Heroin and Methamphetamine Injection: An Emerging Drug Use Pattern

Objective: We sought to describe an emerging drug use pattern characterized by injection of both methamphetamine and heroin. We examined differences in drug injection patterns by demographics, injection behaviors, HIV and HCV status, and overdose. Methods: Persons who inject drugs (PWID) were recruited as part of the National HIV Behavioral Surveillance (NHBS) system in Denver, Colorado. We used chi-square statistics to assess differences between those who reported only heroin injection, only methamphetamine injection, and combined heroin and methamphetamine injection. We used generalized linear models to estimate unadjusted and adjusted prevalence ratios to describe the association between drug injection pattern and reported nonfatal overdose in 2015. We also examined changes in the drug reported as most frequently injected across previous NHBS cycles from 2005, 2009, and 2012. Results: Of 592 participants who completed the survey in 2015, 173 (29.2%) reported only injecting heroin, 123 (20.8%) reported only injecting methamphetamine, and 296 (50.0%) reported injecting both drugs during the past 12 months. Injecting both heroin and methamphetamine was associated with a 2.8 (95% confidence interval: 1.7, 4.5) fold increase in reported overdose in the past 12 months compared with only injecting heroin. The proportion of those reporting methamphetamine as the most frequently injected drug increased from 2.1% in 2005 to 29.6% in 2015 (p < 0.001). Conclusions: The rapid increase in methamphetamine injection, and the emergence of combining methamphetamine with heroin, may have serious public health implications.     

Challenges in valve-in-valve therapy

At present, the majority of surgical heart valves (SHVs) implanted are bioprosthetic valves. Over time however, these are prone to structural deterioration, which may manifest as valvular stenosis, regurgitation or a combination of the two. Re-operation is the current standard of care for these patients but this itself carries a significant risk of mortality and morbidity. As a natural extension of transcatheter aortic valve implantation (TAVI), now an evidence based solution for severe aortic stenosis in high-risk patients, valve-in-valve (VIV) therapy is evolving into an alternative option in selected patients with structural biological valvular deterioration in all four-valve positions. The first of these VIV procedures was performed in Germany in 2007, for failing aortic valve prosthesis and later, reported in other positions. As with any novel emerging therapy, there is a learning curve to the procedure and the operator must be aware of the potential challenges. In this review we describe some of these challenges with the aim of providing awareness as well as guidance on attaining a successful outcome.     

A case of acute esophageal necrosis (black esophagus) in a young man with Down syndrome

Acute esophageal necrosis, commonly referred to as ‘black esophagus?, is a rare clinical entity arising from a combination of ischemic insult, corrosive injury and decreased function of mucosal barrier systems and reparative mechanisms present in debilitating diseases. We describe the case of an 18-year-old man affected by Down syndrome, presenting with a streptococcus β-hemolytic group A infection of the upper airways. Although the patient was intensively treated with antibiotics, he developed a streptococcal toxic shock-like syndrome and died 5 days after admission. At autopsy, circumferential black discoloration of the esophageal mucosa that extended along the entire esophagus and ended abruptly at the esophageal-gastric junction was found. Neither ulceration nor esophageal perforation were present. Black esophagus is well known to the gastroenterology community, whereas it has been described only twice in the pathology literature. To the best of our knowledge, this is the first case ever reported complicating a streptococcal infection.     

Osteonecrosis in kidney recipients: has hypocalcaemia a role?

In a previous study, the musculoskeletal affections among kidney recipients (KR) were reported, with 63 KR suffering from joint affections. We sought to determine the prevalence of osteonecrosis (ON) among those KR with joint affections, its distribution among the affected joints, and possible risk predictors. KR were subjected to biochemical, haematological, and hepatitis serology estimations. Radiographic and magnetic resonance imaging were performed. Relevant data were retrieved from Patient Information System. Fourteen KR were suffering from ON, with an incidence of 22.2% in KR with joint affections and 12.0% in the target population of KR. The femoral head was affected in 57.1% and the femoral condyles in 28.6%. Hypocalcaemia was observed in KR with ON. Whether hypocalcaemia is a causative or associative of ON yet remains to be decided in forthcoming studies.     

Extraskeletal neuroectodermal tumour of the vagina: a single case report and review

Abstract  A case report and review of an extraskeletal neuroectodermal tumour of the vagina. Background  Ewing’s sarcoma (ES) and primitive neuroectodermal tumours (PNETs) account for approximately 6–10% of primary malignant bone tumours and, following osteosarcoma, are the second most common group of bone sarcomas in children. Ewing’s sarcoma rarely affects the genitourinary tract. Case summary  We report a rare case of extraskeletal Ewing’s sarcoma diagnosed in a 47-year-old Indian woman presenting with a simple cystic lesion in the posterior wall of the vagina. The histopathology revealed a rare presentation of a primitive malignant extraskeletal neuroectodermal tumour. Conclusion  As our PubMed review found only six previously reported cases of vaginal extraskeletal Ewing’s sarcoma. Presentation as vaginal masses helped in early disease detection.