Weeping sponge kidney: an unusual phenomenon that should be considered in cases of severe renal haemorrhage

AIM

To describe the clinical presentation, imaging evaluation, endovascular management, and outcomes of multifocal renal capsular haemorrhage, "weeping sponge kidney", and to identify associated risk factors and the pathophysiological mechanism behind this condition.

MATERIALS AND METHODS

This is a case series in which clinical information for each of the cases was collected retrospectively from electronic patient notes as well as the radiology information and picture archiving and communication systems.

RESULTS

Four consecutive cases were included in the series. All of the cases were treated successfully with embolisation. Three of the four patients had chronic renal failure with renal atrophy, which are patient factors that appear to be associated with multifocal renal capsular haemorrhage. Based on the procedural findings and the published literature, a pathophysiological mechanism is described to explain this condition and the relevance of the collateral arterial supply to the kidney in such cases is discussed.

CONCLUSION

Small subcapsular haematomas are usually self-limiting but in patients with renal failure, there may be an increased risk of developing a weeping sponge kidney, which can be life-threatening. The endovascular treatment for multifocal haemorrhage differs from that for a single bleeding point, especially if preservation of renal function is not a priority.

Low skeletal mass predicts poor prognosis of elderly patients after emergency laparotomy: A single Asian institution experience

Introduction: Sarcopenia, defined as low skeletal muscle mass and poor muscle function, has been associated with worse postoperative recovery. This study aims to evaluate the significance of low muscle mass in the elderly who require emergency surgeries and the postoperative outcomes. Method: Data from the emergency laparotomy database were retrieved from Khoo Teck Puat Hospital, Singapore, between 2016 and 2019. A retrospective analysis was performed on patients aged 65 years and above. Data collected included skeletal muscle index (SMI) on computed tomography scan, length of stay, complications and mortality. Low muscle mass was determined based on 25th percentile values and correlation with previous population studies. Results: A total of 289 patients were included for analysis. Low muscle mass was defined as L3 SMI of <22.09cm2/m2 for females and <33.4cm2/m2 for males, respectively. Seventeen percent of our patients were considered to have significantly low muscle mass. In this group, the length of stay (20.8 versus 16.2 P=0.041), rate of Clavien-Dindo IV complications (18.4% vs 7.5% P=0.035) and 1-year mortality (28.6% vs 14.6%, P=0.03) were higher. Further multivariate analysis showed that patients with low muscle mass had increased mortality within a year (odds ratio 2.16, 95% confidence interval 1.02–4.55, P=0.04). Kaplan-Meier analysis also shows that the 1-year overall survival was significantly lower in patients with low muscle mass. Conclusion: Patients with low muscle mass have significantly higher post-surgical complication rates and increased mortality. Keywords: Emergency laparotomy, geriatrics, mortality, postoperative outcome, sarcopenia

Low skeletal muscle mass predicts poor prognosis of elderly patients after emergency laparotomy: A single Asian institution experience

INTRODUCTION

Sarcopenia, defined as low skeletal muscle mass and poor muscle function, has been associated with worse postoperative recovery. This study aims to evaluate the significance of low muscle mass in the elderly who require emergency surgeries and the postoperative outcomes.

METHOD

Data from the emergency laparotomy database were retrieved from Khoo Teck Puat Hospital, Singapore, between 2016 and 2019. A retrospective analysis was performed on patients aged 65 years and above. Data collected included skeletal muscle index (SMI) on computed tomography scan, length of stay, complications and mortality. Low muscle mass was determined based on 25th percentile values and correlation with previous population studies.

RESULTS

A total of 289 patients were included for analysis. Low muscle mass was defined as L3 SMI of <22.09cm2/m2 for females and <33.4cm2/m2 for males, respectively. Seventeen percent of our patients were considered to have significantly low muscle mass. In this group, the length of stay (20.8 versus 16.2 P=0.041), rate of Clavien-Dindo IV complications (18.4% vs 7.5% P=0.035) and 1-year mortality (28.6% vs 14.6%, P=0.03) were higher. Further multivariate analysis showed that patients with low muscle mass had increased mortality within a year (odds ratio 2.16, 95% confidence interval 1.02-4.55, P=0.04). Kaplan-Meier analysis also shows that the 1-year overall survival was significantly lower in patients with low muscle mass.

CONCLUSION

Patients with low muscle mass have significantly higher post-surgical complication rates and increased mortality.

The Role of Interventional Radiology in the Diagnosis and Treatment of Pulmonary Arteriovenous Malformations

Pulmonary arteriovenous malformations (PAVMs) are uncommon, predominantly congenital direct fistulous connections between the pulmonary arteries and pulmonary veins, resulting in a right to left shunt. Patients with PAVMs are usually asymptomatic with lesions detected incidentally when radiological imaging is performed for other indications. In this review, we discuss the classification and radiological features of PAVMs as well as their treatment and follow-up options, with a particular focus on percutaneous endovascular techniques and the evolution of the available equipment for treatment.

Mesenteric panniculitis does not confer an increased risk for cancers: A systematic review and meta-analysis

BACKGROUND

Mesenteric panniculitis (MP) is a non-specific, localized inflammation at the mesentery of small intestines which often gets detected on computed tomography. An association with malignant neoplasms remains unclear. We performed a systematic review and meta-analysis to examine the association of malignancy with MP.

METHODS

MEDLINE, EMBASE, Web of Science, and Cochrane databases were searched for articles published from inception to 2020 that evaluated the association of malignant neoplasms with MP in comparison with control groups. Using random-effects method, a summary odds ratio (OR) estimate with 95% confidence intervals for malignant neoplasms in MP was estimated.

RESULTS

Four case-control studies reporting data on 415 MP patients against 1132 matched-controls met inclusion criteria and were analyzed. The pooled OR for finding a malignant neoplasm in patients with MP was 0.907 (95% CI: 0.688-1.196; P = .489). The heterogeneity was mild and non-significant. Also, there was no heightened risk of any specific type of malignancy with MP. Three more case-series with unmatched-control groups (MP: 282, unmatched-controls: 17,691) were included in a separate analysis where the pooled OR of finding a malignant neoplasm was 2.963 (95% CI: 1.434-6.121; P = .003). There was substantial heterogeneity in this group.

CONCLUSION

This meta-analysis of matched controlled studies proves absence of any significant association of malignant neoplasms with MP. Our study also demonstrates that the putative association of malignancy with MP is mainly driven by uncontrolled studies or case-series.

Does preemptive transjugular intrahepatic portosystemic shunt improve survival after acute variceal bleeding? Systematic review, meta-analysis, and trial sequential analysis of randomized trials

BACKGROUND AND AIM

A preemptive transjugular intrahepatic portosystemic shunt (p-TIPSS) after acute variceal bleeding (AVB) is advocated. However, when compared with the current standard of care, the survival benefit of p-TIPSS is questionable. We performed a systematic review, meta-analysis, and trial sequential analysis of randomized control trials (RCTs) to assess the survival benefit of p-TIPSS in patients with cirrhosis and AVB.

METHODS

Comprehensive literature search of three bibliographic databases (MEDLINE, Embase, and Cochrane) was conducted from inception till May 2021. All study types evaluating the survival benefit of p-TIPSS in AVB were considered for inclusion. The relative risk (RR) of mortality and rebleeding at 6 weeks and mortality at 1 year with a random-effects model was computed. Trial sequential analysis was performed for the primary outcome of 6-week mortality.

RESULTS

A total of nine studies (four RCTs and five cohort studies) comprising 2861 patients with AVB were included. The overall pooled risks of mortality at 6 weeks and 1 year were 17.9% (95% confidence interval [CI]: 16.5-19.3%) and 26.7% (95% CI: 25.0-28.3%), respectively. Although p-TIPSS was associated with lower 6-week rebleeding risk (RR = 0.20; 95% CI = 0.13-0.29, I²  = 0%), data from pooled RCTs showed no significant difference in mortality at 6 weeks (RR = 0.33; 95% CI = 0.08-1.36, I²  = 63%) or at 1 year (RR = 0.76; 95% CI = 0.51-1.14, I²  = 30%). Using trial sequential analysis, required sample size to detect a 20% relative risk reduction in mortality at 6 weeks with p-TIPSS was estimated to be 6317, which is beyond the total number of patients available for analysis.

CONCLUSIONS

This meta-analysis found that the available data from RCTs are insufficient to confer 6-week mortality benefit with p-TIPSS compared with standard of care; thus, adequately powered RCTs are required.

Role of Intercostal Artery Embolization in Management of Traumatic Hemothorax

Intercostal artery bleeding from trauma can result in potentially fatal massive hemothorax. Traumatic hemothorax has traditionally been treated with tube thoracostomy, video-assisted thoracoscopic surgery, or thoracotomy. Transcatheter arterial embolization (TAE), a well-established treatment option for a variety of acute hemorrhage is not widely practiced for the management of traumatic hemothorax. We present 2 cases of delayed massive hemothorax following chest trauma which were successfully managed by transarterial embolization of intercostal arteries. The published studies are reviewed and a systematic approach to the selection of patients for TAE versus emergency thoracotomy is proposed.

YouTube as source of information on 2019 novel coronavirus outbreak: a cross sectional study of English and Mandarin content

BACKGROUND

The current 2019 novel coronavirus outbreak is rapidly evolving. YouTube has been recognized as a popular source of information in previous disease outbreaks. We analyzed the content on YouTube about n-CoV in English and Mandarin languages.

METHODS

YouTube was searched using the terms '2019 novel coronavirus', 'Wuhan virus' and '' (Mandarin for Wuhan virus) on 1st and 2nd February 2020. First 50 videos in each group were analyzed. Videos in other languages, duplicate videos, those without an audio and duration >15 min were excluded .72 videos in English and 42 in Mandarin were reviewed. 2 reviewers classified the videos as useful, misleading or news based on pre specified criterion. Inter-observer agreement was evaluated with kappa coefficient. Modified DISCERN index for reliability and medical information and content index (MICI) score were used for content analysis.

RESULTS

These videos attracted cumulative 21,288,856 views. 67% of English and 50% Mandarin videos had useful information. The viewership of misleading Mandarin videos was higher than the useful ones. WHO accounted for only 4% of useful videos. Mean DISCERN score for reliability was 3.12/5 and 3.25/5 for English and Mandarin videos respectively. Mean cumulative MICI score of useful videos was low (6.71/25 for English and 6.28/25 for Mandarin).

CONCLUSIONS

YouTube viewership during 2019 n-CoV outbreak is higher than previous outbreaks. The medical content of videos is suboptimal International health agencies are underrepresented. Given its popularity, YouTube should be considered as important platform for information dissemination.

Tract sealing with normal saline after percutaneous transthoracic lung biopsies

INTRODUCTION

In the present study, we aimed to assess whether normal saline injection for sealing the biopsy track is useful in reducing the incidence of pneumothorax after computed tomography (CT)-guided percutaneous transthoracic lung biopsy (PTLB).

METHODS

We retrospectively compared the incidence of pneumothorax in 100 consecutive biopsies (n = 100, group A) that had injection of saline along the track, with historical cohort of same number of consecutive patients who underwent PTLB without injection of saline along the needle track (n = 100, group B). CT-guided biopsies were performed by coaxial technique and 1-3 ml of saline was injected along the tract. Patient chjmirocteristics, lesion size, location and other baseline pjmirometers were compared. Incidence of pneumothorax and number of patients who underwent catheter drainage of pneumothorax was compared in both groups.

RESULTS

Baseline chjmirocteristics were compjmiroble in both groups. Track sealing with saline was successful in all patients. Pneumothorax rate was 46% for patients in group B and 32% in group A (P < 0.05). Seven patients (7%) had insertion of chest drain for pneumothorax in the group B and only 1% in the group A (P < 0.05). No mortality was observed in both groups. No complications were observed in any of the patients due to saline injection.

CONCLUSION

Track sealing with saline is a simple and safe technique which significantly reduces the incidence of pneumothorax and chest tube insertion after PTLB.

Usefulness of ultrasonography in diagnosis, percutaneous management and follow up of post-traumatic scalp pseudoaneurysms

Pseudoaneurysms of the scalp are rare. Most common etiology is trauma. The patients usually present clinically with persistent painful swelling in the scalp few days after the trauma. The lesion may or may not be pulsatile clinically. Ultrasonography (US) is the best modality to assess these pseudoaneurysms. It not only helps in the diagnosis, but also to trace the offending arterial branch and helps in treatment. We present two cases of post-traumatic scalp pseudoaneurysms which were diagnosed with US and were managed by US-guided thrombin injection. Follow up US showed complete resolution. We highlight the importance of US scan in diagnosis, management, and follow up of scalp pseudoaneurysms.

Percutaneous transhepatic biliary drainage catheter fracture: A case report

Percutaneous transhepatic biliary drainage (PTBD) is safe treatment for biliary decompression given certain indications. However, this is temporary until definitive drainage is established. We report on a 76-year-old lady with recurrent pyogenic cholangitis and PTBD catheter fracture. She had hepatitis B virus-related Child-Pugh class A liver cirrhosis, hypothyroidism, hyperlipidaemia, and previous atrial fibrillation with a background of mild mitral, tricuspid and aortic valvular regurgitation. She had history of laparoscopic cholecystectomy in the past. She was deemed to be a high operative risk and declined hepatic resection. She had undergone multiple endoscopic and percutaneous biliary interventions to control sepsis and stone burden. A bilateral PTBD catheter was left in situ with plans for 3-monthly change. However, she defaulted follow-up and presented 11 months later with complaints of pain over the drain site and inability to flush the right catheter. Abdominal X-ray and computed tomography scans detected right catheter fracture at two places, making three fragments. She underwent percutaneous removal of the proximal fragment by an interventional radiology team. A temporary 4 Fr catheter was inserted to maintain biliary access. Endoscopic removal of the intra-biliary fragments was done the next day. Complete removal was confirmed on fluoroscopy. Finally, the 4 Fr catheter was replaced by a new 12 Fr catheter. The patient was discharged well.

Rapidly Developing Subdural Empyema in an Adult with Sinusitis: A Neurosurgical Threat Alert

Subdural empyema (SDE) is collection of pus in the potential space between the dura and arachnoid layers of the meninges. Leading causes of SDE are sinonasal and otomastoid infections. Commonly affecting patients in the second and third decades, SDE could have a fulminant course with immediate complications and delayed morbidities including hydrocephalus, focal deficits, and epilepsy.

Marine stingray injuries to the extremities: Series of three cases with emphasis on imaging

Stingray injuries are usually reported from coastal regions. The injury is caused by the tail spine of the stingray, which can penetrate deep into the soft tissues, and the venom in the tail can cause extensive tissue damage. Imaging plays a very important role in patients with stingray injuries, especially to detect the presence of retained foreign bodies and its complications. We present three cases of stingray injuries to the extremities, with a special emphasis on radiographic findings. Embedded foreign bodies that were radiographically visualized were removed in two of the patients (one patient was discharged at request and was lost to follow-up). We also discuss the types of injuries, clinical presentation, importance of imaging and management considerations in stingray injuries.

Epstein-Barr virus (EBV)-related smooth muscle tumors of central nervous system--a report of two cases and review of literature

Epstein-Barr virus-related smooth muscle cell tumors (EBV-SMTs) are rare albeit increasingly recognized tumors in immunocompromised patients. We report on the imaging features of EBV-SMTs occurring in the central nervous system (CNS) in two patients. Central areas of T2 prolongation, surrounding vasogenic edema, mass effect on adjacent neuroparenchyma, dural tails, and underlying bone erosions were the notable imaging findings. Besides the usual differentials of extraaxial tumors like meningioma, hemangiopericytoma, and lymphoma, CNS EBV-SMTs should be considered in immunocompromised patients.