CT cross-sectional imaging classification system for substernal goiter based on risk factors for an extracervical surgical approach.

BACKGROUND: The purpose of this study was to identify risk factors for surgical extracervical approach in patients with substernal goiter. We used a novel classification system based on CT scan cross-sectional imaging (CSI) reconstruction. METHODS: Medical records of 4297 patients with thyroid disease operated on at our department were reviewed. A CSI classification system defined substernal goiter in the cranio-caudal dimension as: grade 1 (above aortic arch), grade 2 (level of aortic arch), and grade 3 (below aortic arch); in the anteroposterior dimension as type A (prevascular), type B (retrovascular-paratracheal), and type C (retrotracheal); in the latero-lateral dimension as: monolateral or bilateral. RESULTS: The prevalence of substernal goiter was 222 of 4297 cases (5.1%). Fifteen of 222 cases (6.7%) required an extracervical approach due to grade ≥2 and/or type C substernal goiter (14 of 15 cases). Ten of 15 patients had malignancy. CONCLUSION: The CT-CSI classification system allows us to identify risk factors for extracervical surgical approach in substernal goiter. They are grade ≥2, type C substernal goiter, and malignancy.

Contrast medium administration in the elderly patient: is advancing age an independent risk factor for contrast nephropathy after angiographic procedures?

Contrast medium-induced nephropathy (CMIN) is the third leading cause of hospital-acquired acute renal dysfunction. Even if the number of patients over 75 years of age undergoing diagnostic and/or interventional procedures and requiring administration of contrast medium (CM) is growing constantly, at present there is no definitive consensus regarding the role of advancing age and related morphologic or functional renal changes as an independent risk factor for CMIN. The authors review the evidence from recent medical literature on the definition, pathophysiology, and clinical presentation of CMIN as well as therapeutic approaches to its prophylaxis. Attention is focused on advancing age as a preexisting physiologic condition that is, per se, able to predispose the patient to CM-induced renal impairment, assuming that every elderly patient is potentially at risk for CMIN.

[Perspectives on treatment of the renal failure]. / Il trattamento dell'insufficienza renale: il futuro prossimo.

The next decade will face an increase in the number of patients affected by end-stage renal disease. In line with the growing incidence of type 2 diabetes, hypertension and old age in the general population, we can expect a dramatic increase of uremic patients needing a substitutive treatment of renal function. On the basis of the current trends, we expect an exponential growth of cardiovascular complications in both dialysis and transplant populations. Progress in the treatment of end-stage renal disease will aim at the prevention of cardiovascular complications, that remain the leading cause of morbidity and mortality in uremic patients. Preventive interventions for cardiovascular complications should focus on traditional risk factors, such as hypertension, dyslipidemia and obesity, diabetes mellitus, smoking, as well as on the non traditional risk factors inherent in the uremic state, such as anemia, hyperphosphoremia, hyperhomocysteinemia, inflammation and malnutrition. Recent and future innovations in peritoneal dialysis solutions include a larger use of icodextrin, a glucose polymer able to enhance ultrafiltration while inducing less glycation and caloric absorption, and perhaps improving blood pressure control. The gene therapy directed to the mesothelial cells should bring about improvements in nutrition, cardiovascular comorbidity, and dialysis adequacy. Patients submitted to increased hemodialysis time or to the implementation of a night or daily hemodialysis program have shown better blood pressure control, cardiovascular stability, tolerability and perhaps reduced mortality. Modifications of dialysis schedules clearly indicate another road to future improvements in renal replacement therapy. In the field of kidney transplantation, much improvement has already been achieved regarding the prevention of acute rejection, and the new therapeutic strategies are aimed at reducing the incidence of the adverse reactions of immunosuppressive drugs, as well as of the chronic allograft nephropathy. Induction of transplantation tolerance remains the most attractive target, which now seems closer than before because many of the mechanisms involved in the tolerance induction have been better elucidated.

[Serum concentration of some tumor markers in renal failure]. / Concentrazioni plasmatiche dei marcatori tumorali nell'insufficienza renale.

This study was undertaken to define the relationship between renal function and the blood level of some tumor markers. In order to evaluate the specificity of tumor markers in cronic renal failure the following alphaFP, CEA, NSE, SCC and beta2 microglobulin were studied in 40 adult patients, with cronic renal failure of different degrees (27 p.), in hemodialyzed patients (6 p.) and in 7 healthy volunteers who did not present any clinical symptoms or signs of neoplasia. The decrease in glomerular filtration rate (GFR) was accompanied by an increase in serum levels of CEA, SCC and beta2 microglobulin. The serum level of CEA, SCC increased gradually when GFR fell below 75 ml/min. The serum level of beta2 microglobulin increased when GFR fall below 30 ml/min. Serum level of CEA, SCC and beta2 microglobulin was found to be increased in hemodialyzed patients. In conclusion in cronic renal failure and in hemodialyzed patients some tumor markers (CEA, SCC and beta2 microglobulin) show a high false positive rate and may be unreliable for monitoring malignancies in uremic patients, while alphaFP and NSE appear to maintain their specificity.