Fat embolism syndrome is a serious multi-system pathology which classically affects the respiratory system, neurological system and causes a petechial rash. We present the case of a 20-year-old farmer who developed fat embolism syndrome following a traumatic femoral fracture. Features developed within 24 h of injury and necessitated a prolonged stay in Intensive Care. He exhibited significant signs of cerebral fat embolism syndrome including coma and seizures but went on to make full functional recovery. Magnetic resonance imaging is the recommended imaging modality for patients with suspected cerebral fat embolism. In this case, computerised tomography was inconclusive, but magnetic resonance imaging demonstrated the "starfield pattern" of multiple high signal foci on a dark background. Supportive treatment of fat embolism syndrome is required in an appropriate setting, such as High Dependency or Intensive Care, for patients at risk of hypoxia or neurological deterioration. Despite major neurological involvement of fat embolism syndrome, full recovery is described by several cases including ours.
Objectives To report a tertiary referral centre’s experience of microwave ablation (MWA) for suspected renal cell carcinoma (RCC), describing complications and oncological outcomes. Patients and Methods Consecutive MWA procedures (n = 113) for renal masses (October 2016 to September 2019) were maintained on a prospective database. Data describing patient, disease, procedure, complications, and oncological outcomes were analysed. Results The median (range) age was 68 (33–85) years, 73% were male, and the median Charlson Comorbidity Index was 0. The median (interquartile range [IQR]) tumour diameter was 25 (20–32) mm. In all, 95% had renal mass biopsy, with histologically confirmed cancer in 75%. The median (IQR) R.E.N.A.L. (Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location) nephrometry score was 7 (6–8). The median ablation time was 6 min and length of stay was 1 day for 95% of the patients. Clavien–Dindo complication Grades I, II, IIIb and IV occurred in 18%, 1.8%, 0.9% and 0.9%, respectively. The median follow‐up was 12 months and the median (IQR) renal function change was −4 (−18 to 0)%. One patient (0.9%) had local recurrence, treated with re‐ablation; two developed metastatic progression; and two (1.8%) had indeterminate findings on follow‐up (one lung nodule and one possible local recurrence), managed with ongoing protocolised computed tomography surveillance. Post‐procedure complications were associated with total ablation time (odds ratio [OR] 1.152/min, 95% confidence interval [CI] 1.040–1.277) and total ablation energy (OR 1.017/kJ, 95% CI 1.001–1.033). Conclusions We describe the largest UK series of MWA treatment for T1a/small T1b renal masses to date. MWA was well tolerated, with 95% discharged the following day and low complication/re‐admission rates. Current follow‐up demonstrates favourable disease control. MWA appears to be safe and effective and should be considered in future prospective comparisons of treatments for T1a/small T1b renal masses.
DESCRIPTIONA 60-year-old man was presented with colicky upper left abdominal pain and vomiting. Haematology and biochemistry were unremarkable and there had been no recent change in bowel habits.An initial non-contrast abdominal CT, performed due to the provisional diagnosis of left renal colic, revealed a midline caecum (figure 1) and an absence of small bowel in the left abdomen (figure 2). The superior mesenteric vein was located anterior to the superior mesenteric artery (figure 3) and the duodenal-jejunal junction was present on the right side, failing to cross the midline (figure 4). The findings were consistent with partial malrotation of the bowel. No renal calculi were present.A subsequent contrast-enhanced CT of the abdomen revealed no evidence of bowel ischaemia, and the superior mesenteric artery and vein were both patent. The pyloric wall was irregularly thickened circumferentially (figure 5) with loss of clarity of the adjacent mesenteric fat and prominent lymph nodes. Subsequent oesophagogastroduodenoscopy confirmed gastric carcinoma.Partial malrotation of the bowel results when the embryonic mid-gut fails to complete the normal 270°of counter clockwise rotation during gestation.1 Adults are often asymptomatic, and such cases are usually diagnosed as incidental findings when imaged for other conditions. 2 Ultrasound, CT or upper gastrointestinal studies may identify the typical characteristics. As highlighted in this case, recognition of partial malrotation in symptomatic patients should therefore prompt a thorough search for additional intra-abdominal pathology. In addition, the anatomical variations exhibited in such cases may also be responsible for atypical presentations of common surgical pathology such as appendicitis. 2This case report highlights the typical CT findings of partial bowel malrotation that will be of benefit to both surgeons and radiologists alike.
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