Acute myocardial infarction associated with initial cocaine use

We have described a young man who had acute myocardial infarction after his first use of cocaine. This case demonstrates that potentially lethal myocardial infarctions may be associated with such initial "experimentation" with cocaine even in relatively small doses. Cocaine intoxication should be considered in young patients with acute myocardial ischemia or necrosis. We recommend that cocaine metabolites be checked in the urine if a drug history is unreliable in such patients.     

Myocardial infarction associated with intravenous immune globulin

OBJECTIVE: To report a case of acute myocardial infarction (MI) experienced by a patient receiving intravenous immune globulin (IVIG) and review other published cases of MI associated with IVIG. CASE SUMMARY: An 81-year-old Vietnamese man was prescribed IVIG for treatment of toxic epidermal necrolysis secondary to allopurinol. Thirty minutes following the start of the IVIG infusion, the patient developed crushing retrosternal chest pain and shortness of breath. The pain improved upon discontinuation of IVIG infusion but recurred when IVIG was restarted. The troponin level reached 140 microg/L, and a persantine sestamibi stress test (MIBI) indicated anterolateral ischemia. The patient was diagnos ed with non-ST-elevation MI. An objective causality assessment using the Naranjo probability scale revealed a probable association between this adverse reaction and IVIG treatment. DISCUSSION: Although an association between IVIG administration and MI has not been demonstrated in clinical trials, accumulating clinical experience suggests that a relationship between IVIG and myocardial ischemia exists. Twenty published case reports were identified. Risk of acute MI seems to be increased with use of high-dose IVIG and in older individuals, especially those with at least one cardiovascular risk factor, such as ischemic heart disease or hypertension. CONCLUSIONS: Case reports suggest a causal relationship between the use of IVIG and MI and other thrombotic events. While cardiovascular disease is not considered an absolute contraindication to therapy, expanding indications and subsequent use of IVIG merit that clinicians be aware of patient characteristics that may increase the risk for adverse reactions and recognize early signs of infarction.     

A case off TTP temporally associated with cocaine use: Implications for treatment of suspected DITMA

Thrombotic microangiopathies are rare diseases associated with significant morbidity and mortality. The treatment of thrombotic thrombocytopenic purpura (TTP) and drug-induced thrombotic microangiopathy (DITMA) remains a diagnostic dilemma as they present similarly but respond differently to standard treatment with plasma exchange. TTP is a deficiency of a disintegrin and metalloprotease with thrombospondin type 1 motif 13 resulting in von Willebrand factor aggregates. DITMA is due to vascular and platelet toxicity. Our case contradicts a notion in current literature that suggests supportive therapy when there is high suspicion for DITMA. We present what appears to be the second published case of cocaine temporally associated with TTP. Our case responded to therapy. We propose this case should influence weighing the risks and benefits of treatment of suspected DITMA and reinforces current official guidelines that suggest treating cases of suspected DITMA as TTP until the diagnosis is confirmed.     

Adverse outcomes associated with inappropriate drug use in nursing homes

BACKGROUND: Little empirical evidence exists regarding the influence and outcomes of inappropriate medication use among elderly nursing home residents. OBJECTIVE: To identify the prevalence of inappropriate medication use among elderly patients in Georgia nursing homes using the Beers criteria and identify the relationship between inappropriate drug use and the likelihood of an adverse health outcome. METHODS: A cohort design was used to review 1117 patient medical records in 15 Georgia nursing homes with a high risk of polypharmacy. Prevalence of inappropriate medication use among elderly patients, as defined by the Beers criteria, was estimated. The adverse health outcomes of hospitalizations, emergency department visits, or deaths were identified from Medicaid claims data. RESULTS: A total of 519 (46.5%) patients received at least one inappropriate medication and 143 (12.8%) patients experienced at least one adverse health outcome. Logistic regression revealed that the total number of medications taken (OR 1.139, 95% CI 1.105 to 1.173) significantly increased the likelihood of receiving an inappropriate drug, while having a diagnosis of "dementia" (OR 0.748, 95% CI 0.565 to 0.991) decreased the likelihood. Inappropriate medication use increased the likelihood of experiencing at least one adverse health outcome more than twofold (OR 2.34, 95% CI 1.61 to 3.40). Propoxyphene use alone was significantly associated with the occurrence of an adverse health outcome (OR 2.39, 95% CI 1.54 to 3.71). CONCLUSIONS: Inappropriate drug use was common in our study cohort. Inappropriate use of medication in the elderly, particularly propoxyphene, is associated with a higher risk of adverse health outcomes.     

Measurement of inappropriate behavior associated with dementia.

Inappropriate behaviors in dementia affect caregivers, causing depression, burden, stress, and affecting caregivers' social life, morale, and somatic health. These behaviors also may signal that the elderly individuals with dementia are distressed and because of a combination of inappropriate behaviors and loss of communication skills, these individuals may not receive adequate assessment or treatment. This article discusses the assessment of behavior problems in elderly individuals suffering from dementia. The following issues are addressed: the need for assessment; difficulties in assessment of inappropriate behaviors; approaches to the assessment of behavior problems, including caregiver ratings, observational methods, and technological devices; and issues in the clinical use of assessments.     

Acute myocardial infarction associated with amphetamine use

Myocardial infarction is a rarely reported complication of amphetamine use. We report the case of a healthy 31-year-old man who presented to our emergency department with no clinical evidence of an acute coronary event after intravenous injection of amphetamines. However, he subsequently experienced a non-Q-wave anterior wall myocardial infarction associated with the use of amphetamines.     

Spontaneous splenic infarction associated with sumatriptan use

Triptans are specific agonists of the serotonergic 5-HT_1B/1D receptors that have increasingly been used in the treatment of migraine and cluster headaches. Though they are generally considered safe, there have been a few reports of myocardial infarction and stroke associated with triptan use. We report a patient who developed spontaneous splenic infarction after the use of sumatriptan for the treatment of migraine headache.     

Cardiovascular disorders associated with cocaine use: myths and truths

Cocaine produces a pattern of cardiovascular responses that are associated with apparent myocardial ischemia, arrhythmias, and other life-threatening complications in some individuals. Despite recent efforts to better understand the causes of cocaine-induced cardiovascular dysfunction, there remain a number of unanswered questions regarding the specific mechanisms by which cocaine elicits hemodynamic responses. This review will describe the actions of cocaine on the cardiovascular system and the evidence for the mechanisms by which cocaine elicits hemodynamic and pathologic responses in humans and animals. The emphasis will be on experimental data that provide the basis for our understanding of the mechanisms of cardiovascular toxicity associated with cocaine. More importantly, this review will identify several controversies regarding the causes of cocaine-induced cardiovascular toxicity that as yet are still debated. The evidence supporting these findings will be described. Finally, this review will outline the obvious deficits in our current concepts regarding the cardiovascular actions of cocaine in hope of encouraging additional studies on this grave problem in our society.     

Acute myocardial infarction following the use of intranasal anesthetic cocaine

The use of cocaine has become largely obsolete in modern medical practice; however, it is still used by otolaryngologists for topical anesthesia in head and neck surgeries. We present the case of a 68-year-old woman who developed a myocardial infarction after the use of topical cocaine during nasal sinus surgery, and review the literature regarding the use of cocaine as a topical anesthetic in otolaryngologic practice. Awareness is raised of a possible complication of myocardial infarction following topical cocaine anesthetic use.