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The most appropriate test to diagnose the cause of abnormal kidney function, proteinuria, and intermittent gross hematuria is kidney biopsy.

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Hematuria can be caused by bleeding anywhere in the urinary tract from the glomeruli to the urethra. Therefore, the differential diagnosis is broad and includes glomerular disease, nephrolithiasis, urologic malignancy, renal papillary necrosis, prostate disorders, acute trauma, infection, hematologic disorders, and other forms of cystitis. Radiation to the pelvis may produce hemorrhagic cystitis, and patients who are excessively anticoagulated may develop hematuria without identifiable structural disease. Abdominal aortic dissection may have associated hematuria due to renal ischemia.

This patient has proteinuria and progressive chronic kidney disease in addition to the hematuria. Taken together, these findings suggest glomerular disease. Definitive diagnosis is obtained only by kidney biopsy and will help guide therapy.

In patients with nonglomerular hematuria, it is appropriate to evaluate the upper and lower urinary tract for causes of hematuria. A CT urogram is considered the study of choice for evaluating all types of nonglomerular hematuria originating in the upper tracts.

Cystoscopy would be the study of choice to evaluate the bladder in a patient with nonglomerular hematuria who was at risk for transitional-cell cancer. Risk factors for transitional-cell cancer include cigarette smoking (50% of cases), chemical exposures, drug exposures (cyclophosphamide, phenacetin), radiation, long urine dwelling times (such as in truck drivers), chronic urinary stone disease, chronic catheterization, chronic infections, and genetic mutations.

Urine cytology was previously recommended to evaluate the lower tract in patients at low risk for bladder cancer, but it is an insensitive study. Furthermore, malignancies that cause hematuria are not generally associated with proteinuria or a significant decline in renal function.

Doppler studies of the renal veins are used to detect renal-vein thrombosis. This entity is more common in the setting of nephrotic syndrome with heavy proteinuria or a hypercoaguable state from a malignancy. Patients may be asymptomatic or complain of flank pain. If there has been a thrombosis of one renal vein, this would not explain the rise in serum creatinine to the degree seen in this patient. Instead, causes of glomerular bleeding should be pursued.

Takotsubo Cardiomyopathy — NEJM

Takotsubo Cardiomyopathy — NEJM: Images in Clinical Medicine from The New England Journal of Medicine — Takotsubo Cardiomyopathy



Takotsubo cardiomyopathy, also called apical ballooning syndrome or stress cardiomyopathy, typically occurs in postmenopausal women and may be preceded by a stressful or emotional event. The clinical presentation may be identical to that seen in patients with acute coronary syndrome, but the condition is characterized by transient left ventricular systolic and diastolic dysfunction of the apex and midventricle in the absence of attributable coronary artery disease

Embryonic Heart Rate as a Prognostic Factor for Chromosomal Abnormalities

Embryonic Heart Rate as a Prognostic Factor for Chromosomal Abnormalities

Abstract

Objective. The purpose of this study was to evaluate the role of a slow embryonic heart rate in embryos before 7 weeks' gestation as a marker in screening for chromosomal abnormalities. Methods. Fifty-seven embryos before 7 weeks' gestation with slow heart rates were compared with 1156 embryos of the same gestational period with normal heart rates. Embryos that showed an increased risk of chromosomal abnormalities in the screening blood tests underwent invasive analysis for abnormal karyotype detection. Results. The rates of first-trimester death were 15.8% for pregnancies with slow embryonic heart rates (9 of 57) and 2.5% for those with normal heart rates (29 of 1156). Because of the increased risk of chromosomal abnormalities, amniocentesis was performed on 6 with slow embryonic heart rates and 61 with normal embryonic heart rates. After karyotype analysis, there were 2 fetuses with trisomy 21 in each group, which represented significantly higher percentage of embryos with trisomy 21 in the slow–heart rate group compared with the normal–heart rate group (P < .05). Conclusions. When a slow embryonic heart rate is detected before 7 weeks' gestation, there is a higher likelihood of chromosomal abnormalities.

Associations of Carotid Artery Intima‐Media Thickness (IMT) With Risk Factors and Prevalent Cardiovascular Disease

Associations of Carotid Artery Intima‐Media Thickness (IMT) With Risk Factors and Prevalent Cardiovascular Disease

Abstract

Objective. The goal of this study was to compare internal carotid artery (ICA) intima-media thickness (IMT) with common carotid artery (CCA) IMT as global markers of cardiovascular disease (CVD). Methods. Cross-sectional measurements of the mean CCA IMT and maximum ICA IMT were made on ultrasound images acquired from the Framingham Offspring cohort (n = 3316; mean age, 58 years; 52.7% women). Linear regression models were used to study the associations of the Framingham risk factors with CCA and ICA IMT. Multivariate logistic regression models and receiver operating characteristic (ROC) curve analysis were used to compare the associations of prevalent CVD with CCA and ICA IMT and determine sensitivity and specificity. Results. The association between age and the mean CCA IMT corresponded to an increase of 0.007 mm/y; the increase was 0.037 mm/y for the ICA IMT. Framingham risk factors accounted for 28.6% and 27.5% of the variability in the CCA and ICA IMT, respectively. Age and gender contributed 23.5% to the variability of the CCA IMT and 22.5% to that of the ICA IMT, with the next most important factor being systolic blood pressure (1.9%) for the CCA IMT and smoking (1.6%) for the ICA IMT. The CCA IMT and ICA IMT were statistically significant predictors of prevalent CVD, with the ICA IMT having a larger area under the ROC curve (0.756 versus 0.695). Conclusions. Associations of risk factors with CCA and ICA IMT are slightly different, and both are independently associated with prevalent CVD. Their value for predicting incident cardiovascular events needs to be compared in outcome studies.

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5 Ways Your Smartphone Is Now a Medical Device

5 Ways Your Smartphone Is Now a Medical Device

It is no secret smartphones are transforming many aspects of medical care. The “medicalized smartphone” is becoming not only a convenient accessory in modern health care, but also a full-fledged diagnostic tool that can be easily used anywhere in the world.

The practical implications of using a smartphone device to diagnose many common health conditions are huge. Most phones’ technical specifications are now so advanced they can compete with technology found in the doctor’s office.

The idea of turning a smartphone into a point-of-care diagnostic tool has become a reality. It is saving money, speeding up the assessment process, making some procedures widely available—even in developing countries—and giving patients/users more control of their own care.

Smartphone Ultrasound, MobiUS SP1 | Mobisante

Smartphone Ultrasound, MobiUS SP1 | Mobisante

Yes, it’s on a smartphone – where you can call up the future of medicine.

This is a game changer.  It’s quick and easy to use.  It can expedite diagnosis and guide injections, aspirations and line placements.  It’s so affordable that cost need not be a barrier to care.  Until now, 60% of the world did not have access to ultrasound. It was too costly or simply not portable enough to get to them. Those days are over.

• Small and portable
  The MobiUS SP1 System can fit in your pocket and it’s light enough to take anywhere.  So you can take imaging to your patient, easily.

• Easy
  We’ve gone to great lengths to ensure the MobiUS SP1 is quick to learn and simple to operate.

• Connected
  Images are readily stored in 8 GB capacity and quickly shared from the MobiUS SP1 smartphone ultrasound device via secure Wi-Fi, cellular networks or USB.

• Affordable
  We’ve put imaging within the economic reach of healthcare professionals  – everywhere.  Now smaller, more resource-constrained facilities and healthcare teams can offer more complete care.