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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Case report
Full Version
Endovascular Management of Ruptured Renal Angiomyolipoma: A Case Report
Correspondence Address :
Dr. Rahul Arkar,
Associate Professor, Department of Interventional Radiology, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri, Pune-411018, Maharashtra, India.
E-mail: rrarkar@gmail.com
Renal angiomyolipoma is classified as a benign tumour comprising fat, smooth muscle cells, and vascular tissue. Renal giant angiomyolipoma with rupture is a relatively rare clinical emergency condition. Here, the authors present a case of a 37-year-old female patient who presented with complaints of right flank pain for six hours. The patient was anaemic and did not have haematuria. On non contrast Computed Tomography (CT) imaging, there was a right perirenal haematoma with a mixed-density, fat-containing tumour in the upper interpolar region of the right kidney. On Contrast-Enhanced Computed Tomography (CECT) imaging, the right renal tumour showed multiple abnormal tortuous vessels with moderate to intense enhancement, consistent with a large angiomyolipoma. She was managed with primary therapeutic endovascular embolisation for a ruptured right renal angiomyolipoma under local anaesthesia via a right transfemoral artery approach. The procedure was uneventful, and postembolisation syndrome was managed with medications. The patient was discharged in a stable condition. During the one-month follow-up, the patient’s symptoms improved, and the need for major surgery like nephrectomy was avoided. Super selective embolisation to devascularise the tumour and preserve renal parenchyma was done under local anaesthesia via a right transfemoral approach without any complications. Postembolisation syndrome was managed medically.
Embolisation syndrome, Nephrectomy, Perirenal haematoma
A 37-year-old woman was brought to the hospital with pain in her right flank for six hours. The pain had an acute onset and was a dull ache that worsened when walking but improved when in the supine position. There was no history of haematuria. On deep palpation, tenderness was observed in the right flank region. She had no history of diabetes, hypertension, or significant medical/surgical conditions. She was anaemic with a haemoglobin level of 9.1 g/dL, but her platelet count was normal. Her Prothrombin Time/International Normalised Ratio (PT/INR) was within the normal range (13.7 seconds /1.09). Urine examination showed no red blood cells.
Her ultrasound (USG) evaluation revealed a large, heterogeneous, predominantly hyperechoic mass in the upper interpolar region of the right kidney. Contrast-Enhanced Computed Tomography (CECT) confirmed a ruptured angiomyolipoma measuring 10.5 cm (Table/Fig 1)a,b, associated with multiple abnormal enlarged tortuous vessels [Table/ Fig-2]a,b and perirenal haematoma.
She was taken for endovascular embolisation of angiomyolipoma via the right common femoral arterial approach. Right renal diagnostic angiogram with 5F Simmons 1 catheter revealed large hypervascular tumour, blush in the upper interpolar region of the right kidney with splaying of normal renal parenchyma. The arterial feeders supplying the tumour were hypertrophied and tortuous (Table/Fig 3)a,b. Superselective angiograms of two major arterial feeders via Progreat microcatheter confirmed the sole supply to the tumour from these abnormal arteries (Table/Fig 4)a,b and these abnormal arteries were not supplying normal renal parenchyma. These abnormal tumour arteries were super selectively embolised (Table/Fig 4)c,d using Polyvinyl Alcohol (PVA) particles of size 300-500 μm injected via Progreat microcatheter. This was to subserve the purpose of occluding distal tumour bed microvasculature. The proximal main stem of the abnormal artery was embolised using coils. Postembolisation angiogram showed complete devascularisation of the tumour with preservation of normal renal parenchymal arteries (Table/Fig 5)a,b. There was no procedure-related complication. Postembolisation syndrome was treated with medical management in the form of antibiotics, analgesics, anti-inflammatory and antiemetic medications and maintaining adequate hydration. Patient was discharged in stable condition. On one month follow-up, there was a significant improvement in the patient’s symptoms with almost complete resolution of flank pain.
Renal angiomyolipoma is classified as a benign tumour comprising fat, smooth muscle cells, and vascular tissue. In cases of rupture, it presents with back/flank pain, haematuria, and retroperitoneal haematoma (1). This emergency condition can be managed by nephrectomy as the primary treatment modality. Endovascular embolisation is a minimally invasive treatment modality with equal efficacy and early patient recovery (2). Imaging is crucial in diagnosing angiomyolipomas, as they can be difficult to 2distinguish from malignancy. Accurate diagnosis is important to avoid unnecessary surgery and preserve renal function (3). Radiological classification CT and Magnetic Resonance Imaging (MRI) classifies angiomyolipomas into fat-rich, fat-poor, and fat-invisible based on the degree of fat content in the lesion (3). In the present case, the tumour was classified as a fat-rich renal angiomyolipoma due to the macroscopic fat content revealed by CT imaging.
Symptomatic patients with angiomyolipomas usually present with flank pain and gross haematuria. A few patients can present with nausea, vomiting, or anaemia (4). Sometimes the presentation is confusing and confounded by high blood pressure or shock (5),(6). In this case, the patient presented with flank pain without evidence of haematuria. Symptoms are more likely to be present in tumours with a size of 4 cm or greater, while patients with tumours smaller than 4 cm are more likely to be asymptomatic (4). Tumour size, the multiplicity of lesions, and significant neovascularity are risk factors in angiomyolipoma (7),(8).
The following factors are considered indications for treatment in angiomyolipoma: unbearable pain, ruptured tumour, significant haematuria, and large tumour size. Symptoms presented by the patient, as well as the size of the tumour, are predominant factors in deciding the type of treatment (9). Previously, surgery was the mainstay of treatment for such patients. Endovascular embolisation has the benefits of being less invasive, protecting renal parenchyma, and having lower procedure-related morbidity/mortality (2). A small tumour (<4 cm) needs yearly imaging follow-up, while large tumours (>4 cm) can be managed by either endovascular embolisation or surgery (9).
Super selective arterial embolisation shows a mean size reduction of the tumour by 43% (9). The procedure-related complications during endovascular embolisation are very few or none relative to open surgery like nephrectomy. There was no rehaemorrhage observed during a five-year follow-up period (9). In the present case, the authors performed super selective endovascular embolisation of two feeding arteries supplying the right upper interpolar renal angiomyolipoma. Authors used a microcatheter to navigate as distally as possible to selectively embolise only the tumour-related arteries while sparing the arteries supplying normal renal parenchyma. Authors used PVA particles and coils to embolise the tumour bed and arteries feeding the tumour, respectively.
The frequency of postembolisation syndrome in cases of angiomyolipoma is lower. Super selective embolisation preserves renal parenchyma, and there were no reported deaths in cases of super selective embolisation for renal angiomyolipoma (9). The patient also experienced symptoms of postembolisation syndrome, which were managed with medical treatment.
A study by Andersen PE et al., has shown that super selective embolisation for angiomyolipoma results in a reduction in tumour volume in addition to devascularising the tumour (10). Super selective endovascular embolisation in cases of renal angiomyolipoma prevents rebleeding during long-term follow-up. It is a minimally invasive and nephron-sparing procedure, with the preservation of renal function being an important consideration (10). In the present case, there was no evidence of tumour rebleeding. However, authors do not have long-term follow-up data, so authors cannot comment on the percentage reduction in tumour size after embolisation, which is a limitation of the present case report.
When considering surgical treatment, partial nephrectomy has the advantage of lower recurrence compared to endovascular embolisation. Complications associated with nephrectomy are also more common compared to embolisation. Radical nephrectomy is indicated when there is a high suspicion of malignancy (9). In the present case, the family consented to endovascular embolisation.
Successful urgent arterial embolisation of ruptured renal angiomyolipoma was described by Kervancioglu S et al., in a case report of angiomyolipoma with rupture and pseudoaneurysm (11). The authors used liquid embolic (glue) for embolisation, as the renal angiogram demonstrated a pseudoaneurysm with active extravasation. In the present case, there was no pseudoaneurysm or active extravasation, so authors opted to use PVA particles for deep penetration into the tumour bed vasculature and coils to occlude the main-stem of abnormal feeding arteries for optimal devascularisation of the tumour.
Altuwayr RM et al., discussed successful endovascular embolisation followed by radical nephrectomy in a 42-year-old patient with a ruptured renal angiomyolipoma, beta-thalassaemia minor, and a family history of glucose-6-phosphate dehydrogenase deficiency (12). In contrast to this, the authors in the present study did not choose to perform nephrectomy as the patient was stable after endovascular embolisation.
The success rate for endovascular embolisation is almost 100%, as mentioned by various authors (2),(5),(6),(13),(14). However, complete embolisation may not always be achieved. There are rare complications associated with embolisation, such as allergy, non targeted embolisation, respiratory complications, retroperitoneal haemorrhage, and complications at the femoral artery puncture site, as elaborated by Murray TE et al., (15). However, no deaths were reported. In the present case, there was no evidence of contrast allergy, non target embolisation, or pseudoaneurysm of the punctured femoral artery.
Ruptured renal angiomyolipoma is a relatively rare clinical emergency condition. Most of the time, the presentation of a ruptured renal angiomyolipoma includes flank pain, haematuria, or retroperitoneal haemorrhage. Endovascular super selective embolisation is an effective, minimally invasive treatment with a high success rate, lower complications, and faster patient recovery while preserving renal parenchyma. Whenever expertise is available, it should be the treatment of choice.
DOI: 10.7860/JCDR/2023/66262.18382
Date of Submission: Jun 27, 2023
Date of Peer Review: Jul 09, 2023
Date of Acceptance: Jul 17, 2023
Date of Publishing: Sep 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jun 30, 2023
• Manual Googling: Jul 10, 2023
• iThenticate Software: Jul 15, 2023 (2%)
ETYMOLOGY: Author Origin
EMENDATIONS: 5
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