Anterior-inferior shoulder instability: treatment based on the Thal method

Purpose of this study is to analyze the results of a consecutive series of 139 patients affected with anterior-inferior shoulder instability and treated by arthroscopic capsuloplasty using the Thal method with absorbable and non-absorbable Mitek knotless anchors. Much attention was paid to the preoperative and intraoperative selection of patients, excluding from the arthroscopic procedure those with bony Bankart lesions measuring more than 25%, with an inverted-pear glenoid, with engaged Hill-Sachs lesions and patients with HAGL lesions. Pre- and postoperative clinical evaluation was carried out using the Rowe scale. Scores rose from 45-55 to 96 postoperatively. Intra-articular mobilization of the anchors did not occur and peri-metallic lysis was not manifested. Areas of bone resorption were observed in 7 cases (7/38, 18.4%) with the presence of peri-insertional geodes with biological anchors, but this had no effect on the clinical results.

[Large volume increase in a trastigian kidney]

With few exceptions renal volume is markedly reduced in patients with end-stage renal disease, a phenomenon which is almost always accompanied by a progressive loss of renal compliance secondary to renal structure fibrosis. We have observed a remarkable renal compliance during an episode of acute pyelonephritis in a patient on long-term dialysis.

[Spinal cord infarction during haemodialysis]

A 26-year-old patient with chronic renal failure presented a spinal cord infarction during haemodialysis. This is the first case of a patient with chronic renal failure maintained on chronic haemodialysis described in literature. In this case, the severity of vascular lesions documented by widespread vascular calcifications were particularly striking.

Effectiveness of thymostimulin and study of lymphocyte-dependent antibacterial activity in children with recurrent respiratory infections

Recurrent respiratory infections (RRI) consist of more relapsing acute respiratory infections than the ones expected for the age [> 6 acute respiratory tract infections (RTI) per year if age is > 3 years, and > 8 acute RTI per year if age is < 3 years]. Concerning the pathogenesis of RRI, several investigations report the important role of environmental factors, early socialization and immunological dysfunctions, such as lymphocyte subpopulations alterations, IgG subclass deficiency and phagocytosis and/or opsonization deficit during acute infections. In this framework, we have studied the lymphocyte-dependent antibacterial activity (ABA) among 121 children affected by RRI. Results show a statistically significant alteration of this function in 38 children (31.4%): 19 of them exhibited an absent ABA (group 1), while in the others same function was reduced (group 2). A bovine thymic extract, thymostimulin, was administered to both groups by intramuscular injections (1 mg/kg) for a 3 month cycle. At the end of therapy we observed a statistical significant rise of ABA only in group 1 and among children aged > 3 years. Among the same patients, 33 children (86.8%) improved in terms of reduction of clinical score and better results were seen among children aged > 3 years. These data emphasize the beneficial role of thymostimulin in RRI-affected children, suggesting a transient immaturity of the immune system as one of the possible pathogenetic factor.

The influence of autonomic failure on plasma ANF concentration in uremic patients on chronic hemodialysis

We compared plasma ANF concentration in 5 diabetic-uremics with combined sympathetic-parasympathetic dysfunction with that in 9 uremic patients without autonomic impairment. Symptomatic dialysis hypotension was a major clinical problem in all diabetic-uremics. In the volume-expanded state, ANF was almost twice as high (p less than 0.025) in diabetic-uremics than in control uremics (152 +/- 29 vs 84 +/- 10 pg/ml) in the face of similar right atrial pressure (14 +/- 3 vs 12 +/- 1 cm H2O). After isolated ultrafiltration, ANF fell significantly in both groups remaining slightly (NS) higher in diabetic-uremics. The slope of the relationship between ANF and right atrial pressure was significantly (p less than 0.01) steeper in diabetic-uremics than in control uremics. The data indicate that autonomic failure amplifies the effect of atrial stretching on plasma ANF in diabetic-uremics on chronic hemodialysis treatment.

The reflex control of vasopressin in haemodialysis patients

We studied the reflex arginine vasopressin (AVP) response to hypotensive, isosmotic fluid subtraction (by isolated UF) in 14 uraemic patients on renal dialysis treatment: five with normal autonomic function and nine with autonomic involvement of various degrees. Fluid subtraction caused a comparable mean arterial pressure (MAP) decrease in the two groups. The reduction in right atrial pressure was inversely related with the severity of autonomic neuropathy (rs = -0.72, P = 0.004), being distinctly attenuated in the second group (P = 0.006). Plasma arginine vasopressin increased similarly in patients with normal autonomic function and in those with autonomic involvement. The response of patients with haemodialysis hypotension was similar to that of other patients. Reflex control of arginine vasopressin is preserved even in the presence of afferent/central neuropathy or more advanced, widespread autonomic damage in uraemic man. The data suggest that it is unlikely that altered release of arginine vasopressin is involved in the pathogenesis of haemodialysis hypotension.

Postprandial alterations in arterial pressure control during hemodialysis in uremic patients

To test the hypothesis that eating may adversely affect the hemodynamic response to ultrafiltration-dialysis, we studied the effect of a standard snack (about 400 Kcal) in 13 patients on RDT. Each patient was studied in random order during two standard hemodialysis sessions (snack-HD and control-HD) performed at identical UF rate. Arterial pressure fell significantly (p less than 0.01) during both the Control-HD (from 135 +/- 8/76 +/- 3 to 121 +/- 10/68 +/- 5 mmHg) and the Snack-HD (from 137 +/- 7/77 +/- 3 to 105 +/- 8/59 +/- 4 mmHg). The rate of fall, however, was significantly higher (p less than 0.01) after the snack than during the corresponding period in the control HD. Consequently, there were more hypotensive episodes requiring saline infusion during Snack-HD (23 in 10 patients) than during Control-HD (12 in 6 patients) (p less than 0.025). In spite of the greater number of interventions, the average fall in arterial pressure after a snack (-22 +/- 3/-13 +/- 2 mmHg) was more marked than during the corresponding period in the control-HD (-13 +/- 3/-9 +/- 2 mmHg). The hypotensive effect of snack was more pronounced in the presence of advanced autonomic neuropathy. Food ingestion impairs the arterial pressure response to UF in patients on RDT. Fasting during hemodialysis may in part prevent hypotension.

Double-blind randomized, crossover trial of calcium supplementation in essential hypertension

In a double-blind, randomized, placebo-controlled, crossover trial, 23 middle-aged patients with mild to moderate essential hypertension were given an oral calcium supplement (1 g/day) for 8 weeks. At the end of this period, eight patients continued with this treatment for an additional 2 weeks but were also given 0.5 micrograms/day of 1,25-(OH)2 vitamin D3. In the 21 patients who completed the study, arterial pressure during the calcium-supplemented phase was almost identical to that of the placebo phase. In eight patients, mean arterial pressure (MAP) had changed by greater than 5 mmHg at the end of the calcium-supplemented period, compared with the end of the placebo phase (six patients showed an increase in MAP and two a decrease). Changes in arterial pressure were unrelated to age, plasma ionized calcium, parathyroid hormone (PTH), plasma renin activity (PRA), plasma aldosterone, 24-h urinary calcium, sodium and potassium and were only weakly related to body weight. In the eight patients who continued with the treatment of calcium plus 1,25-(OH)2 vitamin D3 after the 8-week study period, arterial pressure changed very little and not significantly. These results do not support the suggestion that calcium supplements lower arterial pressure in middle-aged subjects with mild to moderate essential hypertension.

Autonomic function in uremic patients treated by hemodialysis or CAPD and in transplant patients

Tests of autonomic nerve function have been performed in patients receiving dialysis and following transplantation. These tests, consisting of blood pressure and heart rate response to standard stimuli were carried out in four groups of subjects: 10 patients were receiving continuous ambulatory peritoneal dialysis (CAPD), 12 hemodialysis, 11 had functioning transplants and there were 12 healthy subjects. The heart rate responses to the Valsalva maneuver, deep breathing and standing were equally reduced in the hemodialysis and CAPD patients while the responses in the transplant patients were not significantly different from those in the control subjects. Peroneal nerve conduction velocity was used to measure the degree of peripheral neuropathy and while in most patients there was a positive relationship with the autonomic studies, in five patients the results were clearly dissociated. Plasma parathyroid hormone (PTH) levels were elevated in both the dialysis groups but not in the transplanted patients and there was no correlation between the PTH levels and any of the neurological tests. This study has confirmed the presence of autonomic neuropathy in dialysed uremic patients and has demonstrated almost complete resolution of this following transplantation but has failed to show any benefit of CAPD over hemodialysis in protecting against neuropathy.

Parasympathetic function in haemodialysis patients

The long-term course of the parasympathetic neuropathy in patients with chronic renal failure maintained on haemodialysis was investigated. Well-established tests of parasympathetic function (deep breathing test, atropine test) were performed in 45 patients who had been dialysed for periods ranging from 1 to 12 years and in 34 normal subjects. The responses to these tests were clearly compromised in dialysis patients but there was no relationship between duration of haemodialysis treatment and results of parasympathetic tests. In the 13 patients who were re-evaluated after an interval of 4 years there was no evidence of progression of the parasympathetic neuropathy. The results suggest that chronic haemodialysis treatment halts parasympathetic damage in patients with chronic renal failure.

Effect of naloxone on the defective autonomic control of heart rate in uraemic patients

The role of endogenous opioids on the reflex cardiovascular control of chronic uraemic patients was investigated. The opiate antagonist naloxone administered intravenously caused a significant increase in the abnormal Valsalva manoeuvre ratio in nine chronic uraemic patients, but it had no effect in six diabetic patients with normal renal function, whose response to the Valsalva manoeuvre was similar to that of chronic uraemic patients. Naloxone had no effect in eight normal subjects. The increase in the Valsalva ratio observed in uraemic patients was due to restoration of the parasympathetically mediated reflex bradycardia of the release phase of the manoeuvre. Naloxone did not modify supine and standing blood pressure and heart rate in any group. Endogenous opioids may be involved in the defective autonomic control of heart rate in uraemic patients.

Opportunistic Scopulariopsis pneumonia in an immunocompromised host

We have described a patient with fatal Scopulariopsis pneumonia, a previously unreported infection, complicating immunosuppressive therapy for acute myeloblastic leukemia. This Scopulariopsis isolate was highly resistant to available antifungal agents, in part accounting for our patient's death.

Defective reflex control of heart rate in dialysis patients: evidence for an afferent autonomic lesion

1. To localize the site of autonomic abnormality in patients undergoing haemodialysis, tests of overall autonomic function based on either changes in blood pressure (posture, sustained handgrip) or heart rate (Valsalva manoeuvre, 30 : 15 ratio, deep breathing test) were used. Integrity of the sympathetic efferent arc was examined by using the cold pressor test and the parasympathetic efferent arc by the atropine test. Eighteen patients and 12 control subjects were studied. 2. Changes in blood pressure in standing, sustained handgrip and in the cold pressor test were the same in the two groups. 3. In contrast, 11 patients had abnormal results in at least two of the three heart-rate-based tests. 4. Three of the 11 dialysis patients with evidence of autonomic involvement showed abnormal responses to atropine, indicating an efferent parasympathetic lesion, whereas the majority had a normal response to the atropine test, suggesting an afferent lesion only. 5. Evidence of autonomic involvement was not associated with hypertension nor confined to patients with dialysis hypotension.