent predictor of the number of atherosclerotic plaques (r=-0.26) in hemodialysis patients (n=89). Sex, diabetes, Kt/V, duration of dialysis treatment, hemoglobin, serum calcium and phosphate did not add any predictive power to the models. CONCLUSIONS: In dialysis patients arterial pressure and smoking are associated with carotid atherosclerosis. Serum albumin appears to serve as an independent predictor of carotid atherosclerosis.

Screening of relatives of anti-hepatitis-C virus positive hemodialysed patients (preliminary data).

The occurrence of antibodies to hepatitis-C virus (HCV) was investigated (ELISA 2; 4-RIBA) in hemodialysed patients, and in positive cases the analyses were extended to their partners and relatives, too. We screened 70 patients, (mean age 62.4 years, age-range 19-88 years) with an average period of dialyses of 45.2 months (range 3-120 months). Of the study population, 16 subjects (22.8%) were anti-HCV positive, half of them received blood transfusion in the past. The occurrence of anti-HCV was explored by using the same method in 10 of their sexual partners and 40 relatives (parents, siblings, children): none of them proved to be positive. The data obtained indicate that the ways of transmission of HCV infection differ from those known for hepatitis B virus (HBV).

Parathyroid hormone in a population of elderly patients on hemodialysis (preliminary data).

The parathyroid hormone (PTH) represents an important marker of parathyroid secretion and its increase expresses hyperparathyroidism. We studied 28 patients affected by chronic renal insufficiency who had been on hemodialysis for at least 5 years. Half of the patients were younger than 65 years (Group 1), and the remaining other 14 patients were older than 65 years (Group 2). The following laboratory parameters were determined in the blood samples: Ca, P, Mg, alkaline phosphatase (AP), whole molecule PTH (1-84). Mean PTH concentrations were 637.8 pg/ml in Group 1 and 147.6 pg/ml in Group 2, Students' t = 2.812, p = 0.009. No significant differences were observed in Ca, P, Mg and AP concentrations. The multiplicity of the factors involved make it difficult to interpret the diverse, anomalous parathyroid responses to the same clinico-metabolic situations. Nevertheless, a reduced response of the parathyroid gland in the older group to stimuli typical of uremia may be postulated.

Diagnosis of renovascular disease by extra- and intrarenal Doppler parameters.

It is still a matter of debate as to which parameters should be used for noninvasive diagnosis of renovascular disease by renal Doppler sonography (RDS). The accuracy of RDS in the detection of renal artery stenosis (RAS) was tested in 95 consecutive, moderate to severe hypertensive patients (I-II World Health Organization [WHO] stages). Reno-aortic ratio (RAR) for peak systolic velocity (PSV) was also calculated to assist in the diagnosis of significant (>50%) RAS. Paired receiver-operating characteristic (ROC) analysis was plotted for evaluating the relationship between sensitivity and specificity for each parameter. In a subset of 57 kidneys, the influence of blood pressure and age on intraparenchymal parameters was evaluated. Measurements of maximal peak systolic velocity (PSV) at the site of stenosis, RAR for PSV, and minimum acceleration index in the main renal artery showed high accuracy (areas under the ROC curve 0.97, 0.88, and 0.80, respectively). Among intraparenchymal parameters, early systolic acceleration showed the best area under the ROC curve (0.90), but provided a low positive predictive value (29%) and was significantly influenced by blood pressure (multiple r=0.56; p=0.001). Pulsatility and resistive indices were found to be less powerful as absolute values, and both significantly influenced by blood pressure and age (multiple r=0.60 and 0.50; p=0.001, p=0.02, respectively). However, interindividual variance of intrarenal indices should be minimized by calculation of side difference, although this procedure would become misleading or impossible in patients with bilateral RAS or a single kidney, respectively. These results support the use of extraparenchymal parameters for noninvasive detection of RAS, and emphasize that intrarenal parameters cannot be considered as absolute values.

[The prevalence of serum anti-hepatitis C virus antibodies in hemodialyzed patients]. / Prevalenza degli anticorpi sierici anti-virus dell'epatite C in pazienti emodializzati.

Hepatitis C virus (HCV) is responsible for a high percentage of cases of transfusional hepatitis and is often considered the etiological agent of numerous cases of non-A, non-B hepatitis in which parenteral transmission has not been documented. Patients undergoing hemodialysis are at risk for HCV infection. We used an immunoenzymatic method and confirmatory test (neutralization test) to determine serum anti-HCV antibody positivity in order to identify the factors associated with increased risk of HCV infection. We studied 63 hemodialyzed patients from eastern Sicily and compared the mean dialytic age and transfusion case history in positive and negative groups. 17.4 percent of the patients were anti-HCV positive. Mean dialytic age was significantly higher in the anti-HCV positive group. On the contrary no significant differences regarding transfusion case history or number of units of blood transfused were seen in the two groups. Our study confirms that hemodialyzed patients are at risk for HCV infection. This risk seems to increase with dialytic age. The lack of correlation between HCV and transfusion case history suggests that it may be a hospital-acquired infection.

[Peripheral osteoma of the mandibular condyle. Two clinical cases]. / Osteoma periferico del condilo. Due casi clinici.

Two cases of peripheral osteoma of the mandibular condyle are described. This lesions is uncommon. It is suggested that peripheral osteoma of the mandible may be traumatically induced and that muscle traction plays an important role in this lesion.

[Necrotizing sialometaplasia. Report of a case]. / Sialometaplasia necrotizzante. Presentazione di un caso.

Necrotizing sialometaplasia is a benign lesion of the minor and major salivary glands. It occurs with a palatal swelling which rapidly becomes a deep ulcer. Histopathological aspects include ulceration of the surface epithelium, squamous metaplasia and acinar necrosis. In general no treatment is necessary and the lesion heals spontaneously in 4-10 weeks. This condition must be distinguished from more serious diseases such as squamous cell carcinoma and mucoepidermoid carcinoma.

[Non compliance predictive factors in renal transplantation]. / fattori predittivi di non compliance nel trapianto renale.

Currently many authors report a kidney graft survival of 90-95% at one years post-transplantation. The patients' adherence to the immunosuppressive therapy is an important condition for maintaining graft functioning. A review of the medical literature shows that graft survival is significantly worse in non-compliance patients. As a matter of fact, 267 non compliance patients lost their graft of 7206 renal graft recipients. There are usually three different non-compliance profiles in transplantation : 1) 'Accidental non compliers' (47%) identifies those patients who sometimes forget to take the therapy. 2) 'Invulnerables' (28%) are those patients who believe that they do not need to take their immunosuppressive drugs regularly; 3) 'Decisive non compliers' (25%) are those patients who decide what therapy they should take. Many predictive factors have been associated with non compliance: 1) Demographic variables 2) Psychological variables 3) Psychiatric disorders 4) Poor social support 5) Pretransplantation compliance 6) Substance abuse We therefore think that it is particularly useful to identify non compliers before transplantation through psychological screening, in order to increase their compliance by supportive psychological assistance. Unfortunately, these patients tend to avoid specialists' intervention so it is very useful to provide the medical teams with the necessary training to cope with the psychological problems of their patients.

[Nephrological paradox]. / Il paradosso nefrologico.

Patients that are followed by nephrologists from the beginning of the illness, they show a deceleration in the progression of the Chronic Kidney Disease towards dialysis and a better quality of life (less osteodystrophy, anaemia and fluids overload, better pressure management). However, in 2013 it still exists a great lack of knowledge about the professional figure of nephrologist. Residents of Nephrological School of Catania decided to conduct a survey to evaluate common knowledge of renal diseases and their treatments. The survey was conducted in two cities of Sicily. The results show that people are generally uninformed and disoriented about renal illness and their risks.

Validation of the Italian version of the Functioning Assessment Short Test (FAST) for bipolar disorder.

Aim. The Functioning Assessment Short Test (FAST) is a useful instrument for the assessment of overall functioning of people with bipolar disorder, showing good psychometric properties. The aim of this study is to validate the Italian version of FAST. Methods. Translation and back-translation of the original FAST Spanish version were performed. Participants with bipolar disorder (n = 132) and healthy controls (n = 132) completed the FAST as a part of an assessment package including the Montgomery-Asberg Depression Rating Scale and the Young Mania Rating Scale. Internal consistency, inter-rater reliability, construct and discriminant validity were assessed. Results. The FAST Italian version showed good internal consistency, inter-rater reliability and discriminant validity. The cut-off discriminating patients from controls was 15, with a sensitivity of 0.79 and a specificity of 0.80. Principal component analysis with oblique rotation showed factor loadings consistent with the a priori structure of the instrument. Conclusions. This study confirmed the psychometric properties of FAST and extended its generalization and validity to the Italian population.

How safe is oncoplastic breast conservation? Comparative analysis with standard breast conserving surgery.

AIM: Oncoplastic techniques are increasingly used to facilitate breast conservation and maintain breast aesthetics but evidence with regards to the oncological safety of oncoplastic breast conservation surgery (oBCS) remains limited. The aim of this study was to compare re-excision and local recurrence rates for oBCS with standard breast conserving surgery (sBCS). METHODS: From June 2003 to Feb 2010 data was obtained from contemporaneously recorded electronic patient records on patients who had oBCS and sBCS within a single breast cancer centre. Re-excision rates and local recurrence rates were compared. RESULTS: A total of 440 sBCS and 150 oBCS (in 146 women) were included in this study. Median tumour size and specimen weight was 21 mm and 67 g for oBCS and 18 mm and 40 g in the sBCS group (p < 0.001). Re-excision was 2.7% (4/150) and 13.4% (59/440) for oBCS and sBCS respectively (p < 0.001). At a median follow-up of 28 months, local relapse was 2.7% (4) and 2.2% (10) and distant relapse 1.3% (2) and 7.5% (33) for oBCS and sBCS respectively. CONCLUSIONS: Oncoplastic breast conserving techniques decrease re-excision rates. Early follow up data suggests oncological outcomes of oncoplastic breast conservation surgery are similar to standard breast conservation.