Infección del sitio quirúrgico en intervenciones del aparato locomotor

Programa de doctorado: Avances en Traumatología, Medicina del Deporte y Cuidados de Heridas

Valutazione del rapporto urinario proteine totali/creatinina e albumina/creatinina in cani affetti da iperadrenocorticismo e da diabete mellito

INTRODUCTION – In human medicine, diabetes mellitus (DM), hypertension, proteinuria and nephropathy are often associated although it is still not clear whether hypertension is the consequence or the cause of nephropathy and albuminuria. Microalbuminuria, in humans, is an early and sensitive marker which permits timely and effective therapy in the early phase of renal damage. Conversely, in dogs, these relationships were not fully investigated, even though hypertension has been associated with many diseases (Bodey and Michell, 1996). In a previous study, 20% of diabetic dogs were found proteinuric based on a U:P/C > 1 and 46% were hypertensive; this latter finding is similar to the prevalence of hypertension in diabetic people (40-80%) (Struble et al., 1998). In the same canine study, hypertension was also positively correlated with the duration of the disease, as is the case in human beings. Hypertension was also found to be a common complication of hypercortisolism (HC) in dogs, with a prevalence which varies from 50 (Goy-Thollot et al., 2002) to 80% (Danese and Aron, 1994).The aim of our study was to evaluate the urinary albumin to creatinine ratio (U:A/C) in dogs affected by Diabetes Mellitus and HC in order to ascertain if, as in human beings, it could represent an early and more sensitive marker of renal damage than U:P/C. Furthermore, the relationship between proteinuria and hypertension in DM and HC was also investigated. MATERIALS AND METHODS – Twenty dogs with DM, 14 with HC and 21 healthy dogs (control group) were included in the prospective case-control study. Inclusion criteria were hyperglycaemia, glicosuria and serum fructosamine above the reference range for DM dogs and a positive ACTH stimulation test and/or low-dose dexamethasone test and consistent findings of HC on abdominal ultrasonography in HC dogs. Dogs were excluded if affected by urinary tract infections and if the serum creatinine or urea values were above the reference range. At the moment of inclusion, an appropriate therapy had already been instituted less than 1 month earlier in 12 diabetic dogs. The control dogs were considered healthy based on clinical exam and clinicopathological findings. All dogs underwent urine sample collection by cystocentesis and systemic blood pressure measurement by means of either an oscillometric device (BP-88 Next, Colin Corporation, Japan) or by Doppler ultrasonic traducer (Minidop ES-100VX, Hadeco, Japan). The choice of method depended on the dog’s body weight: Doppler ultrasonography was employed in dogs < 20 kg of body weight and the oscillometric method in the other subjects. Dogs were considered hypertensive whenever systemic blood pressure was found ≥ 160 mmHg. The urine was assayed for U:P/C and U:A/C (Gentilini et al., 2005). The data between groups were compared using the Mann-Whitney U test. The reference ranges for U:P/C and U:A/C had already been established by our laboratory as 0.6 and 0.05, respectively. U:P/C and U:A/C findings were correlated to systemic blood pressure and Spearman R correlation coefficients were calculated. In all cases, p < 0.05 was considered statistically significant. RESULTS – The mean ± sd urinary albumin concentration in the three groups was 1.79 mg/dl ± 2.18; 20.02 mg/dl ± 43.25; 52.02 mg/dl ± 98.27, in healthy, diabetic and hypercortisolemic dogs, respectively. The urine albumin concentration differed significantly between healthy and diabetic dogs (p = 0.008) and between healthy and HC dogs (p = 0.011). U:A/C values ranged from 0.00 to 0.34 (mean ± sd 0.02 ± 0.07), 0.00 to 6.72 (mean ± sd 0.62 ± 1.52) and 0.00 to 5.52 (mean ± sd 1.27 ± 1.70) in the control, DM and HC groups, respectively; U:P/C values ranged from 0.1 to 0.6 (mean ± sd 0.17 ± 0.15) 0.1 to 6.6 (mean ± sd 0.93 ± 1.15) and 0.2 to 7.1 (mean ± sd 1.90 ± 2.11) in the control, DM and HC groups, respectively. In diabetic dogs, U:A/C was above the reference range in 11 out of 20 dogs (55%). Among these, 5/20 (25%) showed an increase only in the U:A/C ratio while, in 6/20 (30%), both the U:P/C and the U:A/C were abnormal. Among the latter, 4 dogs had already undergone therapy. In subjects affected with HC, U:P/C and U:A/C were both increased in 10/14 (71%) while in 2/14 (14%) only U:A/C was above the reference range. Overall, by comparing U:P/C and U:A/C in the various groups, a significant increase in protein excretion in disease-affected animals compared to healthy dogs was found. Blood pressure (BP) in diabetic subjects ranged from 88 to 203 mmHg (mean ± sd 143 ± 33 mmHg) and 7/20 (35%) dogs were found to be hypertensive. In HC dogs, BP ranged from 116 to 200 mmHg (mean ± sd 167 ± 26 mmHg) and 9/14 (64%) dogs were hypertensive. Blood pressure and proteinuria were not significantly correlated. Furthermore, in the DM group, U:P/C and U:A/C were both increased in 3 hypertensive dogs and 2 normotensive dogs while the only increase of U:A/C was observed in 2 hypertensive and 3 normotensive dogs. In the HC group, the U:P/C and the U:A/C were both increased in 6 hypertensive and 2 normotensive dogs; the U:A/C was the sole increased parameter in 1 hypertensive dog and in 1 dog with normal pressure. DISCUSSION AND CONCLUSION- The findings of this study suggest that, in dogs affected by DM and HC, an increase in U:P/C, U:A/C and systemic hypertension is frequently present. Remarkably, some dogs affected by both DM and HC showed an U:A/C but not U:P/C above the reference range. In diabetic dogs, albuminuria was observed in 25% of the subjects, suggesting the possibility that this parameter could be employed for detecting renal damage at an early phase when common semiquantiative tests and even U:P/C fall inside the reference range. In HC dogs, a higher number of subjects with overt proteinuria was found while only 14% presented an increase only in the U:A/C. This fact, associated with a greater number of hypertensive dogs having HC rather than DM, could suggest a greater influence on renal function by the mechanisms involved in hypertension secondary to hypercortisolemia. Furthermore, it is possible that, in HC dogs, the diagnosis was more delayed than in DM dogs. However, the lack of a statistically significant correlation between hypertension and increased protein excretion as well as the apparently random distribution of proteinuric subjects in normotensive and hypertensive cases, imply that other factors besides hypertension are involved in causing proteinuria. Longitudinal studies are needed to further investigate the relationship between hypertension and proteinuria.

Patología del aparato auditivo en cetáceos

Doctorado en Sanidad Animal y Seguridad Alimentaria. Instituto Universitario de Sanidad Animal y Seguridad Alimentaria.

El ombligo del aparato anímico freudiano : Un recorrido sobre lo no conocido [unnerkant]

El presente trabajo se propone explorar el uso que hace Freud de la categoría de lo 'no conocido' (unnerkant) a partir de la expresión 'el ombligo del sueño' utilizada en 'La Interpretación de los Sueños'. Intentando recorrer el lugar que tiene esta categoría en el pensamiento Freudiano y en la noción de Aparto Anímico, se recorrerán dos textos articulados a 'La Interpretación de los Sueños': 'Algunas notas adicionales a la interpretación de los sueños en su conjunto' y el 'Complemento Metapsicológico a la doctrina de los sueños'. El ombligo del sueño aparece mencionado en una breve y oscura referencia que realiza Freud en 'La Interpretación de los Sueños' en la cual se localiza lo "no conocido" en el Aparato Anímico. Años más tarde, esta categoría vuelve a ser mencionado en las 'Notas adicionales'. Se trata de tres breves escritos pensados por su autor como anotaciones al final de la Interpretación de los sueños. Algo en ellos, escandalizó a la comunidad analítica de su época y nunca tendrán ese destino. Freud se ocupa allí de temáticas complejas, polémicas: 'Los límites de la interpretabilidad', 'La responsabilidad moral por el contenido de los sueños', y 'El significado ocultista del sueño'. Allí nuevamente Freud no retrocede ante lo 'no conocido'. Nos detendremos en el tercero en donde Freud aborda el enigma de los fenómenos de adivinación, intentando explicarse cómo puede explicarse el mensaje que se recibe 'supuestamente' desde afuera, desde el adivino. Articulará estos fenómenos a un mecanismo que denomina 'transferencia inmediata': alguna moción reprimida pasó del consultante al adivino mientras éste distraía su atención. ¿Cuál es la mediación que no se produjo? ¿Qué lugar tiene allí la atención? Estas preguntas nos llevarán a pensar un modo de operación del Aparato Anímico descripto en 'La Interpretación de los Sueños' como 'Procesos Incorrectos': El segundo sistema solo inviste una representación si está en condiciones de inhibir el desarrollo de displacer que parte del primer sistema. Lo que se sustraiga de esta inhibición queda inasequible al segundo sistema. Por otro lado, dado que el proceso secundario adviene tardíamente, las mociones y deseos del inconsciente, 'núcleo de nuestro ser', permanecen no inhibibles, inasequibles a la investidura del preconsciente. Pero si lo reprimido se inviste con la moción inconsciente y es abandonado por la investidura prcc, queda a merced del proceso psíquico primario y apunta a la descarga motriz o a la reanimación alucinatoria de la identidad perceptiva. Los llama 'Procesos incorrectos', modos de trabajo primario del aparato, cuando ha sido librado de la inhibición. Se muestran allí desplazamientos y contaminaciones idénticos a la 'falta de atención' El lugar entonces de la atención y la conciencia (o Segundo Sistema) nos llevará a una última articulación con el 'Complemento Metapsicológico a la doctrina de los sueños'. Allí Freud estudia la creencia en la realidad del cumplimiento de deseo en el sueño, que pone en serie con algunos fenómenos alucinatorios. Este fenómeno lo llevara a proponer un dispositivo: el examen de realidad. Dirá que se trata del dispositivo que establece la diferencia entre realidad y deseo. El caso de la Psicosis Alucinatoria de Deseo, pondrá en evidencia que puede un deseo cumplido figurarse con creencia plena, como si fuese una realidad exterior. Así, podemos pensar que no ya en el sistema Inconsciente (Primer Sistema), sino en este caso en el Segundo Sistema hay un punto, un punto en el que el aparato se abre y no al mundo exterior. De modo que podemos pensar que para Freud, a la hora de formalizar su experiencia en lo que se conocerá como 'Aparato Anímico' las categorías adentro y afuera no permitirían dar cuenta de su espacialidad. Del mismo modo que los tres tiempos y su clásico ordenamiento, tampoco permiten inscribir la temporalidad con la que tal aparato revela su funcionamiento La exploración de lo no conocido (unnerkant) recorre fenómenos que plantean esta dificultad: algo es abierto y cerrado al mismo tiempo. Como un ombligo. Nos interesa subrayar que, si tenemos en cuenta las 'Notas' y el 'Complemento' esto atraviesa también el funcionamiento del segundo sistema. De modo que parece extenderse al funcionamiento del aparato y no sólo del Inconsciente. Es decir, permite pensar un aparato abierto-cerrado al mismo tiempo