A Case of Refractory Angioedema.

Angioedema is an acute disorder that affects mucous membranes and the deepest layers of the skin along with underlying tissue, marked by rapid swelling, large welts, and pain. There are 3 major subtypes of angioedema: mast-cell mediated, bradykinin-mediated, and multifactorial or unclear mechanism subtype. The most common subtype of bradykinin-mediated angioedema is ACE-inhibitor induced, which disproportionately affects African-Americans. It is most often self-limiting and usually responds to the withdrawal of the offending agent. The prolonged duration of angioedema is uncommon in the absence of a persistent stimulus, though it is more likely when there is an abnormality of the metabolic pathways, such as in hereditary angioedema or other gene polymorphisms affecting the complement system. We present a case of severe angioedema that persisted for over a month and required a tracheostomy to manage the airway.

A Case of Nasal Rhinosporidiosis in the United States.

Rhinosporidiosis, an infectious granulomatous disease, is seldom encountered in the United States. We present a case of rhinosporidiosis in a 26-year-old man, who presented with an unusual mass in his nasal cavity. Suspicion for rhinosporidiosis was high due to the patient's travel and activity history. After imaging and proper diagnosis, surgery was performed to excise the lesion. As international travel resumes during the COVID-19 pandemic, the potential for encountering this rare organism is heightened.

The Reflux Symptom Index and Symptom Overlap in Dysphonic Patients.

OBJECTIVES/HYPOTHESIS: The Reflux Symptom Index (RSI) is a validated quality-of-life instrument that quantifies symptoms associated with laryngopharyngeal reflux (LPR). Many dysphonic patients are managed empirically for reflux. In this study, we examine responses to the RSI in patients with dysphonia attributable to a variety of pathologies. STUDY DESIGN: Retrospective cohort study. METHODS: This is an institutional review board-approved study. All patients presented to a tertiary care voice center January 2011 to June 2016 with the chief complaint of dysphonia. Patients were analyzed by 1) diagnosis and 2) treatment modality: surgery, medicine, or voice therapy (VT). Data collected included pre- and postintervention RSI and Voice Handicap Index, demographic, and clinical information. Statistical analysis was performed using SPSS. RESULTS: Five hundred forty-six dysphonic patients were included. One hundred forty required surgery, 155 were treated with VT alone, and 251 were medically managed (MM). Prior to therapy, 63.4% of surgery patients, 62.5% of VT patients, and 74.6% of MM patients had an abnormal RSI with a score greater than 13. The most common diagnosis for each group was vocal cord paresis/paralysis (surgery), vocal fold atrophy (VT), and LPR (MM). There was a statistically significant improvement in RSI after treatment for each group. CONCLUSIONS: In patients with dysphonia, pretreatment RSI scores were elevated for a variety of laryngeal pathologies. Scores often improved with directed treatment, regardless of etiology. This highlights the symptom overlap between reflux and nonreflux causes of dysphonia, and the importance of a comprehensive workup for patients with voice complaints. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2631-2636, 2020.

Practice Patterns of Referring Physicians in Management of the Dysphonic Patient.

Objective Dysphonia is commonly encountered by primary care physicians and general otolaryngologists. We examine practice patterns of referring physicians to a tertiary voice clinic, including adherence to evidence-based guidelines. Study Design Retrospective case series with chart review. Setting Academic tertiary care hospital. Subjects and Methods In total, 821 charts of patients with voice complaints seen at a tertiary voice clinic between January 2011 and June 2016 were reviewed. Included charts (n = 755) were reviewed for type of referring provider, prior diagnoses, and treatments employed by referring physicians. Additional information regarding findings at the time of laryngoscopy/stroboscopy and diagnoses provided by a laryngologist were also obtained. Statistical analysis was performed to determine significant relationships between variables of interest. Results A total of 244 patients (32.2%) received a diagnosis prior to evaluation in the voice clinic, most commonly laryngopharyngeal reflux disease (n = 134). Prior medical treatment was attempted in 221 (29.3%) patients, typically antireflux medications (n = 141). Of the patients treated with proton pump inhibitors by referring physicians, 65.1% lacked symptoms of gastroesophageal reflux disease. Patients with prior treatment had a median duration of symptoms 6 weeks longer than those without prior treatment ( P = .04). Among previously diagnosed patients, 199 (81.6%) of diagnoses changed after evaluation in the voice clinic. Conclusion Referring physicians frequently treat dysphonic patients empirically, often with antireflux medications. Subspecialist evaluation results in changes in diagnosis in many patients. Empiric treatment can delay referral and appropriate treatment.

A randomized controlled trial of goal choice interventions for alcohol use disorders among men who have sex with men.

This study tested the efficacy of behavioral treatments for alcohol use disorders (AUD) among men who have sex with men (MSM) and who are at risk for HIV transmission. HIV-negative MSM with current AUD (N = 198) were recruited, offered treatment focused on reducing drinking and HIV risk, and followed during treatment and 12 months posttreatment. Participants (n = 89) accepted treatment and were randomized to either 4 sessions of motivational interviewing (MI) or 12 sessions of combined MI and coping skills training (MI + CBT). Other participants (n = 109) declined treatment but were followed, forming a non-help-seeking group (NHS). MI yielded significantly better drinking outcomes during the 12-week treatment period than MI + CBT, but posttreatment outcomes were equivalent. NHS participants significantly reduced their drinking as well. Service delivery and treatment research implications are discussed.

Barriers to employability among substance dependent and nonsubstance-affected women on federal welfare: implications for program design.

OBJECTIVE: This study examined barriers to employability among women meeting criteria for a substance dependence disorder who were identified by routine screening conducted in welfare offices. The characteristics of these women were compared to other women on welfare who did not have a substance use disorder. METHOD: A sample of 214 substance dependent women on federal welfare were recruited to participate in a substance use disorders welfare demonstration project. An additional 69 nonsubstance-affected women on welfare served as a comparison sample. All participants were assessed in welfare settings through a standardized battery of measures. RESULTS: Substance dependent women reported moderate to severe substance use problems. They also reported significantly higher rates than the women with no substance use disorder of other barriers such as domestic violence, mental health problems, legal problems, child welfare investigations and fewer job skills. CONCLUSIONS: Findings raise questions about the likely effectiveness of existing welfare reform services in addressing the needs of substance dependent women.

Non-Paraphilic Compulsive Sexual Behavior and Psychiatric Co-morbidities in Gay and Bisexual Men.

This study explored the features of non-paraphilic compulsive sexual behavior (NPCSB) in a community sample of 183 gay and bisexual men in New York City who reported difficulty controlling their sexual behavior. Several diagnostic and face valid measures of NPCSB and Axis I comorbidity were administered. Results indicated that NPCSB is associated with a range of problem behaviors, a fairly coherent pattern of symptoms that can be assessed with good inter-rater reliability, is distinct from other related disorders, and provides a moderate fit to the dependence model but with other unique features. Implications for classification and treatment will be discussed.

Randomized trial to reduce club drug use and HIV risk behaviors among men who have sex with men.

The authors examined the effectiveness of motivational interviewing (MI) on club drug use and risky sex in non-treatment-seeking men who have sex with men (MSM). MSM (N = 150) were assessed and randomly assigned to 4 sessions of MI or an educational control intervention. Follow-up occurred at quarterly intervals for 1 year. Primary outcomes were days of any club drug use and number of unsafe sex acts. On average, club drug use declined during follow-up. A significant interaction effect showed that MI was associated with less club drug use during follow-up compared with education but only among participants with lower severity of drug dependence (p < .02; small to medium effect size). MI did not result in a significant reduction in risky sex relative to education. The results support the use of MI targeting club drug use in at-risk or mildly dependent users not seeking treatment but not in more severely dependent users. MI does not appear effective in reducing risky sexual behavior in this population.

Alcohol and sexual HIV risk behavior among problem drinking men who have sex with men: An event level analysis of timeline followback data.

While heavy drinking among men who have sex with men (MSM) has been shown to be associated with an increase in sexual risk taking, a temporal relationship between drinking and an increase in subsequent HIV risk behaviors among adult samples has been less obvious. This study used an event level analysis to examine this relationship among HIV negative problem drinking MSM. Within subjects analyses show a higher probability of unprotected anal intercourse after drinking. Post-hoc analyses of within subjects data indicate that drinking increases risk taking when engaging in receptive anal intercourse but not for insertive anal intercourse. Findings from this study support evidence that drinking is a factor that increases risk taking among HIV negative problem drinking MSM, particularly for receptive anal intercourse.

A double-blind study of citalopram versus placebo in the treatment of compulsive sexual behaviors in gay and bisexual men.

OBJECTIVE: Compulsive sexual behavior (CSB) is a condition characterized by loss of control over sexual behavior and repeated negative consequences, including unsafe sex. Selective serotonin reuptake inhibitors have been found to reduce CSB symptomatology in open-label trials. The objective of this study was to conduct a preliminary double-blind, placebo-controlled evaluation of the efficacy, acceptability, and tolerability of citalopram in the treatment of CSB. METHOD: Twenty-eight men who have sex with men who met the threshold for CSB on the basis of existing validated measures participated in a 12-week, double-blind trial of citalopram 20 to 60 mg/day to evaluate its effects on CSB symptoms. The primary efficacy measure was the Yale-Brown Obsessive Compulsive Scale-Compulsive Sexual Behavior. The study was conducted from June 2002 to April 2004. RESULTS: Significant treatment effects were obtained for sexual desire/drive (p < .05) and frequency of masturbation (p < .01) and pornography use (p < .05). Both groups reduced sexual risk, but did not differ significantly. CONCLUSIONS: This study provides partial support for the effectiveness of citalopram for reducing symptoms of CSB in this population. Larger-scale trials are recommended to determine the public health benefits of this treatment.

Drug-use patterns among men who have sex with men presenting for alcohol treatment: differences in ethnic and sexual identity.

Two important gaps in our current understanding of drug and alcohol use among men who have sex with men (MSM) are that, first, little is known about the extent of drug- and alcohol-use disorders among MSM and, second, how these may vary among MSM who differ by ethnic/racial or sexual identity. This article is a descriptive study of the alcohol- and drug-use patterns and alcohol and drug diagnoses in an ethnically and sexually diverse sample of treatment-seeking MSM whose primary diagnosis is either alcohol abuse or alcohol dependence. The severity of alcohol problems did not vary by either ethnic or sexual identity, although the types of drugs that were used by participants did. African Americans reported a significantly higher number of drinks per drinking day compared with those in the other ethnic categories.Gay-identified men and those identified as either non-Hispanic Whites or Hispanic/Latino were significantly more likely to have used stimulant drugs (amphetamine or methamphetamine) in the past 6 months, and non-Hispanic Whites were less likely to have used marijuana compared with the other ethnic groups. A very high rate of comorbidity of drug- and alcohol-use disorders was found in this sample of ethnically diverse MSM. These results have important implications for the design of effective treatment interventions.