Transcript The Effects of a Required Autopsy Exercise on Medical

Title Text/Name of Presentation
Presenter's Name, Additional Names
Department of
The University of Texas Medical Branch, Galveston, Texas
Headline
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Drug interaction is a significant problem in
patients who are on multiple medications
especially in the geriatric population.
We report an interesting case of drug
interaction between warfarin and vaginal
miconazole preparation, presenting as a small
bowel intra-mural haematoma necessitating
surgery.
The incidence of intramural haematoma of the
small bowel in the setting of anticoagulation is
a rare but dangerous complication estimated
to be 1 in 25001.
Headline
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Physical examination was notable for tachycardia and mild diffuse abdominal tenderness. Labs showed
an INR >13, hemoglobin of 12.2gm/dl and heme-occult positive stool.
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She was managed conservatively with IV fluids, NPO,6 units of FFP and vitamin K.
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Headline
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Headline
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Intramural bowel hematoma is a rare but
dangerous complication of over
anticoagulation.
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We believe that the addition of miconazole
caused a supratheraputic elevation of INR
resulting in the above condition.
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Exercise caution while adding or removing
drugs in patients on warfarin.
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More frequent monitoring of INR needed till
new steady state is achieved.
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High index of suspicion is needed.
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CT Abdomen is the diagnostic modality of
choice2 .
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Most cases can be managed conservatively
but surgery may be needed if symptoms
worsen3 .
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Even topical and mucosal application of
anti-fungals capable of raising INR to
supatheraputic levels.
18 hrs later abdominal pain worsened along with multiple episodes of vomiting and malena. She now had
diffuse rebound tenderness and orthostatic hypotension. INR decreased to 6 but Hgb dropped to 8.2
gm/dl.
CT abdomen revealed numerous fluid filled loops of small bowel, which were edematous and thickened.
Patient underwent emergent exploratory laparoscopy. Intraoperatively a 20 cm length of jejunum was
hemorrhagic and devitalized requiring resection.
Histopathology revealed an intramural bowel hematoma.
Headline
A 72 yr old Hispanic female with history of
mechanical mitral valve replacement on
warfarin presented with severe abdominal
pain, for 5 days. Her medication included
levothyroxine, candesartan, digoxin,
furosemide, metoprolol, alendronate and
sertraline.
A week prior to presentation, Miconazole 1%
topical cream for vaginal candidiasis was
started by her PCP for vaginal candidiasis.
Patient had been on warfarin for the past 20
yrs with excellent control and her last known
INR which was during the same PCP visit was
2.5
Headline
Photo or Graphic
1 Bettler
S, Montani S, Bachmann F. Incidence of intramural
digestive system hematoma in anticoagulation. Epidemiologic
study and clinical aspects of 59 cases observed in Switzerland
(1970-1975). Schweiz Med Wochenschr 1983;113:630
2
Abbas MA, Collins JM, Olden KW, Kelly KA. Spontaneous
intramural small-bowel hematoma: clinical presentation and
long-term outcome. Arch Surg. 2002;137:306-10
3 Macari
M, Chandarane H, Balthazar and, Babb J. Intestinal
ischemia versus intramural hemorrhage: CT evaluation. AJR
A.m. J Roentgenol. 2003;180:177-84
Title Text/Name of Presentation
Presenter's Name1, Additional Names2
1Department of, 2Department of
The University of Texas Medical Branch, Galveston, TX
Headline
PYLORUS
RAT BRAIN
2Hz
0.1
59.9
D3R
The incidence of intramural haematoma of the small bowel in the
setting of anticoagulation is a rare but dangerous complication
estimated to be 1 in 25001.
41.4
Immunoprecipitated proteins
4 Hz
8 Hz
16 Hz
0.2
103.6
AUC/mg of tissue
•
We report an interesting case of drug interaction between warfarin
and vaginal miconazole preparation, presenting as a small bowel
intra-mural haematoma necessitating surgery.
ANTRUM
(KD)
PYLORUS
ANTRUMa
MW STD
•
Gastric Emptying is significantly delayed in
rats injected with a D3R agonist.
Drug interaction is a significant problem in patients who are on
multiple medications especially in the geriatric population.
RAT BRAIN
•
Results
P=0.011 by two -way ANOVA
0
Krebs
-0.1
D3RA 0.1
-0.2
D3RA 1.0
-0.3
D3RA 10.0
-0.4
-0.5
Precleared control
-0.6
Aim
To investigate the effect of selective activations of the D3 receptor
(D3R0 on gastric motility in the rat.
Methods
•
•
•
Drug interaction is a significant problem in patients who are on
multiple medications especially in the geriatric population.
We report an interesting case of drug interaction between warfarin
and vaginal miconazole preparation, presenting as a small bowel
intra-mural haematoma necessitating surgery.
The incidence of intramural haematoma of the small bowel in the
setting of anticoagulation is a rare but dangerous complication
estimated to be 1 in 25001.
We report an interesting case of drug interaction between
warfarin and vaginal miconazole preparation, presenting as a
small bowel intra-mural haematoma necessitating surgery.
Drug interaction is a significant problem in patients
who are on multiple medications especially in the
geriatric population.Drug interaction is a significant
problem.
Gastric Emptying is significantly delayed in
rats injected with a D3R agonist.
Conclusions
100%
90%
% gastric emptying
•
Drug interaction is a significant problem in patients
who are on multiple medications especially in the
geriatric population.Drug interaction is a significant
problem.
*
80%
70%
**
60%
•
Our data show that activation of D3R impairs pyloric relaxation
of D3R impairs pyloric relaxation
•
We report an interesting case of drug interaction between
warfarin and vaginal miconazole preparation, presenting as a
small bowel intra-mural haematoma necessitating surgery.
•
The incidence of intramural haematoma of the small bowel in the
setting of anticoagulation is a rare but dangerous complication
estimated to be 1 in 25001.
50%
40%
30%
20%
10%
0%
PBS
*P<0.05
**P<0.001
one-way ANOVA
D3R agonist
0.2 mg/kg
D3R agonist
0.5 mg/kg
D3R agonist 1
mg/kg
Title Text/Name of Presentation
Presenter's Name1, Additional Names2
1Department of, 2Department of
The University of Texas Medical Branch, Galveston, TX
Headline
PYLORUS
(KD)
RAT BRAIN
MW STD
ANTRUM
We report an interesting case of drug interaction between warfarin
and vaginal miconazole preparation, presenting as a small bowel
intra-mural haematoma necessitating surgery.
PYLORUS
•
Gastric Emptying is significantly delayed in
rats injected with a D3R agonist.
D3R is present in the rat stomach
RAT BRAIN
Drug interaction is a significant problem in patients who are on
multiple medications especially in the geriatric population.
ANTRUMa
•
Results
2Hz
0.1
AUC/mg of tissue
The incidence of intramural haematoma of the small bowel in the
setting of anticoagulation is a rare but dangerous complication
estimated to be 1 in 25001.
D3R
41.4
Immunoprecipitated proteins
Precleared control
•
•
•
•
Drug interaction is a significant problem in patients who are on
multiple medications especially in the geriatric population.
We report an interesting case of drug interaction between warfarin
and vaginal miconazole preparation, presenting as a small bowel
intra-mural haematoma necessitating surgery.
The incidence of intramural haematoma of the small bowel in the
setting of anticoagulation is a rare but dangerous complication
estimated to be 1 in 25001.
We report an interesting case of drug interaction between
warfarin and vaginal miconazole preparation, presenting as a
small bowel intra-mural haematoma necessitating surgery.
P=0.011 by two -way ANOVA
0
Krebs
-0.1
D3RA 0.1
-0.2
D3RA 1.0
-0.3
D3RA 10.0
-0.4
-0.6
Drug interaction is a significant problem in patients
who are on multiple medications especially in the
geriatric population.Drug interaction is a significant
problem.
Drug interaction is a significant problem in patients
who are on multiple medications especially in the
geriatric population.Drug interaction is a significant
problem.
Gastric Emptying is significantly delayed in
rats injected with a D3R agonist.
Conclusions
100%
90%
% gastric emptying
Methods
16 Hz
-0.5
Aim
To investigate the effect of selective activations of the D3 receptor
(D3R0 on gastric motility in the rat.
8 Hz
0.2
103.6
59.9
•
4 Hz
*
80%
70%
•
Our data show that activation of D3R impairs pyloric relaxation
of D3R impairs pyloric relaxation
•
We report an interesting case of drug interaction between
warfarin and vaginal miconazole preparation, presenting as a
small bowel intra-mural haematoma necessitating surgery.
•
The incidence of intramural haematoma of the small bowel in the
setting of anticoagulation is a rare but dangerous complication
estimated to be 1 in 25001.
**
60%
50%
40%
30%
20%
10%
0%
PBS
*P<0.05
**P<0.001
one-way ANOVA
D3R agonist
0.2 mg/kg
D3R agonist
0.5 mg/kg
D3R agonist 1
mg/kg
Title Text/Name of Presentation
2nd line available for title
Presenter's Name, Additional Names
Internal Medicine
The University of Texas Medical Branch, Galveston, TX
Headline
CC: Fever
HPI: A 33-year-old man who presented to our hospital
with fever, chills, rigors x 2 weeks. He had
associated weight loss, nausea, vomiting.
PMH: Diabetes mellitus type 2
Schizoaffective disorder
SH: Smoking: 30 pack years
ETOH: Occasional IV Drug Use: Cocaine, last
used 5 weeks prior to admission
PE: T 40°C
80bpm
BP 130/80mmHg
RR19/min
Endocarditis in IV Drug User
• Right sided involving tricuspid valve
• Persistent fever and pulmonary symptoms
• Most common cause is Staphylococcus aureus
IMAGES
Headline
Headline
Photo or Graph
Photo or Graph
Pulse
Findings of Note:
Lungs: Clear to auscultation bilaterally
CV: II/VI Holosystolic murmur at lower left sternal
border
Headline
CBC
• WBC 15.1Kcells/ml
90.8% granulocytes
6.3% lymphocytes
2.5% monocytes
Increased bands
• Hg 10.3
BLOOD CULTURES
• Actinomyces odontolytica,
• Veillonella species
• Prevotella melaninogenica
• HACEK organisms negative after 6 weeks
incubation
Multiple cavitary lesions in both
lungs
Largest in left lower lobe (3.2cm)
Headline
Modified Parasternal Long Axis View
Echodense mobile structure on anterior
leaflet of TV
Unusual Organisms & Unusual Practices
• Neisseria sicca found to cause IE in IVDA who licks
blood off
needle of an unsuccessful stick before next attempt.1
• Haemophilus parainfluenzae found to cause IE in
IVDA blows
into and sucks on needles to ensure patency.2
• Pseudomonas species found to cause IE in IVDA
who washes
needle in contaminated water.3
Causative Organisms in Our Patient
• Actinomyces odontolytica, Veillonella species and
Prevotella
melaninogenica are oral anaerobes.
• Anaerobes cause peridontal disease, dental plaque,
pleuropulmonary disease, abscesses, genital tract
infections.
• A part of a cluster of organisms on the dorsal and
lateral
surfaces of the tongue as compared to other
organisms and
other locations.4
Headline
Headline
• Patient was re-interviewed regarding his IV drug use habits.
• The patient admitted to reusing needles and routinely licking the needle to dorsum
of tongue before inserting it into his arm.
• The numbing effect of the cocaine on his tongue allows him to determine the
quantity of cocaine that he will inject into his bloodstream for desired effects.
• Contamination from oral flora and polymicrobial
•
endocarditis should be considered in an IVDA with
anaerobic bacteremia.
We emphasize the importance of obtaining a
detailed history of the intravenous drug abuse.,
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