Treatment options in femoral radiation fractures following soft tissue sarcoma: Incidence, risk factors, failures and flowchart of treatment.

INTRODUCTION: The femur is the most frequent involved site by post-attinic fractures. The appropriate treatment of pathological fractures after radiotherapy is still controversial as they are associated with a high risk of delayed consolidation and non-union. Authors review a single Center series of pathological fractures after radiation therapy in patients affected by soft tissue sarcomas analyzing incidence, risk factors, failure rate and proposing a flow chart of treatment of postattinic fractures of the femur. METHODS: Authors selected 570 patients treated by limb salvage surgery associated to radiation therapy from 1992 to 2018. A pathological fracture during follow up was observed in 28 cases (5%). The mean time between the onset of the fracture after the prior surgery + radiotherapy was 70 months (range 3-182). The mean follow-up from the fracture was 86 months (range 9-222). RESULTS: The fracture treatment was performed with an intramedullary nail in 15 cases. Eight femoral fractures healed uneventfully (57%) and 6 required further surgical procedures. A total of eight patients underwent prosthetic replacement, 3 as a primary treatment and 5 as a salvage procedure after failure of internal fixation. Five patients developed a deep infection (62.5%).We observed 10 non-union (53%) in 19 patients treated with osteosynthesis. Overall amputation rate of the entire series was 18%. Authors propose a flowchart of treatment for femoral fractures. CONCLUSION: Intramedullary nailing is the treatment of choice in postradiation diaphyseal fractures of long bones, prosthetic replacement in meta-epiphyseal fracture site. Free vascularized grafts remain a valid salvage solution after failure of internal fixation.

Ultrasonography for diagnosis and management of nephrolithiasis: state of the art and new perspectives / L'ultrasonografia nella diagnosi e nel management della nefrolitiasi: stato dell'arte e prospettive future

The correct management of patients with kidney stones is a crucial issue for nephrologists. In recent years, the incidence and prevalence rates of nephrolithiasis have maintained a growing trend worldwide, showing a strong correlation with other systemic disease such as diabetes mellitus, hypertension, obesity, metabolic syndrome and chronic kidney disease. International guidelines indicate computed tomography as the first choice for all adult patients with suspected acute symptoms for obstructive nephrolithiasis. Intravenous pyelogram is more useful in the follow-up of patients with relapsing nephrolithiasis and known stone composition, while the high costs and the long image acquisition times limit the routine use of magnetic resonance. Recent innovative tools have improved the accuracy of kidney stone localization and measuring with B-Mode and color Doppler imaging, thereby reducing the gap between ultrasonography and computer tomography. The aim of this review is to report the latest evidence on risk factors and on the pathophysiology of nephrolithiasis, and to compare the utility of the available imaging techniques in the management of patients with kidney stones, focusing on the role of ultrasonography and the present and future strategies to improve its accuracy.

Amplified biochemical activation of endothelial function in hypertension associated with moderate to severe renal failure.

BACKGROUND: Arterial hypertension and endothelial dysfunction have a role in the development of athero-sclerosis. This study assessed autocrine-paracrine endothelial function in patients with hypertension associated with renal failure. METHODS: Angiotensin II (Ang II), endothelin-1 ( ET-1), basic fibroblast growth factor (bFGF), transforming growth factor-beta (TGF-beta), soluble forms of adhesion molecules (ICAM-1, VCAM-1), E-selectin, von Willebrand factor (vWf) and nitric oxide (NO) were measured in 26 patients with hypertension and chronic renal failure (CRF), in 19 essential hypertensives (EH) and in 28 normotensive healthy subjects. RESULTS: Plasma concentrations of Ang-II, ET-1, ICAM-1, VCAM-1, E-selectin, bFGF and TGF-beta all were significantly higher in patients than in healthy subjects and EH. Furthermore, in CRF, serum creatinine correlated negatively with NO plasma levels (r = - 0.51; p < 0.0) and this relationship held true after adjusting the data for potential confounders. Plasma NO was inversely related with ET-1 and bFGF (P < 0.01). CONCLUSION: Hypertension in CRF is characterized by biochemical evidence of marked endothelial dysfunction, apparently more pronounced than in patients with EH. Amplified endothelial activation in CRF probably contributes to the high rate of atherosclerotic complications in CRF.

Insulin resistance and glomerular hemodynamics in essential hypertension.

BACKGROUND: Arterial hypertension is an important cause of end-stage renal failure. Insulin has been shown to modify glomerular hemodynamics in hypertensive subjects. The aim of this work, therefore, was to observe the relationships between renal hemodynamics and insulin resistance in arterial hypertension. METHODS: Sixty-two non-diabetic hypertensive patients and 25 healthy normal subjects were studied. Renal plasma flow and the glomerular filtration fraction were determined by renoscintigraphy and the insulin sensitivity by an oral glucose test. RESULTS: Renal plasma flow in hypertensive subjects was lower than expected and was related to pressure values, whereas the mean glomerular filtration rates were not different in the two groups. In most patients the filtration fraction was higher than expected. A lower glomerular filtration rate and lower filtration fraction were found in patients with higher insulin resistance. CONCLUSIONS: The progressive decrease of glomerular function in subjects with hypertension is linked with insulin-resistance.