Dinkar Kaw

Hydralazine-induced ANCA vasculitis with pulmonary renal syndrome: a rare clinical presentation

Hydralazine is a commonly used drug for treatment of hypertension and is known to cause drug-induced lupus erythematosus. It has rarely been reported to cause anti neutrophil cytoplasmic antibody positive vasculitis, a life-threatening complication. Presentation could be extremely variable delaying diagnosis. Although drug-induced vasculitis has been infrequently associated with rapidly progressing glomerulonephritis, pulmonary involvement presenting as pulmonary renal syndrome is extremely rare. We report a case of hydralazine-induced vasculitis presenting as pulmonary renal syndrome with fatal outcome even after aggressive treatment. Numerous antibodies are associated with hydralazine including anti myeloperoxidase antibody, anti-nuclear antibody, anti-histone antibody, and anti-elastase antibody. Additionally, we also report the presence of anti-phospholipid antibodies specific to anti-cardiolipin, anti-beta2 glycoprotein, and anti-phosphatid that have not been previously reported. We conclude that early diagnosis and prompt discontinuation of the drug is necessary for the treatment of hydralazine-induced anti neutrophil cytoplasmic antibody vasculitis.

Evaluation and enhancement of medical knowledge competency by monthly tests: a single institution experience.

Background In-training examination (ITE) has been used as a predictor of performance at the American Board of Internal Medicine (ABIM) certifying examination. ITE however may not be an ideal modality as it is held once a year and represents snapshots of performance as compared with a trend. We instituted monthly tests (MTs) to continually assess the performance of trainees throughout their residency. Objective To determine the predictors of ABIM performance and to assess whether the MTs can be used as a tool to predict passing the ABIM examination. Methods The MTs, core competencies, and ITE scores were analyzed for a cohort of graduates who appeared for the ABIM examination from 2010 to 2013. Logistic regression was performed to identify the predictors of a successful performance at the ABIM examination. Results Fifty-one residents appeared for the ABIM examination between 2010 and 2013 with a pass rate of 84%. The MT score for the first year (odds ratio [OR] =1.302, CI =1.004–1.687, P=0.04) and second year (OR =1.125, CI =1.004–1.261, P=0.04) were independent predictors of ABIM performance along with the second-year ITE scores (OR =1.248, CI =1.096–1.420, P=0.001). Conclusion The MT is a valuable tool to predict the performance at the ABIM examination. Not only it helps in the assessment of likelihood of passing the certification examination, it also helps to identify those residents who may require more assistance earlier during their residency. It may also highlight the areas of weakness in program curriculum and guide curriculum development.

Rebuttal: Relationship of left ventricular hypertrophy, age, and renal artery stenosis

WereceivedtheletterbyBarbaroandcolleagueswithgreat interestandarehappytoclarifysomeofthepointsraised.We agree with them that age likely plays a role in left ventricular hypertrophy (LVH)in this population.However, arecentsystematic review of 37,700 adult and elderly, both treated and untreated, demonstrated that the prevalence of LVH ranged from 36% to 41%. 1 Our study showed an even higher prevalence of LVH in individuals with renal artery stenosis. They also pointed out that a prior study had demonstrated noreductioninleftventricularmassindexafterrevascularizationofrenalarterystenosis. 2 Thisstudyexcludedsevererenal artery stenosis patients, and the degree of functional stenosis was unclear. However, we would also concur more broadly with Barbaro and colleagues that renal artery stenting has notbeenshowntohavebenefitoverstandardmedicaltherapy for the prevention of clinically important adverse events. 3

HEMATOLOGY: ISSUES IN THE DIALYSIS PATIENT: Platelet Dysfunction and End-Stage Renal Disease: PLATELET DYSFUNCTION AND ESRD

Patients with end‐stage renal disease (ESRD) develop hemostatic disorders mainly in the form of bleeding diatheses. Hemorrhage can occur at cutaneous, mucosal, or serosal sites. Retroperitoneal or intracranial hemorrhages also occur. Platelet dysfunction is the main factor responsible for hemorrhagic tendencies in advanced kidney disease. Anemia, dialysis, the accumulation of medications due to poor clearance, and anticoagulation used during dialysis have some role in causing impaired hemostasis in ESRD patients. Platelet dysfunction occurs both as a result of intrinsic platelet abnormalities and impaired platelet–vessel wall interaction. The normal platelet response to vessel wall injury with platelet activation, recruitment, adhesion, and aggregation is defective in advanced renal failure. Dialysis may partially correct these defects, but cannot totally eliminate them. The hemodialysis process itself may in fact contribute to bleeding. Hemodialysis is also associated with thrombosis as a result of chronic platelet activation due to contact with artificial surfaces during dialysis. Desmopressin acetate and conjugated estrogen are treatment modalities that can be used for uremic bleeding. Achieving a hematocrit of 30% improves bleeding time in ESRD patients.