Sara Viganò

Double-needle ultrasound-guided percutaneous treatment of rotator cuff calcific tendinitis: tips & tricks

Rotator cuff calcific tendinitis is a very common disease and may result in a very painful shoulder. Aetiology of this disease is still poorly understood. When symptoms are mild, this disease may be treated conservatively. Several treatment options have been proposed. Among them, ultrasound-guided procedures have been recently described. All procedures use one or two needles to inject a fluid, to dissolve calcium and to aspirate it. In the present article, we review some tips and tricks that may be useful to improve performance of an ultrasound-guided double-needle procedure.

Pharmacokinetic of cyclosporine microemulsion in pediatric kidney recipients receiving A quadruple immunosuppressive regimen: the value of C2 blood levels.

Background. The management of cyclosporine therapy in pediatric kidney-transplant recipients is largely based on single centers experience rather than on a univocal pharmacokinetic approach based on therapeutic drug monitoring. A prospective multicenter trial was designed to address the question whether C2 blood level monitoring of cyclosporine microemulsion therapy is feasible in the pediatric setting. Methods. Sixty-four pediatric kidney-transplant recipients receiving a triple immunosuppressive regimen based on cyclosporine microemulsion had their cyclosporine dose adjusted to the same protocol-defined C2 targets from the time of the transplant until 2 years posttransplant. The interim analyses after 1 year of enrolment is presented in this study. Results. One-year patient and graft survival were 100% and 94.8%, respectively. One-year rejection rate was 15%. C2 management of cyclosporine did not affect graft function: 1-year serum creatinine and glomerular filtration rate were 1.3±1 mg/mL and 71.2±20 mL/min/1.73 m2, respectively. C2 was the best single-point predictor of the area under the concentration curve throughout the entire follow-up, with a mean coefficient of correlation of 0.97±0.01. Conclusions. C2 management of cyclosporine microemulsion therapy is effective and safe in pediatric kidney-transplant recipients given a combined immunosuppressive treatment.

Prescription of drugs blocking the renin-angiotensin system in Italian children

Little is known about the prescription pattern of antihypertensive drugs for children with impaired kidney function. We have therefore documented the use of antihypertensive drugs in this patient group by evaluating the Italian pediatric population-based registry of patients with chronic kidney disease on conservative treatment (ItalKid) from 1995 to 2003. In 1995, prescriptions written for antihypertensive drugs for use by children were approximately equally divided among drugs blocking the renin-angiotensin system and calcium channel blockers (38 vs. 43% of all prescriptions), followed by β-blockers and diuretics (15 and 4%, respectively). During subsequent years the proportion of prescriptions for drugs blocking the renin-angiotensin system increased (2003: 61%; p<0.001) and that of calcium channel blockers decreased (2003: 18%, p<0.001). In 1995, blockers of the renin-angiotensin system were prescribed, either as monotherapy or in combination, in 53% of the patients, but the relative frequency of the patients prescribed these drugs increased up to 83% in 2003 (p<0.0005). In conclusion, physicians caring for Italian children with impaired kidney function are increasingly prescribing drugs blocking the renin-angiotensin system.

Subclinical impairment of coronary flow velocity reserve assessed by transthoracic echocardiography in young renal transplant recipients

BACKGROUND In renal transplant recipients (RTR) an increased risk to develop cardiovascular injury is present. Transthoracic Doppler echocardiographic assessment of coronary flow velocity reserve (CFVR), a sensitive and minimally invasive technique, was recently employed to detect both macrovascular and microvascular coronary artery disease (CAD) in different clinical settings. The prevalence of coronary involvement in young adult RTR is still unknown. The aim of the study was to investigate the presence of early cardiovascular damage in asymptomatic young adult RTR. METHODS Transthoracic Doppler echocardiographic-derived CFVR and common carotid intima-media thickness (IMT) were assessed in 25 asymptomatic young adult RTR (mean age 25.7+/-7.0 years; range 17.3-43.9) without CAD and 25 healthy controls. RESULTS CFVR was lower in young adult RTR compared to controls (2.8+/-0.6 vs. 3.5+/-0.8; P<0.001), meanwhile left ventricular wall motion and common carotid IMT were comparable in both groups. We found a negative correlation between CFVR and age (r=-0.50; P=0.018) and months on dialysis (r=-0.54; P<0.01). CONCLUSIONS Young adult RTR showed a reduced CFVR reflecting an impaired coronary microcirculation, which is significantly related to the age and duration of dialysis; coronary microvascular damage is detectable in the absence of changes in common carotid IMT. Non-invasive evaluation of CFVR by transthoracic stress echocardiography could be a reliable method for identification of early coronary microvascular involvement in young adult RTR.

Lessons from Recent Trials on Hemodialysis

Today, hemodialysis (HD) represents a rescue therapy for an increasing number of patients worldwide. Thanks to continuous improvements, it is now better tolerated; thus, allowing patients relief from uremic symptoms and increasing survival. However, many questions regarding the best way of ameliorating the outcomes of chronic kidney disease patients requiring dialysis are still open. Recently, 2 randomized controlled clinical trials tried to give some answers to the current debates around dialysis. The first one--the IDEAL trial--evaluated the effects of beginning early or late dialysis on patient mortality and morbidity, and it did not find any significant difference between the 2 groups, suggesting that starting dialysis on the basis of an estimate of GFR alone is not suitable. The second one--the FHN daily trial--compared in-center conventional (3 times per week) with in-center frequent (6 times per week) HD. It found that daily dialysis is associated with improvements in left ventricular mass, physical health composite scores and some secondary outcomes (hypertension and hyperphosphatemia) - although it also discovered there had been more frequent interventions related to vascular access. Despite the fact that both studies presented some unavoidable limitations, they gave important information which is useful in everyday clinical practice. According to evidence-based medicine, such well-designed and well-conducted randomized controlled trials are the best way to improve our knowledge.

Are natriuretic peptides a reliable marker for mortality in ESRD patients

Among the markers of cardiovascular diseases (CVDs) studied in the last 15–20 years, both B-type natriuretic peptide (BNP) and its N-terminal fragment (NT-proBNP) represent a very interesting group of markers. Several studies have demonstrated their role in the development of cardiac failure and other CVD, and BNP has been introduced in the interventional guideline algorithms proposed by the main scientific societies [1,2]. These guidelines suggest analysing BNP and NT-proBNP in untreated but symptomatic patients, and levels of BNP >400 pg/mL and NT-proBNP >2000 pg/mL are considered suggestive for chronic heart failure. It is well known that CVDs are the most frequent cause of morbidity and mortality in patients with chronic kidney disease (CKD) [3], and individuals with CKD have up to 20-fold greater risks of cardiac death, compared to ageand sex-matched controls without CKD. It has also been demonstrated that plasma levels of BNP are increased both in non-dialysisand dialysis-dependent CKD patients. BNP is a reliable test to diagnose significant structural or functional CVDs even in children [4]. Natriuretic peptides (NPs) offer the potential for early detection and risk stratification of CVD in patients admitted to the emergency department [5]. These markers could also be useful for CKD patients asymptomatic for CVD [6]. In this issue of the Journal, Paniagua et al. [7] publish an interesting paper, highlighting what several previous papers demonstrated mainly in the general population, i.e. both BNP and proBNP plasma values in CKD stage 5D patients are directly correlated with extracellular fluid expansion and left ventricular myocardial mass, and are inversely closely correlated with residual renal function [8–11]. High NP values are also associated with inflammation, while there is no clear correlation with obesity and diabetes [12,13]. Besides, NT-proBNP levels are both markers of myocardial damage and fluid overload [9,10]. In the family of NPs, NT-proBNP seems to be the best predictor of clinical outcome and marker of extracellular fluid overload. In fact, the synthesis of NT-proBNP in the left ventricle represents a response to stimuli requiring greater ventricular work. This peptide is larger and has a longer half-life than BNP (the active form), making its measurement easier and also less dependent on acute changes, while this is an important factor affecting the concentration of other NPs [14]. During the last years, the value of the NT-proBNP plasma concentration has been a ‘hot topic’ not only as an independent predictor of general and cardiovascular mortality but also as a marker of fluid control in dialysis patients. The role of NT-proBNP as a predictive marker of clinical outcome in patients on dialysis has been proven, but there are no data about its interaction with fluid volume control and dialysis modality. The aim of the paper from Paniagua et al. [6] was just to demonstrate the interaction between NT-proBNP, fluid volume control and different dialysis modalities.

C0 or C2 driven cyclosporine monitoring in long-term pediatric kidney transplant recipients: is there any threat for chronic rejection development?

Abstract:  The clinical management of cyclosporine has evolved greatly during the last decade thanks to the use of pharmacokinetic (PK) studies which confirmed the dose relationship between drug exposure and its biological effects. Therefore, cyclosporine PK monitoring during the early phase of the post‐transplant period became essential to avoid over or underexposure to the drug thus preventing the risk of nephrotoxicity or acute rejection episodes. More recently, a simple PK determination based on cyclosporine blood concentration measured 2 h after the morning dose, has proven to be very effective for monitoring cyclosporine exposure in the early postoperative period. In this paper, the authors present a set of PK profiles obtained from a stable, long‐term pediatric kidney transplant population and correlate these parameters with the risk of chronic rejection development. The study shows how cyclosporine monitoring based on the sole trough level determination misled a correct therapeutic behavior, as revealed by the PK parameters that were constantly below the therapeutic threshold in a small patient cohort who eventually developed chronic rejection. The C2 determination should be considered as the gold standard for cyclosporine monitoring in long‐term pediatric recipients.

Prospective randomized pilot study on the effects of two synthetic high-flux dialyzers on dialysis patient anemia.

Purpose: Anemia in chronic kidney disease dialysis patients is a complex syndrome involving many causes. Adequate dialysis can contribute to its correction through many mechanisms, including the removal of molecules that may inhibit erythropoiesis. The aim of this pilot study was to evaluate the effect on renal anemia of two synthetic, high-flux dialyzers (polynephron vs. high-flux polysulphone). Methods: 20 dialysis patients (11 male; mean age: 72 years) were randomly assigned and studied for 6 months. There were 2 dropouts in each group. Each patient underwent 3 hemodialysis treatments per week without any difference in dialysis prescription. At T = 0 and T = 6 (after 6 months), instantaneous plasma clearances and reduction rates of small solutes, β2-microglobulin protein (β2-μ); hemoglobin (Hb), and iron pattern were measured. The effect on anemia was evaluated by calculating the Erythropoesis Stimulating Agent (ESA) doses and the Erythropoietin Resistance Index (ERI). Results: Kt/V increased between T0 and T6 in both groups. β2-μ pre-dialysis levels significantly decreased between T0 and T6 in both dialyzer groups (p<0.001 in both groups). The Hb levels increased between T0 and T6, but significantly only for the polynephron patient group (p = 0.006 and 0.142). ESA dose did not change significantly. The ERI decreased by 22.7% between T0 and T6 in the polynephron-group and increased by 14% in the others; these changes were not significant. Conclusions: High-flux filters improved Hb levels, although only significantly in the polynephron group, suggesting a possible different effect. The results should be interpreted with caution and tested in an appropriately powered, large, prospective, randomized control trial.

Detection methods for long lived particles at the LHC

Almost all the extensions of the Standard Model predict the existence of new charged particles; these particles should be very heavy since they have excaped detection so far. In general, such heavy particles decay as soon as they are produced, but under certain circumstances they can be long-lived or even stable. There are two classes of models which predicts the existence of long-lived particles [3]: models with a weakly broken symmetry, where the particle would be stable if the symmetry were exact; and models with an exact symmetry which forbids the decay of heavy exotics into ordinary particles, where the decay of the charged particle into a neutral particle is suppressed either by small couplings or by phase space. Examples of the second kind are supersymmetric models with exact R-parity, where the lightest supersymmetric particle is the gravitino. In this talk we will focus on GMSB (Gauge Mediated Supersymmetry Breaking) which belongs to this kind of models. In GMSB supersymmetry is broken in a so called hidden sector at a scale \( \sqrt F \) and transmitted to SM particles via a messenger sector. The transmission of the supersymmetry breaking is mediated by gauge fields, in particular by N singlet representations of SU(5).

Breast Foreign Body Extraction Using the Breast Lesion Excision System

The breast lesion excision system is a percutaneous image-guided device that uses radiofrequency energy to deliver intact gross specimens. We describe its use for removal of a breast foreign body. A 56year-old woman who carried the BRCA1 gene mutation could not undergo magnetic resonance imaging surveillance because a mammogram revealed a 0.5-cm radiopaque foreign body in the upper-outer quadrant of the left breast. The procedure was performed under local