Background: Patients with chronic kidney disease (CKD) manifest an increased prevalence of cardiovascular morbidity and mortality compared with age-matched persons, and this relationship is directly proportional to the severity of CKD. After age, left ventricular hypertrophy (LVH) is considered to be the strongest independent predictor of cardiovascular disease and events, cardiovascular death and total mortality. In CKD patients, LVH contributes to diastolic dysfunction, congestive heart failure, arrhythmia and sudden death. Aim of the Work: The aim of this study is to clarify the relationship between ESRD and left ventricular dysfunction Methods: All patients were subjected to the following :: Complete history and physical examination, Routine laboratory investigations including: Complete blood picture,Blood urea and serum creatinine, Random blood suger, calcium, phosphors,, uric acid urine analysis, PTH Special investigations in the form of 2D echocardiography. Results: The collected data were computerized and statistically analyzed using SPSS program (Statistical Package for Social Science) version 24.

BackgroundThe application of electrical stimulation can lead to a greater and faster increase in the rate of wound healing, especially when applying the cathodal (negative) stimulation for the first week, followed by the anodal (positive) polarity for the rest of the treatment period. AimThe present work aimed to study the effect of polarity reversal of microelectrical current stimulation (MES) on the healing process in an experimentally induced Achilles tendon injury in rats. Materials and methodsForty three male albino rats were used in this study; they were classified into group I (control group) and group II (experimentally injured group), which was further classified into subgroups I, II, III, and IV. Subgroup I represents the injured tendon without MES treatment, whereas subgroups II, III, and IV represent the MES-treated ones. The obtained tendon sections were subjected to H&E staining, Masson's trichrome stain, and immunohistochemical staining for alpha smooth muscle actin (αSMA), followed by morphometric study and statistical analysis. ResultsSubgroup I showed signs of inflammation, a few thin irregularly arranged collagen, active fibroblasts that start to align in rows on the regenerating collagen bundles, and αSMA immunoreactivity. In anodal-treated tendons, signs of inflammation had started to disappear; collagen fibers appeared thin and irregularly arranged, active fibroblasts were obviously observed and minimal αSMA immunoreactivity were recorded only in subgroup II. Cathodal-treated tendons showed rapid disappearance of cellular infiltration; most collagen fibers appeared regularly arranged with mature fibrocytes in between and multiple ovoid αSMA immunoreactive myofibroblasts were maximally observed in subgroup II. Conclusion αSMA was suggested to play a role in wound healing due to its high immunoreactivity in myofibroblasts during wound healing. Moreover, the application of electrical stimulation by applying cathodal (negative) stimulation for the first week, followed by anodal (positive) polarity for the rest of the treatment period may lead to better repaired tissue due to myofibroblast directional attraction to the cathode, especially when applied for 4-week duration.

INTRODUCTION:Levamisole is a contaminant present in street cocaine. It has been associated with a number of clinical side effects, including vasculitis. We present a case of a patient with acute pulmonary, cutaneous and Musculoskeletal symptoms following cocaine use who was found to have an overlap features of Granulomatosis with Polyangiitis (GPA) and Eosinophilic Granulomatosis with Polyangiitis (EGPA). CASE PRESENTATION:A 31 year old male with no past medical history presented with fatigue, polyarthralgia, generalized body ache and scattered blisters over the upper and lower extremities. Days prior to presentation, he used injected cocaine. His vital signs were notable for tachycardia (140s). Exam was notable for swollen hand joints, scabbed lesions over the arms and legs. WBC was 21 with Absolute Eosinophil count 8.23 . Serum IgE was 1500. Urine toxicology was positive for cocaine metabolites. CXR showed multiple bilateral infiltrates. During hospitalization, he continued to have severe polyarthralgia. He developed worsening cough with small volume hemoptysis. CT of the chest showed bilateral patchy peripheral infiltrates. Bronchoscopy with Bronchoalveolar Lavage (BAL) revealed bloody secretions not meeting criteria for DAH. BAL sample had 107 cells with 80% eosinophils. Extensive infectious, hypersensitivity and autoimmune workup was sent. Results returned positive for C-ANCA and Anti-PR3. He underwent left lung wedge biopsy which revealed Active Interstitial Pneumonitis with marked intra-alveolar and interstitial eosinophilia that was more consistent with Eosinophilic Granulomatosis with Polyangiitis. This lead to a diagnosis overlap syndrome of GPA and EGPA that was likely Levamisole induced. DISCUSSION: Our case illustrates drug induced systemic ANCA vasculitis with overlap features of Granulomatosis with Polyangiitis (GPA) and Eosinophilic Granulomatosis with Polyangiitis (EGPA) following cocaine use . Levamisole is a synthetic imidazothiazole analogue that has immunomodulatory properties. It is currently being used as an anthelmintic agent in veterinary medicine. It is a frequent contaminant of street cocaine. It has been associated with a number of side effects including vasculitis. Our patient presented with Pulmonary, cutaneous and musculoskeletal manifestations after cocaine use. Elevated C-ANCA along with presence of peripheral eosinophilia, marked IgE elevation and lung tissue biopsy finding of eosinophilic interstitial pneumonitis lead to a diagnosis of drug induced GPA/EGPA overlap syndrome. Rare reports of similar syndrome were rported but none of which were drug induced.CONCLUSIONS: This case highlights the importance of considering substance induce Autoimmune conditions in patients presenting with multisystem syndrome with pulmonary involvement. Levamisole which is a contaminant present in cocaine can induce ANCA associated vasculitis with variable manifestations.

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