Diagnosis of Granulocytic Ehrlichiosis in Humans by Immunofluorescence Assay

Serodiagnostic tests are widely available for tick-borne diseases. We evaluated a cell-free antigen of the human granulocytic ehrlichiosis agent. Immunofluorescence assay (IFA) with this antigen is as efficient as with the MRL kit and allows a one-step IFA with other cell-free antigens that is useful when testing sera from patients bitten by ticks.     

Naltrexone augmentation of neuroleptic treatment in alcohol abusing patients with schizophrenia

Objective Alcohol abuse in patients with schizophrenia is associated with psychiatric and social complications. While two medications have been approved by the Federal Drug Administration (FDA) for the treatment of alcoholism: disulfiram and naltrexone, no medications have been approved for individuals with alcohol dependence and comorbid schizophrenia. The purpose of this study was to evaluate the efficacy of naltrexone in alcohol-abusing schizophrenic patients.Method Thirty-one patients with schizophrenia and comorbid alcohol abuse or dependence were treated for 12 weeks in an outpatient study using naltrexone or placebo in a randomized, double-blind fashion in addition to their neuroleptic medication. Patients also participated in a weekly therapy using cognitive-behavioral drug relapse prevention strategies combined with skills training. Outcomes included drinking measured by the time line follow-back method, craving using the Tiffany Craving Questionnaire, psychotic symptoms using the Positive and Negative Symptoms Scale (PANSS), side effects and a measures of abnormal involuntary movements.Results There were no significant differences in treatment exposure or medication compliance between groups. Naltrexone treated patients had significantly fewer drinking days, heavy drinking days (>5 drinks) and reported less craving compared to the placebo treated patients. Naltrexone did not affect symptoms of schizophrenia, such as psychosis. The medication was well tolerated and there were no group differences in side effects.Conclusions These data suggest that naltrexone may be an effective medication for individuals with comorbid alcohol dependence and schizophrenia. Given the widespread problems associated with alcohol misuse in this population, and the lack of effective pharmacotherapies, these findings represent an exciting clinical development.An erratum to this article can be found at Preliminary results from this study were presented at the Society of Biological Psychiatry 57th Annual Scientific Convention, Philadelphia, Pa., USA in May 2002. The VA Naltrexone Study Collaboration Group: West Haven: Diana Congdon, Ned Cooney, Roberto Gil, Kathy Keegan, Debra Miles, Alison Oville, Barbara Peluse, Louis Trevisan; Northampton: Lynn Gordon, John Reino, Wayne Costello, Christopher Cryan; Bedford: Nitigna Desai, Marylee Losardo, Doreen Farrell, Barbara E. Rofman. W. Costello is deceased.     

The heart in neurofibromatosis type 1: an echocardiographic study

Background Comprehensive data are unavailable for cardiac abnormalities in patients with neurofibromatosis type 1 (NF1). The goal of this study was to evaluate the prevalence of cardiovascular abnormalities with echocardiography with color Doppler scan (ECHO) in a large, consecutive series of patients with NF1. Methods We studied 48 patients with NF1 (mean age, 10 years). Thirty healthy subjects comparable for age and sex served as the control group. All ECHO studies were performed by the same cardiologist and reviewed by a second cardiologist blinded to the physical findings of the subjects. Results Cardiac abnormalities were found in 13 of the 48 young patients (27%). A secundum atrial septal defect with a left to right shunt was found in 2 children. ECHO evidence of mild left pulmonary artery stenosis was found in 1 participant. A moderate coarctation of the thoracic aorta was found in 1 patient. ECHO criteria for mitral valve prolapse and evidence of trivial mitral regurgitation with myxomatous mitral valve was present in 1 case. Mild mitral regurgitation was found in 2 patients. A regurgitant mild flow signal was detected from the aortic valve in 2 subjects. Atrial septal aneurysm was found in 2 patients without patent foramen ovale. Two patients had septal to posterior left ventricular free wall ratio greater than 1.5, suggesting hypertrophic cardiomyopathy. Conclusion This is the first attempt to evaluate the prevalence of cardiovascular abnormalities in patients with NF1 with ECHO. The study's most striking finding is the high prevalence of cardiovascular abnormalities. Congenital lesions have potential long-term hemodynamic consequences that justify an early diagnosis. Thus, a cardiologic assessment at regular intervals, including ECHO study, is mandatory for patients with NF1. (Am Heart J 2002;143:883-8.)     

Prevalence and clinical relevance of the morphological substrate of ventricular arrhythmias in patients without known cardiac conditions detected by cardiovascular MR

Objective

Cardiac MR (CMR) identifies the substrate of ventricular arrhythmia (VA) in cardiomyopathies and coronary heart disease. However, little is known about the value of CMR in patients with VA without previously known cardiac disorders.

Methods

76 patients with VA (Lown ≥2) without known cardiac disease after regular diagnostic work-up were studied with CMR, and findings were correlated with electrocardiogram (ECG) and electrophysiological stimulation (EPS). Structural abnormalities matching the VA origin as defined by ECG and/or EPS, or a CMR-detected cardiac condition known to cause arrhythmia were defined as VA substrate. CMR findings were defined as clinically relevant, if resulting in a new diagnosis, change of treatment or additional diagnostic procedure.

Results

44/76 patients demonstrated pathological CMR findings. In 24/76 patients, the pathology was detected by CMR and not by echocardiography. CMR-based diagnoses of cardiac disease were established in 20/76 patients, and all were morphological substrates for VA. In seven patients, the location of the CMR finding (scar) directly matched the VA origin. CMR findings resulted in a change of treatment in 21 patients and/or additional diagnostics in 8 patients.

Conclusion

Undetected cardiac conditions are frequent causes of VA. This is the first study demonstrating the value of CMR for detection of morphological substrate and/or underlying cardiac disorders in VA patients without known cardiac disease.

Advances in knowledge

The high incidence of clinically relevant CMR findings which were not detected during initial diagnostic work-up strongly supports the use of CMR to screen VA patients for underlying heart disease.Although the value of cardiac MR (CMR) for the diagnosis of cardiac diseases such as myocarditis is undisputed, CMR is also predictive of patients at high risk for ventricular arrhythmias (VAs) with conditions such as hypertrophic cardiomyopathy (HCM) and coronary heart disease (CHD).^1–3 Recent studies have demonstrated the ability of CMR to identify the anatomical correlate of VA in those patients. This anatomical correlate has been characterized by CMR as a structural abnormality (e.g. fibrosis or peri-infarct region), which may go undetected using other non-invasive imaging modalities.^4,5 A number of studies have been undertaken, or are ongoing, to further elucidate the added value of CMR in patients with known cardiac conditions, to improve risk stratification for VA and to optimize therapy.^1,6–8 However, little is known to date regarding the added value of CMR for detection of an arrhythmogenic substrate or underlying cardiac condition in patients who present with VAs without known cardiac disease.Thus, the purpose of this study was to investigate the added value of CMR in patients with VAs for detection of underlying heart disease and an arrhythmogenic morphological substrate, and also to investigate the clinical relevance of CMR in those patients with positive findings.     

Second-degree burn induced by high-concentration topical capsaicin with mobility sequelae: A case report

High-concentration topical capsaicin is used as a second-line treatment for neuropathic pain. Transient, mild burning sensation and erythema are expected adverse drug reactions. Here, we report the first case of second degree burn after the application of a high-concentration topical capsaicin patch with secondary mobility sequelae. Nine months after the application, neuropathic pain still remained and the patient described mobility difficulties in daily activities, preventing her from returning to work. This report aims to raise the question of the benefit/risk ratio of high concentration topical capsaicin.     

Bleeding risk with concurrent use of anticoagulants and ibrutinib: A population-based nested case-control study

Data regarding the safety of co-administration of ibrutinib with anticoagulants in real-life settings are scarce. Using a nationwide database, we conducted a nested case-control study in a cohort of new users of ibrutinib to assess the risk of clinically relevant bleeding (CRB) associated with anticoagulation. Cases were patients with a diagnosis of CRB, defined as hospitalization with a diagnosis of bleeding. The date of CRB constituted the index date. Up to four controls were matched on sex, age at index date and duration of follow-up. The risk of CRB associated with anticoagulation in patients receiving ibrutinib was estimated using conditional logistic regression models, providing odds ratios (OR) adjusted for risk factors of bleeding. Among 614 cases and 2407 matched controls, the risk of CRB was significantly higher in patients receiving both ibrutinib and anticoagulants (adjusted OR [aOR] 2.54, confidence interval [CI] 95% [1.94; 3.32]). When considering anticoagulant class, aOR was 1.99 (CI 95% [1.19; 3.33]) for VKA, 2.48 (CI 95% [1.76; 3.47]) for direct oral anticoagulants and 3.40 (CI 95% [2.01; 5.75]) for parenteral anticoagulants. In conclusion, this study found a 2.5-fold increased risk of CRB in patients receiving both ibrutinib and anticoagulants in real-life settings, and similar aOR among oral anticoagulants.