Cutaneous toxicity of oral low-dose methotrexate.

Chemotherapy-induced acral erythema has been a known side effect of intravenous dosing but has not been reported with oral therapy. Herein we describe two patients receiving treatment with low-dose oral methotrexate who presented with acral erythema. Clinicians and rheumatologists should be aware of this potentially serious side effect of oral chemotherapy in various patient populations. This complication related to methotrexate, though rare, should be anticipated in patients on multiple medications who develop mucocutaneous toxicities.

Persistent Median Artery As A Cause Of Nonmaturing AV Fistula.

A 68-year-old right handed male with End-Stage Renal Disease with a left radiocephalic fistula created 8 months ago was referred for the evaluation of a nonmaturing access. Patient had an arterial anastomosis lesion that underwent successful angioplasty. Diagnostic arteriogram of the AV access extremity revealed the presence of a short radial artery and dominant common interosseous artery manifesting as a persistent median artery in the distal forearm and was anastomosed to the fistula and then continues as the median-ulnar superficial arch in the palm. Balloon angioplasty of the common interosseous artery led to a complication when the distal 30 cm of the 0.018 guide wire fractured and had to be retrieved using a snare device. In addition to anticipating and treating the common complications of vascular access procedures, it is also important to be aware of the anomalies of the distal forearm arterial anatomy and perform a detailed arterial evaluation prior to creating the arterio-venous anastomosis.

Obstructive sleep apnea: a cardiopulmonary perspective and medical therapeutics.

The clinical importance of obstructive sleep apnea (OSA) is gradually rising to the extent that many clinicians now consider OSA as an underlying etiology or precipitating factor for many cardiovascular and pulmonary events. Although the incidence and pathophysiology underlying these cardiopulmonary structural and functional abnormalities are not well defined, various mechanisms are hypothesized. These include but are not limited to sympathetic activation, oxidative stress, inflammation, and endothelial dysfunction. Given the rising awareness of OSA, it is timely to review the effects of OSA on cardiovascular complications like arrhythmias and ventricular remodeling. In the later part of the review, we focused on the role of therapeutics in the management of patients with OSA. Although the role of medical therapeutics is not well defined, we reviewed the available literature focusing on the available options, supporting evidence and their role in specific subgroup of patients with OSA.

Cyclophosphamide therapy in granulomatous hepatitis: cure or culprit?

Three months after diagnosis of Wegener granulomatosis, an 84-year-old woman who was treated with cyclophosphamide (CPY) and prednisone developed deranged liver function tests (LFTs). Treatment with CPY was held, which led to normalization of LFTs, but after reinitiating of CPY, LFTs started increasing. Liver biopsy showed noncaseating epithelioid granulomas within liver lobules consistent with granulomatous hepatitis. Patient died within 2 months secondary to liver failure. This elevation of transaminases was considered to be secondary to CPY-induced hepatotoxicity. Involvement of liver in patients with Wegener granulomatosis is seen but it presents with necrotizing granulomatous vasculitis. CPY-induced hepatitis is an extremely rare phenomenon with only 1 case reported in literature. Clinicians and hepatologists should be aware of this potentially serious complication when CPY therapy is initiated. Baseline LFTs and periodic assessment are recommended before and during treatment with CPY.