A 28-year-old woman with ESRD due to hypertension presented to the emergency room with a 2-day history of pain and swelling on the left side of her neck and jaw. She denied any inciting factors prior to symptoms, but relayed that her dialysis treatment could not be performed through her left-sided upper arm Hemodialysis Reliable Outflow (HeRO) (Merit Medical Systems, Inc., South Jordan, UT, USA) graft the prior day as it had appeared to have clotted.On physical examination the patient had a markedly edematous left neck with a large tender palpable mass. Her vital signs were normal, no bruit or thrill was appreciated over her AVG site, and no other obvious findings were appreciated. A computed tomography (CT) scan of the neck revealed a large hematoma within the left sternocleidomastoid muscle (Figure 1). Concerns about the integrity of the HeRO graft prompted a chest radiograph (CXR), which was compared to previous imaging collected 1 month earlier (Figures 2A-1 month ago, and 2B-present). Questions?1) What do the chest radiographs demonstrate?2) What is the optimal management at this time? Answers: 1) The venous outflow component of the HeRO graft had uncoupled and migrated into the superior vena cava, with the end of the uncoupled component of the catheter terminating in the right ventricle. The hematoma was due to the disconnection of the arterial inflow component and the venous outflow component, allowing blood to pool in the subcutaneous space. HeRO grafts are rigid wire mesh supported grafts that when placed through a stenotic segment of a central vein improves the lumen size and patency of that vein. The venous outflow portion of the HeRO terminates in or near the right atrium while the arterial inflow component is a standard AV graft. The two components are held together by a connector (Figure 3). This provides adequate flow so that the normal arterial inflow portion of the AV graft can be cannulated for hemodialysis not unlike any standard AV graft. Complications associated with HeRO grafts include right atrial clots and pulmonary emboli, 1,2 infection, 2 and gastrointestinal bleeding from downstream esophageal varices. 3 This is the first case we are aware of reporting an uncoupling of HeRO graft components. Fortunately the bleeding was confined and limited by the subcutaneous space to prevent continued hemorrhage. 2) The patient was placed on continuous cardiac monitoring to evaluate for arrhythmias. Interventional Radiology was consulted with successful HeRO graft retrieval and placement of a new tunneled HD access catheter. F I G U R E 1 Computed tomography (CT) revealing a large hematoma within the left sternocleidomastoid muscle (arrow)
BackgroundGlucocorticoids are commonly used in a wide variety of inflammatory conditions treated by rheumatologists. Bone loss from glucocorticoids is known to occur early and with relatively small doses. The American College of Rheumatology outlines that Glucocorticoid-Induced Osteoporosis (GIOP) is under screened and undertreated. The ACR guidelines suggest standard clinical care to obtain a baseline DEXA in any individual with anticipated long-term steroid use, primary prevention with calcium, and vitamin D initiation and medical therapy when appropriate based on fracture risk assessments.ObjectivesThe objective of this study was to determine how successfully the ACR GIOP guidelines are implemented in daily rheumatologic practice. The study investigates the prevalence of osteoporosis screening, prevention, and treatment in patients with rheumatologic diseases over a 2 year period at a large medical centre.MethodsA retrospective cohort study of patients who received rheumatology care between 2014 and 2015 at a large medical centre was performed. Patients were included if they were older than 18 years of age, had a diagnosis of rheumatoid arthritis, systemic lupus, vasculitis, polymyalgia rheumatica, or gout and were receiving ≥5 mg prednisone daily for ≥90 days. Electronic medical records were reviewed and medication history was evaluated. Screening was defined as bone mineral density testing with DEXA within one year of glucocorticoid initiation. Primary prevention and treatment were derived from ACR GIOP criteria and included the initiation of appropriate doses of calcium and vitamin D and initiation of medical therapy to prevent bone loss. The prevalence of screening and treatment was assessed and the relationships with age, gender, and ethnicity were evaluated using Chi Squared analyses and independent samples t-tests.ResultsOf the 600 patients reviewed, 61 met criteria of new long-term glucocorticoid initiations. Overall 61% received BMD testing and 48% received osteoporosis primary prevention. Of those who qualified for treatment by ACR GIOP criteria, only 19% received treatment. Patients who received a baseline DEXA were older than those who did not (65±15 vs 57±16 years, p=0.046). Age did not influence treatment. More women compared to men received screening DEXA (68% F vs 41% M, p=0.053) and primary prevention (55% F vs 29% M, p=0.078). Patients who received a longer duration of steroid treatment were more likely to receive primary prevention (16±10 months vs 10±8 months, p=0.015). There was no association between ethnicity or disease status on screening, prevention, or treatment.ConclusionsGlucocorticoid-induced osteoporosis in the setting of a rheumatology practice is a common and manageable condition that should be screened, prevented, and treated. These results from one large academic medical centre in the United States suggest that rheumatologists may not be following ACR guidelines for the assessment and management of patients on chronic steroids. Quality improvement initiatives may be necessary i...
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
customersupport@researchsolutions.com
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.