A Case of Drug-induced Hepatotoxicity: Amiodarone is Not Always to Blame

Case Presentation A 54 year-old male presented to the hospital with a two weekhistory of new onset jaundice, anorexia and fatigue. Thepatient has a past medical history of hypertension, coronaryartery disease, and ischemic cardiomyopathy with an ejectionfraction of 10% to 15%. He also has a history of atrial fibrillationand paroxysmal ventricular tachycardia with an automatedimplantable cardioverter-defibrillator placed. He deniedany history of blood transfusions, alcohol use, intravenousdrug abuse, or known hepatitis. He also denied taking herbalmedications or vitamins. The patient denied fevers, night sweats,nausea, shortness of breath, abdominal pain, blood in his stool,or easy bruising. Four weeks prior to admission, the patientwas diagnosed with hyperthyroidism thought to be secondary tolong-term amiodarone use which the patient had been taking foreight years for treatment of atrial fibrillation. At that time he wasstarted on 10 mg of methimazole daily, and his amiodarone wasstopped. All of his other medications were chronic and includeatenolol, pantoprazole, aspirin, clopidogrel, and furosemide. Hehas no known drug allergies. Upon admission his methimazolewas stopped since his symptoms could be attributable to this medication

A Woman With Chest Pain, Syncope, and Transaminitis

Case Presentation The patient is a 49 year-old female with past medical history ofanxiety and hyperlipidemia who presented to an outside hospitalwith complaints of five hours of substernal chest pain followed bythree episodes of syncope witnessed by her son. At presentationin the emergency department the patient denied any currentchest pain or shortness of breath. She received 325 mg of aspirinen route to the hospital by EMS. Her vital signs were temperature100° Fahrenheit, heart rate 60 beats/minute, blood pressure101/50 mm Hg, respiratory rate 20 breaths/minute, and a pulseoxygenation of 98% on room air. The patient’s EKG showed STelevations in the inferior leads. The patient’s laboratory studieswere: white blood cell (wbc) count 14 B/L, hemoglobin 13.2 g/dL, platelets 153 B/L, CKMB 32 U/L, troponin 8.27 ug/L, andCK 24.5 U/L. The patient was started on intravenous heparinand integrillin drips and transferred to Jefferson for emergentcardiac catheterization

Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE)

Background: Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown. Methods: This prospective, observational study recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events. Results: Infants (n=5609) born at mean (standard deviation [sd]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (>30% decrease in blood pressure) or reduced oxygenation (SpO2 <85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]=1.16; 95% confidence interval [CI], 1.04-1.28) and in those requiring preoperative intensive support (RR=1.27; 95% CI, 1.15-1.41). Additional complications occurred in 16.3% of patients by 30 days, and overall 90-day mortality was 3.2% (95% CI, 2.7-3.7%). Co-occurrence of intraoperative hypotension, hypoxaemia, and anaemia was associated with increased risk of morbidity (RR=3.56; 95% CI, 1.64-7.71) and mortality (RR=19.80; 95% CI, 5.87-66.7). Conclusions: Variability in physiological thresholds that triggered an intervention, and the impact of poor tissue oxygenation on patient's outcome, highlight the need for more standardised perioperative management guidelines for neonates and infants