Nephrotic syndrome and rituximab: facts and perspectives

Idiopathic nephrotic syndrome is the most frequent glomerular disease that presents during childhood and is mainly due to minimal change nephropathy (MCNS) and focal-segmental glomerulosclerosis (FSGS). Its treatment is still challenging, with up to 50% of the patients who are initially steroid sensitive (usually MCNS) being frequent relapsers and requiring additional long-term immunosuppression. However, current immunosuppressive regimens are associated with severe toxicity. Only half of the steroid-resistant patients (usually FSGS) achieve long-term remission even with intensive immunosuppression and plasma exchange. Rituximab (RTX), a chimeric monoclonal antibody inhibiting CD20-mediated B-cell proliferation and differentiation, has recently gained attention as a potentially successful therapy for complicated idiopathic nephrotic syndrome in children. A number of case reports and one prospective non-controlled multicenter trial point to the beneficial effects of RTX as a rescue therapy in children with steroid/cyclosporine-dependent or -resistant nephrotic syndrome. However, publication bias often results in positive outcomes being more likely to be reported than negative ones and, in particular, the safety profile of this drug in this group of patients remains unclear. Therefore, controlled randomized studies are required to assess this issue, to develop treatment guidelines, to evaluate the therapeutic and economical efficacy, and to define criteria for the selection of patients.     

Androgen deficiency and the aging male: new urologic perspectives

Among the most prominent health care issues of the 21st century are those relating to aging. Indeed, the elderly represent the fastest growing segment of our population. Typically, a urology practice includes a significant number of elderly males, providing the physician with both a challenge and an opportunity. Androgen deficiency in the aging male, with its detrimental effects on bone, muscle and body composition, sexual function, and psychological well-being, is an area of increasing interest in both the lay press and the medical community. The urologist must understand the pathophysiology of androgen deficiency in the male, recognize and investigate the subtle signs and symptoms of hypogonadism, determine the appropriateness of treatment, and offer informed options to the patient. Health care professionals have a responsibility to make “healthy” aging a priority.     

Controversies in nephrology: response to 'renal albumin handling, facts, and artifacts'

For 40 years indirect measurements of the glomerular sieving coefficient of albumin yielded very low values. The first direct measurement by 2-photon microscopy by Russo et al (Kidney Int (2007) 71, 504-513) gives values 50-times higher. This demonstrated that relatively large quantities of albumin are normally filtered based on size selectivity alone. Most of this albumin is retrieved and returned to the blood supply. These new discoveries represent a paradigm shift in our understanding of albumin processing by the kidney. They also serve to explain several anomalous aspects of previous studies on glomerular filtration and mechanism of albuminuria and support the fact that glomerular charge selectivity is not a major factor controlling glomerular permselectivity.     

The shoulder: facts,confusions and myths

Summary The purpose of this paper is to address some of the myths, facts and confusions about the shoulder. Myth: Recurrent subluxation or dislocation of the shoulder requires surgery. Fact: The most important shoulder muscle is the anterior deltoid. Myth: You can diagnose shoulder problems with two anterior/posterior x-rays. Fact: You must keep track of the pins you insert for shoulder problems. Confusion: The position of the shoulder for arthrodesis: which to choose? Confusion: What if the arthrodesis is painful? Myth: You don't need the clavicle and can resect it without any problems. Fact: All sternoclavicular dislocations are not dislocations. Fact: Do not repair or reconstruct spontaneous sternoclavicular dislocations in children and young adults. Confusion: What is the role of the arthroscope in the diagnosis and treatment of shoulder problems? Fact: There are more than just Type I, II and III injuries to the acromioclavicular joint. Fact: Total shoulder arthroplasty is not an experimental operation. Myth: All patients with a sore shoulder need an arthrogram. All patients with positive arthrograms need an operation. All rotator cuffs must be repaired.

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Résumé Le but de cet exposé est de parler de quelques uns des mythes, certitudes et questions concernant l'épaule. Mythe: La subluxation et la luxation récidivantes de l'épaule nécessitent une intervention chirurgicale. Certitude: Le muscle le plus important de l'épaule est le faisceau antérieur du dèltoïde. Mythe: On peut résoudre les problèmes d'épaule avec deux radiographies, antérieure et postérieure. Certitude: On doit surveiller la situation des broches mises en place pour des problèmes d'épaule. Question: Position de l'épaule en cas d'arthrodèse: laquelle choisir? Question: Que faire si la douleur persiste après arthrodèse? Mythe: La clavicule n'est pas indispensable et peut être réséquée sans aucun problème. Certitude: Toutes les luxations sterno-claviculaires ne sont pas des luxations. Certitude: Il ne faut pas réparer ou reconstruire les luxations sterno-claviculaires chez l'enfant et l'adulte jeune. Question: Quelle est la place de l'arthroscopie dans le diagnostic et le traitement des problèmes d'épaule? Certitude: Il y a d'autres traumatismes de l'articulation acromio-claviculaire que les types I, II et III. Certitude: L'arthroplastie totale de l'épaule n'est pas une opération expérimentale. Mythe: Tous les malades ayant des douleurs de l'épaule doivent avoir une arthrographie. Tous les malades ayant une arthrographie positive doivent être opérés. Toutes les coiffes des rotateurs doivent être réparées.

     

Pregnancy, childbirth, and sexual function: perceptions and facts

Introduction and hypothesis

Data on the effect of pregnancy and mode of delivery on postpartum sexual function are very heterogenic and inconclusive. The aim of this review is to examine the current literature for reliable data on the role of pregnancy and the route of delivery on sexual health and different dysfunctions.

Methods

A Medline search was performed for the terms “sexuality,” “sexual function,” “sexual dysfunction,” and “pregnancy,” “childbirth,“ “mode of delivery,” “delivery,” “cesarean section,” “puerperium,” and “postpartum.” Randomized, prospective, and retrospective studies in published in the English language from 1960 to November 2012 were evaluated.

Results

Sexual function decreases throughout pregnancy, getting worse as the pregnancy progresses. Decreasing desire and orgasm, increasing pain and other sexual dysfunction problems in the first 3 months gradually improved within 6 months after delivery. This process is affected by many factors such as socio-cultural, age, parity, breastfeeding, depression, tiredness, sexual inactivity during the first trimester, postpartum body image, worries about getting pregnant again, and concomitant urinary tract infections are reported as independent risk factors for sexual dysfunction.

Conclusions

In this review there is no clear evidence of a relationship between the mode of delivery and changes in sexual function. Quality of sexual life should be part of history taking because of the possible sequelae of pregnancy and delivery. More adequately powered studies are necessary to answer the many open questions.     

Calcaneus fractures: facts, controversies and recent developments

The management of calcaneus fractures and their associated soft tissue injuries are challenging tasks for the surgeon. Open reduction and stable internal fixation with a lateral plate and without joint transfixation has been established as a standard therapy for displaced intra-articular fractures with good to excellent results in two-thirds to three-quarters of cases in larger clinical series. Bone grafting appears not useful in the vast majority of cases. Anatomical reduction of joint congruity and the overall shape of the calcaneus are important prognostic factors. The quality of joint reduction should be reliably proven intra-operatively either with Brodén views, high-resolution fluoroscopy or open subtalar arthroscopy. Treatment results are adversely affected by open fractures, delayed reduction after more than 14 days and individual risk factors such as high body mass index and smoking. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposure of the fractured lateral wall, and the subtalar and calcaneocuboid joints in most fractures. In selected fracture patterns percutaneous screw fixation, possibly with arthroscopic control, is a good alternative. Open fractures, compartment syndrome and fractures with severe soft tissue compromise are treated as emergency cases. Early, stable soft tissue coverage appears promising in treating complex open fractures. The benefits of newly developed plate designs and subtalar arthrolysis at the time of hardware removal remains to be proven in further studies. Calcaneal malunions after conservative therapy of displaced fractures are disabling conditions that can be treated successfully with a staged protocol according to the type of deformity. Treatment options include lateral wall decompression, subtalar in situ, or corrective, arthrodesis and calcaneal osteotomy along the former fracture line.     

Transdermal oxybutynin: sticking to the facts

OBJECTIVES: This article critically reviews all the available published and presented data about transdermal oxybutynin to provide a summary of its efficacy, tolerability, and acceptability. RESULTS: For patients with urge incontinence or mixed incontinence, transdermal oxybutynin offers equivalent efficacy to variable dose oral oxybutynin IR and tolterodine LA 4 mg/d. At present no data are available for patients with frequency and urgency but without incontinence (overactive bladder [OAB] dry). Transdermal oxybutynin offers marked improvements compared with placebo in incontinence episodes, daily urinary frequency, and nocturia. These objective improvements are matched by improvements in quality of life. The rate of anticholinergic side-effects is lower than that for oral anticholinergic preparations. This benefit is offset by a rate of local skin reactions. CONCLUSIONS: The balance of efficacy and tolerability suggests that transdermal oxybutynin should be considered as a potential first-line therapy in OAB or mixed incontinence.