Background-The segment of the vein mobilized for arterial anastomosis in the creation of an arteriovenous fistula (AVF) is the swing segment. This segment may experience turbulent flow and altered shear mechanical stress that result in stenosis. We sought to determine the frequency of stenotic lesions in the swing segment.

Renal artery stenosis (RAS) is a common cause of secondary hypertension, with the activation of the renin-angiotensin-aldosterone system being the pathophysiologic hallmark of the disease. Renovascular hypertension, ischemic nephropathy, proteinuria, and flash pulmonary edema are the main clinical syndromes associated with RAS. The prevalence of RAS is on the rise, owing to an increasing prevalence of diabetes and atherosclerotic disease among our aging population. This rise in RAS prevalence poses major challenges for clinicians making diagnostic and treatment decisions. Although renal angioplasty is of proven benefit in fibromuscular dysplasia, randomized trials in atherosclerotic RAS have not shown any advantage for revascularization over medical therapy in terms of blood pressure control or renal function preservation. Angioplasty and surgical interventions should be reserved for patients with preserved kidney size and hemodynamically significant stenosis.

Objectives: Controversy exists regarding utility of cardiac troponin I (cTnI) in predicting significant coronary artery disease (CAD) in hemodialysis (HD) patients with chest pain and no acute ischemia on electrocardiogram (non-ST segment elevation myocardial infarction, non-STEMI). We sought to determine if cTnI elevation predicts significant CAD (>70% stenosis) in these patients. Methods: Ninety patients with non-STEMI referred for cardiac catheterization were included, divided equally into HD and non-HD groups. Results: Mean age and baseline characteristics were not significantly different between groups, except for left ventricular hypertrophy which was higher in HD patients (56 vs. 27%, p = 0.012). Initial cTnI correlated with obstructive CAD and was stratified into <0.3 and >0.3 ng/ml. By logistic regression, cTnI >0.3 ng/ml was not predictive of CAD in HD patients [odds ratio = 0.87 (95% CI 0.19–4.0), p = 0.8], while non-HD patients had an increased risk of CAD if first cTnI was >0.3 ng/ml [odds ratio = 1.461 (95% CI 1.01–2.11), p = 0.04] as expected. Sensitivity, specificity, negative and positive predictive values of cTnI in predicting obstructive CAD were better in non-HD patients. Conclusion: cTnI in these patients had no predictive value for obstructive CAD. This contrasts with the general population, suggesting a higher index of suspicion for high-grade CAD irrespective of cTnI levels in HD patients.

Rare coexistence of disease or pathology Background:The management of (Coronavirus disease 2019) COVID-19 pneumonia is ever-evolving. Tocilizumab, a monoclonal antibody against interleukin-6 (IL-6) receptor, have known mortality benefit in severe COVID-19 pneumonia, but data are limited regarding safety. Attributable to the immunomodulatory nature of this medication, patients may be at risk for opportunistic infections, including chronic cavitary pulmonary aspergillosis (CPPA), a slowly progressive disease characterized pulmonary infiltrates and often a newly-formed cavity. However, current guidelines do not emphasize post-treatment surveillance of patients for opportunistic infections, including CPPA. Case Report:We present a particular case of a 64-year-old man treated for COVID-19 pneumonia with Tocilizumab and dexamethasone who developed cavitary pulmonary aspergillosis. He presented to the emergency department with hemoptysis, associated with worsening productive cough, shortness of breath, and weight loss. Computed tomography (CT) of the chest showed areas of focal consolidation and a cavitary lung lesion within the left upper lobe. Sputum culture was positive for Aspergillus niger. The patient received a long course of oral triazole therapy for CPPA, with clinical improvement. CT scan of the chest at 9 months showed that the Itraconazole therapy was effective in resolving the extensive airspace disease and decreasing the size of the upper-lobe cavity and fungal ball. Conclusions:This article illustrates the possibility of a serious infection such as CCPA as an adverse effect of Tocilizumab treatment, especially with concurrent immunosuppressive therapy. Furthermore, this case highlights the importance of regular monitoring of patients who have received Tocilizumab therapy to ensure that early signs of opportunistic infections such as CPPA are detected and treated promptly to prevent permanent lung damage.

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