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