“Ghost tablet” husks excreted in feces in large bupropion XL overdose

Background: Extended-release medications are widely prescribed across the spectrum of medical specialties; however, there is heterogeneity in how they are formulated. Commonly, they consist of an insoluble matrix or shell from which drug elutes, which may then be observed by patients when excreted in feces. We describe the case of a patient who ingested a large amount of extended-release bupropion tablets and subsequently passed a large number of these so-called “ghost tablets” in his stool. Case Details: A 19-year-old male presented in status epilepticus following intentional overdose of an unknown substance. He had prolonged QRS and QT intervals on ECG, hypotension requiring vasopressors, and tachycardia, and progressed to cardiac arrest and respiratory failure. On hospital day 4, he passed several large bowel movements containing apparent tablets. Serum bupropion and hydroxybupropion levels performed on serum taken at time of admission were 1800 ng/mL and 4200 ng/mL, respectively. Case Discussion: “Ghost tablets,” the insoluble remnant of some extended-release dosage forms, have been previously reported to appear in patients' stool in the course of therapeutic dosing. We present the case of a considerable quantity of these ghost tablets recovered from stool following a large bupropion XL overdose. Conclusion: Healthcare providers should be aware of the potential for this phenomenon to occur in poisoned patients. It should be documented as physical evidence of overdose in addition to clinical evidence

Clamping of Intracellular pH in Neurons from Neonatal Rat Brainstem during Hypercapnia

In this work, I have made attempts to clamp intracellular pH in the presence of hypercapnic acidosis (HA) in neurons from the locus coeruleus (LC) and nucleus of the solitary tract (NTS) in neonatal rat (ages P3 to P17) brainstem slices. Two approaches were used to minimize hypercapnia-induced ΔpHi: 1) an increase in intracellular buffering power with a high HEPES concentration using whole cell patching techniques in individual neurons, and 2) a weak acid diffusion technique that relies on an efflux of weak acid to counterbalance HA influx thereby clamping pHi in multiple neurons at once. pHi was measured using two pH-sensitive fluorescent dyes: membrane impermeable pyranine for the former approach, and the acetoxymethyl ester form of membrane permeable 2\u27,7\u27-bis-(2-carboxyethyl)-5-(and-6)-carboxyfluorescein (BCECF) for the latter. Blunting with HEPES buffer was performed in the NTS only, with a calculated average percent blunting of hypercapnia-induced acidification of 73.4%. Experiments blunting via weak acid diffusion utilized an inverted microscope and two weak acids: acetic acid and caproic (hexanoic) acid. In NTS neurons (n=56), acetic acid blunted acidification by only 33.1% and in LC neurons by only 19.6% (n=52). Caproic acid blunted hypercapnia-induced acidification by 50.7% (n=58) and 45.8% (n=47) in NTS and LC neurons, respectively. Experiments were also repeated using an upright microscope. In these experiments, acidification was blunted by 45.8% (n=56) and 52.6% (n=52) in NTS and LC neurons, respectively. Concurrent influx of weak base, trimethyl amine, with HA was also used to blunt ΔpHi, but the results showed no blunting and, in fact, a greater acidification in response to HA: -18.1% in the NTS (n=40) and -27.8% in the LC (n=28). These techniques are clearly insufficient to accomplish a complete clamping of hypercapnia-induced changes in pHi. However, we have determined that the ability to clamp pHi is highly affected by diffusion of the weak acid both up to and into the cell. Blunting could be improved with better superfusion of slices and the use of more permeable weak acids. Overall, the ability to blunt ΔpHi, especially in numerous cells simultaneously, would be valuable in studying systems where pHi may play a role in cellular function, such as the involvement of pHi in chemosensitive signaling, bicarbonate reabsorption in the proximal tubule, free fatty acid diffusion in adipocytes, and acid-sensing taste receptors

The Combination of Gastroschisis, Jejunal Atresia, and Colonic Atresia in a Newborn

We encountered a rare case of gastroschisis associated with jejunal atresia and colonic atresia. In our case, the jejunal atresia was not discovered for 27 days after the initial abdominal wall closure. The colonic atresia was not discovered for 48 days after initial repair of the gastroschisis secondary to the rarity of the disorder. Both types of atresia were repaired with primary hand-sewn anastomoses. Other than the prolonged parenteral nutrition and hyperbilirubinemia, our patient did very well throughout his hospital course. Based on our case presentation, small bowel atresia and colonic atresia must be considered in patients who undergo abdominal wall closure for gastroschisis with prolonged symptoms suggestive of bowel obstruction. Our case report also demonstrates primary enteric anastomosis as a safe, well-tolerated surgical option for patients with types of intestinal atresia

Adolescent Male Human Papillomavirus Vaccination

Objective . To determine male vaccination rates with quadrivalent human papillomavirus vaccine (HPV4) before and after the October 2011 national recommendation to routinely immunize adolescent males. Methods . We reviewed HPV4 dose 1 (HPV4-1) uptake in 292 adolescent males in our urban clinic prior to national recommendations and followed-up for HPV4 series completion rates. After national recommendation, 248 urban clinic and 247 suburban clinic males were reviewed for HPV4-1 uptake. Factors associated with HPV4-1 refusal were determined with multiple logistic regression. Results . Of the initial 292 males, 78% received HPV4-1 and 38% received the 3-dose series. After recommendation, HPV4-1 uptake was 59% and 7% in urban and suburban clinics, respectively. Variables associated with HPV4-1 uptake/refusal included time period, race, type of insurance, and receipt of concurrent vaccines. Conclusions . HPV4-1 vaccination rates in our urban clinic were high before and after routine HPV vaccine recommendations for adolescent males. Our vaccination rates were much higher than in a suburban practice

Comparison of Resident and Faculty Patient Satisfaction Surveys in a Pediatric Ambulatory Clinic

Background: Patient satisfaction is an important component of quality of care. To date, no studies have looked at differences in faculty and resident patient satisfaction in a pediatric practice. Purpose: The purpose was to compare physician measures of patient satisfaction among residents in training and faculty attendings. Methods: We conducted satisfaction surveys containing 4 questions related to physician performance at a children\u27s health clinic. We compared satisfaction scores across training levels of physicians. Results: We analyzed 676 surveys. The 2nd-year and 3rd/4th-year residents had similar high scores on all questions compared to faculty preceptors. The 1st-year residents scored significantly lower than faculty preceptors, 3rd/4th-year residents, and 2nd-year residents on 1 question and the combined average of the 3 physician-specific questions. Conclusions: The 1st-year residents scored lower on patient satisfaction than physicians at higher levels of training. The 2nd-year and 3rd/4th-year residents achieved high satisfaction scores in a primary care clinic, comparable to scores of experienced practitioners. Copyright © 2006 by Lawrence Erlbaum Associates, Inc