Predicting Post Renal Biopsy Complications

At our institution, kidney biopsies are performed by an interventional nephrologist with standardized guidelines using real‐time ultrasound. We hypothesized that patient factors could predict post biopsy complications. We did a retrospective review of 100 patients who underwent renal biopsy. Prebiopsy data obtained included demographics, blood pressure, laboratory studies, and kidney size. Biopsy procedure information was also recorded. Complications and post biopsy imaging was noted. A minor complication was defined as one not requiring intervention while a major complication required interventions like readmission or blood transfusion. The average age was 47 years, 41 were men, 51 were black, 30 had diabetes, 42 were obese, and 81 had hypertension. Twenty‐six patients had a complication; 14 minor and 12 major including 1 nephrectomy. Factors predictive of a complication were thrombocytopenia (p = 0.002) and inpatient status (p = 0.04). Drop in hemoglobin at 6 hours was moderately sensitive and specific for a bleeding complication with an ROC of 0.723. Thrombocytopenia and inpatient status are risk factors for complications after renal biopsy. Serum creatinine, obesity, blood pressure, kidney size, needle size, and number of passes were not predictive of a major complication in our study.     

Real Time Three‐Dimensional Transthoracic Echocardiography of Ruptured Left Sinus of Valsalva Aneurysm to Left Ventricle

Aneurysms arising from the sinus of Valsalva are a rare cardiac defect that can present with various signs and symptoms, and if not diagnosed and treated rapidly can lead to fatal outcomes. Unruptured aneurysms are usually asymptomatic and found incidentally during diagnostic studies. More commonly, aneurysm of sinus of Valsalva is detected after the occurrence of rupture. Echocardiography has become the investigative tool of choice for this condition, not only for diagnosis but also for quantification of severity. We hereby report a rare case of a 15‐year‐old patient presenting with complaints of effort dyspnea and palpitations. Two‐dimensional transthoracic echocardiography (TTE) showed aneurysmal dilatation of left sinus of Valsalva which had ruptured into the left ventricle. Also, there was an intimal flap within the sinus of Valsalva aneurysm. The anatomical relationship between the aorta, aneurysm, and the left ventricle as well as the intimal flap within the aneurysm was clearly delineated with the help of three‐dimensional TTE. After confirmation of the diagnosis with multidetector computed tomography, patient underwent successful surgical repair of the defect.     

Use of Unique Doppler Flow‐Pattern for the Diagnosis of Left Ventricular Diverticulum

Isolated congenital left ventricular diverticulum (LV) is reportedly a rare finding. It is frequently associated with other congenital defects involving heart, pericardium, sternum, diaphragm, and abdominal wall. It is an outpouching from the ventricle and has all three layers of left ventricular free walls. We present the case of a 53‐year‐old woman who was discovered to have an outpouching of the LV apex on a nongated chest CT scan raising possibility of a pseudoaneurysm. A transesophageal echocardiogram (TEE) showed systolic diminution of this outpouching with unique Doppler flow‐patterns suggesting a diagnosis of a muscular type of LV diverticulum instead of a postinfarct LV pseudoaneurysm. The patient was reassured and treated conservatively.     

Multimodality Imaging of Submitral Left Ventricular Aneurysm

Submitral left ventricular aneurysms are a rare nonischemic aneurysm thought to be developmental in origin. These aneurysms invariably occur at the site of posterior mitral annulus and lead to mitral valve incompetence. We hereby describe a case of a 30‐year‐old adult with a rare form of submitral left ventricular aneurysm involving whole of the posterior mitral annulus. Multimodality imaging with two‐dimensional echocardiography, three‐dimensional echocardiography, computed tomography and invasive left ventriculography helped the patient to undergo successful resection of the aneurysm along with mitral valve replacement.     

Platelet glycoprotein IIb/IIIa inhibition using eptifibatide with primary coronary stenting for acute myocardial infarction: a 30-day follow-up study.

The results of primary coronary stenting for acute myocardial infarction (AMI) have been reported to improve significantly with the concomitant administration of platelet glycoprotein IIb/IIIa inhibitor abciximab. There are, however, no data available with the use of eptifibatide, a more cost-effective, small-molecule GP IIb/IIIa blocker with a shorter half-life. In a prospective multicenter feasibility and efficacy study, we assigned 55 consecutive patients with AMI being taken up for primary stenting to receive eptifibatide just before the procedure (two boluses of 180 microg/kg 10 min apart and a 24-hr infusion of 2 microg/kg/min). Clinical outcomes were evaluated at 30 days after the procedure. The angiographic patency of the vessel with TIMI flow rates, TIMI myocardial perfusion (TMP) grade, and corrected TIMI frame counts were assessed at the end of procedure and before hospital discharge. At 30 days, the primary endpoint, a composite of death, myocardial infarction, and urgent target vessel revascularization (TVR) was seen in 12.7% of patients. The TIMI 3 and TMP grade 3 flow, which was seen in 93% and 86% of patient, respectively, at the end of the procedure, declined to 86% and 78%, respectively (P < 0.05) before hospital discharge. Corrected TIMI frame counts also decreased from 25.7 +/- 7.2 to 22.9 +/- 6.8 (P < 0.05). There were five (9.1%) instances of subacute thrombosis (SAT) presenting as AMI, needing urgent TVR in all, within 3-5 days of the primary procedure. No excessive bleeding complication, directly attributable to the use of eptifibatide, was observed. The study was terminated prematurely because of an unacceptable SAT rate. Administration of eptifibatide along with primary stenting for AMI is associated with a high TIMI 3 and TMP grade 3 flow acutely. However, these flows decline significantly before hospital discharge and lead to a high rate of SAT. The dosage and duration of infusion of eptifibatide in this setting needs further evaluation.     

Decreased expression of phospholipase C-beta 2 isozyme in human platelets with impaired function

Platelets from a patient with a mild inherited bleeding disorder and abnormal platelet aggregation and secretion show reduced generation of inositol 1,4,5-trisphosphate, mobilization of intracellular Ca2+, and phosphorylation of pleckstrin in response to several G protein mediated agonists, suggesting a possible defect at the level of phospholipase C (PLC) activation (see accompanying report). A procedure was developed that allows quantitation of platelet PLC isozymes. After fractionation of platelet extracts by high-performance liquid chromatography, 7 out of 10 known PLC isoforms were detected by immunoblot analysis. The amount of these isoforms in normal platelets decreased in the order PLC- gamma 2 > PLC-beta 2 > PLC-beta 3 > PLC-beta 1 > PLC-gamma 1 > PLC- delta 1 > PLC-beta 4. Compared with normal platelets, platelets from the patient contained approximately one-third the amount of PLC-beta 2, whereas PLC-beta 4 was increased threefold. These results suggest that the impaired platelet function in the patient in response to multiple G protein mediated agonists is attributable to a deficiency of PLC-beta 2. They document for the first time a specific PLC isozyme deficiency in human platelets and provide an unique opportunity to understand the role of different PLC isozymes in normal platelet function.     

Differences in presentation and follow-up between HIV-1 antibody positive teenagers and adults: the need for a more focused approach to care?

Our findings show a high rate of loss to follow-up in HIV-positive teenagers compared with adults. Of concern is the fact that this group also have high rates of sexually transmitted infections, unprotected sex and pregnancy. There is an urgent need to examine the reasons for this and adopt strategies to minimize risk-taking behaviour and to improve access to appropriate healthcare.