Faculty Bibliography

A 45-year-old woman with cirrhosis secondary to alcohol abuse was transferred from an outside hospital for management of a painful cutaneous eruption, progressively worsening over 2 weeks. On examination, the patient was a middle-aged white woman lying in bed in no acute distress, with jaundice and a protuberant abdomen consistent with ascites. The patient was afebrile (98.2°F), heart rate of 79 beats per minute, blood pressure of 105/61 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 93% on room air. She had multiple large stellate lesions of retiform purpura with central hemorrhagic necrosis on both thighs, with surrounding induration (Figures 1 and 2). These purpuric plaques and perilesional skin were exquisitely painful to palpation.

OBJECTIVE: Few studies exist on pharmacological interventions for adolescents with substance use disorders (SUD). To this end, we evaluated the response of bupropion hydrochloride sustained release (SR) in SUD adolescents with comorbid psychopathology (both attention-deficit/ hyperactivity disorder (ADHD) and a mood disorder). Methods: Fourteen adolescent outpatients were treated naturalistically and followed openly for 6 months. Adolescents were rated using the Drug Use Screening Inventory--Revised (DUSI-R), ADHD Symptom Checklist, and the Hamilton Rating Scale for Depression (HAM-D). Clinical Global Impression (CGI) Scale scores were obtained for Substance Abuse, ADHD, Anxiety, and Depression. The ratings were completed at baseline, at month 3, and at the 6-month endpoint. Bupropion SR was initiated at 100 mg once-daily and titrated naturalistically to a maximum dose of 400 mg/day. RESULTS: Of the 14 subjects followed, 13 subjects completed 6 months of treatment. At the 6- month endpoint compared to baseline, treatment with bupropion was associated with clinical and significant reductions in DUSI scores (-39%; p < 0.05), ADHD symptom checklist (-43%; p < 0.001), HAM-D (-76%; p < or = 0.001); and reductions in the CGIs for ADHD (p < or = 0.001), depression (p < or = 0.001), and substance abuse (p < 0.05). The mean daily dose of bupropion SR was 315 mg (in divided doses). No significant adverse events were noted during the follow-up period. CONCLUSIONS: These naturalistic data suggest that bupropion is well tolerated and may be an effective medication for the treatment of substance abusing adolescents with comorbid mood disorders and ADHD.

BACKGROUND:Celiac disease may be complicated by symptoms that raise the suspicion of small-intestinal malignancy. The objective is to evaluate wireless capsule endoscopy (WCE) in complicated celiac disease. METHODS:This is a prospective study at a university referral center. There were 47 patients. The indications for WCE were abdominal pain (57%), cancer surveillance (23%), blood in the stool, or persistent iron deficiency (19%). RESULTS:Findings were consistent with celiac disease in 87%: atrophy (68%), fissuring (62%), and mosaic pattern (19%), extending to the ileum in 34%. Unexpected findings were ulceration in 45% (n = 21), cancer (1), polyps (1), stricture (1), submucosal mass (1), ulcerated nodular mucosa (2), and intussusception (1) were seen in 60%. CONCLUSIONS:WCE has a high yield in complicated celiac disease, by identifying mucosal abnormalities and by excluding adenocarcinoma.

Gammadelta T cells are primarily found in the gastrointestinal mucosa and play an important role in the first line of defense against viral, bacterial, and fungal pathogens. We sought to examine the impact of human immunodeficiency virus type 1 (HIV-1) infection on mucosal as well as peripheral blood gammadelta T-cell populations. Our results demonstrate that HIV-1 infection is associated with significant expansion of Vdelta1 and contraction of Vdelta2 cell populations in both the mucosa and peripheral blood. Such changes were observed during acute HIV-1 infection and persisted throughout the chronic phase, without apparent reversion after treatment with highly active antiretroviral therapy (HAART). Despite an increase in the expression of CCR9 and CD103 mucosal homing receptors on peripheral blood gammadelta T cells in infected individuals, mucosal and peripheral blood gammadelta T cells appeared to be distinct populations, as reflected by distinct CDR3 length polymorphisms and sequences in the two compartments. Although the underlying mechanism responsible for triggering the expansion of Vdelta1 gammadelta T cells remains unknown, HIV-1 infection appears to have a dramatic impact on gammadelta T cells, which could have important implications for HIV-1 pathogenesis.