Lamotrigine-associated reversible severe hepatitis: A case report

Introduction

Anticonvulsant hypersensitivity syndrome is a severe idiosyncratic reaction to antiepileptic drugs. We report a case of a woman with lamotrigine-associated hepatitis who recovered spontaneously with supportive treatment.

Case Report

A 43-year-old woman was being treated with oxcarbazepine for depression and was started on lamotrigine 2 weeks prior to her presentation. The patient then developed nausea and a generalized pruritic macular rash, and was found to have elevated liver enzymes, which peaked at AST, 6079 IU/L; ALT, 6900 IU/L; total bilirubin, 3.9 mg/dL(66.7 μmol/L); alkaline phosphatase, 149 IU/L; international normalized ration (INR), 1.9. The patient showed no signs of encephalopathy and her clinical examination was essentially normal except for very mild jaundice and a diffuse erythematous pruritic macular rash. The patient was hydrated and managed with supportive care. On the third day of hospitalization, her liver enzymes had improved substantially and she was discharged. At follow-up 1 month later the patient’s liver enzymes were within the normal range.

Discussion

We hypothesize that lamotrigine was directly responsible for the patient’s rash and liver impairment given the time sequence of drug introduction and resolution of symptoms and liver enzyme abnormality once the drug was withdrawn. The patient suffered severe transaminitis when lamotrigine was added to oxcarbazepine, which resolved after termination of the medication and supportive management. We recommend monitoring the hepatic function in patients who have just been initiated on lamotrigine, especially if they develop jaundice.     

Profile of lifetime methamphetamine use among homeless adults in Los Angeles

Although the dramatic rise of methamphetamine use in the general population has been well-documented, little is known about methamphetamine use in the homeless population. This study examines self-reported methamphetamine use and its correlates among a sample of 664 urban homeless adults in Los Angeles. Over one-quarter of the overall sample, and 60% of whites, disclosed lifetime methamphetamine use. Less than 10% of African-Americans reported ever using methamphetamine. Approximately one-tenth of respondents reported current methamphetamine use; almost 90% of current users shared straws to snort methamphetamine and half used it daily. Logistic regression analysis in younger (18-39) and older (40+) respondents revealed that white ethnicity, polydrug use and binge drinking were independently associated with lifetime methamphetamine use, regardless of age. Injection drug use (IDU) was also an important correlate of methamphetamine use for older African-Americans. IDU was not important for the younger group. Findings suggest that there is need for greater surveillance of methamphetamine use among homeless whites and Hispanics, and methamphetamine-use prevention and reduction targeted to younger, polydrug-using, alcohol-binging homeless adults.     

Improvement of the comprehension of written information given to healthy volunteers in biomedical research: a single-blind randomized controlled study

Writing an informed consent form (ICF) for biomedical research is a difficult task. We conducted a multicenter single-blind randomized controlled trial to identify whether a working group or the systematic improvement in lexico-syntactic readability or an association of the two could increase the comprehension of the written information given to healthy volunteers enrolled in biomedical research. Participants were randomized to read one of four versions of the ICF: unchanged ICF (A), ICF with systematic lexico-syntactic readability improvement (B), ICF modified by a working group (C), and ICF modified by the working group followed by systematic lexico-syntactic improvement (D). The primary end-point was the objective comprehension score at day 0 for each study group. The scores of objective comprehension at day 0 were statistically different between the four study groups (anovaP = 0.020). The pairwise analysis showed an improvement in the working group vs. the unchanged group (P = 0.003), and a tendency to improvement in the group who read the ICF modified using lexico-syntactic readability and in the group who read the ICF modified using the two methods (P = 0.020 and 0.027 respectively). We conducted a two-way anova to identify some characteristics of the population which could explain this score. There was a significant interaction between the type of informed consent document (ICD) and the gender. Improving the ICD in phase I biomedical research leads to better comprehension, whether the method used is systematic lexico-syntactic improvement or a review by a working group. The improvement is specifically observed in men compared with women. Conversely, while both methods diverge in their effect on lexico-syntactic readability, their association is not mandatory. We suggest that in all phase I clinical trials, the ICF be improved by either method.     

Differential reporting of drug use among gay,bisexual and transgender stimulant-using homeless adults post intervention

Homeless gay and bisexual (G/B) men, and transgender female stimulant users are at high risk for continued substance use and dependency; yet, there is a limited understanding of reasons for differential reporting of drug use (defined as different outcomes of drug use when assessed by self-report versus urinalysis) post intervention among this population. This study examined self-reported drug use versus urinalysis reporting at four-month follow-up evaluation of a longitudinal study conducted among 166 G/B and transgender stimulant-using homeless adults. Follow-up data were collected from a two-group intervention focused on reducing stimulants and other illicit drug use as well as promoting HBV, HCV and HIV disease prevention. Findings of logistic regression revealed that transgender women and those who reported fair-or-poor health were more likely to self-report drug use which differed from the urinalysis biomarker. Amphetamines were the drugs most often differentially reported, possibly due to the fact that methamphetamine was cut with amphetamine or that the majority of the sample used methamphetamine which was metabolized into amphetamine. While the numbers of other drugs differentially reported were small, one-third to one half of the sample who were positive on urine testing for cocaine and opiates, respectively, did not report the use of these drugs. Findings highlight the need for biomarker assessment of drug use, especially post intervention.     

Homeless Women: Who is Really at Risk for Unintended Pregnancy?

Objective To identify correlates of failure to use contraception among homeless women at risk for unintended pregnancy. Study Design A representative sample of 974 homeless women surveyed in Los Angeles County in 1997 included 457 who were at risk for unintended pregnancy. Logistic regression modeling was used to identify important predictors of contraceptive nonuse or rare use in the past year. Results One third of the sample used contraception rarely or never in the past year. Having a partner, being monogamous, and not engaging in sex trade predicted contraceptive nonuse or rare use (odds ratios 2.43–4.73, P < .05). Partner dislike and uncertainty about which contraceptive to use were also associated with failure to use contraception (odds ratios 2.64–2.96, P < .05). Having a regular source of care and having been encouraged to use contraception protected against failure to use contraception. Conclusions Homeless women, including those at apparently low risk for unintended pregnancy, need to be targeted with integrated services that include education, a regular source of medical care, and encouragement to use contraception.     

Evaluation of male sexual function by the International Index of Erectile Function after deep dorsal vein arterialization of the penis.

PURPOSE: The objective of vascular surgery for erectile dysfunction is to provide long-term improvement of erectile function. We evaluated that claim after deep dorsal vein arterialization by a cross-sectional study of multifaceted male sexual function with the validated International Index of Erectile Function (IIEF). MATERIALS AND METHODS: We performed a mail survey of male sexual function after deep dorsal vein arterialization in 68 consecutive literate men who underwent surgery between 1984 and 1998 for severe erectile dysfunction. The IIEF questionnaire and a questionnaire on patient characteristics were answered in a self-administered and nominative manner. Scores of the responders pertaining to the 5 domains of male sexuality were compared with those of the control groups used for the psychometric validation of the IIEF. RESULTS: Of the patients 38 (55.9%) with a mean age plus or minus standard deviation of 46.5 +/- 11.9 years responded. Mean followup was 61.2 +/- 34.7 months. Compared to controls with erectile dysfunction controls men who underwent deep dorsal vein penile arterialization had significantly higher scores for erectile function, sexual desire, orgasmic function, intercourse satisfaction and overall satisfaction. Conversely compared with normal controls these patients reported significantly lower erectile function, orgasmic function, intercourse satisfaction and overall satisfaction scores, whereas sexual desire scores were similar in the 2 groups. No correlations were noted of the 5 IIEF domains with the duration of followup after arterialization. When erectile function scores were graded, 25.0% and 28.1% of patients reported no and or mild dysfunction, respectively, while 15.6% still complained of severe erectile dysfunction. CONCLUSIONS: Long-term improvement in the various aspects of male sexual function was observed after deep dorsal vein penile arterialization in a significant proportion of patients.     

Caring for Special Populations: Total Pain Theory in Advanced Heart Failure: Applications to Research and Practice

TOPIC.  Total pain theory.
PURPOSE.  Describe total pain theory and apply it to research and practice in advanced heart failure (HF).
SOURCE OF INFORMATION.  Total pain theory provides a holistic perspective for improving care, especially at the end of life. In advanced HF, multiple domains of well-being known to influence pain perception are adversely affected by declining health and increasing frailty. A conceptual framework is suggested which addresses domains of well-being identified by total pain theory.
CONCLUSION.  By applying total pain theory, providers may be more effective in mitigating the suffering of individuals with progressive, life-limiting diseases.