Ulnar-Sided Upper Extremity Traumatic Wounds: What Should We Expect to Find?

Background: Upper limb traumatic injuries have a significant impact on social and professional life; however, there is still a paucity of studies focusing on the injuries of the ulnar border of the forearm, wrist and hand. Methods: We designed a retrospective single-blinded study, including all patients with deep traumatic wounds affecting the ulnar side of the forearm, wrist or hand, that received surgical treatment from 2006 until 2016. A characterisation of the sample, assessment of concomitant injuries and clinical outcomes, as well as neurological and functional evaluation were performed. Results: We obtained a sample of 61 patients, 69% with injuries affecting the wrist and 90% of patients with a neurological lesion, most frequently of the ulnar nerve lesion (UNL). Concomitant injuries included tendinous lesions, more frequently of the flexor carpi ulnaris (64%) and fractures (13%). And 39% of patients presented an ulnar artery lesion, without significant differences in outcomes regarding the completion of arteriorrhaphy or not. At the end of the 8.6 years follow-up, 34% of patients had no deficits; however, patients with UNL showed worse functional scores and greater risk of sequelae. Besides motor function compromise, sensory deficits were also associated with worst functional outcomes. Conclusions: The UNL subgroup showed important impairment of the first ray, probably related to the level of UNL. Furthermore, besides the implications of the motor sequelae, sensory deficits were also associated with worst functional scores. Due to the high percentage of neurovascular and tendinous lesions in ulnar-sided upper extremity wounds, the authors recommend surgical exploration of these lesions. Level of Evidence: Level IV (Therapeutic).

Effects of Aspirin on Kidney Biopsy Bleeding Complications: A Systematic Review and Meta-Analysis (PROSPERO 2021 CRD42021261005).

Postprocedural bleeding is the main complication of percutaneous kidney biopsy (PKB). Therefore, aspirin is routinely withheld in patients undergoing PKB to reduce the bleeding risk. The authors aimed to examine the association between aspirin use and bleeding during PKB. This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The article search was performed on MEDLINE and Scopus using queries specific to each database. Article inclusion was limited to primary studies. The meta-analysis compared the risk of major bleeding events between the aspirin-exposed versus nonexposed group. Pooled effect estimate was examined using random effects presented as odds ratio with 95% confidence intervals. Heterogeneity was assessed through Cochrane I 2 test statistics. Sensitivity and subgroup analyses were also performed according to kidney type. Ten studies were included in the review and four studies were included in the meta-analysis, reviewing a total of 34,067 PKBs. Definitions for significant aspirin exposure were inconsistent between studies, limiting comparisons. Studies with broader definitions for aspirin exposure mostly showed no correlation between aspirin use and postbiopsy bleeding. Studies with strict definitions for aspirin exposure found an increased risk of hemorrhagic events in the aspirin-exposed group. No significant differences were found between the aspirin-exposed and comparison groups regarding major bleeding events (odds ratio 1.72; 95% confidence interval 0.50 to 5.89, I 2 =84%). High-quality evidence on the effect of aspirin on the bleeding risk is limited. Our meta-analysis did not show a significantly increased risk of major bleeding complications in aspirin-exposed patients. Further studies are needed to define a more comprehensive approach for clinical practice.

The impact of early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury on mortality and clinical outcomes: a meta-analysis.

Background: Renal replacement therapy (RRT) is essential in the presence of life-threatening complications associated with acute kidney injury (AKI). In the absence of urgent indications, the optimal timing for RRT initiation is still under debate. This meta-analysis aims to compare the benefits between early and late RRT initiation strategies in critically ill patients with AKI. Methods: Studies were obtained from three databases [Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL) and Scopus], searched from inception to May 2021. The selected primary outcome was 28-day mortality. Secondary outcomes included overall mortality, recovery of renal function (RRF) and RRT-associated adverse events. A random-effects model was used for summary measures. Heterogeneity was assessed through Cochrane I 2 test statistics. Potential sources of heterogeneity for the primary outcome were sought using sensitivity analyses. Further subgroup analyses were conducted based on RRT modality and study population. Results: A total of 13 randomized controlled trials including 5193 participants were analysed. No significant differences were found between early and late RRT initiation regarding 28-day mortality [risk ratio (RR) 1.00; 95% confidence interval (CI) 0.89-1.12, I² = 30%], overall mortality (RR 1.00; 95% CI 0.90-1.12, I² = 42%) and RRF (RR 1.02; 95% CI 0.92-1.13, I² = 53%). However, early RRT initiation was associated with a significantly higher incidence of hypotensive (RR 1.34; 95% CI 1.17-1.53, I² = 6%) and infectious events (RR 1.83; 95% CI 1.11-3.02, I² = 0%). Conclusions: Early RRT initiation does not improve the 28-day and overall mortality, nor the likelihood of RRF, and increases the risk for RRT-associated adverse events, namely hypotension and infection.

Carcinoma neuroendocrine de célula pequeña en la amígdala. Un caso clínico / Small Cell neuroendocrine carcinoma of the tonsil. A case report

Primary small neuroendocrine carcinoma (SNEC) of the tonsil it’s a rarity. We present the case of a 64 year-old Caucasian male patient referred to our hospital due to a neck mass. A fixed non-tender rock hard supraclavicular right mass and ipsilateral cervical lymphadenopathy was palpable. Biopsy was performed and showed poor differentiated neoplasm with features of SNEC. A fludeoxyglucose positron emission tomography (FDG-PET) scan showed intense uptake in the right tonsil. The patient underwent right tonsillectomy and immunochemistry was positive for characteristic features of small cell neuroendocrine carcinoma. Right tonsil SNEC was diagnosed and the patient was proposed to chemotherapy. (AU)

Circulating Renalase as Predictor of Renal and Cardiovascular Outcomes in Pre-Dialysis CKD Patients: A 5-Year Prospective Cohort Study.

Chronic kidney disease (CKD) is an independent risk factor for adverse cardiovascular and cerebrovascular events (MACCEs), and mortality since the earlier stages. Therefore, it is critical to identify the link between CKD and cardiovascular risk (CVR) through early and reliable biomarkers. Acknowledging that CKD and CKD progression are associated with increased sympathetic tone, which is implicated in CVR, and that renalase metabolizes catecholamines, we aimed to evaluate the relationship between renalase serum levels (RNLS) and cardiovascular and renal outcomes. The study included 40 pre-dialysis CKD patients (19F:21M) with median age of 61 (IQ 45-66) years. At baseline, we measured RNLS as well as routine biomarkers of renal and cardiovascular risk. A prospective analysis was performed to determine whether RNLS are associated with CKD progression, MACCEs, hospitalizations and all-cause mortality. At baseline, the median level of RNLS and median estimated glomerular filtration rate (eGFR) were 63.5 (IQ 48.4-82.7) µg/mL and 47 (IQ 13-119) mL/min/1.73 m2, respectively. In univariate analysis, RNLS were strongly associated with eGFR, age and Charlson Index. Over the course of a mean follow-up of 65 (47 to 70) months, 3 (7.5%) deaths, 2 (5%) fatal MACCEs, 17 (42.5%) hospital admissions occurred, and 16 (40%) patients experienced CKD progression. In univariate analysis, RNLS were associated with CKD progression (p = 0.001), hospitalizations (p = 0.001) and all-cause mortality (p = 0.022) but not with MACCEs (p = 0.094). In adjusted analysis, RNLS predicted CKD progression and hospitalizations regardless of age, Charlson comorbidity index, cardiovascular disease, hypertension, diabetes and dyslipidemia. Our results suggest that RNLS, closely related with renal function, might have a potential role as predictor of renal outcomes, hospitalizations, and mortality in pre-dialysis CKD patients.

Endothelial Dysfunction Is Associated with Cerebrovascular Events in Pre-Dialysis CKD Patients: A Prospective Study.

BACKGROUND: Patients with chronic kidney disease (CKD) have markedly increased rates of end stage renal disease, major adverse cardiovascular/cerebrovascular events (MACCEs), and mortality. Endothelial dysfunction (ED) is an early marker of atherosclerosis that is emerging as an increasingly important non-traditional cardiovascular risk factor in CKD. There is a lack of clinical studies examining the association between ED and both cardiovascular and renal endpoints in patients with CKD. AIMS: We examined the association between reactive hyperemia index (RHI), a validated measure of endothelial function measured by peripheral arterial tonometry (PAT), with traditional cardiovascular risk factors in pre-dialysis CKD patients and prospectively evaluated the role of RHI as predictor of renal and cardiovascular outcomes in this population. METHODS: One hundred and twenty pre-dialysis patients with CKD stages 1 to 5 (CKD group) and 18 healthy kidney donor candidates (control group) were recruited and had a successful RHI measurement by PAT. General demographic and clinical information including traditional cardiovascular risk factors were registered from all participants. Thereafter, patients were prospectively followed-up for a median time of 47 (IQR 19-66) months to determine associations of RHI with renal outcomes, MACCEs, hospitalizations or mortality. RESULTS: In the CKD patient population, the mean age was 57.7 ± 15.5 years, the mean eGFR was 54.9 ± 36.7 mL/min/1.73 m2 (CKD-EPI) and 57 were males (47.5%). At baseline, in univariate analysis, RHI in the CKD group correlated positively with eGFR (r = 0.332, p < 0.0001) and correlated negatively with age (r = -0.469, p < 0.0001), Charlson index (r = -0.399, p < 0.0001), systolic blood pressure (r = -0.256, p = 0.005), and proteinuria (r = 0.211, p = 0.027). Reactive hyperemia index in the control group did not significantly differ from RHI observed in patients with CKD stages 1 to 5 (2.09 ± 0.40 vs. 2.01 ± 0.06, p = 0.493). In adjusted analysis, only age (ß = -0.014, p = 0.003) remained independently associated with RHI at baseline. During follow-up, 8 patients suffered a MACCEs, 33 patients experienced renal function deterioration, 17 patients were hospitalized for medical reasons and 6 patients died. RHI at baseline was not significantly associated with CKD progression (1.94 vs. 2.02, p = 0.584), hospitalizations (1.90 vs. 2.04, p = 0.334), and all-cause mortality (1.65 vs. 2.01, p = 0.208) or MACCEs (1.77 vs. 2.01, p = 0.356), but was significantly associated with cerebrovascular events (1.27 vs. 2.02, p = 0.004) and with a composite cardiovascular outcome (MACCEs, hospital admissions and death; 1.73 vs. 2.07, p = 0.035). Conclusion: Our results suggest that RHI may be a predictor for the development of cerebrovascular events in pre-dialysis CKD patients who may benefit from more aggressive preventive measures.

Clearing the clouds: Case-report and review of the literature.

In peritoneal dialysis (PD), a cloudy dialysate is an alarming finding. Bacterial peritonitis is the most common cause, however, atypical infections and non-infectious causes must be considered. A 46-year-old man presented with asthenia, paraesthesia, foamy urine and hypertension. Laboratory testing revealed severe azotaemia, anaemia, hyperkalaemia and nephrotic-range proteinuria. Haemodialysis was started through a central venous catheter. Later, due to patient preference, a Tenckhoff catheter was inserted. Conversion to PD occurred 3 weeks later, during hospitalization for a presumed central line infection. A month later, the patient was hospitalized for neutropenic fever. He was diagnosed an acute parvovirus infection and was discharged under isoniazid for latent tuberculosis. Four months later, the patient presented with fever and a cloudy effluent. Peritoneal fluid (PF) cytology was suggestive of infectious peritonitis, but the symptoms persisted despite antibiotic therapy. Bacterial and mycological cultures were negative. No neoplastic cells were detected. Mycobacterium tuberculosis eventually grew in PF cultures, despite previous negative molecular tests. Directed therapy was then initiated with excellent response. Thus, facing a cloudy effluent, one must consider multiple aetiologies. Diagnosis of peritoneal tuberculosis is hampered by the lack of highly sensitive and specific exams. Here, diagnosis was only possible due to positive mycobacterial cultures.