We report the rare case of a patient with intractable epilepsy and escalating aggression, resulting in murder, who had complete resolution of her seizures and explosive behavior following a right temporal lobectomy.We searched the available literature from 1880 to 2013 for cases of epilepsy being used as a court defense for murder and collected information regarding the final sentencing outcomes. We selected 15 papers with a total of 50 homicides.We describe the case of a 47-year-old woman with drug-resistant right temporal epilepsy who developed increasing emotional lability, outbursts of anger and escalating violent behavior culminating in a violent murder. The patient was imprisoned while awaiting trial. In the interim, she underwent a successful temporal lobectomy with full resolution of seizures, interictal rage and aggressive behaviors. After the surgery, her charges were downgraded and she was transferred to a psychiatric facility.The aggressive behavior associated with epilepsy has been described in the literature for over a century. A link between epilepsy and aggression has been disproportionally emphasized. These patients share some common characteristics: they are usually young men with a long history of epilepsy and lower than average intelligence. The violent act is postictal, sudden-onset, more likely to occur after a cluster of seizures and is usually related with alcohol abuse.

SESSION TYPE: Cardiovascular Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

First described in 1866 by Brooks, anomalous origin of the coronary arteries from the pulmonary artery is a rare congenital anomaly that tends to occur in isolation. It comprises 0.4% of all congenital heart diseases. Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) has an estimated incidence of 1 in 300,000. It is also known as Bland-White-Garland syndrome since they first described it clinically in 1933. We present a rare case of the 1st presentation of ALCAPA in adulthood with ventricular fibrillation and cardiac arrest.

CASE PRESENTATION:

A 30-year old man with a past medical history of polysubstance abuse and hepatitis C was found down. He received defibrillation for ventricular fibrillation as part of cardiopulmonary resuscitation in the field. On arrival, the patient was alert and with an unrevealing physical examination. Initial lab work showed mildly elevated cardiac troponins. EKG showed left bundle branch block, left axis deviation and signs of left atrial enlargement. Urine drug screen was negative and chest radiograph was unremarkable. Echocardiography showed reduced left ventricular ejection fraction (LVEF) along with regional wall motion abnormalities in the distribution of the left anterior descending and left circumflex coronary arteries. Coronary angiography revealed global hypokinesis of the left ventricle with a LVEF at 35% and anomalous origin of the left main coronary artery from the pulmonary artery with otherwise normal coronaries. The patient underwent surgical correction with aortic reimplantation of the left coronary artery as well as ICD implantation for secondary prevention.

DISCUSSION:

ALCAPA is a rare congenital anomaly with 85% of cases presenting in the first few months of life; usually with severe left sided heart failure and mitral insufficiency. Delayed presentations of ALCAPA into late adulthood have been reported and are ascribed to good collateral flow from the right coronary system. In adulthood, ALCAPA can present with symptoms of heart failure, mitral valve insufficiency, angina or arrhythmias. Arrhythmias in ALCAPA either arise from scar tissue after previous myocardial infarctions as with our patient or are triggered from an acute ischemic event due to coronary steal phenomenon.

CONCLUSIONS:

ALCAPA as a rare cause of arrhythmias and left sided heart failure should be considered in adults in the absence of atherosclerotic coronary artery disease. Diagnosis with CT angiography is equivalent if not superior to coronary angiography. Recognition of this rare entity is important since surgical treatment generally results in an excellent prognosis.1) Kristensen, T., Kofoed, K.F., Helqvist, S., Helvind, M. & Sondergaard, L. Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) presenting with ventricular fibrillation in an adult: a case report. J Cardiothorac Surg 3, 33 (2008).DISCLOSURE: The following authors have nothing to disclose: Mona SelejNo Product/Research Disclosure InformationIndiana University, Indianapolis, IN.

OBJECTIVES

To assess differences in prescription monitoring program (PMP) use between two states with different PMP accessibility (Connecticut [CT] and Rhode Island [RI]), to explore use of PMPs in pharmacy practice, and to examine associations between PMP use and pharmacists' responses to suspected diversion or "doctor shopping." DESIGN Descriptive nonexperimental study. SETTING CT and RI from March through August 2011. PARTICIPANTS Licensed pharmacists in CT and RI. INTERVENTION Anonymous surveys e-mailed to pharmacists MAIN OUTCOME MEASURES PMP use, use of patient reports in pharmacy practice, and responses to suspected doctor shopping or diversion.

RESULTS

Responses from 294 pharmacists were received (CT: 198; RI: 96). PMP users were more likely to use the PMP to detect drug abuse (CT: 79%; RI: 21.9%; P < 0.01) and doctor shopping (67%; 7%; P < 0.01). When faced with suspicious medication use behavior, PMP users were less likely than nonusers to discuss their concerns with the patient (adjusted odds ratio 0.48 [95% CI 0.25-0.92]) but as likely to contact the provider (0.86 [0.21-3.47]), refer the patient back to the prescriber (1.50 [0.79-2.86]), and refuse to fill the prescription (0.63 [0.30-1.30]). PMP users were less likely to state they were out of stock of the drug (0.27 [0.12-0.60]) compared with nonusers. Pharmacists reported high interest in attending continuing education on safe dispensing (72.8%).

CONCLUSION

Pharmacists are important participants in the effort to address prescription drug misuse and abuse. Current PMP use with prevailing systems had limited influence on pharmacy practice. Findings point to future research and needed practice and education innovations to improve patient safety and safer opioid dispensing for pharmacists.

While glutamate in the nucleus accumbens (NAS) contributes to the promotion of drug-seeking by drug-predictive cues, it also appears to play a role in the inhibition of drug-seeking following extinction procedures. Thus we measured extracellular fluctuations of NAS glutamate in response to discriminative stimuli that signaled either cocaine availability or cocaine omission. We trained rats to self-administer intravenous cocaine and then to recognize discriminative odor cues that predicted either sessions where cocaine was available or alternating sessions where it was not (saline substituted for cocaine). Whereas responding in cocaine availability sessions remained stable, responding in cocaine omission sessions progressively declined to chance levels. We then determined the effects of each odor cue on extracellular glutamate in the core and shell subregions of NAS preceding and accompanying lever pressing under an extinction condition. Glutamate levels were elevated in both core and shell by the availability odor and depressed in the core but not the shell by the omission odor. Infusion of kynurenic acid (an antagonist for ionotropic glutamate receptors) into core but not shell suppressed responding associated with the availability odor, but had no effect on the suppression associated with the omission odor. Thus cocaine-predictive cues appear to promote cocaine seeking in part by elevating glutamatergic neurotransmission in the core of NAS, whereas cocaine-omission cues appear to suppress cocaine seeking in part by depressing glutamatergic receptor activation in the same region.

SESSION TYPE: Cancer Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Lung cancer risk is 3 to 4 times higher in HIV-infected patients than in uninfected persons Adenocarcinoma is the most common cell type and commonly presents with peripheral solitary nodule with early invasion of pleura and metastasis to the brain. The majority of HIV patients present at advanced stages of lung cancer. HIV patients have a worse outcome to therapy. We present a unique case of adenocarcimoa presenting as bilobular mass projecting from hilum.

CASE PRESENTATION:

A 63 years old AA male with PMH of HIV presented with hiccups and chest discomfort for three days. The chest discomfort was over the left pericardial region. Air entry was reduced and there was dullness to percussion over left chest. Leukocytosis was seen on labs. Chest X-ray showed a large mass lesion on the left upper lobe. CT chest showed a large hypodense mass filling the upper half of the hemithorax, partially encasing the hilum with mass effect upon the left bronchovascular structures and in contiguity with a bulky left paratracheal lymph node. Mass appeared bilobular projection measuring 10.5x17cm on the left upper lobe. CT guided transthoracic needle biopsy histopathology and immunohistochemistry showed poorly differentiated adenocarcinoma. He received palliation radiotherapy.

DISCUSSION:

Lung cancer is the most prevalent non-AIDS-defining malignancy. The major features of these patients include: male gender, young age, a history of intravenous drug abuse, preponderance of adenocarcinoma cell type and advanced clinical stage at diagnosis. Adenocarcinoma is the most common histological subtype, and the majority of patients are diagnosed with locally advanced or metastatic carcinoma. Surgery with curative intent remains the treatment of choice for early-stage disease. There is increasing experience in using radiation and chemotherapy for HIV-infected patients who do not have surgical options. Evidence-based treatments for smoking-cessation with demonstrated efficacy in the general population must be routinely incorporated into the care of HIV-positive smokers.

CONCLUSIONS:

Pulmonary involvement in HIV includes Kaposi's sarcoma, Non-Hodgkin lymphoma, and primary lung cancer. Adenocarcinoma can have very aggressive clinical course and can present in locally advanced stage as oppose to what has been previously described as extensive pleural involvement. Patients with advanced NSCLC have poor prognosis. Prospective clinical trials are needed to define the optimal detection and treatment strategies for lung cancer in HIV infected patients.1) Carcinoma of the lung in HIV-positive patients: findings on chest radiographs and CT scans. White CS. Haramati LB. Elder KH. Karp J. Belani CP. American Journal of Roentgenology. 164(3):593-7, Mar 1995.DISCLOSURE: The following authors have nothing to disclose: Ameer Rasheed, Viswanath Vasudevan, Farhad ArjomandNo Product/Research Disclosure InformationThe Brooklyn Hospital Center, Brooklyn, NY.

SESSION TYPE: Critical Care Student/Resident Case Report Posters IPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Bath salts are derivatives of cathinone and their toxic effects are largely the same effects seen with amphetamines in large doses. Bath salts can be ingested, smoked or used intravenously. Their use is on the rise and responsible for a large number of emergency room visits. The presentation is similar to other stimulant overdoses, though there may be a more intense degree of delirium associated with bath salt intoxication.

CASE PRESENTATION:

Our case series involves five patients (six hospital courses) who presented with bath salts ingestion. The presentations involved signs and symptoms of intense sympathetic response and the hospital course had varied outcomes including cardiac arrest in one case. All patients had a history of drug abuse, and most had psychiatric disorders as well. All patients suffered some degree of delirium, rhabdomyolsis and acute renal failure. Treatments included benzodiazepenes, mechanical ventilation, and intravenous hydration. Three of the five patients had an encounter with law enforcement prior to their arrival at the hospital.

DISCUSSION:

Bath salts are available for around twenty dollar packets at truck stops and on the Internet, usually marketed with the disclaimer, "not for human consumption". Symptoms include hallucinogenic-delusional symptoms, extreme agitation, and combativeness. Management is largely supportive and includes aggressive IV hydration, dampening of the excessive sympathetic outflow with benzodiazepines and close monitoring in ICU setting. On Sept. 7, 2011, the U.S. Drug Enforcement Administration (DEA) invoked its "emergency scheduling authority" to control these synthetic stimulants. The DEA plans to make possessing and selling these chemicals, or products that contain them, illegal in the United States.

CONCLUSIONS:

Bath salts are one of the growing list of drugs of abuse. Patients can still obtain these legally in many states and despite warnings to not ingest or smoke, this has become a significant problem. The presentation mimics other sympathetic drugs and cause a significant amount of delirium, rhabdomyolysis and visits to the emergency room often leading to hospitalizations.1) Ross EA. "Bath Salts "Intoxication. N Engl J Med. 2011; 365:967-968.2) "Chemicals Used in "Bath Salts" Now Under Federal Control and Regulation." United States Drug Enforcement Administration. 21 Oct 2011.3) Benzie F. "Emergency department visits after use of a drug sold as "bath salts"-Michigan, November, 13, 2010-March 31, 2011. Morb Mortal Wkly Rep. 2011; 60(19):624-627.DISCLOSURE: The following authors have nothing to disclose: Syed Imam, Hetalben Patel, Monay Mahmoud, Nisha Prakash, Matthew King, Richard FremontNo Product/Research Disclosure InformationMeharry Medical College, Nashville, TN.

SESSION TYPE: Critical Care Student/Resident Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Beta blockers are one of the most commonly prescribed medications and have many indications, including hypertension, coronary artery disease, migraine prophylaxis, and symptomatic control of anxiety.

CASE PRESENTATION:

A previously healthy 24-year old male with a remote history of polysubstance abuse five years previously was brought to the emergency department for acute onset altered mental status and agitation. On the morning of admission, the patient was found disoriented and agitated. He was restrained by law enforcement with Taser due to severe agitation. Upon arrival to the emergency department, he remained agitated and required chemical and physical restraints. Due to concern for airway protection, he was intubated and sent to the ICU. Upon arrival, he was tachycardiac (155 bpm) and hypertensive (200 /115 mmHg) with diaphoresis and mydriasis. Laboratory results were significant for WBC count of 13.3 x109/L (3.5-10.5), lactate 7.3 (0.6-2.3 mmol/L), CK 510 (52-336 U/L) bicarbonate 16 (22-29 mmol/L) with anion gap of 16. Creatinine and electrolytes were unremarkable. Evaluation for altered mental status, included negative CXR, head CT, cultures, urine drug abuse and toxicology screen (including prescription drugs, methanol, ethanol, acetone, isopropanol, ethylene glycol). In addition, CSF examination was unremarkable. Within 24 hours, patient stabilized and was extubated. Further history revealed ingestion of propranolol tablets the prior evening.

DISCUSSION:

Propranolol, specifically, has more central nervous system effects due to its relatively higher lipophilicity allowing it to cross the blood-brain barrier more easily.1 Reported side effects include sleep disturbances, depression, and psychotic behaviors, which have been reported to occur at both low and high doses. The etiology of propranolol induced psychosis is unknown. One hypothesis is that high concentrations in the brain tissue leads to blockade of post-synaptic serotonin and beta-adrenergic receptors, inhibiting norepinephrine release.1 This causes an imbalance between parasympathetic and sympathetic activity, resulting in the side effects of tachycardia, mydriasis, delirium, and diaphoresis.

CONCLUSIONS:

Although this is an overall rare side effect of these medications, it is important to remember given their widespread use.1) McGahan DJ, Wojslaw A, Prasad V, Blankenship S. Propranolol-induced psychosis. Drug Intell Clin Pharm 1984;18(7-8):601-603.DISCLOSURE: The following authors have nothing to disclose: Diana Kelm, Cassie KennedyNo Product/Research Disclosure InformationMayo Clinic, Rochester, MN.

SESSION TYPE: Infectious Disease Student/Resident Case Report Posters IIIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Erythema nodosum are tender, erythematous, subcutaneous nodules that typically are located symmetrically on the anterior surface of the lower extremities. Erythema nodosum may be the first sign of a systemic disease such as tuberculosis, viral, bacterial or fungal infections (1).

CASE PRESENTATION:

24 year old, 8 weeks pregnant Mexican American female presents with symptoms of shortness of breath, pleuritic chest pain, productive cough and a new painful rash on her lower extremities of two weeks duration. As an outpatient, patient was found to have a left lower lobe consolidation on chest Xray and was treated with azithromycin. Patient has lived in Phoenix Arizona for the past 17 years. She denies any sick contacts or recent travel. She denies alcohol, tobacco and drug abuse. Sexual history includes her husband only. Past medical history includes latent tuberculosis treated with nine months of isoniazide one year ago. Throughout her stay, patient was afebrile and had no leukoctosis. Sputum and blood cultures were negative. Urine strep antigen, viral cultures, infuenza, and rapid strep antigen detection test were negative. Coccidioidomycosis IgM and IgG serologies were positive. Skin biopsy was consistent for erythema nodosum. She was started on IV fluconazole, and her symptoms of shortness of breath, chest pain, and rash all subsided within a few days.

DISCUSSION:

Coccidioides immitis is endemic in certain parts of the desert south west region. It is a fungus that resides in the soil that breaks off into airborne spores. Infection is caused by inhalation of the particles and is not transmitted from person to person. Serious complications include severe pneumonia, lung nodules, and disseminated disease. The disseminated form of valley fever can devastate almost any organ in the body, causing skin ulcers, abscesses, bone lesions, meningitis, and often death(2). Coccidioidomycosis during pregnancy is a serious illness for which high rates of mortality have been reported in many studies. It has been associated with a greater likelihood of extra-pulmonary dissemination and more serious outcomes. Although when erythema nodosum was present, outcomes were more favorable(3).

CONCLUSIONS:

Diagnosing the precipitating source of erythema nodosum may be quite challenging. Having a broad differential diagnosis for erythema nodosum will avoid missing rare and life threatening infections. Keeping coccidioidomycosis as a differential in almost all infectious workups in the desert south west will help clinicians not miss this commonly seen "Valley Fever."1) Schwartz RA, Nervi SJ. Erythema nodosum: a sign of systemic disease. Am Fam Physician. 2007 Mar 1;75(5):695-700.2) Stevens DA. Coccidioidomycosis. N Engl J Med. 1995 Apr 20;332(16):1077-823) Arsura EL, Kilgore WB, Ratnayake SN. Erythema nodosum in pregnant patients with coccidioidomycosis. Clin Infect Dis. 1998 Nov;27(5):1201-3.DISCLOSURE: The following authors have nothing to disclose: Yousef Usta, Wesley ShealeyNo Product/Research Disclosure InformationSt. Joseph Hospital Medical Center, Phoenix, AZ.

OBJECTIVES:

We aimed to identify the factors associated with developing AIDS 6 months or more after an HIV diagnosis, and to examine how post-HIV diagnosis AIDS (PHDA) patients differed from true late presenters (HIV diagnosed concurrent with the first AIDS presenting event) in their demographics and comorbidities.

METHODS:

A retrospective analysis was undertaken of all inpatients admitted to a large HIV unit presenting with the following AIDS-defining infections: cryptococcal meningitis, cerebral toxoplasmosis or Pneumocystis jirovecii pneumonia between 1 January 2005 and 31 December 2010.

RESULTS:

114 HIV-positive patients presented with AIDS-defining infections. Compared with late presenters, PHDA patients had a larger proportion of migrants and visitors (53.7% vs 34.0%, p=0.047), were more likely to inject drugs (9.3% vs 0.0%, p=0.032), had more previous HIV-associated diseases (57.4% vs 12.8%, p=0.000), psychiatric comorbidities (35.2% vs 12.8%, p=0.009), rates of alcohol abuse (24.1% vs 4.3%, p=0.005) and reported social issues (25.9% vs 0.00%, p=0.000). 88.9% of PHDA patients were lost to follow-up for a period of at least 4 months since diagnosis. Common reasons for clinic non-attendance included travel, social issues, transfer of care and treatment avoidance. Common reasons for antiretroviral treatment breaks included drug side effects, negative beliefs about medication, incompatible lifestyles and social issues.

CONCLUSIONS:

Compared with late presenters, PHDA patients demonstrate clear demographical differences including higher rates of psychiatric comorbidities, social issues, alcohol and substance abuse. Many PHDA patients default follow-up. The retention of HIV patients in care and on treatment must be addressed by clinicians to prevent avoidable morbidity.

Chronic daily administration of nicotine and other drugs of abuse has been found to entrain pre- and post-drug circadian locomotor activity episodes that oscillate on a 24-h schedule and persist for several days after administration ceases. This drug-entrainable oscillator system could conceivably lead to circadian rhythms of drug seeking and drug use in human drug addicts. The present study (1) characterizes the ability of daily nicotine administration to entrain circadian wheel-running activity episodes in rats across a range of doses, lighting schedules, and food access; and (2) tests whether pre- and post-nicotine episodes can be altered through pharmacological manipulations. Adult female rats were housed in wheel boxes for 35-60 d, and both wheel-running and feeding-related behaviors were measured continuously. Following acclimation, nicotine or saline was administered for 16-24 d, and the rats were left undisturbed for several test days to observe the persistence of nicotine-entrained activity. The results showed that nicotine dose-dependently entrains wheel-running activity, and the highest dose of 1.0 mg/kg produces robust pre- and post-nicotine circadian activity episodes under constant, fixed, and variable light/dark schedules. In the pharmacological manipulation experiment, nicotine-entrained rats were administered one of seven pharmacological treatments (varenicline, mecamylamine, acamprosate, topiramate, naltrexone, SB-334867, or bupropion) in place of the nicotine injection for 2 d, and the rats were not disturbed for four subsequent days. Most of the treatment drugs significantly reduced post-nicotine activity episodes, but only three treatments affected pre-nicotine episodes: the μ- and κ-opioid receptor antagonist naltrexone, the orexin-1 receptor antagonist SB-334867, and the AMPA (2-amino-3-(3-hydroxy-5-methyl-isoxazol-4-yl)propanoic acid)/kainate antagonist topiramate. These results show that chronic daily nicotine administration is a robust zeitgeber that dose-dependently entrains a nonphotic oscillator system that includes opioid, orexin, and glutamate pathways.