Aniline and methanol toxicity after shoe dye ingestion.

A 39-year-old woman intentionally ingested Amberes shoe dye containing both methanol and aniline. She subsequently developed life-threatening methanol poisoning, methemoglobinemia, hemolytic anemia, and sulfhemoglobinemia. Treatment involved methylene blue infusion, emergent hemodialysis, fomepizole therapy, and blood products. Multiple toxicities can occur after ingestion of shoe dyes

The effect of cyclosporine A on survival time in salicylate-poisoned rats.

Salicylate (SAL) produces mitochondrial membrane permeability transition (MPT) with resultant oxidative phosphorylation uncoupling. Cyclosporine A (CSA) inhibits SAL-induced MPT. This study determined if CSA pretreatment prolonged survival time in SAL-poisoned rats. Twenty-nine rats were randomized to receive pre-treatment with either 30 mg/kg CSA or equal volume of control diluent intraperitoneally (i.p.). Four hours later, all rats received 1700 mg/kg sodium salicylate i.p. Survival time, whole blood CSA ([CSA]), and serum sodium ([Na]), glucose and SAL ([SAL]) concentrations were determined. The results showed median survival time for controls was 18 min (95% CI 14-22 min) and for CSA animals was 14 min (95% CI 13-15 min). Univariate and multivariate analyses and Cox proportional hazard regression revealed CSA treatment was associated with higher [SAL], which was associated with shortened survival times. The CSA group also demonstrated shorter survival times for a given [SAL]. In conclusion, CSA pre-treatment shortened survival in SAL-poisoned rats

Seasonal variation of hip fractures in patients with Benign Paroxysmal Positional Vertigo

Introduction: Seasonal variation of benign paroxysmal positional vertigo (BPPV) presentation has been reported, with higher rates of presentation in months associated with times of lower serum vitamin D levels. The purpose of this study was to examine the association between the timing of hip fracture in patients with BPPV. Methods: A retrospective review (2013 to 2019) of adult patients was performed at a tertiary care academic center to identify patients with hip fracture due to ground level fall (ICD-10 code S72) and a previously established diagnosis of vestibular disorder (ICD-10 codes H81-83, A88.1, and R42). Included patients were matched by age and sex to control for patients who had hip fracture without a vestibular diagnosis. Patient charts were reviewed, and demographic and clinical data were extracted related to hip fracture and prior vestibular diagnosis. Groups were subdivided based on whether patients had a hip fracture from January to June versus July to December. Fisher’s exact test was used to evaluate for a difference in seasonal variation between groups. Results: There were 201 patients with vestibular disorders of whom 27 patients carried the diagnosis of BPPV, with a mean age of 80.4 years. The rates of hip fracture among patients with BPPV was higher in the period extending from January to June (63.0%) versus July to December (37.0%), [odds ratio 1.59, 95% CI 0.66-4.00]. The rate of hip fracture was not significantly different between these time periods for the control group (51.7% versus 48.3%) or the vestibular group (53.2% versus 46.8%). Conclusion: These results offer preliminary evidence that, in addition to an increased presentation for BPPV during months associated with decreased serum vitamin D, injuries due to BPPV may be increased as well. The present study is limited by the statistical power afforded by the small number of patients with BPPV and hip fracture that were identified

The effect of single-dose tramadol on oxycodone clearance.

We have noticed increased prescribing of tramadol by emergency physicians for breakthrough pain in patients chronically taking oxycodone. Both oxycodone and tramadol undergo oxidative metabolism by CYP2D6 and CYP3A4, suggesting the possibility that tramadol may compete with oxycodone for metabolism. A randomized controlled trial in 10 human volunteers was performed to determine if single-dose tramadol therapy would impair oxycodone clearance. Subjects were randomized whether to enter the control or experimental arm of the study first, with each subject serving as his or her own control. In the control arm, each subject received 10 mg immediate-release oxycodone orally and had serial plasma oxycodone and oxymorphone concentrations measured over 8 h. The experimental arm was identical except that 100 mg tramadol was ingested 1.5 h before oxycodone. Clearance divided by fraction absorbed (CL/f) was calculated using the dose and the area under the 8-h time-plasma oxycodone concentration curve. Peak plasma oxycodone concentrations (C(max)) and time until peak oxycodone concentrations (T(max)) were secondary outcome parameters. Group size was chosen to produce a power of 0.8 to detect a 20% difference in CL/f between study arms. Values for CL/f, C(max), and T(max) were compared between study arms using two-tailed, paired t-tests. No statistically significant difference between groups was demonstrated for any parameter. We failed to demonstrate that single doses of tramadol impaired oxycodone clearance

Retropharyngeal Abscess and Pott’s Disease Due to Tuberculosis: A Case Report

Introduction: Extrapulmonary mycobacterial infection can lead to vertebral spondylitis and osteomyelitis (Pott’s disease). Retropharyngeal abscess with concurrent spinal osteomyelitis is a rare presentation of tuberculosis in the US. Chart review on a patient was completed, and the relevant published literature was reviewed. Case Presentation: A previously healthy 34-year-old male originally from Sudan presented to an outside hospital with a 2-month history of neck pain, sore throat, odynophagia, fevers, and chills. MRI showed a retropharyngeal abscess and suspected cervical spine osteomyelitis. Acid-fast bacillus (AFB) smear was positive from a neck drain specimen, but sputum was negative. Chest imaging did not show findings consistent with pulmonary tuberculosis. He was treated with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) along with moxifloxacin and linezolid due to concern for possible multidrug resistant tuberculosis and transferred to our center for further care. Culture isolated Mycobacterium tuberculosis. CT neck showed vertebral tuberculous osteomyelitis (Pott’s disease) of C1-C3 with a multiloculated retropharyngeal and prevertebral abscess (Figure 1). The patient was taken to the OR for posterior spinal fusion from occiput to C4 and transoral incision and drainage of the abscess. The post-operative course was uneventful, and moxifloxacin and linezolid were discontinued when Xpert MTB/RIF test revealed rifampin susceptibility. At follow-up the patient’s symptoms had resolved. Patient consent was obtained to utilize this case for educational purposes. Conclusions: This report presents the multidisciplinary treatment of this patient requiring infection control measures and antibiotic therapy by infectious disease, posterior spine fusion by orthopedic surgery, and retropharyngeal abscess drainage by otolaryngology

Initial postmarketing experience with crotalidae polyvalent immune Fab for treatment of rattlesnake envenomation.

STUDY OBJECTIVE: We describe our postmarketing experience with patients receiving Crotalidae polyvalent immune Fab (CroFab; FabAV) antivenom for treatment of rattlesnake envenomation. METHODS: The charts of 28 patients admitted between March 1 and September 9, 2001, with rattlesnake envenomation and treated with FabAV were reviewed for demographic information, time until antivenom treatment, laboratory findings, evidence of hypersensitivity reaction, length of hospital stay, and readmission to the hospital. RESULTS: All patients had swelling, 20 patients had elevated prothrombin times (\u3e14 seconds), 12 patients had low fibrinogen levels (/dL), and 6 patients had thrombocytopenia (platelet count \u3c120,000/mm(3)) on presentation. The total dose of FabAV ranged from 10 to 47 vials per patient. Hypofibrinogenemia was resistant to FabAV in some patients. On follow-up, recurrence of coagulopathy was detected in 3 patients, and recurrence of thrombocytopenia was detected in 1 patient. Two patients demonstrated delayed-onset severe thrombocytopenia. Recurrence or delayed-onset toxicity might have been underestimated because of incomplete follow-up in some patients. No acute hypersensitivity reactions occurred. Two patients reported mild symptoms of possible serum sickness on follow-up. CONCLUSION: FabAV effectively controlled the effects of envenomation; however, initial control of coagulopathy was difficult to achieve in some cases, and recurrence or delayed-onset hematotoxicity was common. When initially managing hematotoxicity, a trend toward normalization of laboratory values might be a more reasonable end point for FabAV treatment than attainment of normal reference values in nonbleeding patients

An exploratory analysis of the impact of family functioning on treatment for depression in adolescents.

This article explores aspects of family environment and parent-child conflict that may predict or moderate response to acute treatments among depressed adolescents (N = 439) randomly assigned to fluoxetine, cognitive behavioral therapy, their combination, or placebo. Outcomes were Week 12 scores on measures of depression and global impairment. Of 20 candidate variables, one predictor emerged: Across treatments, adolescents with mothers who reported less parent-child conflict were more likely to benefit than their counterparts. When family functioning moderated outcome, adolescents who endorsed more negative environments were more likely to benefit from fluoxetine. Similarly, when moderating effects were seen on cognitive behavioral therapy conditions, they were in the direction of being less effective among teens reporting poorer family environments

Exoplanet Diversity in the Era of Space-based Direct Imaging Missions

This whitepaper discusses the diversity of exoplanets that could be detected by future observations, so that comparative exoplanetology can be performed in the upcoming era of large space-based flagship missions. The primary focus will be on characterizing Earth-like worlds around Sun-like stars. However, we will also be able to characterize companion planets in the system simultaneously. This will not only provide a contextual picture with regards to our Solar system, but also presents a unique opportunity to observe size dependent planetary atmospheres at different orbital distances. We propose a preliminary scheme based on chemical behavior of gases and condensates in a planet's atmosphere that classifies them with respect to planetary radius and incident stellar flux.Comment: A white paper submitted to the National Academy of Sciences Exoplanet Science Strateg

Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop

<p>Abstract</p> <p>Background</p> <p>Envenomation by crotaline snakes (rattlesnake, cottonmouth, copperhead) is a complex, potentially lethal condition affecting thousands of people in the United States each year. Treatment of crotaline envenomation is not standardized, and significant variation in practice exists.</p> <p>Methods</p> <p>A geographically diverse panel of experts was convened for the purpose of deriving an evidence-informed unified treatment algorithm. Research staff analyzed the extant medical literature and performed targeted analyses of existing databases to inform specific clinical decisions. A trained external facilitator used modified Delphi and structured consensus methodology to achieve consensus on the final treatment algorithm.</p> <p>Results</p> <p>A unified treatment algorithm was produced and endorsed by all nine expert panel members. This algorithm provides guidance about clinical and laboratory observations, indications for and dosing of antivenom, adjunctive therapies, post-stabilization care, and management of complications from envenomation and therapy.</p> <p>Conclusions</p> <p>Clinical manifestations and ideal treatment of crotaline snakebite differ greatly, and can result in severe complications. Using a modified Delphi method, we provide evidence-informed treatment guidelines in an attempt to reduce variation in care and possibly improve clinical outcomes.</p

Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery:a systematic review and meta-analysis

Background - Postcardiotomy cardiogenic shock (PCCS) refractory to inotropic support and intra-aortic balloon pump (IABP) occurs rarely but is almost universally fatal without mechanical circulatory support. In this systematic review and meta-analysis we looked at the evidence behind the use of veno-arterial extra-corporeal membrane oxygenation (VA ECMO) in refractory PCCS from a patient survival rate and determinants of outcome viewpoint. Methods - A systematic review was performed in January 2017 using PubMed (with no defined time period) using the keywords “postcardiotomy”, “cardiogenic shock”, “extracorporeal membrane oxygenation” and “cardiac surgery”. We excluded papers pertaining to ECMO following paediatric cardiac surgery, medical causes of cardiogenic shock, as well as case reports, review articles, expert opinions, and letters to the editor. Once the studies were collated, a meta-analysis was performed on the proportion of survivors in those papers that met the inclusion criteria. Meta-regression was performed for the most commonly reported adverse prognostic indicators (API). Results - We identified 24 studies and a cumulative pool of 1926 patients from 1992 to 2016. We tabulated the demographic data, including the strengths and weaknesses for each of the studies, outcomes of VA ECMO for refractory PCCS, complications, and APIs. All the studies were retrospective cohort studies. Meta-analysis of the moderately heterogeneous data (95% CI 0.29 to 0.34, p 70 years, 95% CI −0.057 to 0.001, P = 0.058), and long ECMO support (95% CI −0.068 to 0.166, P = 0.412). Postoperative renal failure, high EuroSCORE (>20%), diabetes mellitus, obesity, rising lactate whilst on ECMO, gastrointestinal complications had also been reported. Conclusion - Haemodynamic support with VA ECMO provides a survival benefit with reasonable intermediate and long-term outcomes. Many studies had reported advanced age, renal failure and prolonged VA ECMO support as the most likely APIs for VA ECMO in PCCS. EuroSCORE can be utilized to anticipate the need for prophylactic perioperative VA ECMO in the high-risk category. APIs can be used to aid decision-making regarding both the institution and weaning of ECMO for refractory PCCS