[Survival is not enough: improving quality of life]. / Sopravvivere non basta--migliorare la qualità della vita.

We need a new health care system that is based on patients' needs. The present cadre of health managers who acquired power by cutting expenditures must be removed from office. We need to educate a new cadre of health managers who are 1) convinced that safeguarding health does not use up the resources of the next generations; 2) capable of switching the system from curative to preventive medicine; and 3) able to reinforce clinical research. Such principles have been recently adopted by the French President Sarkozy in devising the national health care program.

Renal reserve is normal in patients with dilative cardiomyopathy waiting for heart transplantation.

Renal reserve was explored by means of an oral protein load (2 g/kg body weight) under the form of cooked red meat in a group of 9 patients with end-stage heart failure (ESHF), class III of the New York Heart Association receiving loop diuretics and angiotensin-converting enzyme (ACE) inhibitors, and in a group of 18 healthy controls (HC) matched for age, gender, and height under an identical dietary regimen providing 40 cal/kg per day, 1 g/kg body weight of protein per day, Na 120 mmol/day, and K 50 mmol/day. Baseline glomerular filtration rate averaged 109.5+/-9.89 ml/min x 1.73 m2 in HC and 71.9+/-8.8 ml/min x 1.73 m2 in ESHF. Renal plasma flow averaged 540+/-27 ml/min x 1.73 m2 in HC and 235+/-47 ml/min x 1.73 m2 in ESHF. The filtration fraction was significantly higher in ESHF (p<0.01). Renal reserve averaged 26.03+/-3.28 ml/min x 1.73 m2 in HC and 27.2+/-7.12 ml/min x 1.73 m2 (not significant). Renal reserve averaged 123.9+/-2.9% in HC and 137.3+/-6.68% in ESHF (not significant). The filtration capacity was significantly higher in HC (p<0.001). The data point to a normalcy of renal reserve in ESHF which may depend on the chronic use of ACE inhibitors.

Berengario da Carpi.

Berengario da Carpi was magister of anatomy and surgery at the University of Bologna from 1502 to 1527. Eustachio and Falloppia defined him as 'the restaurator of anatomy'. He was a great surgeon, anatomist and physician of illustrious patients including Lorenzo II dei Medici, Giovanni dalle Bande Nere, Galeazzo Pallavicini, Cardinal Colonna, and Alessandro Soderini. He had strong links to the intellectuals of his time (Forni, Bonamici, Manuzio, Pomponazzi) as well as with the Medici family. He was respected by the Popes Julius II, Leo X and Clement VII. His main contributions are the Isogogae Breves, De Fractura calvae sive cranei, and the illustrated Commentaria on the Anatomy of Mondino de Liucci, a textbook utilized for more than 200 years, which Berengario aimed to restore to its initial text. The Commentaria constitutes the material for the last part of this paper which concludes with a personal translation of some passages on 'The kidney', where the author gives poignant examples of experimental ingenuity.

A history of salt.

The medical history of salt begins in ancient times and is closely related to different aspects of human history. Salt may be extracted from sea water, mineral deposits, surface encrustations, saline lakes and brine springs. In many inland areas, wood was used as a fuel source for evaporation of brine and this practice led to major deafforestation in central Europe. Salt played a central role in the economies of many regions, and is often reflected in place names. Salt was also used as a basis for population censuses and taxation, and salt monopolies were practised in many states. Salt was sometimes implicated in the outbreak of conflict, e.g. the French Revolution and the Indian War of Independence. Salt has also been invested with many cultural and religious meanings, from the ancient Egyptians to the Middle Ages. Man's innate appetite for salt may be related to his evolution from predominantly vegetarian anthropoids, and it is noteworthy that those people who live mainly on protein and milk or who drink salty water do not generally salt their food, whereas those who live mainly on vegetables, rice and cereals use much more salt. Medicinal use tended to emphasize the positive aspects of salt, e.g. prevention of putrefaction, reduction of tissue swelling, treatment of diarrhea. Evidence was also available to ancient peoples of its relationship to fertility, particularly in domestic animals. The history of salt thus represents a unique example for studying the impact of a widely used dietary substance on different important aspects of man's life, including medical philosophy.

Renal functional reserve.

The available data on renal reserve and on the fraction of filtration capacity utilized at rest in childhood are analyzed both in healthy state and in renal disease. The methodological problems which might have biased available information are also discussed.

TSH response to TRH in hemodialysis and CAPD patients.

The thyroid status was studied in 19 uremic patients (11 on HD and 8 on CAPD) and in a group of 17 healthy adult patients. In uremic patients T3 and T4 were significantly reduced (p less than 0.001) and rT3 was increased (p less than 0.001). The time course TSH response to TRH showed a lower peak response (in 5 patients it did not exceed 5 microU/ml) which on turn was also delayed (the peak was observed at 60 minutes in 63% of them). TSH concentrations in uremics were increased at 0 time (p less than 0.02), lower at 20 minutes (p less than 0.01) and increased at 120 minutes (p less than 0.02). No difference existed between HD and CAPD. The thyroid response to TSH was normal as showed by a normal percent increase over basal values of T3 concentrations at 120 minutes. Uremic patients also showed a peak GH response at 20 minutes which was not observed in controls. The data exclude the existence on a primary form of hypothyroidism and point to the existence of hypothalamic-pituitary abnormalities, which should not be taken as indicative of secondary and/or tertiary hypothyroidism since FT4 values were normal in HD and increased in patients undergoing CAPD (p less than 0.05) who on turn showed lower plasma albumin concentrations (p less than 0.05).

Metabolic aspects of continuous ambulatory peritoneal dialysis with reference to energy-protein input and growth.

Glucose utilization from the dialysate of up to 140 g/day was found during CAPD therapy in 5 children on short and long term studies. The energy input via the dialysate was associated with increased insulin secretion as indicated by the daily insulin response calculated from analyzing the area under the insulin curve during 5 daily exchanges of dialysate. After 6 months glucose tolerance was normal with normal values for early and late insulin response as well as for glucose disappearance rate during an intravenous glucose tolerance test. Nitrogen balance on free diets (energy input 100% RDA and protein input 133% RDA) showed that CAPD is an anabolic technique since the balance was positive when measured during 42 days out of 12 months in each child. Growth was normal in one boy and in addition a girl reached her final height; it was unsatisfactory in the other children. It is concluded that CAPD is an anabolic technique which favourably affects many factors associated with growth retardation in children with end stage renal failure and therefore it represents an interesting tool for defining a more rationale approach for research in this field.

Thyroidal status in uremia - effects of hemodialysis and CAPD.

Thyroid function was explored in 27 CAPD patients and 25 HD patients. Dialysis was associated with low T3 and T4 levels, increased rT3 concentrations, normal T4 : T3 and reduced T4 : rT3 ratios, normal FT3 and Thyroglobulin concentrations. TSH levels increased during dialysis but still fell within normal limits. The data rule out a condition of primary hypothyroidism and point out to increased thyroidal dismission associated with the block T4-T3 in peripheral cells. Also the increased FT4 levels in CAPD patients could be due to de novo dismission of thyroidal T4.

[Blood sugar and the hematocrit: relation to acclimatization at 4560 m. altitude]. / Glicemia ed ematocrito: rapporti con l'acclimatazione a 4560 m.

We had intended to study the relation between glycemia and hematocrit during high altitude acclimatization (Morococha, Peru-4560 m) and to observe if, subsequently to an increase of hematocrit, glycemia should become lower. From obtained results upon 176 hematologic observations of glycemia, hematocrit, hemoglobin and erythrocyte production, on 38 healthy European subjects (27-58 years aged), it doesn't result, from the first analysis, the existence of this relation. We reserve ourselves, in any case, to accomplish further tests, such as insulinemic dosage for evaluating pancreatic activity.

Studies on amino acids in diabetic patients undergoing CAPD.

Studies in patients with uremia due to diabetes mellitus treated with CAPD show that the kinetics of amino acid equilibration between dialysate and plasma behave differently from those in patients with uremia of different etiology. Diabetics also have larger amino acid losses in dialysate.

Kinetics of amino acids equilibration in the dialysate during CAPD.

The equilibrium between plasma and peritoneal dialysis fluid has been studies for 23 amino acids during peritoneal exchanges at dwell times up to 8 hours in patients on CAPD. It is demonstrated that equilibration is a particular process typical for each amino acid which after 8 hour is nearly complete only for Glycine, Alanine and Asparagine.

Amino acid losses during CAPD.

Amino acid losses in peritoneal dialyzate during CAPD were less than 2 g a day (15, 128 micrometers). CAPD does not correct the tyrosine/phenylalanine ratio in plasma and does not prevent accumulation of 3-methylhistidine.

Further studies on the realization of a cold carbon portable artificial kidney.

Optimal conditions have been determined for the realization of a closed-loop, cold carbon, portable artificial kidney to depurate the dialysate of urea and other catabolites. It has been noticed that a dialysate flow rate of about 250 ml/min represents an optimal compromise between urea mass transfer through the dialytic membrane and its mass adsorption on cold carbon. Under this condition, the use of a 2-kg carbon column to remove urea is satisfactory for a routine dialysis treatment. Our experiments have been performed on simulated dialysis. A portable cold carbon artificial kidney requires a cooling unit and a heat exchanger to recover the power necessary to produce the 0 degrees C temperature. A flat heat exchanger, consisting of three superposed plates, with a heat exchange surface of about 0.09 m2 and a total coefficient of thermal exchange Ht, of 380 Kcal/m2-degrees C-hour has been chosen. With heat recovery, the cooling power required is 1/3 hp to allow for parasitic cold losses and the power necessary to reach a steady state. All mechanical parts necessary for heating and cooling weigh about 12 kg.

Protein requirement of patients on CAPD: a study on nitrogen balance.

Nitrogen balance studies were performed in 8 patients undergoing CAPD. Patients were studied in a metabolic ward for 14 days while eating a diet providing 1.2 g/kg B.W. of proteins and supplying 166-188 KG/Kg. From these studies it is concluded that 1.2 g/Kg are a safe intake for patients on CAPD. Nevertheless it is strongly suggested that patients on CAPD should undergo a nitrogen balance study in order to ascertain whether such a diet is safe or should be modified for energy and/or protein supply.