2 patients on 2 consecutive nights from a Naval Medical Center.
Both were stone studies, which was a reasonable clinical suspicion since that is probably the most common cause of flank pain. Both of them also presented with elevated creatinine precluding contrast out of concern for contrast nephropathy.
As an aside, acetylcysteine has no protective effects on the kidneys in the prevention of contrast induced nephropathy. I do not know of any institutions who were actually using this on a regular basis but from time to time it pops back up as a prophylactic measure in CIN. This was recently commented on in up-to-date.
What made me notice this “pattern” if you will, was that perinephric stranding is fairly uncommon in the young military population in the absence of chronic disease or urolithiasis. On seeing the 2nd case on a consecutive night, I did some digging to find out whether the previous case was actually the night before and from the same institution. The biggest concern in my mind was whether there was an epidemiologic issue such as HUS-TTP.
My suspicion is that it turns out it is an epidemiologic issue but unrelated to infection. Both patients reported to the emergency department with flank pain and no trauma after vigorous physical training (PT) workouts. They did have hematuria. Creatinine was above 2.0 in both patients. Although CT is unreliable, they both seemed adequately hydrated (IVC distention).
I would love to hear follow-up on these cases as it seems that this is probably rhabdomyolysis with acute renal injury secondary to vigorous exercise. I cannot remember seeing such a close association however the most likely thing is that this happens often and I simply miss it because the patients are not imaged or other people take up the studies.
For me it is a reminder that military training is not a benign process. To create the outstanding fighting force, young men and women not only sacrifice the best years of their life, they endure physical and psychological hardship for the benefit of the homeland.
I have commented in the past that I read for several military hospitals as a part of teleradiology. In general, the physicians at these military hospitals appear far more judicious than other hospitals I have worked for (Moses Cone Hospital) in their use of imaging, particularly “high-end imaging”.
Private physicians have a low threshold for ordering advanced imaging which seems to be out of fear of litigation or patient demand. Regardless, this is a degradation of the physician’s fiduciary responsibility to the patient. This is an unfortunate reality of modern medicine. Unfortunately, this leads to greater expense and does not improve the quality of healthcare overall. This has been well demonstrated epidemiologically.
This is probably an effect of decreased threat of litigation and less practicing of defensive medicine than is seen in the civilian sector. This is a great example of appropriate use of imaging by a beleaguered overworked ER physician. The patient had compelling findings on the exam and was sent for MRI for orthopedic evaluation.
Although the amount of retraction is mild at the quadriceps tendon rupture, this is appropriate use of imaging because the sooner the tendon is repaired, the less retraction the surgeon has to deal with. With this workup in the night, the orthopedic surgeons can repair the tendon early the next day provided operating room space is available.
It makes me think that practicing medicine with the military is probably the closest the United States will ever come to a reasonable decision-making practice model and mitigate the effects of defensive medicine.
I have no problem admitting that I have pathology. I’m aware of much of my psychopathology however people do not hesitate to point it out most of the time. This is an example of a part of my pathology as a runner and an experimental thinker.
All serious runners know that when you find a shoe that works for you, you hang onto it for dear life. It’s rare to find a runner that bounces from shoe to shoe, let alone brand to brand.
NEW BALANCE SHOES USED to make it easy to simply look up the last (the pattern of the sole) of the shoe that fit your foot and continue ordering however with their newer naming scheme, this has become much more difficult. Now the process involves getting a “test shoe” and then buying more of them if that shoe works for you. This has led to show rooming at local shoe stores if you’re unsure of what you’re buying.
The problem lies in the fact that I try to buy several pairs of running shoes at a time and become quite attached to them over the 500 to 1000 miles that I typically put on them. My wife who is also an avid runner has recently convinced me that trail shoes are a good option in addition to the road shoes I’ve typically worn. I’ve been disappointed with new balance 993’s in recent memory and I don’t think they offer the performance justified by their price any longer.
This winter, for training I am using a pair of 4 from Joe’s new balance outlet. I have also obtained MEN’S NEW BALANCE 690 V2. The former pair is a typical road shoe at the higher end of the new balance spectrum but still reasonably priced when on clearance. The latter is a trail shoe. Both shoes have an appropriate last for my foot and fit well.
I will say that the trail shoe (690 V2 Trail) is the more comfortable of the 2 shoes right out of the box. Shortly after purchasing my 1st set, there was a closeout and I was able to get a 2nd set for less than the 1st.
I’m casually aware of the association of plasticizers and loss of elasticity with age. Anyone with a car old enough to have a crack in the dashboard understands this principle. Plasticizers evaporate or become hard over time and whether this remains true for running shoes is a question of debate. I have decided to undertake an experiment with my trail shoes where over the winter, one pair of shoes will be actively used while the other are vacuum sealed to prevent loss of elasticity which would theoretically be due to evaporative causes. Vacuum sealing works well in food medium which is probably a more critical test. This post will serve as documentation to assess whether the seal holds and whether the shoes feel “factory fresh” when they come out of the box. I’ve attached some pictures as documentation of the process.