Effect of Combined Low Dose Human Gonadotropic Hormone, Follicle Stimulating Hormone, and Testosterone Therapy (LFT Regimen) Versus Conventional High Dose Human Gonadotropic Hormone and Follicle Stimulating Hormone on Spermatogenesis and Biomarkers in Men With Hypogonadotropic Hypogonadism.

OBJECTIVE: In male congenital hypogonadotropic hypogonadism (CHH), it was observed that lower dose human gonadotropic hormone (hCG) can maintain normal intratesticular testosterone levels. We propose this study to compare the low-dose hCG, follicle stimulating hormone (FSH), and Testosterone (T) [LFT Regimen] to conventional treatment to induce virilization and fertility. DESIGN: This open-label randomized pilot study was conducted from June 2020 to December 2021. SUBJECTS AND OUTCOME MEASURES: CHH were randomly assigned to either the LFT regimen (Group A)-low-dose hCG (500U thrice per week), FSH (150U thrice per week), and T(100 mg biweekly) or conventional therapy(GroupB) with high hCG dose(2000U thrice per week) and the same FSH dose. The hCG dosage was titrated to reduce anti-mullerian hormone (AMH) by 50% and normalization of plasma T in groups A and B, respectively. The primary objective was to compare the percentage of individuals who achieved spermatogenesis between the two groups. RESULTS: Out of 30 patients, 23 (76·7%) subjects achieved spermatogenesis, and the median time was 12 (9-14·9) months. There was no difference in achieving spermatogenesis between the two groups (64·3% vs 7·5%,P = 0·204), and even the median time for spermatogenesis was similar (15months vs 12months,P = 0·248). Both groups had nonsignificant median plasma AMH at spermatogenesis, [6·6 ng/ml (3·3-9·76) vs4·41 ng/ml (2·3-6·47), P = 0·298]. Similarly, the median plasma Inhibin B at spermatogenesis between groups were comparable [152·4 pg/ml (101·7-198·0) vs49·1 pg/ml (128·7-237·3), P = 0·488]. CONCLUSIONS: A reasonable approach to induce fertility in male CHH is to initiate combination therapy using FSH, low-dose hCG targeting AMH <6·9 ng/ml, along with T to achieve normal range. Monitoring AMH could serve as a proxy indicator of spermatogenesis.

Augmented mannose-binding lectin levels in primary membranous nephropathy: A pilot study.

There is evidence to suggest that M-type phospholipase A2 (PLA2R) antibodies activate the mannose-binding lectin (MBL) cascade, resulting in glomerular damage and proteinuria in patients with primary membranous nephropathy (PMN). Furthermore, there are few reports indicating that aberrant MBL activation is associated with endothelial dysfunction and accelerated atherosclerosis. While PMN is a common cause of adult nephrotic syndrome, and patients are at increased risk of cardiovascular disease (CVD), there is a lack of research that explores the factors that contribute to this condition. This study aims to determine the MBL levels in PMN and their relation to the clinical activity and endothelial dysfunction in PMN. The MBL levels of 22 biopsy-confirmed PMN patients were assessed at baseline and after 6 months of immunosuppressive therapy. In order to evaluate endothelial dysfunction in PMN patients, flow-mediated vasodilation (FMD) was measured at baseline and after treatment. A total of 22 healthy controls were included in this study to measure MBL levels and FMD. A significant difference was observed between MBL levels in PMN patients and healthy controls (p < .01). MBL levels decreased significantly after immunosuppressive therapy (p = .04). The baseline MBL levels and FMD levels exhibited a strong correlation (Spearman correlation coefficient [ρ] = 0.51: p = .01). In conclusion, the study signals the activation of the MBL cascade and its association with endothelial dysfunction in PMN patients.

Penile Epithelioid Hemangioendothelioma in a Child.

An 8-year-old boy initially thought to have a penile arteriovenous malformation was later diagnosed with a rare vascular sarcoma, epithelioid hemangioendothelioma (EHE). Despite challenges in diagnosis, he underwent supraselective angioembolization and partial penectomy for oncological clearance. EHE, a low-grade malignancy, requires prompt identification and treatment due to potential systemic involvement.

Assessment of Sarcopenia Using Muscle Ultrasound in Patients With Cirrhosis and Sarcopenic Obesity (AMUSE STUDY).

BACKGROUND AND AIMS: Sarcopenic obesity (SO) marks a confluence of 2 complex entities involving the muscle-liver-adipose tissue axis. Computed tomographic (CT) scan-derived skeletal muscle index (SMI) remains the gold standard for sarcopenia assessment in SO. However, it has intrinsic limitations of cost, radiation, and point of care applicability. We assessed the role of muscle ultrasound (US) in SO. METHODS: A total of 52 patients with cirrhosis and obesity were assessed for sarcopenia using SMI. US assessment of thigh and forearm muscles was done to record quadriceps muscle thickness (QMT), quadriceps feather index (QMFI), forearm muscle thickness (FMT), and forearm feather index (FFI), respectively. Evaluated US parameters were correlated with SMI and assessed for diagnostic accuracy using the area under the curve. RESULTS: A total of 40 (76.9%) males and 12 (23.1%) females [mean age: 50.9 y (43.8 to 53.5 y)] were included. QMT [0.45 cm/m 2 (0.42 to 0.48 cm/m 2 ) vs. 0.67 cm/m 2 (0.63 to 0.70 cm/m 2 )], QMFI [0.82 cm/m 2 (0.77 to 0.87 cm/m 2 ) vs. 1.12 cm/m 2 (1.06 to 1.19 cm/m 2 )], FMT [0.19 cm/m 2 (0.17 to 0.20 cm/m 2 ) vs. 0.25 cm/m 2 (0.23 to 0.27 cm/m 2 )], and FFI [0.38 cm/m 2 (0.35 to 0.412 cm/m 2 ) vs. 0.47 cm/m 2 (0.44 to 0.50 cm/m 2 )] were significantly lower in patients with SO ( P <0.01). A positive correlation with SMI was seen for all parameters in the entire cohort. The strongest correlation was exhibited by QMT ( r =0.70) and QMFI ( r =0.70) in males. The area under the curve of QMT, QMFI, FMT, and FFI were 0.98 (95% confidence interval: 0.96-1), 0.95 (0.89-1), 0.85 (0.75-0.96), and 0.80 (0.68-0.93), respectively. CONCLUSIONS: US-based assessment of sarcopenia has excellent diagnostic accuracy and correlates well with computed tomography-SMI in patients with SO. US may serve as an easy-to-use, point of care tool for assessing sarcopenia in SO with the advantage of repeated sequential assessment.

Home-based intensive nutrition therapy improves frailty and sarcopenia in patients with decompensated cirrhosis: A randomized clinical trial.

BACKGROUND AND AIM: The majority of patients with decompensated cirrhosis suffer from malnutrition, a potentially modifiable contributor to frailty and sarcopenia. The present study investigated the impact of a 6-month dietician-supported home-based intensive nutrition therapy (HINT) intervention on objective frailty and sarcopenia metrics in patients with decompensated cirrhosis. METHODS: One hundred adult patients with decompensated cirrhosis, frailty, and sarcopenia at baseline were randomized 1:1 to receive standard medical therapy (SMT) plus HINT (intervention) versus SMT (control) alone. The primary outcome was an improvement in frailty as measured by the liver frailty index (LFI). Secondary outcome measures included sarcopenia metrics, liver disease severity scores, hospitalization, and death. RESULTS: The LFI improved more in the intervention arm as compared with controls (0.8 vs 0.4; P < 0.001). Baseline and end-of-study skeletal muscle index (SMI) was available in a subset of 32 male patients, with greater improvements seen in the intervention arm compared with controls (6.36 vs 0.80; P = 0.02). Patients in the intervention arm had less hospitalizations over the 6-month follow-up (19 [38%] vs 29 [58%]; P = 0.04). On subgroup analysis, in the 64% of patients who were adherent to calorie and protein intake targets at 6 months, significant improvement was seen in liver disease severity scores and survival (P < 0.05). CONCLUSION: In patients with decompensated cirrhosis, frailty, and sarcopenia, a 6-month dietitian-supported home-based intensive outpatient nutrition therapy was associated with statistically and clinically relevant improvement in frailty. The subgroup of adherent patients showed improvement in their liver disease scores and reduction in mortality. These findings support the key role of food as medicine in the management of cirrhosis.

Long-term complications in patients with childhood-onset nephrotic syndrome.

BACKGROUND: Reports on long-term complications of childhood-onset nephrotic syndrome (NS), such as obesity, osteoporosis, growth failure, and hypertension, are mostly from developed countries not representing South Asian ethnicities. Furthermore, data on cardiovascular health among patients with childhood-onset NS are limited. METHODS: This was an observational study involving patients attending a tertiary care center. Patients aged 15 years and older were examined for long-term complications and remission of NS at their visit in December 2021. Childhood-onset NS meant onset of NS before 10 years of age. Long-term complications included obesity, growth failure, low bone mineral density (BMD) Z score, hypertension, and increased carotid intima-media thickness (cIMT). Long-term remission was defined as no relapse for the last [Formula: see text] 3 consecutive years without immunosuppressive medication to maintain remission. RESULTS: Of 101 patients studied (~ 80% with frequent relapsing (FR)/steroid-dependent (SD) NS), the mean age was 17.6 (± 2.4) years at the time of study. Long-term complications were noted in 89.1% of patients which included one or more of the following: obesity (22.7%), growth failure (31.7%), low BMD Z score (53.5%), hypertension (31.7%), and high cIMT (50.5%). Thirty-nine patients (38.6%) were in long-term remission at the time of the study. Growth failure and low BMD Z scores were less frequent in patients with long-term remission compared to those without long-term remission. CONCLUSIONS: In patients with childhood-onset NS (predominantly FR/SDNS) who were studied at [Formula: see text] 15 years of age, ~ 90% had long-term complications which included high cIMT in 50%. Only ~ 40% were in long-term remission. A higher resolution version of the Graphical abstract is available as Supplementary information.

Assessing the Efficacy and Outcomes Following Irrigation with Streptokinase Versus Hydrogen Peroxide in Necrotizing Pancreatitis: A Randomized Pilot Study.

BACKGROUND: Percutaneous catheter drainage (PCD's) are prone to blockage because of necrosum. To improve the efficacy of PCD, necrolytic agents have been used. The present study compared the use of Streptokinase with H2O2 in saline irrigation. MATERIALS AND METHODS: This is a single-center randomized pilot study (from July 2018 to Dec 2019). Patients with infected pancreatic necrosis not showing response to PCD and saline irrigation were included in the study. Patients received either Streptokinase (Streptokinase group 50,000 IU in 100 ml normal saline) or 3% H2O2 (3% H2O2 in 100 ml normal saline in 1:10 dilution). Primary endpoints were the need for surgery and mortality while secondary endpoints were hospital stay and complications attributable to necrolytic agents. RESULTS: There were 30 patients in the study, 15 in each arm. Organ failure was seen in 23 (76.6%), single organ failure was present in 11 (47%), and multi-organ failure in 12 (53%). Bleeding complications (20% in H2O2 vs 6.6% in Streptokinase), need for surgery (73% in H2O2 vs 33.3% in Streptokinase) and mortality (60% in H2O2 vs 33% in Streptokinase) were higher in H2O2 group but the difference was not significant statistically. Post-irrigation hospital stay was lesser in the Streptokinase group compared to H2O2 group but the difference did not reach statistical significance (14.1 ± 7.7 vs 19.2 ± 11.7, p = 0.09) CONCLUSIONS: Streptokinase irrigation led to a trend for reduced need for necrosectomy and mortality. H2O2 group had more bleeding complications. Post-irrigation hospital stay was lesser in Streptokinase group.

Coarctation of the aorta in a young female treated with left subclavian artery to descending thoracic aorta bypass: a case report.

Coarctation of the aorta is a rare congenital abnormality, with an incidence of 6-8% of all congenital heart problems. It is usually diagnosed in childhood during routine clinical examination and adults mostly present with hypertension. Various investigations like transthoracic echocardiography, computed tomography, and magnetic resonance angiography can help with diagnosis. Prognosis depends on age at presentation and the severity of coarctation. Treatment options available are open and endovascular repair. Extra-anatomical bypass is the preferred option in cases with unfavorable anatomy. Long term follow up is required post repair due to risk of restenosis and aneurysm formation. Here is a case in which a young female presented with hypertension, was diagnosed with coarctation of the aorta, and was treated a left subclavian artery to descending thoracic aorta bypass. Her postoperative course was uneventful and she had improvement in hypertension.

A coarctação da aorta é uma anomalia congênita rara, com incidência de 6-8% entre todos os problemas cardíacos congênitos. É geralmente diagnosticada na infância durante o exame clínico de rotina, e os adultos normalmente apresentam hipertensão. Diversas investigações, como ecocardiografia transtorácica, tomografia computadorizada e angiorressonância magnética, podem auxiliar no diagnóstico. O prognóstico depende da idade na apresentação e da gravidade da coarctação. As opções de tratamento disponíveis são o reparo aberto e o reparo endovascular. O bypass extra-anatômico é a opção preferida em caso de anatomia desfavorável. O acompanhamento de longo prazo é necessário após o reparo devido ao risco de reestenose e formação de aneurisma. Descrevemos o caso de uma jovem do sexo feminino que apresentou hipertensão, a qual foi diagnosticada como coarctação da aorta. Foi realizada derivação da artéria subclávia esquerda para a aorta torácica descendente. O pós-operatório transcorreu sem intercorrências, e a paciente apresentou melhora da hipertensão.

Comparison of high-pitch prospective electrocardiogram-gated pulmonary CT angiography with standard CT pulmonary angiography on dual-source CT for detection of subsegmental pulmonary embolism in patients suspected of acute pulmonary embolism.

Purpose: Objective of this study was to compare high-pitch prospective electrocardiogram (ECG)-gated computed tomography (CT) pulmonary angiography (HP-PECG-gated CTPA) with standard-pitch non-ECG-gated CT pulmonary angiography (SP-NECG-gated CTPA) on 128-slice dual-source CT (DSCT) for the detection of subsegmental pulmonary embolism (SSPE) in patients suspected of acute pulmonary embolism (APE) with radiation and contrastoptimized protocols. Cardiac-related motion artefacts, lung image quality, and quantitative parameter (pulmonary arterial enhancement, radiation exposure, and contrast) volumes were also compared. Material and methods: This prospective study enrolled 87 patients clinically suspected of APE and randomly distributed to either group by software. Two radiologists blinded to each other interpreted the images for assessment of SSPE, image quality, and quantitative parameters. Results: SSPE was diagnosed in 15/44 (34.09%) patients in HP-PECG-gated CTPA, in comparison to 8/43 (18.60%) patients in SP-NECG-gated CTPA. Cardiac motion-related artefacts (blurring of bronchovascular structures and double-line artefacts) were statistically significantly less, with p-value < 0.05. Lung image quality was also better, with p-value < 0.001. Effective radiation dose and contrast volume in HP-PECG-gated CTPA were (2.54 ± 0.80 mSv, 45.05 ± 6 ml) versus SP-NECG-gated CTPA (3.17 ± 1.20 mSv, 74.19 ± 7.63 ml) with p-values of 0.007 and 0.001, respectively. Conclusions: Radiation and contrast volume-optimized HP-PECG-gated CTPA provides reduced cardiac motion related artefacts of pulmonary arteries, which allows enhanced detection of SSPE. It also provides better image quality of lung and parenchyma with lower radiation exposure and less contrast volume.

Percutaneous transthoracic embolisation for massive haemoptysis secondary to peripheral pulmonary artery pseudoaneurysms.

OBJECTIVE: Pulmonary artery pseudoaneurysms (PAPs) are rare, but important and treatable cause of massive haemoptysis. Minimal data exists on their interventional radiology management due to their rarity, especially direct percutaneous injection. Here, we report our experience of direct percutaneous management of such pseudoaneurysms. METHODS: Data of patients presenting to our department from January 2014 to November 2019 was retrospectively analysed, who presented with massive haemoptysis, and CT angiography positive for pulmonary artery pseudoaneurysms. Only patients treated with direct percutaneous intervention were included. Twelve patients who were managed endovascularly were excluded from the study. Observations were tabulated under age, sex, underlying pathology, lobe involved, number and size of the pseudoaneurysm, imaging guidance and embolising agent. Technical and clinical success and complications were then analysed. RESULTS: Twenty-nine pseudoaneurysms were treated in 27 patients with a mean age of 41.4 years. The most common underlying aetiology was tuberculosis (85.1%), with the most common location being bilateral upper lobes (31% each). CT guidance was the most frequently used imaging guidance (26/29). N-butyl cyanoacrylate (NBCA) glue mixture was used in 79.3% and reconstituted thrombin in the remaining 20.7% pseudoaneurysms. Complete technical and clinical success rates were 93.1% and 88.9% respectively. No major complications were seen except for development of significant pneumothorax in one patient. CONCLUSION: Pulmonary pseudoaneurysms are rare but fatal cause for massive haemoptysis. Interventional radiology management via direct percutaneous embolisation is a safe and minimally invasive treatment measure in selective patients, with successful outcomes and minimal complication and recurrence rates. KEY POINTS: • Pulmonary artery pseudoaneurysms are rare but important and treatable cause of massive haemoptysis. • This study shows the advantages of percutaneous management of these pseudoaneurysms as an alternate to endovascular embolisation, in case endovascular embolisation is not feasible or practical. • It is a safe and minimally invasive treatment, with technical success of 93.1% and clinical success of 88.9% in this study.

Role of pre-transplant chest high-resolution computed tomography and serum galactomannan index in predicting post-transplant invasive pulmonary aspergillosis in allogeneic hematopoietic cell transplant recipients.

INTRODUCTION: The role of pre-HCT chest high-resolution computed tomography (HRCT) and serum galactomannan index (GMI) in predicting the post-allogeneic hematopoietic cell transplant (HCT) invasive pulmonary aspergillosis (IPA) is debatable. METHODS: This was a single-center, prospective study from 2014 to 2019. The primary objective was to study if pre-HCT chest HRCT and serum GMI predicted IPA post-HCT. The secondary objective was day +100 mortality. All consecutive, consenting patients of ≥12 years of age undergoing allo-HCT were included and had pre-HCT chest HRCT and serum GMI. All patients received mold active antifungal prophylaxis. The EORTC/MSG criteria were used for the diagnosis of IPA. RESULTS: A total of 82 patients with median age 27 years (12-59 years) were included. The underlying diagnoses included hematological malignancies (79%) and aplastic anemia (21%). Fifteen percent of patients was treated for prior history of probable IPA (>6 weeks before HCT). Pre-HCT chest HRCT satisfied EORTC clinical criteria in 24% patients. Serum GMI ≥0.5 was seen in 27% of patients. Post-HCT probable IPA was seen in 24% of patients. There were more patients with pre-HCT chest HRCT findings satisfying EORTC clinical criteria (45% vs. 18%, P = .014) and GMI ≥0.5 (45% vs. 21%, P = .03) in the group with post-HCT IPA compared to those without IPA. There was higher day+100 mortality in patients with post-HCT IPA (55% vs. 18%, P = .001). CONCLUSIONS: The presence of EORTC clinical criteria on pre-HCT chest HRCT, serum GMI ≥0.5, and prior history of IPA predicted post-HCT IPA.

Prophylactic ligation of the opacified thoracic duct in minimally invasive esophagectomy - feasibility and safety.

BACKGROUND: Chyle leak is a rare but morbid complication of esophagectomy. We assessed the feasibility of visualization and prophylactic ligation of the opacified thoracic duct (TD) after administration of 50 ml of olive oil. METHODS: This prospective single center study considered all patients with carcinoma of the middle and lower thirds of the thoracic esophagus including the gastroesophageal junction (GEJ), managed from January 2018 to December 2019, for inclusion. All patients underwent McKeown minimally invasive esophagectomy. After anesthesia and endotracheal intubation, 50 ml of olive oil was administered through a nasogastric (NG) tube. During thoracoscopic esophageal mobilization, the opacified thoracic duct was identified and ligated using Weck Hem-o-lok clips immediately above the diaphragmatic hiatus. Postoperatively, the nature, volume, and triglyceride levels of the fluid from the chest drain were recorded. RESULTS: Forty-three patients with carcinoma of the esophagus were assessed for inclusion and eventually, 33 were enrolled. The median age of the study population was 55 years, and there were 20 males. The tumor site was the lower esophagus in 24 (72.7%) patients. The most common histolopathological finding was squamous cell carcinoma (97%). The opacified thoracic duct could be identified and ligated in 31 (93.9%) patients. The median duration from the administration of olive oil to the ligation of the thoracic duct was 100 min. The median chest drain output and triglyceride levels on postoperative day (POD) one were 250 ml and 48 mg% respectively. No patient developed postoperative chylothorax. CONCLUSION: Opacification and visualization of the thoracic duct during thoracoscopy can be aided by administering olive oil. Ligation of this opacified duct is feasible and safe.

Development and validation of a novel prediction model for predicting renal function recovery after diversion in patients with obstructive uropathy.

OBJECTIVE: To develop and validate a novel prediction model predicting renal function recovery following diversion in patients with obstructive uropathy (OU) to the emergency department (ED). METHODS: After a systematic literature search, a novel prediction model called PGIMER Obstructive Uropathy Score (POUS) was constructed including five variables: age (<60 or >60 years), duration of symptoms (<4 or >4 weeks), presence of solitary functioning kidney, baseline hemoglobin levels and venous blood pH. This model was then validated in a prospective, observational single-center study of patients presenting with OU caused by various etiologies. Patients with OU and raised serum creatinine (>2 mg/dL) presenting to our ED were included. Renal function recovery was defined as creatinine value <1.5 mg/dL at 4 weeks following diversion. RESULTS: In this study, 174 consecutive patients with OU were recruited, and 74 (42.5%) patients had renal function recovery. All the variables included in the POUS were noted to be statistically significant on univariate analysis. On multivariate logistic regression analysis, only POUS was identified as an independent predictor of renal function recovery. On receiver operating curve analysis, the area under the curve for POUS was 0.832 for predicting recovery. A POUS of 5 or more had specificity and sensitivity of 83% and 73.6%, respectively, in predicting renal function recovery. The goodness of fit and calibration plots showed good concordance of the predicted values with the observed values. CONCLUSIONS: The POUS model is an accurate and simple-to-use tool for predicting renal function recovery. POUS model requires external validation prior to clinical use in different populations.

Interventional radiology management of extremity pseudoaneurysms: a pictorial essay.

Pseudoaneurysms are vascular abnormalities caused by a damaging force on an arterial wall, resulting in a persistent extravasation of blood into the surrounding tissue, which can be the result of infection, inflammation, trauma or any iatrogenic procedure. The incidence of extremity artery pseudoaneurysms is rising because of increased number of endovascular procedures. As a number of complications are associated with these false aneurysms, it is important to know the treatment modalities available. Ultrasound is the most common method of diagnosing extremity pseudoaneurysm because of their superficial location. Computed tomographic angiography is the next investigation of choice as it has three-dimensional capability and can help evaluate the vascular bed. Digital subtraction angiography is rarely used for diagnosis alone, and is used only when a therapeutic procedure is planned. Treatment of these pseudoaneurysms has shifted from open surgical procedures to minimally invasive treatment in recent years. The different techniques for tackling these lesions include ultrasound-guided compression, percutaneous thrombin or glue embolisation and endovascular coil or stent graft placement. In this pictorial essay, we review the different treatment modalities so that an interventional radiologist is aware of all the treatments he can offer when confronted with these lesions.

Utility of percutaneous thrombin injection for treating visceral pseudoaneurysms.

PURPOSE: To assess the efficacy and outcome of percutaneous thrombin injection in treatment of visceral arterial pseudoaneurysms (PAs) in a selective group of patients. MATERIAL AND METHODS: Retrospective review of the institutional database showed 19 cases of visceral arterial pseudoaneurysms that were treated with percutaneous ultrasound-guided thrombin injection between January 2014 and December 2019 (13 men and 6 women). Of the pseudoaneurysms, 36% were due to pancreatitis, 35% were iatrogenic, 21% were infective and 8% traumatic. Most of the pseudoaneurysms arose from the hepatic artery (27%) followed by the splenic artery (26%) and renal artery (21%). Mean sac size of the pseudoaneurysms was 23 mm (range, 8 -40 mm). Technical success was defined as absence of flow within the PAs on follow-up ultrasonography (USG) 24 h and 3 days after thrombin injection. RESULTS: Overall technical success was seen in 10/19 patients. Technical success of thrombin injection was higher in cases of distal branch PAs as compared to main vessel PAs (9/13 vs. 1/6). Success rates were higher with smaller (<23mm) pseudoaneurysms (7/12) as compared to larger ones (3/7). There were no procedure-related complications. CONCLUSION: Ultrasound-guided percutaneous thrombin injection is a novel method of treating visceral pseudoaneurysms as a painless, cheap and radiation-free procedure. However, further large-scale studies are needed to prove the efficacy in treating visceral pseudoaneurysms.

Ex-vivo repair for multiple and intraparenchymal renal artery aneurysms.

A 45-year-old woman with known hypothyroidism and no other comorbidities was incidentally found to have multiple right renal artery aneurysms. The largest aneurysm measured 5 x 4.5 cm and arose from an inferior segmental branch while two smaller aneurysms arose from an upper segmental branch of the right renal artery. We performed an ex-vivo repair with reverse saphenous vein graft under cold preservation followed by orthotopic kidney auto-transplantation. Her postoperative course was unremarkable and at 1-year follow-up her right kidney is preserved. In this article, we report successful treatment of complex multiple right renal artery aneurysms and describe the surgical technique used for successful repair.

Uma mulher de 45 anos com hipotireoidismo conhecido e sem outras comorbidades teve achado incidental de múltiplos aneurismas da artéria renal direita. O maior aneurisma media 5 x 4,5 cm e tinha origem no ramo segmentar inferior, juntamente com dois pequenos aneurismas originários do ramo segmentar superior da artéria renal direita. Realizamos o reparo ex vivo com enxerto reverso de veia safena, sob preservação a frio, seguido de autotransplante renal ortotópico. O pós-operatório ocorreu sem intercorrências, e a paciente teve o rim direito preservado no seguimento de 1 ano. Neste artigo, relatamos o tratamento bem-sucedido de múltiplos aneurismas complexos da artéria renal direita e descrevemos a técnica cirúrgica utilizada para o reparo bem-sucedido.

Trifecta and pentafecta outcomes following robot-assisted partial nephrectomy for hilar versus nonhilar tumors: A propensity-matched analysis.

INTRODUCTION: Hilar tumors are a unique subset of complex renal masses posing a potential surgical challenge during partial nephrectomy. The outcomes of hilar masses have not been compared to non-hilar renal masses of similar RENAL nephrometry score (RNS). In this study, we analyzed the outcomes of hilar versus nonhilar masses after a propensity score matching. METHODS: Prospectively maintained database of patients who underwent robot assisted PN between November 2014 and December 2018 was abstracted for hilar and nonhilar tumors. We performed propensity matching for baseline variables such as age, sex, body mass index, comorbidities, preoperative glomerular filtration rate, and RNS for each patient on the basis of propensity scores. RESULTS: We included 48 patients with hilar tumors and 153 with nonhilar tumors. On propensity matching, 41 patients were included in each group. The mean operative time (162.4 ± 48.9 min vs. 144.1 ± 38.8 min, P = 0.48), warm ischemia time (29.0 ± 8.8 min vs. 24.4 ± 8.2 min, P = 0.12), and the estimated blood loss (201.8 ± 184.7 ml vs. 150.6 ± 160.5 ml, P = 0.37) were not significantly different between the hilar and the nonhilar groups. Trifecta was achieved in only 14/41 (34.1%) of the patients in the hilar group as compared to 24/41 (58.5%) in the nonhilar group (P = 0.027). Logistic regression analysis identified that hilar location of the tumors was not an independent predictor of overall complications (OR 6.37, confidence interval [CI] 0.5-69.4, P = 0.4), trifecta (OR 0.38, CI 0.14-1.0, P = 0.051), and pentafecta outcomes (OR 0.4, CI 0.1-1.51, P = 0.17). CONCLUSIONS: Hilar location was associated with poorer trifecta outcomes compared to the nonhilar tumors. However, hilar location per se was not an independent predictor of overall complications and trifecta and pentafecta outcomes.

Gastrointestinal Failure Is a Predictor of Poor Outcome in Patients with Acute Pancreatitis.

OBJECTIVE: Although gastrointestinal dysfunction is common in patients with acute pancreatitis, its impact on the outcome of disease has not been adequately studied. The present study was conducted to study the frequency of gastrointestinal failure (GIF) as well as its effect on outcome in patients with acute pancreatitis. METHODS: Patients with acute pancreatitis admitted in our unit were prospectively studied. Gastrointestinal dysfunction and intra-abdominal pressures were measured daily till their resolution, and gastrointestinal failure score was calculated. Baseline parameters including various severity scores were noted. The patients were followed till clinical recovery or death. RESULTS: Sixty-four patients (mean age 41.52 ± 16.28 years; 45 (70.3%) males) were prospectively studied. Forty-five (70.3%) patients had severe disease, and 18 (28.1%) patients succumbed to illness. GIF was present in 31 (48.4%) patients. The median duration of GIF was 5 (range 1-20) days. The presence of GIF was significantly associated with mortality (p value < 0.05). On multivariate analysis, the presence of GIF [OR 10.6 (95% CI 1.97-57.04)] and duration of ICU stay [OR 1.08 (95% CI 1.015-1.15)] were found to be independent predictors of mortality. CONCLUSION: Gastrointestinal failure is an important organ failure in patients with acute pancreatitis and is an independent predictor of mortality. Incorporation of gastrointestinal failure scores in dynamic assessment of patients with acute pancreatitis could help us in better stratifying severity of patients and predicting outcome.

Primary seminal vesicle adenocarcinoma: A case report of rare entity and discussion of its differential diagnosis using immunohistochemical approach for the core biopsy specimen.

Primary seminal vesicle adenocarcinoma is a rare malignancy of the male genito-urinary system with only a few confirmed reported cases. Initial tissue diagnostic modality is often a core biopsy specimen. Here, we report this rare entity in a 50-year-old male, highlighting the histomorphological and immunohistochemical approach to the core biopsy specimen of the seminal vesicle mass. The patient presented with a history of haematospermia and gross haematuria for one year, and radiological workup was found to have a right seminal vesicle mass. A trans-rectal ultrasound guided core biopsy revealed a tumourous lesion with a predominant papillary architecture and cytological features of neoplasia. Based on positivity for CK7, PAX-8 and CA-125, and Ki-67 index of 30%-40% and negativity for PSA, AMACR, CK20, CDX-2, p63, GATA3, WT1 and calretinin, a diagnosis of primary seminal vesicle adenocarcinoma was offered. The diagnosis was also confirmed on the surgically resected specimen. This case depicts the approach of a pathologist to diagnose this rare entity on the core biopsy specimen and the possible differential diagnoses one must consider.

Percutaneous glue embolization as a primary treatment for visceral pseudoaneurysms.

Aim: To evaluate the feasibility and outcome of percutaneous glue embolisation as primary treatment for pseudoaneurysms in selective patients.Material and methods: A review of the pseudoaneurysm cases managed with percutaneous glue at our institute was analyzed in this study. A total of 21 patients over a period of last one year who were treated for pseudoaneurysm at varied sites primarily with percutaneous n-butyl cynoacrylate were retrospectively evaluated. Site of pseudoaneurysm was Pulmonary (seven cases), renal (four cases), pelvic (4four cases) and miscellaneous abdomen (six cases). Combined ultrasound and fluoroscopy approach was used in 17 cases, CT guidance in three cases and combined ultrasound and CT guidance in one case. Patients were evaluated for therapeutic response (radiological and clinical) and procedure related complications.Results: Complete occlusion of the pseudoaneurysm was seen in all patients. Two patients showed mild pneumothorax and one patient showed reflux into the intercostal artery. All the patients showed symptomatic improvement and discharged in stable condition.Conclusions: Percutaneous glue embolisation of the pseudoaneurysms as a primary treatment is feasible and can be safely carried out in select group of patients with good therapeutic response and minimal complications.