Unveiling May-Thurner Syndrome in a Case of Recurrent Deep Venous Thrombosis With Bilateral Pulmonary Embolism.

May-Thurner syndrome (MTS) is a rare cause of deep venous thrombosis (DVT), characterized by the external compression of the left common iliac vein by the right common iliac artery against bony structures. Risk factors for MTS include female sex (postpartum, multiparous, and using oral contraceptive pills), spinal abnormalities like scoliosis, prior aortoiliac vascular stent placement, dehydration, and hypercoagulability. MTS patients with partial obstruction can be asymptomatic, but progression to extensive symptomatic DVT and/or chronic venous insufficiency can occur. MTS can be diagnosed by non-invasive imaging studies including ultrasound (US), computed tomography (CT) scan, magnetic resonance imaging (MRI), venogram, catheter-based venogram, and intravascular US. For MTS patients with moderate to severe symptoms, we suggest thrombectomy, angioplasty, and stenting of the affected segment. In this case report, we highlight a 44-year-old male with a recent diagnosis of left-sided DVT on apixaban who presented with worsening leg swelling. DVT, pulmonary embolism (PE), and MTS were diagnosed with a lower extremity US, chest CT angiography, and abdominal/pelvic CT scan and venography, respectively. The patient underwent interventional radiology-guided local thrombolysis, thrombectomy, and venoplasty along with stent placement in the left common iliac vein. Subsequently, the patient was discharged on rivaroxaban.

Rare adverse effects of bisphosphonate therapy.

PURPOSE OF REVIEW: To give an update on the latest developments regarding rare adverse effects of bisphosphonate therapy. RECENT FINDINGS: Recent studies covering osteonecrosis of the jaw (ONJ) and atypical femoral fractures (AFFs) provided several updates to the literature. Identification of ONJ in large population databases is a challenge but based on one systematic review, the ICD-10 diagnosis code K10.2 (inflammatory conditions of the jaw) seems to be the most commonly used code for this condition. Duration of bisphosphonate therapy was determined to be an important predictor of AFFs. Appropriate duration of therapy followed by a timely drug holiday was shown to be the best strategy for improving bone mineral density and reducing fracture risk, while minimizing risk of rare adverse effects of therapy. The utility of bone turnover markers as a monitoring tool during drug holidays needs to be further investigated. SUMMARY: ONJ and AFFs are two of the rare adverse effects associated with bisphosphonate therapy. Population-level trends of bisphosphonate use suggest a decline in prescriptions, pointing to broad fears of these side effects. Careful patient evaluation, duration of bisphosphonate therapy, and use of drug holidays can help limit any risk associated with therapy.

Novel insights into the pathophysiology and clinical aspects of diabetic nephropathy.

Diabetic nephropathy (DN) is a well-described complication of diabetes mellitus and the leading cause of end stage renal disease (ESRD). Although increased albuminuria has been the gold standard for screening, data suggests that renal damage starts long before the onset of clinically apparent increases in macro and even micro-albuminuria. Clinical practice guidelines for the prevention of DN have been traditionally focused on the control of serum glucose, blood pressure and dyslipidemia, with some focus on the renin-angiotensin-aldosterone system (RAAS) as a main target for successful therapy. Recent evidence has led to a better understanding of the underlying mechanisms of the pathophysiology of this disease and suggests that various novels pathways can be targeted to delay and even prevent the progression of DN. Hence a more comprehensive therapeutic approach to therapy is on the horizon, carrying the promise for a more successful and impactful management. This review will highlight new insights into the pathophysiology, clinical aspects and future diagnostic and therapeutic modalities for DN.