Renal artery pseudoaneurysms are rare after blunt abdominal trauma; only 11 cases have been previously reported. Pseudoaneurysms are caused by decelerating injuries of the renal artery after major falls or automobile accidents. Patients may be asymptomatic for many years, and the pseudoaneurysm may expand and rupture before diagnosis or treatment. The patients in four untreated cases died. The diagnosis of renal artery pseudoaneurysm can be made by Doppler sonography, computerized tomography, renal perfusion imaging, or contrast angiography. Treatment requires either surgical or percutaneous intervention. Renal salvage was possible in five of the seven patients treated. We report two additional patients with successful outcomes after surgical intervention.
The term "posterior nutcracker phenomenon" refers to the compression of the retroaortic left renal vein between the aorta (A and B, arrowhead) and the vertebral column (A and B, arrow). This entity is better known through its anterior variant, the "anterior nutcracker phenomenon," where the anterior left renal vein is compressed between the aorta and the superior mesenteric artery.A retroaortic renal vein is a rare anomaly, with an incidence of 1% to 2.4%. Fewer than 20 cases of a posterior nutcracker phenomenon have been reported. 1,2 The resulting venous hypertension in the left renal vein is manifested by recurrent, intermittent left flank or abdominal pain, or both, and intermittent unilateral hematuria. The nutcracker phenomenon occurs in relatively young, healthy patients.This disorder is easily overlooked if routine diagnostic procedures are used alone. The natural history of this disease is characterized by repeated diagnostic procedures and delayed treatments. With the advent of multidetector computed tomography (MDCT), however, the precise anatomy of the renal vessels and the aorta can be delineated as well as the compression of the left renal vein and its delayed emptying into the vena cava (Cover). Contributing factors have been suggested, such as ptosis of the left kidney with the subsequent stretching of the vein, the presence of an abdominal aortic aneurysm, or pregnancy, but these factors are absent in most patients. 2 This 52-year-old man presented with flank pain and microscopic hematuria on urine analysis. The diagnosis was pointed out after MDCT: It revealed a posterior nutcracker phenomenon owing to the compression of his left retroaortic renal vein between the aorta and osteophytes bulging anteriorly out of the vertebral body (C). This patient had spontaneous resolution of flank pain and hematuria within 10 days and was treated conservatively. During a 12-month follow-up, he reported another isolated episode of flank pain that lasted for 5 days. To our knowledge, this is the first case of nutcracker phenomenon involving vertebral osteophytes. Osteophytes are extremely frequent in elderly individuals, and with the liberal use of multislice CT, these images may be more frequently encountered in older patients. REFERENCES1. Lau JL, Lo R, Chan FL, Wong KK. The posterior "nutcracker": hematuria secondary to retroaortic left renal vein. Urology 1986;28:437-9.
Background Treatment with erythropoietin is well established for anemia in chronic kidney disease patients but not well studied in acute kidney injury.MethodsThis is a multicenter, randomized, pragmatic controlled clinical trial. It included 134 hospitalized patients with anemia defined as hemoglobin <11 g/dL and acute kidney injury defined as an increase of serum creatinine of 0.3 mg/dL within 48 hours or 1.5 times baseline. One arm received recombinant human erythropoietin 4000 UI subcutaneously every other day (intervention; n=67) and the second received standard of care (control; n=67) during the hospitalization until discharge or death. The primary outcome was the need for transfusion; secondary outcomes were death, renal recovery, need for dialysis.ResultsThere was no statistically significant difference in transfusion need (RR=1.05, 95%CI 0.65,1.68; p=0.855), in renal recovery full or partial (RR=0.96, 95%CI 0.81,1.15; p=0.671), in need for dialysis (RR=11.00, 95%CI 0.62, 195.08; p=0.102) or in death (RR=1.43, 95%CI 0.58,3.53; p=0.440) between the erythropoietin and the control group. ConclusionsErythropoietin treatment had no impact on transfusions, renal recovery or mortality in acute kidney injury patients with anemia. The trial was registered on ClinicalTrials.gov (NCT03401710, 17/01/2018).
BackgroundDuring their training, Lebanese medical students develop a high medical expertise but are not focusing on other competencies such as communication, collaboration, erudition, professionalism, leadership and health promotion. There is also insufficient data about patients’ preference for these skills. This study describes the different weights patients attribute to these physician’s competencies.MethodsThis is a cross-sectional study based on a questionnaire distributed to 133 Lebanese patients. It included 15 questions assessing how patients prioritize the physician’s competencies, with open-ended questions asking them to define “the good doctor”. Krippendorff’s alpha coefficient was used to analyze the reliability of the competencies’ classification.ResultsOne hundred twenty five patients completed the questionnaire in this cross-sectional study. Their mean age was 48 ± 16.76 years. When classifying competencies, 73.6% opted for medical expertise as first choice and 48% put communication as second. Based on the Krippendorff’s coefficient, we identified a moderate agreement for the seven choices (alpha = 0.44). In open-ended questions, patients defined the good doctor in 325 answers: 64.3% mentioned medical expertise, 34.1% high ethics and 26.2% communication.ConclusionsThis patient-centered study concurs well with the worldwide practice that puts medical expertise at the center of medical education. However Lebanese patients don’t perceive equally other competencies and favor professionalism and communication that should be integrated in priority in students’ curricula.
Background: Coronavirus disease 2019 (COVID-19) is a rapidly spreading infective disease caused by the severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2). The management of this disease remains a challenge particularly in certain subgroups of patients such in hemodialysis patients who have higher exposure rates due to the nature of their in-hospital care, and higher mortality due to their burden of comorbidities. Moreover, molecules used in the general population to treat COVID-19 lack data regarding their pharmacodynamics in the hemodialysis population.Case presentation: We report a case of a 52-year-old patient with Von Hippel Lindau syndrome and end stage renal disease on hemodialysis who contracted COVID-19 infection. Due to the patient’s rapidly deteriorating clinical status he was successfully treated with Tocilizumab, despite the lack of data concerning the use of this molecule in this population. The patient was later discharged after a long hospital stay and progressive clinical, biological and radiological improvement.Conclusion: This sub group of patients should be carefully approached due to the unique nature of their comorbidities, and to their immune’s system response to the virus itself and to novel therapies. Although few studies were available regarding the use of Tocilizumab in the dialysis population, its use proved to be effective and well tolerated in our patient.
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