Serotonin toxicity after addition of mirtazapine to escitalopram

Inpatient Management of Hyperemesis Gravidarum

Hyperemesis gravidarum has a reported incidence of approximately 0.3-3% of pregnancies. Without treatment, refractory hyperemesis gravidarum can result in dehydration, electrolyte deficiencies, and severe nutritional deficiencies, resulting in significant maternal morbidity. The overall goals of inpatient management of refractory hyperemesis gravidarum are the resumption of oral intake to an adequate level to maintain hydration and nutrition, including the ability to tolerate oral pharmacotherapy. Patients initially are stabilized with rehydration and electrolyte repletion. There are numerous pharmacotherapeutics available that can be administered intravenously to control symptoms when oral intake is not an option. However, despite maximizing typical antiemetics, there will be cases refractory to these medications, and alternative pharmacotherapeutics and nutrition-support modalities must be considered. Mirtazapine, olanzapine, corticosteroids, and gabapentin are examples of alternative pharmacotherapeutics, and enteral and parenteral nutrition are alternative therapies that can be used when oral intake is not tolerated for prolonged time periods with ongoing weight loss. In refractory cases of hyperemesis gravidarum, the risks and benefits of these alternative forms of management must be considered, along with the risks of undertreated hyperemesis gravidarum and the overall effect of hyperemesis gravidarum on patients' quality of life.

Commercial Aircraft-Assisted Suicide Accident Investigations Re-Visited—Agreeing to Disagree?

Background: The number of aircraft-assisted suicides can only be considered a rough estimate because it is difficult and, at times, impossible to identify all cases of suicide. Methods: Four recent reports of accidents occurring in 1997 in Indonesia, 1999 in Massachusetts in the United States, 2013 in Namibia, and 2015 in France related to commercial aircraft-assisted suicides were analyzed. This analysis relied on data extracted from the accident reports that supported aircraft-assisted suicide from the: (a) cockpit voice recorder (CVR) and flight data recorder (FDR), (b) medical history, (c) psychosocial history, (d) toxicology, (e) autopsy, and (f) any methodology that utilized aviation medicine. There are some limitations in this study. Although all analyzed accident investigations followed ICAO Annex 13 guidelines, there is variability in their accident investigations and reporting. In addition, accident investigation reports represent accidents from 1997 to 2015, and during this time, there has been a change in the way accidents are reported. The nature of this analysis is explorative. The aim was to identify how the various aircraft accident investigators concluded that the accidents were due to suicidal acts. Results: In all four accident reports, FDR data were available. CVR data were also available, except for one accident where CVR data were only partially available. Comprehensive medical and psychosocial histories were available in only one of four of the accident reports. Conclusion: To prevent accidents involving commercial aircraft, it is necessary to identify the causes of these accidents to be able to provide meaningful safety recommendations. A detailed psychological autopsy of pilots can and likely will assist in investigations, as well as generate recommendations that will substantially contribute to mitigating accidents due to pilot suicide. Airborne image recording may be a useful tool to provide additional information about events leading up to a crash and thus assist in accident investigations.

Management of severe arterial hypertension associated with serotonin syndrome: a case report analysis based on systematic review techniques

Serotonin syndrome is thought to arise from serotonin excess. In many cases, symptoms are mild and self-limiting. But serotonin syndrome can become life threatening, when neuromuscular hyperexcitability spins out of control. Uncontainable neuromuscular hyperexcitability may lead to cardiovascular complications, linked to extreme changes in blood pressure. Currently, there is little guidance on how to control blood pressure in hyperserotonergic states. We report a case with treatment-resistant arterial hypertension, followed by a clinical review (using systematic review principles and techniques) of the available evidence from case reports published between 2004 and 2016 to identify measures to control arterial hypertension associated with serotonin syndrome. We conclude that classic antihypertensives may not be effective for the treatment of severe hypertension associated with serotonin syndrome. Benzodiazepines may lower blood pressure. Patients with severe hypertension not responding to benzodiazepines may benefit from cyproheptadine, propofol or both. In severe cases, higher cyproheptadine doses than currently recommended may be necessary.

Treatment options for hyperemesis gravidarum

Hyperemesis gravidarum (HG) is a severe and prolonged form of nausea and/or vomiting during pregnancy. HG affects 0.3-2% of pregnancies and is defined by dehydration, ketonuria, and more than 5% body weight loss. Initial pharmacologic treatment for HG includes a combination of doxylamine and pyridoxine. Additional interventions include ondansetron or dopamine antagonists such as metoclopramide or promethazine. The options are limited for women who are not adequately treated with these medications. We suggest that mirtazapine is a useful drug in this context and its efficacy has been described in case studies. Mirtazapine acts on noradrenergic, serotonergic, histaminergic, and muscarinic receptors to produce antidepressant, anxiolytic, antiemetic, sedative, and appetite-stimulating effects. Mirtazapine is not associated with an independent increased risk of birth defects. Further investigation of mirtazapine as a treatment for HG holds promise to expand treatment options for women suffering from HG.