Intravenous substance abuse and a presacral mass.
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Abscess↗
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Group A beta-hemolytic streptococcal bacteremia and intravenous substance abuse. A growing clinical problem?
Over an 18-month period, the incidence of group A beta-hemolytic streptococcal bacteremia rose from an average of 2.5 per 10,000 patient discharges to 17.9. A retrospective analysis was performed comparing patients with group A beta-hemolytic streptococcal bacteremia during this 18-month period with those who presented over the preceding 36 months. Most of the increased incidence was attributable to individuals hospitalized with a diagnosis of drug addiction who had concomitant soft-tissue infection, although the absolute number of hospitalized drug addicts did not change during this interval. No common or distinctive group A streptococcal serotypic patterns were discovered. This experience suggests that group A beta-hemolytic streptococcal bacteremia and soft-tissue infection may present in epidemic fashion among parenteral drug addicts in the absence of a common source.
Adult↗
Polychondritis resulting from intravenous substance abuse.
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Adult↗
Acute aortic occlusion secondary to Aspergillus endocarditis in an intravenous drug abuser.
A 55-year-old black man, an intravenous substance abuser who had an acute arterial embolus to the distal aorta originating from his mitral valve, was noted on pathologic examination of the clot to have aspergillosis emboli. The infective endocarditis also resulted in emboli to the brain with subsequent death.
Acute Disease↗
Doubling skeletal mass during adult life: the syndrome of diffuse osteosclerosis after intravenous drug abuse.
A former intravenous substance abuser, seropositive for hepatitis C virus infection, was referred for diffuse osteosclerosis. There was no history of fracture or skeletal deformity. Cortical and trabecular bone density was approximately twice the mean value for controls. Skeletal histology revealed dense lamellar bone. Recognized causes of acquired generalized osteosclerosis or hyperostosis were excluded. This patient verifies the syndrome of painful diffuse osteosclerosis after intravenous drug abuse and shows that skeletal mass can be markedly increased with histologically normal, structurally sound bone during adult life. Elucidation of the etiology and pathogenesis could offer an effective treatment for osteoporosis.
Absorptiometry, Photon↗
Massive hemoptysis in pregnancy treated with bronchial artery embolization.
Massive hemoptysis is a life-threatening situation that rarely complicates pregnancy. Presented is a case of massive hemoptysis during pregnancy, which was successfully diagnosed and treated with bronchial artery angiogram and embolization. A 26-year-old multigravida at 19 weeks' gestational age with a history of intravenous substance abuse and infective endocarditis presented with hemoptysis. Extensive workup, including bronchoscopy, echocardiography, and magnetic resonance pulmonary angiography were negative. The patient left the hospital against medical advice to return 4 weeks later with massive hemoptysis. Bronchial arteriography revealed multiple areas of potential bleeding in the right and left lower lobes. Bilateral bronchial artery embolization was performed. The patient carried the pregnancy to term with no further episodes of hemoptysis. Hemoptysis during pregnancy requires a thorough workup and prompt treatment if the etiology is diagnosed. When faced with massive hemoptysis, the obstetrician should strongly consider bronchial artery angiography and embolization.
Adult↗
Positive captopril renal scintigraphy in a patient with extensive bilateral renal interlobar arterial disease.
The authors determined an unusual cause of renovascular hypertension in a 29-year-old man with the recent onset of hypertension and a history of intravenous substance abuse. Captopril renal scintigraphy (CRS) demonstrated bilateral renogram changes and a decrease in estimated global glomerular filtration rate. The abdominal aortogram failed to show renal artery or branch artery stenosis. Magnified selective views of the kidneys demonstrated extensive, bilateral, small vessel interlobar disease. Two major points are illustrated in this patient. First, in the presence of positive CRS results and a history of renovascular hypertension, bilateral, selective, magnified renal angiography should be performed in accordance with standard abdominal aortic views when large vessel disease is not detected. Second, although surgical intervention is not an option in such patients, finding the cause of hypertension is important for patient management.
Adult↗
Ethical decision-making when caring for the noncompliant patient.
Ethical dilemmas frequently occur when nurses care for patients with a history of intravenous substance abuse who are hospitalized on medical-surgical units. This article discusses the recent findings on substance abuse, including its impact on the brain, effects on society and healthcare, available treatment options, and medical complications related to substance abuse. An ethical model is introduced to analyze ethical dilemmas with an accompanying case scenario. Resources available to nursing staff in many healthcare settings are identified as well as strategies to improve nursing care for this challenging population. The purpose of this article is to reduce nurses' feelings of frustration and stress in order to improve their morale. Finally, this particular contemporary ethical issue will be viewed as if perceived by Florence Nightingale.
Adult↗
Percutaneus translumbar inferior vena cava venous access in an intensive care patient.
We report the case of a critically ill 30-year-old chronic haemodialysis patient with a history of intravenous substance abuse whose intravenous access sites had become exhausted. She subsequently underwent elective insertion of a percutaneous translumbar inferior vena caval paired Tesio catheter and peripherally inserted central catheter (PICC line). This technique has been used successfully in patients who require longstanding central venous access (hyperalimentation, chemotherapy, chronic renal hemodialysis patients). This approach could be an alternative where the standard access routes have become non-viable.
Adult↗
[HIV and pregnancy].
Since 1990 216 HIV-infected pregnant women have been enrolled in an ongoing nationwide study named "HIV and Pregnancy" financed by the Swiss Federal Office of Health (No. 90-7007 and 93-7131). Of a total of 228 recorded pregnancies 154 continued to parturition. Until now it has been definitively established whether or not 89 offsprings have been infected with HIV by their mothers. According to clinical and immunological findings most of the pregnant women are still in early, stable stages of HIV-infection (stages II and III of the CDC classification system in 94% of the subjects; mean CD4-cell count around 600/microliters). HIV infection was the consequence of an intravenous substance abuse in two thirds of the women. Detailed interviews revealed an alarming negligence with regard to compliance with safer sex recommendations and contraception. Advisory services of specialized AIDS information centers have very rarely been called on. In our group, the vertical transmission rate shows a statistically significant correlation with low maternal anti-HIV-p24 antibody titers, high serum neopterin- and IgA-concentrations, and also with the use of forceps and vacuum in vaginal delivery. Maternal substance abuse but not HIV infection itself resulted in an incidence of preterm deliveries roughly twice as high as in the normal Swiss population.
Abortion, Induced↗
A potential vaccine for cocaine abuse prophylaxis.
Presently, there are estimated to be 1.5 to 2.0 million individuals infected with HIV-1 in the U.S. and about 12 million worldwide. In the U.S. over 90% of reported cases of AIDS occurred among two subgroups, homosexual males and intravenous substance abusers (IVSAs). Currently, there is no anti-cocaine addiction medication available. In order to explore vaccination as an alternative means for protection against cocaine addition, we immunized inbred male Fisher rats with either cocaine emulsification in complete Freund adjuvant (CFA) or with cocaine conjugated with keyhole limpet hemocyanin (KLH), as carrier plus CFA. Animals were initially immunized with 0.1 mg/animal of cocaine or cocaine-KLH. Animals were given a booster with the corresponding agents after 4 weeks. Ten animals/group were used. Controls received normal saline at the time of immunizations. These animals were injected, intraperitoneally, with 25 mg/kg of cocaine, and were examined for the analgesic effect of cocaine by the hot plate method. The average analgesic effect of cocaine was significantly reduced (p greater than 0.03) in animals immunized with cocaine-KLH (13.77 s) as compared to saline controls (21.6 s). Fifty percent of the animals (5/10) in the cocaine-KLH group and 33% of the animals (3/9) in the cocaine immunized group appeared completely resistant to the effect of cocaine on the central nervous system (CNS). We also have determined the levels of cocaine-specific antibodies produced by each animal by an ELISA method. Degree of protection from cocaine seems to correlate well with the amount of anti-cocaine antibodies produced by each animal (-0.61).(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Dexmedetomidine in the treatment of withdrawal syndromes in cardiothoracic surgery patients.
Dexmedetomidine (Precedex, Abbott Laboratories, Abbott Park, IL) is an alpha 2 adrenergic agonist that possesses a high ratio of specificity for the alpha 2 versus the alpha 1 receptor. It is currently approved for the provision of sedation during mechanical ventilation in adults. Given previous experience with clonidine for the treatment of substance withdrawal and the preliminary anecdotal experience with dexmedetomidine, it appears that dexmedetomidine may be a useful agent for treatment of substance withdrawal in the intensive care setting. The authors present their experience with the use of dexmedetomidine to control withdrawal behavior in 3 patients following cardiothoracic surgery. Previous reports regarding the use of dexmedetomidine to treat withdrawal and its potential application in this clinical arena are reviewed.
Adolescent↗
Intravenous morphine increases glucose utilization in the shell of the rat nucleus accumbens.
The [14C]2-deoxyglucose method was applied to measure the effects of the acute intravenous administration of morphine sulphate (0.2-0.4 mg/kg) on cerebral glucose utilization in rats. Morphine produced dose-dependent increases of glucose metabolism in the shell of the nucleus accumbens, without affecting functional activity in any other brain area. These results provide further evidence for the preferential effects of intravenously abused substances in the shell of the nucleus accumbens.
Animals↗
Management of hospitalized intravenous drug users: role of the internist.
Intravenous drug users present significant clinical challenges to internists. In this paper, we review common clinical dilemmas faced by internists when managing intravenous drug users in the inpatient hospital setting. Articles were identified through a MEDLINE search and bibliographies of published articles. Studies and reviews were selected for information relevant to the management of hospitalized intravenous drug users. Seventy-three papers were selected for this review. We summarize data and information from the relevant literature concerning common presenting medical problems (fever, musculoskeletal pain, and dyspnea), the importance of knowing patients' HIV status, common behavioral issues, special concerns of women, and the diagnosis and management of drug withdrawal in intravenous drug users. We also offer recommendations for hospital discharge planning. With appropriate knowledge of the epidemiology and management of important medical and substance use problems among intravenous drug users, internists may more effectively care for them in the hospital setting.
Dyspnea↗
Event-related potential changes in cocaine withdrawal: evidence for long-term cognitive effects.
The effects of cocaine withdrawal on the latency of the P300 cognitive event-related potential were studied in 36 subjects. All subjects had used cocaine within 48 h of admission to an inpatient unit. P300 was recorded in a traditional auditory oddball paradigm 2 and 6 days following admission. P300 latency decreased from day 2 to day 6 in subjects with a history of intravenous use, but was unchanged in subjects who had only used cocaine orally. The neurotransmitter systems mediating this effect, and the differential cognitive effects of route of administration are discussed.
Adolescent↗
Simulated opioid withdrawal engenders risk-prone choice: a comparison of intravenous and intranasal-using populations.
Risk-sensitive foraging theory refers to a group of different models that predict the occurrence of risk-prone behavior; therefore, these models may help to characterize the risky behavior that is a hallmark of opioid dependence. The daily energy budget (DEB) rule, one model of risk-sensitivity, suggests that foragers will prefer highly variable food sources over less variable ones when all current options provide means that are insufficient to meet metabolic requirements. The tenets of the DEB rule were tested in the context of opioid dependence, the primary hypothesis being that opioid withdrawal may foster risky choice. Intravenous and intranasal-using opioid-dependent patients enrolled in a buprenorphine treatment program read scripts simulating opioid-agonist and -antagonist symptoms, and then made a series of decisions between two different opioid dealers. One dealer provided a constant source of heroin, and the other, a variable source. Separate measures were utilized to expose participants to either variability in delay of opioids or quantity of opioids. Participants were also required to complete a money questionnaire in which two hypothetical slot machines differed in respect to payoff amounts and probabilities. Results demonstrate that preference for the risky option was mediated by hypothetical drug deprivation in all circumstances, but this effect was more considerable in opioid-dependent participants who used intravenously. The current findings suggest that intravenous delivery places greater metabolic constraints on the user and therefore engenders greater risk-taking during withdrawal. The DEB rule is applicable to opioid dependence and provides a useful framework from which to examine the behaviors associated with opioid withdrawal.
Administration, Intranasal↗
Naloxone-induced withdrawal in patients with buprenorphine dependence.
Naloxone-induced withdrawal was studied in seven patients currently dependent only on injecting buprenorphine, within 3 to 6 hours of their last dose. Withdrawal severity began to rise from 5 minutes and reached a peak at 60 minutes after 1.2 mg naloxone given intravenously. The mean withdrawal severity score was significantly higher at 30, 60 and 90 minutes compared to the baseline. The most frequent withdrawal signs and symptoms were mydriasis, systolic hypertension, tachypnoea, muscle pains, yawning, anxiety, restlessness and craving.
Adolescent↗
Emergency management of inadvertent accelerated opiate withdrawal in dependent opiate users.
Six opiate-dependent drug users presented to the local emergency department within a 10-day period with symptoms of severe opioid withdrawal immediately following intravenous use of recently acquired street 'heroin'. The withdrawal picture was similar to that described in patients undergoing rapid opioid detoxification, suggesting that the substance injected was contaminated with an opiate antagonist. A number of potential compounds are discussed, including naltrexone and buprenorphine, and recommendations for the medical management of severe opiate withdrawal within an emergency setting are outlined. [Lubman DI, Koutsogiannis Z, Kronborg I. Emergency management of inadvertent accelerated opiate withdrawal in dependent opiate users.
Adult↗