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Li M, Tang Z, Yu L, Li Y, Ma W, Li J, Li G, Xiong L, Lei N, Guo P, Xie Y. The arousal effect of An-Gong-Niu-Huang-Wan on alcoholic-induced coma rats: A research based on EEG. J Ethnopharmacol 2024; 328:117974. [PMID: 38467317 DOI: 10.1016/j.jep.2024.117974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/13/2024]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Acute alcohol intoxication is one of the leading causes of coma. A well-regarded Chinese herbal formula, known as An-Gong-Niu-Huang-Wan (AGNHW), has garnered recognition for its efficacy in treating various brain disorders associated with impaired consciousness, including acute alcohol-induced coma. Despite its clinical effectiveness, the scientific community lacks comprehensive research on the mechanistic aspects of AGNHW's impact on the electroencephalogram (EEG) patterns observed during alcohol-induced coma. Gaining a deeper understanding of AGNHW's mechanism of action in relation to EEG characteristics would hold immense importance, serving as a solid foundation for further advancing its clinical therapeutic application. AIM OF THE STUDY The study sought to investigate the impact of AGNHW on EEG activity and sleep EEG patterns in rats with alcoholic-induced coma. MATERIALS AND METHODS A rat model of alcohol-induced coma was used to examine the effects of AGNHW on EEG patterns. Male Sprague-Dawley rats were intraperitoneally injected with 32% ethanol to induce a coma, followed by treatment with AGNHW. Wireless electrodes were implanted in the cortex of the rats to obtain EEG signals. Our analysis focused on evaluating alterations in the Rat Coma Scale (RCS), as well as assessing changes in the frequency and distribution of EEG patterns, sleep rhythms, and body temperature subsequent to AGNHW treatment. RESULTS The study found a significant increase in the δ-band power ratio, as well as a decrease in RCS scores and β-band power ratio after modeling. AGNHW treatment significantly reduced the δ-band power ratio and increased the β-band power ratio compared to naloxone, suggesting its superior arousal effects. The results also revealed a decrease in the time proportion of WAKE and REM EEG patterns after modeling, accompanied by a significant increase in the time proportion of NREM EEG patterns. Both naloxone and AGNHW effectively counteracted the disordered sleep EEG patterns. Additionally, AGNHW was more effective than naloxone in improving hypothermia caused by acute alcohol poisoning in rats. CONCLUSION Our study provides evidence for the arousal effects of AGNHW in alcohol-induced coma rats. It also suggests a potential role for AGNHW in regulating post-comatose sleep rhythm disorders.
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Affiliation(s)
- Minghong Li
- Basic Medical School, Yunnan University of Chinese Medicine, Kunming, 650500, China
| | - Zilei Tang
- College of Traditional Chinese Medicine, Yunnan University of Chinese Medicine, Kunming, 650500, China
| | - Liuyan Yu
- College of Traditional Chinese Medicine, Yunnan University of Chinese Medicine, Kunming, 650500, China
| | - Yingming Li
- College of Traditional Chinese Medicine, Yunnan University of Chinese Medicine, Kunming, 650500, China
| | - Wenyu Ma
- College of Traditional Chinese Medicine, Yunnan University of Chinese Medicine, Kunming, 650500, China
| | - Jincun Li
- College of Traditional Chinese Medicine, Yunnan University of Chinese Medicine, Kunming, 650500, China
| | - Gang Li
- Basic Medical School, Yunnan University of Chinese Medicine, Kunming, 650500, China; Yunnan Provincial University Key Laboratory of Aromatic Chinese Herb Research, Kunming, 650500, China
| | - Lei Xiong
- School of Clinical Medicine, Yunnan University of Chinese Medicine, Kunming, 650500, China; Yunnan Provincial University Key Laboratory of Aromatic Chinese Herb Research, Kunming, 650500, China; Yunnan Innovation Team of Application Research on Traditional Chinese Medicine Theory of Disease Prevention at Yunnan University of Chinese Medicine, Kunming, 650500, China
| | - Na Lei
- Basic Medical School, Yunnan University of Chinese Medicine, Kunming, 650500, China.
| | - Peixin Guo
- College of Ethnic Medicine, Yunnan University of Chinese Medicine, Kunming, 650500, China; Yunnan Innovation Team of Application Research on Traditional Chinese Medicine Theory of Disease Prevention at Yunnan University of Chinese Medicine, Kunming, 650500, China.
| | - Yuhuan Xie
- Yunnan Provincial University Key Laboratory of Aromatic Chinese Herb Research, Kunming, 650500, China; Yunnan Innovation Team of Application Research on Traditional Chinese Medicine Theory of Disease Prevention at Yunnan University of Chinese Medicine, Kunming, 650500, China.
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Bernasconi L, Schicchi A, Petrolini VM, Malovini A, Lonati D, Fassio F, Buscaglia E, Scaravaggi G, Crema F, Locatelli CA. Clinical characteristics of acute lacosamide poisoning: Pavia Poison Control Centre experience. Br J Clin Pharmacol 2024; 90:812-818. [PMID: 37953463 DOI: 10.1111/bcp.15964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023] Open
Abstract
AIMS Lacosamide is a third-generation antiepileptic drug used as adjunctive therapy for partial seizures. Since its approval in 2008 very few cases of lacosamide overdose have been described in literature. The aim of our study was to evaluate clinical characteristics of acute lacosamide poisoning. METHODS A retrospective observational study was performed including all cases of acute lacosamide poisoning referred to Pavia Poison Control Centre from January 2012 to December 2021. For each patient age, sex, ingested dose, coingestants, clinical manifestations, treatment and outcome were collected. RESULTS A total of 31 subjects (median age 39 years, [interquartile range: 26.5-46.5]; females 22/31) were included. The median lacosamide ingested dose was 1500 mg [650-2800]. In 35.5% of cases lacosamide was the single ingested substance, while in 64.5% coingestants were also present. Coingestants varied from a minimum of 1 to a maximum of 3, with the more common being benzodiazepines and valproic acid. Clinical manifestations were present in 87% patients the most common were: vomiting (29%); seizures (29%), coma (25.8%), drowsiness (25.8%), confusion (12.9%), agitation (12.9%), tachycardia (12.9%), tremors (9.7%), bradycardia (9.7%), headache (6.5%) and hypertension (3.2%). The median lacosamide ingested dose was significantly higher in patients that experienced coma compared to patient who did not (2800 vs. 800 mg; P = .0082). Orotracheal intubation was necessary in 32.3% of patients. All patients fully recovered. CONCLUSION Lacosamide acute overdose may lead to a severe clinical picture. Dentral nervous system symptoms predominated, particularly seizures and coma occurred in a high percentage of cases.
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Affiliation(s)
- Lucia Bernasconi
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
- Postgraduate School of Pharmacology and Clinical Toxicology, University of Pavia, Pavia, Italy
| | - Azzurra Schicchi
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
- Experimental Medicine PhD Program, University of Pavia, Pavia, Italy
| | - Valeria M Petrolini
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Alberto Malovini
- Laboratory of Informatics and Systems Engineering for Clinical Research, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Davide Lonati
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Federico Fassio
- Department of Public Health, Experimental and Forensic Medicine, Section of Biostatistics and Clinical Epidemiology, University of Pavia, Pavia, Italy
| | - Eleonora Buscaglia
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Giulia Scaravaggi
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Francesca Crema
- Department of Internal Medicine and Therapeutics, Section of Pharmacology, University of Pavia, Pavia, Italy
| | - Carlo A Locatelli
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
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Qian ET, Wang L, Stollings JL, Casey JD, Rice TW, Semler MW. Piperacillin-Tazobactam Versus Anti-Pseudomonal Cephalosporins and Renal and Neurologic Outcomes in Critically Ill Adults: A Secondary Analysis of the SMART Trial. J Intensive Care Med 2023; 38:1127-1135. [PMID: 37357717 PMCID: PMC10616997 DOI: 10.1177/08850666231184177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 06/27/2023]
Abstract
Background: Prior studies suggest associations between receipt of piperacillin-tazobactam and development of acute kidney injury and receipt of anti-pseudomonal cephalosporins and neurotoxicity. We compared clinically-relevant renal and neurologic outcomes in critically ill patients who received piperacillin-tazobactam versus anti-pseudomonal cephalosporins. Methods: We conducted a secondary analysis of data from the Isotonic Solutions and Major Adverse Renal Events Trial examining patients who received piperacillin-tazobactam or an anti-pseudomonal cephalosporin within 24 h of intensive care unit admission. We performed multivariable analysis using a proportional odds model to examine the association between the first antibiotic received and the outcomes of Major Adverse Kidney Events within 30 days (MAKE30) and days alive and free of delirium and coma to day 28. Results: 3199 were included in the study; 2375 (74%) receiving piperacillin-tazobactam and 824 (26%) receiving anti-pseudomonal cephalosporin. After adjustment for prespecified confounders, initial receipt of piperacillin-tazobactam, compared to anti-pseudomonal cephalosporins, was not associated with higher incidence of MAKE30 (adjusted odds ratio, 1.03; 95% CI, 0.83-1.27; P = .80) but was associated with a greater number of days alive and free of delirium and coma (adjusted odds ratio, 1.18; 95% CI, 1.00-1.38; P = .04). In a sensitivity analysis adjusting for baseline receipt of medications which may impact neuro function, this finding was not significant. Conclusion: Among critically ill adults, receipt of piperacillin-tazobactam was not associated with an increased incidence of death, renal replacement therapy, or persistent renal dysfunction or a greater number of days alive and free of delirium and coma. Randomized trials are needed to inform the choice of antibiotics for empiric treatment infection in critically ill adults.
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Affiliation(s)
- Edward T. Qian
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanna L. Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt University Medical Center, Critical Illness Brain Dysfunction Survivorship Center, Nashville, TN, USA
| | - Jonathan D. Casey
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W. Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
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Berger S, Kuster T, Sutter R, Fisch U. Neurological evolution of severe baclofen intoxication: from brain death mimic to recovered brain function. BMJ Case Rep 2023; 16:e257391. [PMID: 37802597 PMCID: PMC10565328 DOI: 10.1136/bcr-2023-257391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2023] [Indexed: 10/10/2023] Open
Abstract
Patients with brain death have by definition irreversible and complete loss of brainstem reflexes. Before a definite diagnosis of brain death can be confirmed, all potential confounders must be thoroughly excluded. Baclofen intoxication is a rare cause of brain death mimic characterised by transient deep coma and absence of brainstem reflexes and might be mistaken with brain death. We report the case of a female patient in her 70s who ingested baclofen with suicidal intent and was admitted with a deep coma and loss of all brainstem reflexes and a spontaneous burst-suppression pattern in the electroencephalography which resolved over 10 hours. After a state mimicking brain death for 6 hours, the patient experienced complete recovery. Severe baclofen intoxication can mimic brain death clinically and is associated with temporary pathological electroencephalographic findings. Awareness of this toxidrome is crucial, as appropriate management can lead to full recovery.
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Affiliation(s)
- Sebastian Berger
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Tobias Kuster
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Urs Fisch
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
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Kohara S, Kamijo Y, Seki S, Hasegawa E. Poisoning by abnormally high blood phenobarbital concentration treated with extracorporeal therapy. Am J Emerg Med 2023; 72:221.e5-221.e7. [PMID: 37635049 DOI: 10.1016/j.ajem.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 07/27/2023] [Accepted: 08/18/2023] [Indexed: 08/29/2023] Open
Abstract
Phenobarbital poisoning, which may cause circulatory collapse as well as respiratory arrest in severe cases, has one of the highest mortality rates among acute drug poisonings. A 58-year-old man arrived at the emergency room in a deep coma (Glasgow Coma Scale E1V1M1) after taking an unknown dose of phenobarbital which had been prescribed for his cat's seizures. Venous blood gas analysis revealed hypercapnia (PvCO2: 113.0 mmHg) and a blood phenobarbital concentration of 197.3 μg/mL. Shortly after his arrival, respiratory arrest and circulatory collapse occurred. Mechanical ventilation after intubation, intravenous noradrenaline infusion, and multiple-dose activated charcoal through a nasogastric tube was started. Six hours after arrival, blood phenobarbital concentration was abnormally elevated to 356.8 μg/mL with circulatory collapse requiring an increased dose of intravenous noradrenaline infusion (up to 0.13 μg/kg/min). Continuous renal replacement therapy including high flow continuous hemodialysis was performed until hospital day 5, during which blood phenobarbital concentration decreased to 96.2 μg/mL on hospital day 4, resulting in a sufficient resumption of spontaneous breathing and full improvement of circulatory collapse. A search of the literature revealed that the peak phenobarbital concentration in the present case exceeded those of fatal cases, as well as those of survivors of acute phenobarbital poisoning. However, the patient was successfully treated with continuous renal replacement therapy. Among modalities of extracorporeal treatment, continuous renal replacement therapy could be considered if a patient's circulation is unstable.
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Affiliation(s)
- Saeko Kohara
- Department of Clinical Toxicology, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 355-0495, Japan; Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midoricho, Tachikawa, Tokyo, 190-0014, Japan.
| | - Yoshito Kamijo
- Department of Clinical Toxicology, Saitama Medical University, 38 Morohongo, Moroyama-cho, Iruma-gun, Saitama, 355-0495, Japan
| | - Satoshi Seki
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midoricho, Tachikawa, Tokyo, 190-0014, Japan
| | - Eiju Hasegawa
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256 Midoricho, Tachikawa, Tokyo, 190-0014, Japan
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Oh S, Kim DA. Comment on "Psychogenic coma after general anesthesia with remimazolam and remifentanil -a case report-". Korean J Anesthesiol 2023; 76:510-511. [PMID: 37021437 PMCID: PMC10562077 DOI: 10.4097/kja.23202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/04/2023] [Indexed: 04/07/2023] Open
Affiliation(s)
- Saecheol Oh
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dal-ah Kim
- Department of Anesthesiology and Pain Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Sokołowski G, Motyka M, Gilis-Januszewska A, Stefańska A, Hubalewska-Dydejczyk A. Liquid levothyroxine in the treatment of myxoedema coma. Endokrynol Pol 2023; 74:215-216. [PMID: 37039496 DOI: 10.5603/ep.a2023.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 04/12/2023]
Abstract
Not required for Clinical Vignette.
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Affiliation(s)
- Grzegorz Sokołowski
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - Marcin Motyka
- Department of Endocrinology, Endocrine Oncology and Nuclear Medicine, University Hospital, Krakow, Poland
| | | | - Agnieszka Stefańska
- Department of Endocrinology, Endocrine Oncology and Nuclear Medicine, University Hospital, Krakow, Poland
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8
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Hodgson SE, Wong A. Utility of NT-proBNP monitoring in prolonged coma following massive baclofen exposure. Emerg Med Australas 2023; 35:359-361. [PMID: 36529482 DOI: 10.1111/1742-6723.14154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Sarah E Hodgson
- Victorian Poisons Information Centre, Austin Health, Melbourne, Victoria, Australia
- Emergency Department, Austin Health, Melbourne, Victoria, Australia
| | - Anselm Wong
- Victorian Poisons Information Centre, Austin Health, Melbourne, Victoria, Australia
- Emergency Department, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
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9
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Widmer D, Studhalter M. [Shock and Coma after Ingestion of Morels]. Praxis (Bern 1994) 2023; 112:242-244. [PMID: 36919323 DOI: 10.1024/1661-8157/a004019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Shock and Coma after Ingestion of Morels Abstract. We present the case report of a previously healthy, 42-year-old woman who suffered from a hypovolemic shock, hypoglycemic coma, NSTEMI and temporary dependency on dialysis following the ingestion of morels. Alas there is little public knowledge about the toxicity of morels and the importance of their appropriate preparation so that intoxications can be prevented.
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Affiliation(s)
- Daniel Widmer
- Interdisziplinäre Intensivstation, Kantonsspital Olten, Olten, Schweiz
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10
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Kim SH, Kim KM, Lim YH, Yoo BH, Cho J, Jun IJ. Psychogenic coma after general anesthesia with remimazolam and remifentanil -a case report. Korean J Anesthesiol 2022; 75:449-452. [PMID: 35535428 PMCID: PMC9539421 DOI: 10.4097/kja.22242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delayed emergence from general anesthesia is associated with life-threatening conditions with pharmacological, neurological, metabolic, and rarely, psychiatric causes. This case report was presented to report psychogenic coma after recovery from anesthesia with remimazolam and remifentanil. CASE An elderly woman was unresponsive after recovery from anesthesia with remimazolam and remifentanil. Physical examination, laboratory testing, and radiographic imaging did not reveal any obvious organic causes. Pharmacological or metabolic abnormalities were not found. Absence of those causes strongly suggests that prolonged unconsciousness is related to psychiatric origin. The patient spontaneously regained consciousness after 48 h without any neurological complications. CONCLUSIONS Anesthesiologists should be aware of the possibility of psychogenic coma for patients with unexplained delay in emergence from anesthesia after the exclusion of other causes.
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Affiliation(s)
- Song Hyun Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Kye Min Kim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Yun-Hee Lim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Byung Hoon Yoo
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Joonho Cho
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - In-Jung Jun
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
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Philips JC, Radermecker RP, Lebrethon MC, S S. [Nasal glucagon (Baqsimi®), new treatment for hypoglycaemic coma]. Rev Med Liege 2022; 77:538-543. [PMID: 36082602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with insulin-treated type 1 diabetes (T1D) are exposed to hypoglycaemia, which may be serious. Serious cognitive impairment (including coma and seizure) that requires the help of a third party is a medical emergency. Besides the intravenous injection of glucose by a health care provider, its treatment consists of the subcutaneous or intramuscular injection of glucagon which may be performed by a family member. However, such an injection is not easy and puts off some people, which retards the initiation of a potentially life-saving therapy. The intranasal administration of 3 mg glucagon has been shown as efficacious as the subcutaneous or intramuscular injection of 1 mg glucagon in controlled studies carried out in both adult and youth patients with T1D. Stimulation and real-life studies among caregivers, patients and acquaintances showed a preference for nasal glucagon because of its easy and quick use. The launch of nasal glucagon (Baqsimi®) offers new perspectives for the ambulatory emergency management of severe hypoglycaemia and hypoglycaemic coma with a special obvious advantage in children.
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Affiliation(s)
- J C Philips
- Service de Diabétologie, Nutrition et Maladies métaboliques, Département de Médecine interne, CHU Liège, Belgique
| | - R P Radermecker
- Service de Diabétologie, Nutrition et Maladies métaboliques, Département de Médecine interne, CHU Liège, Belgique
| | | | - Scheen S
- Service de Diabétologie, Nutrition et Maladies métaboliques, Département de Médecine interne, CHU Liège, Belgique
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12
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Lin C, Li X, Qiu Y, Chen Z, Liu J. PD-1 inhibitor-associated type 1 diabetes: A case report and systematic review. Front Public Health 2022; 10:885001. [PMID: 35991054 PMCID: PMC9389003 DOI: 10.3389/fpubh.2022.885001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/22/2022] [Indexed: 12/01/2022] Open
Abstract
Objective This study aimed to summarize the clinical characteristics of programmed death receptor 1 (PD-1) inhibitor-associated type 1 diabetes so as to improve the ability of clinicians to correctly diagnose and treat it. Methods We reported a case of a 70-year-old woman with gastric cancer who developed hyperosmolar hyperglycemic coma during camrelizumab (a PD-1 inhibitor) treatment and was diagnosed with PD-1 inhibitor-associated type 1 diabetes. We conducted a systematic review of 74 case reports of type 1 diabetes associated with PD-1 inhibitor therapy published before June 2022. Results The patient developed type 1 diabetes with hyperosmolar hyperglycemic coma after receiving camrelizumab chemotherapy for 6 months (9 cycles). We searched 69 English articles comprising 75 patients, all of whom had been treated with a PD-1 inhibitor (nivolumab or pembrolizumab) and progressed to diabetes after an average of 6.11 (1–28) cycles. Nivolumab combined with ipilimumab (a cytotoxic T lymphocyte-associated protein 4 inhibitor) had the shortest onset (4.47 cycles on average). A total of 76% (57/75) of patients developed diabetic ketoacidosis (DKA) at onset, and 50.67% (38/75) of patients had C-peptide <0.1 ng/mL. Most of the patients were tested for insulin autoantibodies, with a positive rate of 33.33% (23/69); of these, 86.96% (20/23) were tested for glutamate decarboxylase antibody and 46.67% (35/75) were tested for human leukocyte antigen (HLA). HLA-DR4 was the most common type. Conclusions The progression of type 1 diabetes induced by PD-1 inhibitors is relatively rapid. Islet failure often occurs when detected, seriously endangering patients' lives. Patients treated with PD-1 inhibitors should closely monitor their plasma glucose level during treatment to detect, diagnose, and treat diabetes on time.
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Abstract
Background: Failure to escape from the Wolff-Chaikoff effect (WCE) causes hypothyroidism. Methods: This is the first report of myxedema coma after iohexol administration. The failure of the escape phenomenon in this patient was longer than existing reports. Results: The patient received 42,000 mg of iodine in iohexol cumulatively and developed myxedema coma after 16 days. She was subsequently found to have pre-existing primary hypothyroidism that was treated with levothyroxine 50 μg daily, but had defaulted treatment. She was discharged with levothyroxine 100 μg daily and this was weaned to 50 μg daily over 12 months. Conclusions: Iodine-based contrast media (ICM) can aggravate primary hypothyroidism. In severe cases, it may precipitate myxedema coma. Patients with thyroid disorders should be informed to monitor for aggravation of their symptoms after ICM administration. Long-term follow-up of thyroid function may be needed in patients who fail to escape from the WCE.
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Affiliation(s)
- Eng-Loon Tng
- Department of Medicine, Ng Teng Fong General Hospital; and National University Hospital, University Medicine Cluster; National University Health System, Singapore
| | - Aye Thida Aung
- Department of Medicine, Ng Teng Fong General Hospital; and National University Hospital, University Medicine Cluster; National University Health System, Singapore
| | - Nicole Chong
- Department of Endocrinology, National University Hospital, University Medicine Cluster; National University Health System, Singapore
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de Vries LJ, Boekema J, Sediq R, Bontemps-Visser A, de Haan-Lauteslager MI. [Antidepressant overdose resulting in coma and hypothermia]. Ned Tijdschr Geneeskd 2022; 166:D6166. [PMID: 35499563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Cognitive disorders lead to an increased risk of misuse of medication, resulting in possible auto-intoxication. CASE DESCRIPTION We describe the case of a 68-year-old patient, with hypothermia and a coma, with accidental tricyclic antidepressant (TCA) intoxication. What is remarkable about this case is that there were no cardiac or hemodynamic abnormalities, which is to be expected with both hypothermia and TCA-intoxication. CONCLUSION Intoxication should be considered in patients with hypothermia and a decreased level of consciousness, in addition to primarily neurological or metabolic causes. A good (hetero)anamnesis with attention to pre-existent cognitive functioning is important. Early screening for intoxication in patients with cognitive disorders with a coma and hypothermia is advisable, even in the absence of a typical toxidrome.
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Affiliation(s)
- Linda J de Vries
- Medisch Centrum Leeuwarden, Leeuwarden: Afd. Spoedeisende Hulp
- Contact: Linda J. de Vries
| | - Jeroen Boekema
- Medisch Centrum Leeuwarden, Leeuwarden: Afd. Interne Geneeskunde
| | - Rahmat Sediq
- Medisch Centrum Leeuwarden, Leeuwarden: Afd. Klinische Farmacie
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15
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Takenouchi H, Anno T, Kimura Y, Kawasaki F, Shirai R, Kaneto H, Kurokawa K, Tomoda K. Case Report: A Patient With Neuroleptic Malignant Syndrome, Water Intoxication and Hyponatremia Associated With Severe Cerebral Edema and Coma. Front Endocrinol (Lausanne) 2022; 13:822679. [PMID: 35360072 PMCID: PMC8960374 DOI: 10.3389/fendo.2022.822679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/14/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Water intoxication is typically caused by primary or psychogenic polydipsia that potentially may lead to fatal disturbance in brain functions. Neuroleptic malignant syndrome (NMS) is a serious complication induced by administration of antipsychotics and other psychotropic drugs. The combination of inappropriate secretion of antidiuretic hormone (SIDAH), NMS and rhabdomyolysis have been rarely reported. Our patient also developed severe water intoxication. CASE PRESENTATION Herein we report a comatose case of NMS complicated with water intoxication, syndrome of SIADH and rhabdomyolysis. This patient had severe cerebral edema and hyponatremia that were improved rapidly by the correction of hyponatremia within a couple of days. CONCLUSIONS Malignant neuroleptic syndrome water intoxication, SIADH and rhabdomyolysis can occur simultaneously. Comatose conditions induced by cerebral edema and hyponatremia can be successfully treated by meticulous fluid management and the correction of hyponatremia.
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Affiliation(s)
- Haruka Takenouchi
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan
| | - Takatoshi Anno
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan
- *Correspondence: Takatoshi Anno,
| | - Yukiko Kimura
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan
| | - Fumiko Kawasaki
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan
| | - Ryo Shirai
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan
| | - Hideaki Kaneto
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Katsumi Kurokawa
- Department of Neurology, Kawasaki Medical School, Okayama, Japan
| | - Koichi Tomoda
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan
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16
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Gonin A, Delpierre A, Micheneau P, Mahalli R, Veyrine A, Zlowodzki AS, Denis F. Simulated Coma during a Dental Treatment Session: A Case Report. Psychiatr Danub 2021; 33:333-334. [PMID: 35150505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Arthur Gonin
- Department of Odontology, University of Clermont Auvergne, Clermont-Ferrand, France
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17
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Mehamha H, Doudka N, Minodier P, Néant N, Lacarelle B, Solas C, Fabresse N. Unintentional cannabis poisoning in toddlers: A one year study in Marseille. Forensic Sci Int 2021; 325:110858. [PMID: 34091410 DOI: 10.1016/j.forsciint.2021.110858] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 11/18/2022]
Abstract
France is the country with the highest prevalence of cannabis use in Europe, despite the fact that cannabis has not been legalized. This prevalence is still increasing along with THC content in cannabis products. In the meantime, unintentional cannabis poisoning by ingestion in toddlers is constantly rising. The aim of this study was to document children's cannabis poisoning biologically and clinically. Plasma and urine samples were extracted by solid phase extraction and analyzed by liquid chromatography coupled to tandem mass spectrometry. Children under 4 years old admitted in pediatric emergency departments for cannabis intoxication between February 1st 2019 and January 31st 2020 were included in this study. Twenty-six children were included (14 female and 12 male), the mean age was 17 months (10-41 months). THC, 11-OH-THC and THC-COOH plasma concentrations ranged from 2.9 to 93 ng/mL, 2.6-65 ng/mL and 29-914 ng/mL, respectively. The most frequent symptoms were drowsiness and hypotonia. Six critical cases were observed: 5 coma and 1 respiratory depression. All children having THC plasma concentrations over 60 ng/mL were in coma. Cannabis poisoning in toddlers become more frequent, 9 cases/year were reported in Marseille in 2007 and 26 cases/year in this study. There is a rising in severe clinical cases, particularly coma. These observations could be explained by an increase in THC content in cannabis products, and a trivialization of cannabis consumption. The unintentional ingestion of cannabis by children is a serious public health concern, and cannabis legalization could worsen this problem.
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Affiliation(s)
- Hilel Mehamha
- Laboratory of Pharmacokinetics and Toxicology, La Timone University Hospital, 264 rue Saint Pierre, 13385 Marseille Cedex 5, France
| | - Natalia Doudka
- Department of Clinical Pharmacology and Pharmacovigilance, La Timone University Hospital, 264 rue Saint Pierre, 13385 Marseille Cedex 5, France; Aix Marseille University, Institut de neurosciences des systèmes, Inserm UMR 1106, Marseille 13385, France
| | - Philippe Minodier
- Pediatric Department, North University Hospital, Chemin des Bourrely, 13015 Marseille, France
| | - Nadège Néant
- Laboratory of Pharmacokinetics and Toxicology, La Timone University Hospital, 264 rue Saint Pierre, 13385 Marseille Cedex 5, France
| | - Bruno Lacarelle
- Laboratory of Pharmacokinetics and Toxicology, La Timone University Hospital, 264 rue Saint Pierre, 13385 Marseille Cedex 5, France
| | - Caroline Solas
- Laboratory of Pharmacokinetics and Toxicology, La Timone University Hospital, 264 rue Saint Pierre, 13385 Marseille Cedex 5, France; Aix-Marseille University, Emerging Viruses Unit (UVE) IRD 190, INSERM 1207, Marseille 13385, France
| | - Nicolas Fabresse
- Laboratory of Pharmacokinetics and Toxicology, La Timone University Hospital, 264 rue Saint Pierre, 13385 Marseille Cedex 5, France; Aix Marseille University, INSERM, IRD, SESSTIM, Economic and Social Sciences of Health and Medical Information Processing, Marseille, France.
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18
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Velle F, Lewén A, Howells T, Nilsson P, Enblad P. Temporal effects of barbiturate coma on intracranial pressure and compensatory reserve in children with traumatic brain injury. Acta Neurochir (Wien) 2021; 163:489-498. [PMID: 33341913 PMCID: PMC7815615 DOI: 10.1007/s00701-020-04677-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/07/2020] [Indexed: 01/18/2023]
Abstract
Background The aim was to study the effects of barbiturate coma treatment (BCT) on intracranial pressure (ICP) and intracranial compensatory reserve (RAP index) in children (< 17 years of age) with traumatic brain injury (TBI) and refractory intracranial hypertension (RICH). Methods High-resolution monitoring data were used to study the effects of BCT on ICP, mean arterial pressure (MAP), cerebral perfusion pressure (CPP), and RAP index. Four half hour long periods were studied: before bolus injection and at 5, 10, and 24 hours thereafter, respectively, and a fifth tapering period with S-thiopental between < 100 and < 30 μmol/L. S-thiopental concentrations and administered doses were registered. Results Seventeen children treated with BCT 2007–2017 with high-resolution data were included; median age 15 (range 6–17) and median Glasgow coma score 7 (range 3–8). Median time from trauma to start of BCT was 44.5 h (range 2.5–197.5) and from start to stop 99.0 h (range 21.0–329.0). Median ICP was 22 (IQR 20–25) in the half hour period before onset of BCT and 16 (IQR 11–20) in the half hour period 5 h later (p = 0.011). The corresponding figures for CPP were 65 (IQR 62–71) and 63 (57–71) (p > 0.05). The RAP index was in the half hour period before onset of BCT 0.6 (IQR 0.1–0.7), in the half hour period 5 h later 0.3 (IQR 0.1–0.7) (p = 0.331), and in the whole BCT period 0.3 (IQR 0.2–0.4) (p = 0.004). Eighty-two percent (14/17) had favorable outcome (good recovery = 8 patients and moderate disability = 6 patients). Conclusion BCT significantly reduced ICP and RAP index with preserved CPP. BCT should be considered in case of RICH.
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Affiliation(s)
- Fartein Velle
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE 751 85, Uppsala, Sweden.
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE 751 85, Uppsala, Sweden
| | - Timothy Howells
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE 751 85, Uppsala, Sweden
| | - Pelle Nilsson
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE 751 85, Uppsala, Sweden
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19
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Zhang M, Parikh B, Dirlikov B, Cage T, Lee M, Singh H. Elevated risk of venous thromboembolism among post-traumatic brain injury patients requiring pharmaceutical immobilization. J Clin Neurosci 2020; 75:66-70. [PMID: 32245600 DOI: 10.1016/j.jocn.2020.03.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/20/2020] [Indexed: 11/19/2022]
Abstract
Traumatic brain injury (TBI) patients are known to have a high rate of venous thromboembolism (VTE), and additional neuromuscular blockade or barbiturate coma therapy has the theoretical risk of exacerbating baseline hemostasis and elevating the incidence of thromboembolic events. We conducted a single-institution retrospective review of patients surviving severe TBI, as determined by need for intracranial pressure (ICP) monitoring, who further required paralytics or barbiturate therapy to maintain ICP control. Patients were administered VTE prophylaxis as clinically appropriate. Predictors for VTE were subsequently determined with univariate and logistic multivariate regression analyses. The main cohort includes 144 patients, 34 of whom received pharmaceutical immobilization for ICP control. Mean ISS and GCS at intake were 31.9 and 5.2, respectively. Among those receiving vs not-receiving paralytics and/or barbiturate therapy, there was a statistical difference of 12/34 (35.3%) vs 18/110 (16.4%, p = 0.0280) in VTE events, at a mean time greater than two weeks from the time of trauma. Multivariate logistics regression indicated 3.2 times increased odds of developing a VTE (log odds = 1.17, p = 0.023). No pediatric patients were positive for an event (0/12 vs 7/22, p = 0.0356), and infections were only documented among those with VTE (0/22 vs 4/12, p = 0.0107). Overall, paralytics and barbiturate therapy were correlated with a higher incidence of VTE among TBI patients. Although the need for ICP control will outweigh an increase in thromboembolic risk, there is value for increased surveillance and screening during the prolonged inpatient stay of these patients.
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Affiliation(s)
- Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA 94305, USA
| | - Bhavya Parikh
- Meharry Medical College, School of Medicine, 1005 Dr. D.B. Todd Jr. Blvd, Nashville, TN 37208, USA; Department of Neurosurgery, Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Ben Dirlikov
- Department of Neurosurgery, Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Tene Cage
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA 94305, USA; Department of Neurosurgery, Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Marco Lee
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA 94305, USA; Department of Neurosurgery, Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Harminder Singh
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA 94305, USA; Department of Neurosurgery, Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA.
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20
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Dasgupta K, Nielson S. Coma and Respiratory Failure in a 2-Year-Old Child After Accidental Overdose of Baclofen. S D Med 2020; 73:106-110. [PMID: 32142228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Baclofen (Lioresal) is a derivative of gamma-aminobutyric acid and is used in both adults and children mainly for symptomatic treatment of muscle spasticity. It is absorbed completely from the gastrointestinal tract, metabolized minimally in the liver and is excreted almost unchanged by the kidneys. Being lipophilic it can cross the blood-brain barrier easily. Baclofen overdose can result in life threatening complications such as respiratory failure, metabolic encephalopathy, seizures, deep coma and autonomic instability leading to hypertension and bradycardia.1-5 The literature on oral baclofen overdose in young children is very sparse. Here we report a 2-year-old-girl who was found by her parents after an accidental ingestion of her father's baclofen. The child presented with respiratory failure, coma, hypotonia and bradycardia. The patient was managed conservatively; mechanically ventilated for 16 hours and was discharged home after 48 hours with no sequelae.
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Affiliation(s)
- Kingshuk Dasgupta
- Pediatric Critical Care, Avera McKennan Children's Hospital and University Health Center, Sioux Falls, South Dakota
- Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | - Shelby Nielson
- Avera Mckennan Children's Hospital and University Health Center, Sioux Falls, South Dakota
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21
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Affiliation(s)
- M Runnstrom
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - S S Kalra
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - J Lascano
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - D C Patel
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
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22
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Kounis N, Koniari I, Tsigkas G, Davlouros P. Rectosigmoid ischemia and cerebral coma following gadolinium-induced anaphylaxis: A new manifestation of Kounis syndrome presented as devastating complication. Ann Ital Chir 2020; 91:442-444. [PMID: 33833137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Gadolinium-based contrast mediums are the most commonly used agents in magnetic resonance imaging for both angiography, and brain tumor enhancement due to their association with the degradation of the blood-brain barrier. When oxidation is removed from gadolinium medium and gadolinium salts, a silvery-white metal anions remain that are able to induce allergic reactions and anaphylaxis. Whereas such reactions are not common, other reactions including nephrogenic systemic fibrosis and acute kidney injury due to primary excretion of gadolinium from the kidneys and various cardiac arrhythmias including QTc electrocardiographic prolongation are occasionally encountered 1,2. Despite that gadolinium-based contrast mediums are characterized as benign agents, in some occasions they can lead to life threatening conditions and Kounis syndrome 2-5. The concurrence of acute coronary syndromes such as coronary spasm, acute myocardial infarction, and stent thrombosis, with conditions associated with mast-cell and platelet activation involving other interrelated and interacting inflammatory cells, such as macrophages and Tlymphocytes in the setting of allergic or hypersensitivity and anaphylactic or anaphylactoid insults constitute the Kounis syndrome 6. This syndrome is caused by inflammatory mediators such as histamine, neutral proteases, arachidonic acid products, platelet-activating factor, and a variety of cytokines and chemokines released during the degranulation process of these inflammatory cells. Platelets bearing specific fragment crystallizable region receptors are also involved in the activation cascade 7. All these inflammatory cells participate in an inflammatory cycle and activate each other via multidirectional signals.
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23
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Takeuchi I, Yanagawa Y, Nagasawa H, Jitsuiki K, Madokoro S, Takahashi N, Ohsaka H, Ishikawa K, Omori K. Decrease in Butyrylcholinesterase Accompanied by Intermediate-like Syndrome after Massive Ingestion of a Glyphosate-surfactant. Intern Med 2019; 58:3057-3059. [PMID: 31243240 PMCID: PMC6859399 DOI: 10.2169/internalmedicine.2562-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 04/18/2019] [Indexed: 12/02/2022] Open
Abstract
An 86-year-old woman intentionally drank approximately 300 mL of a glyphosate-surfactant. She was found with consciousness disturbance and experienced several vomiting episodes. On arrival, serum biochemistry revealed a decreased level of butyrylcholinesterase (B-CHE) [11 (normal range: 180-450) IU/L]. Later, her B-CHE level further decreased to single-digit values, and she became comatose with involuntary movement and an increase in muscle tone. Her consciousness level and muscle tone improved with the recovery of her B-CHE level. Physicians should be alert for the occurrence of intermediate syndrome when the B-CHE levels of patients who have consumed a massive amount of glyphosate-surfactant show a prolonged decrease.
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Affiliation(s)
- Ikuto Takeuchi
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Youichi Yanagawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Hiroki Nagasawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Kei Jitsuiki
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Shunsuke Madokoro
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Norihito Takahashi
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Hiromichi Ohsaka
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Kouhei Ishikawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
| | - Kazuhiko Omori
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Japan
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24
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Gao S, Proekt A, Renier N, Calderon DP, Pfaff DW. Activating an anterior nucleus gigantocellularis subpopulation triggers emergence from pharmacologically-induced coma in rodents. Nat Commun 2019; 10:2897. [PMID: 31263107 PMCID: PMC6603023 DOI: 10.1038/s41467-019-10797-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 06/01/2019] [Indexed: 02/08/2023] Open
Abstract
Multiple areas within the reticular activating system (RAS) can hasten awakening from sleep or light planes of anesthesia. However, stimulation in individual sites has shown limited recovery from deep global suppression of brain activity, such as coma. Here we identify a subset of RAS neurons within the anterior portion of nucleus gigantocellularis (aNGC) capable of producing a high degree of awakening represented by a broad high frequency cortical reactivation associated with organized movements and behavioral reactivity to the environment from two different models of deep pharmacologically-induced coma (PIC): isoflurane (1.25%-1.5%) and induced hypoglycemic coma. Activating aNGC neurons triggered awakening by recruiting cholinergic, noradrenergic, and glutamatergic arousal pathways. In summary, we identify an evolutionarily conserved population of RAS neurons, which broadly restore cerebral cortical activation and motor behavior in rodents through the coordinated activation of multiple arousal-promoting circuits.
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Affiliation(s)
- S Gao
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, 10065, USA
| | - A Proekt
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, 10065, USA
- Laboratory of Neurobiology and Behavior, the Rockefeller University, New York, NY, 10065, USA
| | - N Renier
- ICM, Brain and Spine Institute, Hopital de la Pitie-Salpetriere, Sorbonne Universite, Inserm, CNRS, Paris, 75013, France
| | - D P Calderon
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, 10065, USA.
- Laboratory of Neurobiology and Behavior, the Rockefeller University, New York, NY, 10065, USA.
| | - D W Pfaff
- Laboratory of Neurobiology and Behavior, the Rockefeller University, New York, NY, 10065, USA
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25
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Raposo Pereira F, Zhutovsky P, Mcmaster MT, Polderman N, de Vries YD, van den Brink W, van Wingen GA. Recreational use of GHB is associated with alterations of resting state functional connectivity of the central executive and default mode networks. Hum Brain Mapp 2019; 40:2413-2421. [PMID: 30720906 PMCID: PMC6590661 DOI: 10.1002/hbm.24532] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 12/11/2018] [Accepted: 01/16/2019] [Indexed: 12/18/2022] Open
Abstract
Gamma-hydroxybutyrate acid (GHB) is a recreational drug with a high addictive potential. Severe side effects such as GHB-induced coma are common and linked to increased emergency room attendances. Task-based functional-imaging studies have revealed an association between the regular use of GHB and multiple GHB-induced comas, and altered neurocognitive function. However the effects of multiple GHB-induced comas and regular GHB-use on intrinsic brain connectivity during rest remain unknown. The study population consisted of 23 GHB-users with ≥4 GHB-induced comas (GHB-Coma), 22 GHB-users who never experienced a GHB-induced coma (GHB-NoComa) and 24 polydrug users who never used GHB (No-GHB). Resting-state scans were collected to assess resting-state functional-connectivity within and between the default mode network (DMN), the bilateral central executive network (CEN) and the salience network (SN). The GHB-NoComa group showed decreased rsFC of the right CEN with a region in the anterior cingulate cortex (pFWE = 0.048) and decreased rsFC between the right CEN and the DMN (pFWE = 0.048) when compared with the No-GHB group. These results suggest that regular GHB-use is associated with decreased rsFC within the right CEN and between the right CEN and the DMN. The presence of multiple GHB-induced comas is not associated with (additional) alterations in rsFC.
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Affiliation(s)
- Filipa Raposo Pereira
- Department of Psychiatry, Amsterdam NeuroscienceAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
- Amsterdam Brain and CognitionUniversity of AmsterdamAmsterdamthe Netherlands
| | - Paul Zhutovsky
- Department of Psychiatry, Amsterdam NeuroscienceAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
- Amsterdam Brain and CognitionUniversity of AmsterdamAmsterdamthe Netherlands
| | - Minni T.B. Mcmaster
- Department of Psychiatry, Amsterdam NeuroscienceAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
- Amsterdam Brain and CognitionUniversity of AmsterdamAmsterdamthe Netherlands
| | - Nikki Polderman
- Department of Psychiatry, Amsterdam NeuroscienceAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
| | - Yvon D.A.T. de Vries
- Department of Psychiatry, Amsterdam NeuroscienceAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
| | - Wim van den Brink
- Department of Psychiatry, Amsterdam NeuroscienceAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
- Amsterdam Brain and CognitionUniversity of AmsterdamAmsterdamthe Netherlands
| | - Guido A. van Wingen
- Department of Psychiatry, Amsterdam NeuroscienceAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
- Amsterdam Brain and CognitionUniversity of AmsterdamAmsterdamthe Netherlands
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26
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Nawashiro H. Respiratory arrest immediately after thrombolysis for posterior circulation stroke. Neurol India 2019; 67:861-862. [PMID: 31347567 DOI: 10.4103/0028-3886.263202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Hiroshi Nawashiro
- Stroke Center, Department of Neurosurgery, Tokorozawa Chuo Hospital, 3-18-1 Kusunokidai, Tokorozawa, Saitama, Japan
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27
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Ryu JA, Jung W, Jung YJ, Kwon DY, Kang K, Choi H, Kong DS, Seol HJ, Lee JI. Early prediction of neurological outcome after barbiturate coma therapy in patients undergoing brain tumor surgery. PLoS One 2019; 14:e0215280. [PMID: 30995269 PMCID: PMC6469802 DOI: 10.1371/journal.pone.0215280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/31/2019] [Indexed: 11/18/2022] Open
Abstract
After a difficult brain tumor surgery, refractory intracranial hypertension (RICH) may occur due to residual tumor or post-operative complications such as hemorrhage, infarction, and aggravated brain edema. We investigated which predictors are associated with prognosis when using barbiturate coma therapy (BCT) as a second-tier therapy to control RICH after brain tumor surgery. The study included adult patients who underwent BCT after brain tumor surgery between January 2010 and December 2016. The primary outcome was neurological status upon hospital discharge, which was assessed using the Glasgow Outcome Scale (GOS). In the study period, 4,296 patients underwent brain tumor surgery in total. Of these patients, BCT was performed in 73 patients (1.7%). Among these 73 patients, 56 (76.7%) survived to discharge and 25 (34.2%) showed favorable neurological outcomes (GOS scores of 4 and 5). Invasive monitoring of intracranial pressure (ICP) was performed in 60 (82.2%) patients, and revealed that the maximal ICP within 6 h after BCT was significantly lower in patients with favorable neurological outcome as well as in survivors (p = 0.008 and p = 0.028, respectively). Uncontrolled RICH (ICP ≥ 22 mm Hg within 6 h of BCT) was an important predictor of mortality after BCT (adjusted hazard ratio 12.91, 95% confidence interval [CI] 2.788–59.749), and in particular, ICP ≥ 15 mm Hg within 6 h of BCT was associated with poor neurological outcome (adjusted odds ratio 9.36, 95% CI 1.664–52.614). Therefore, early-controlled ICP after BCT was associated with clinical prognosis. There were no significant differences in the complications associated with BCT between the two neurological outcome groups. No BCT-induced death was observed. The active and timely control of RICH may be beneficial for clinical outcomes in patients with RICH after brain tumor surgery.
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Affiliation(s)
- Jeong-Am Ryu
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Wonkyung Jung
- Department of Nursing, Neurosurgery Intensive Care Unit, Samsung Medical Center, Seoul, Republic of Korea
| | - Yoo Jin Jung
- Department of Nursing, Neurosurgery Intensive Care Unit, Samsung Medical Center, Seoul, Republic of Korea
| | - Do Yeon Kwon
- Department of Nursing, Neurosurgery Intensive Care Unit, Samsung Medical Center, Seoul, Republic of Korea
| | - Kina Kang
- Department of Nursing, Neurosurgery Intensive Care Unit, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyeok Choi
- Department of Nursing, Neurosurgery Intensive Care Unit, Samsung Medical Center, Seoul, Republic of Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- * E-mail:
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Abstract
RATIONALE This is the first reported severe thallium poisoning patient successfully treated with Prussian blue (PB) and plasma exchange (PE). PATIENT CONCERNS A 42-year-old woman in a coma owing to severe thallium poisoning was admitted to our department after day 44 of poisoning. At admission, blood and urine thallium concentrations were 380.0 and 2580.0 ng/mL, respectively. DIAGNOSIS The patient was diagnosed with toxic encephalopathy induced by thallium poisoning; in addition, she was also diagnosed with bilateral pneumonia, respiratory failure, moderate anemia, hypoproteinemia, and electrolyte imbalance based on her chest X-ray, blood gas analysis, Hb level, albumin levels, and serum electrolyte results. INTERVENTIONS The patient was intubated and treated with PB (6600 mg/d, 15 days in total) combined with PE (once daily, 5 days in total) as well as other symptomatic supportive care measures. OUTCOMES After treatments, her blood and urinary thallium concentrations gradually decreased and on the 13th day after admission, the blood thallium concentration decreased to 0 ng/mL. The oxygenation index gradually improved, meantime, the patient gradually regained consciousness, and on the 50th day of admission, the patient's consciousness reverted to a clear-headed state. The patient recovered mostly after 37 months of follow-up. LESSONS Through this case, we learned that the gradual reduction in blood and urine thallium concentration and the patient's improved condition is correlated with PB and PE treatment. For patients with severe thallium poisoning, this treatment method might be effective; but the exact curative effect is unconfirmed, requiring further research to verify.
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Affiliation(s)
- Guodong Lin
- Poisoning Treatment Department, Affiliated Hospital Academy of Military Medical Sciences
| | - Luo Yuan
- State Key Laboratory of Toxicology and Medical Countermeasures, Institutes of Pharmacology and Toxicology, Academy of Military Medical Sciences, Beijing, People's Republic of China
| | - Lili Bai
- Poisoning Treatment Department, Affiliated Hospital Academy of Military Medical Sciences
| | - Yanqing Liu
- Poisoning Treatment Department, Affiliated Hospital Academy of Military Medical Sciences
| | - Yongan Wang
- State Key Laboratory of Toxicology and Medical Countermeasures, Institutes of Pharmacology and Toxicology, Academy of Military Medical Sciences, Beijing, People's Republic of China
| | - Zewu Qiu
- Poisoning Treatment Department, Affiliated Hospital Academy of Military Medical Sciences
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Abstract
Isoniazid is an anti-tuberculosis drug, used commonly for treatment and prophylaxis of tuberculosis. Acute isoniazid intoxication is characterized by a clinical triad consisting of metabolic acidosis resistant to treatment with sodium bicarbonate, seizures which may be fatal and refractory to standard anticonvulsant therapy, and coma. Treatment requires admission to the intensive care unit for ventilatory support, management of seizures and metabolic acidosis. Pyridoxine, in a dose equivalent to the amount of isoniazid ingested, is the only effective antidote. We report the successful treatment of two isoniazid intoxication cases: the case of a child developing an accidental acute isoniazid intoxication and an adult case of isoniazid intoxication with the intent of suicide.
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Affiliation(s)
- I Topcu
- Department of Anesthesiology and Reanimation, Celal Bayar University, Manisa, Turkey
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Gocho N, Aoki E, Okada C, Hirashima T. Myxedema Coma Following the Administration of Gonadotropin-releasing Hormone Agonist Complicated by Acute Pancreatitis. Intern Med 2018; 57:3117-3122. [PMID: 29877268 PMCID: PMC6262710 DOI: 10.2169/internalmedicine.0639-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 03/05/2018] [Indexed: 11/29/2022] Open
Abstract
Gonadotropin-releasing hormone (GnRH) agonists have been used for the treatment of various diseases. Although autoimmune thyroid disease has been reported as a rare complication of these agents, the symptoms are almost always transient and non-life-threatening. We herein report a rare case of an 83-year-old man receiving GnRH agonist treatment for prostate cancer who developed myxedema coma complicated by acute pancreatitis. This is the first report of myxedema coma potentially associated with a GnRH agonist. The follow-up of the thyroid function is necessary for patients undergoing treatment with GnRH agonists, especially those known to have or to be susceptible to autoimmune thyroid disease.
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Affiliation(s)
- Naoki Gocho
- Diabetes Center, Ebina General Hospital, Japan
| | - Ema Aoki
- Diabetes Center, Ebina General Hospital, Japan
| | - Chiho Okada
- Diabetes Center, Ebina General Hospital, Japan
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Raposo Pereira F, McMaster MTB, Polderman N, de Vries YDAT, van den Brink W, van Wingen GA. Effect of GHB-use and GHB-induced comas on dorsolateral prefrontal cortex functioning in humans. Neuroimage Clin 2018; 20:923-930. [PMID: 30308378 PMCID: PMC6178194 DOI: 10.1016/j.nicl.2018.09.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 08/15/2018] [Accepted: 09/25/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Gamma-hydroxybutyric acid (GHB) is a recreational drug associated with increasing numbers of GHB-dependent patients and emergency attendances often related to GHB-induced comas. Working memory (WM) deficits have been reported in association with GHB use, and animal studies have shown that GHB induces oxidative stress in vulnerable WM-related brain areas such as the dorsolateral prefrontal cortex (DLPFC). However, the effects of chronic GHB use and multiple GHB-induced comas on WM-related brain function in humans remains unknown. METHODS We recruited 27 GHB users with ≥4 GHB-induced comas (GHB-Coma), 27 GHB users who never experienced GHB-induced coma (GHB-NoComa), and 27 polydrug users who never used GHB (No-GHB). Participants performed an n-back WM task during functional magnetic resonance imaging (fMRI) to probe DLPFC functioning. RESULTS The GHB-Coma group had lower premorbid IQ (p = .006) than the GHB-NoComa group despite comparable age and education level. There were also group differences in the use of other drugs than GHB. Therefore, all group comparisons were adjusted for IQ and drug use other than GHB. Compared with the GHB-NoComa and the No-GHB groups, the GHB-Coma group showed increased activity in the right DLPFC (pSVC = 0.028) and increased functional connectivity of the right DLPFC with a cluster comprising the left anterior cingulate and medial frontal gyrus (pFWE = 0.003). No significant fMRI differences were observed between the GHB-NoComa and No-GHB groups. Due to technical problems, no behavioural data were collected. DISCUSSION These results suggest that multiple GHB-induced comas, but not GHB-use per se, are associated with alterations in WM-related brain function. Public awareness campaigns are required to minimize the potential adverse effects induced by GHB recreational use, and especially GHB-induced comas, even if no immediate side effects are experienced.
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Affiliation(s)
- Filipa Raposo Pereira
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, the Netherlands; Amsterdam Brain and Cognition, University of Amsterdam, the Netherlands.
| | - Minni T B McMaster
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, the Netherlands; Amsterdam Brain and Cognition, University of Amsterdam, the Netherlands
| | - Nikki Polderman
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Yvon D A T de Vries
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Wim van den Brink
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, the Netherlands; Amsterdam Brain and Cognition, University of Amsterdam, the Netherlands
| | - Guido A van Wingen
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, the Netherlands; Amsterdam Brain and Cognition, University of Amsterdam, the Netherlands
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Demchuk E, Ball SL, Le SL, Prussia AJ. Concentration-time extrapolation of short-term inhalation exposure levels: dimethyl sulfide, a case study using a chemical-specific toxic load exponent. Inhal Toxicol 2018; 30:448-462. [PMID: 30600740 PMCID: PMC8260034 DOI: 10.1080/08958378.2018.1551444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/25/2018] [Accepted: 11/19/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Dimethyl sulfide (DMS, CAS 75-18-3) is an industrial chemical. It is both an irritant and neurotoxicant that may be life-threatening because of accidental release. The effects of DMS on public health and associated public health response depend on the exposure concentration and duration. However, currently, public health advisory information exists for only a 1 h exposure duration, developed by the American Industrial Hygiene Association (AIHA). In the present work, the AIHA-reviewed data were computationally extrapolated to other common short-term durations. METHODS The extrapolation was carried out using the toxic load equation, Cn × t = TL, where C and t are exposure concentration and duration, TL is toxic load, and n is a chemical-specific toxic load exponent derived in the present work using probit meta-analysis. The developed threshold levels were vetted against the AIHA database of clinical and animal health effects induced by DMS. RESULTS Tier-1 levels were derived based on human exposures that resulted in an easily detectable odor, because DMS is known to have a disagreeable odor that may cause nausea. Tier-2 levels were derived from the lower 95% confidence bounds on a benchmark concentration that caused 10% incidence (BMCL10) of coma in rats during a 15 min inhalation exposure to DMS. Tier-3 levels were based on a BMCL05 for mortality in rats. CONCLUSION Emergency responders and health assessors may consider these computationally derived threshold levels as a supplement to traditional chemical risk assessment procedures in instances where AIHA developed public health advisory levels do not exist.
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Affiliation(s)
- Eugene Demchuk
- Agency for Toxic Substances and Disease Registry, Atlanta, GA, USA
| | - Shannon L. Ball
- Agency for Toxic Substances and Disease Registry, Atlanta, GA, USA
| | - San L. Le
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Affiliation(s)
- Raquel Farias-Moeller
- Department of Child Neurology, Children's National Health System, 111 Michigan Avenue, Washington, DC, 20010, USA.
| | - Jessica L Carpenter
- Department of Child Neurology, Children's National Health System, 111 Michigan Avenue, Washington, DC, 20010, USA
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Manesh A, Mani RS, Pichamuthu K, Jagannati M, Mathew V, Karthik R, Abraham OC, Chacko G, Varghese GM. Case Report: Failure of Therapeutic Coma in Rabies Encephalitis. Am J Trop Med Hyg 2018; 98:207-210. [PMID: 29141755 PMCID: PMC5928693 DOI: 10.4269/ajtmh.17-0153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 08/31/2017] [Indexed: 12/25/2022] Open
Abstract
Rabies encephalitis is a fulminant, almost universally fatal infection involving the central nervous system. A unique treatment protocol, including anti-exicitotoxic therapy and induced coma was credited with the survival of a vaccinated teenager with bat rabies encephalitis in 2005. However, multiple efforts to replicate this expensive and intense protocol have not been successful. In this article, we report the failure of the protocol in Indian patients with canine-acquired rabies and elucidate the potential explanations for the failure of the protocol in our patients.
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Affiliation(s)
- Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Reeta Subramaniam Mani
- Department of Neurovirology, WHO Collaborating Centre for Reference and Research on Rabies, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Kishore Pichamuthu
- Division of Critical Care, Christian Medical College, Vellore, Tamil Nadu, India
| | - Manjeera Jagannati
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- Department of Neurological Sciences, Neurology Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rajiv Karthik
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Geeta Chacko
- Section of Neuropathology, Department of Neurological Sciences & Pathology, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - George M. Varghese
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
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35
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Diaz-Rangel M, Grande-Martin A, Monsalve-Naharro JA, Domingo-Chiva E, Cuesta-Montero P, Lopez-Perez A. [Valproate-induced hyperammonemic encephalopathy]. Rev Neurol 2017; 65:574-575. [PMID: 29235622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- M Diaz-Rangel
- Gerencia de Atencion Integrada de Albacete, Albacete, Espana
| | - A Grande-Martin
- Gerencia de Atencion Integrada de Albacete, Albacete, Espana
| | | | - E Domingo-Chiva
- Gerencia de Atencion Integrada de Albacete, Albacete, Espana
| | | | - A Lopez-Perez
- Gerencia de Atencion Integrada de Albacete, Albacete, Espana
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Abstract
Althoughtricyclic antidepressants(TCAs) are frequently prescribed to patients with depression, these drugs can also be misused. A 21-year-old comatose patient was referred to our hospital presenting with ventricular tachycardia. Despite initial treatment including intravascular lipid emulsion, ventricular fibrillation occurred soon after arrival. Venoarterial extracorporeal membrane oxygenation and therapeutic hypothermia were administered. Refractory arrhythmia disappeared on the next day. A high concentration of amitriptyline was identified in his blood samples on arrival. Mechanical bowel obstruction followed after abdominal compartment syndrome caused by anticholinergic effects, and refractory seizure occurred due to TCA intoxication. Although seizure was brought under control with anticonvulsant agents, his Glasgow Coma Scale did not recover to the full score. MRI presented irreversible damage to the bilateral frontal lobe and insula. Amitriptyline has the potential to cause unusual serious complications, such as abdominal compartment syndrome, irreversible central nervous system disability and lethal arrhythmia.
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Affiliation(s)
- Takeshi Nishimura
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Hayato Maruguchi
- Department of Plastic Surgery, Kobe University Hospital, Kobe, Japan
| | - Atsunori Nakao
- Department of Emergency and Critical Care Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Shinichi Nakayama
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
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Vallianou N, Giannopoulou M, Trigkidis K, Bei E, Margellou E, Apostolou T. A case of severe carbamazepine overdose treated successfully with combined hemoperfusion and hemodialysis technique. Saudi J Kidney Dis Transpl 2017; 28:906-908. [PMID: 28748895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
Carbamazepine intoxication manifests as altered mental status ranging from drowsiness to a coma and/or cardiac abnormalities such as sinus tachycardia, prolongation of the QRS interval, ventricular tachycardia, and hypotension. The patient may be agitated, but central nervous system (CNS) depression and presentation with coma is more common and could be lethal. Serious CNS toxicity often requires hemoperfusion and/or hemodialysis (HD). Herein, we present a case of a comatose patient, who was treated with a combination of hemoperfusion and HD in series. Our approach to treat the patient with a combination of hemoperfusion and HD was based on evidence from the literature supporting that the hemoperfusion and HD in series might provide the best clearance of carbamazepine.
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Affiliation(s)
- Natalia Vallianou
- Department of Internal Medicine, Evangelismos General Hospital, Athens, Greece
| | | | - Kyriakos Trigkidis
- Department of Internal Medicine, Evangelismos General Hospital, Athens, Greece
| | - Elefteria Bei
- Department of Nephrology, Evangelismos General Hospital, Athens, Greece
| | - Evangelia Margellou
- Department of Internal Medicine, Evangelismos General Hospital, Athens, Greece
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van Gorp F, Wejden LC, Stienstra NA, Kuck EM, Haas LEM. Severe neurological symptoms following synthetic cannabinoid intoxication. Neth J Med 2017; 75:158-160. [PMID: 28522773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Synthetic cannabinoids are becoming increasingly popular as substances of abuse. However, in the Netherlands synthetic cannabinoid intoxications are rare. We report a 16-year-old male who became deeply comatose and was admitted to the intensive care unit for invasive mechanical ventilation after a buse of aninitially unknown drug. Routine toxicology screening with an immunoassay only detected tetrahydrocannabinol, but additional tests with liquid chromatography mass spectrometry revealed synthetic cannabinoid use. This case underlines the challenging diagnosis of synthetic cannabinoid intoxications and the severe complications they can produce.
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Affiliation(s)
- F van Gorp
- 1Department of Hospital Pharmacy, Diakonessenhuis Utrecht, Utrecht, the Netherlands
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Gallego Muñoz C, Olmos Gutiérrez L, Guerrero Navarro N, Parra Alonso E. [Young patient diagnosed with hydroxychloroquine intoxication]. Farm Hosp 2017; 41:431-432. [PMID: 28478759 DOI: 10.7399/fh.2017.41.3.10734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
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40
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Guo X, Wei J, Gao L, Xing B, Xu Z. Hyperammonemic coma after craniotomy: Hepatic encephalopathy from upper gastrointestinal hemorrhage or valproate side effect?: Case report and literature review. Medicine (Baltimore) 2017; 96:e6588. [PMID: 28403092 PMCID: PMC5403089 DOI: 10.1097/md.0000000000006588] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Postoperative coma is not uncommon in patients after craniotomy. It generally presents as mental state changes and is usually caused by intracranial hematoma, brain edema, or swelling. Hyperammonemia can also result in postoperative coma; however, it is rarely recognized as a potential cause in coma patients. Hyperammonemic coma is determined through a complicated differential diagnosis, and although it can also be induced as a side effect of valproate (VPA), this cause is frequently unrecognized or confused with upper gastrointestinal hemorrhage (UGH)-induced hepatic encephalopathy. We herein present a case of valproate-induced hyperammonemic encephalopathy (VHE) to illustrate the rarity of such cases and emphasize the importance of correct diagnosis and proper treatment. PATIENT CONCERNS AND DIAGNOSES A 61-year-old woman with meningioma was admitted into our hospital. Radical resection of the tumor was performed, and the patient recovered well as expected. After administration of valproate for 7 days, the patient was suddenly found in a deep coma, and her mental state deteriorated rapidly. The diagnoses of hepatic encephalopathy was confirmed. However, whether it origins from upper gastrointestinal hemorrhage or valproate side effect is uncertain. INTERVENTIONS AND OUTCOMES The patient's condition fluctuated without improvement during the subsequent 3 days under the treatment of reducing ammonia. With the discontinuation of valproate treatment, the patient regained complete consciousness within 48 hours, and her blood ammonia decreased to the normal range within 4 days. LESSONS SUBSECTIONS VHE is a rare but serious complication in patients after craniotomy and is diagnosed by mental state changes and elevated blood ammonia. Thus, the regular perioperative administration of VPA, which is frequently neglected as a cause of VHE, should be emphasized. In addition, excluding UGH prior to providing a diagnosis and immediately discontinuing VPA administration are recommended.
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Bochicchio GV, Bochicchio K, Nehman S, Casey C, Andrews P, Scalea TM. Tolerance and Efficacy of Enteral Nutrition in Traumatic Brain–Injured Patients Induced Into Barbiturate Coma. JPEN J Parenter Enteral Nutr 2017; 30:503-6. [PMID: 17047175 DOI: 10.1177/0148607106030006503] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a paucity of data evaluating the efficacy of nutrition support in traumatic brain-injured patients induced into barbiturate coma for refractory intracranial hypertension. Our objective was to evaluate the efficacy of enteral nutrition in a select group of trauma patients. METHODS Prospective data were collected on severe traumatic brain-injured patients over a 4-year period. Patients were stratified by whether or not they were induced into a barbiturate coma. Barbiturate coma was defined as per American Association of Neurological Surgeons (AANS) guidelines. All patients were initially fed via the enteral route via a nasogastric feeding tube. Patients who did not tolerate feedings within 48 hours started receiving prokinetic agents. Feeding tolerance was defined as ability to tolerate enteral feedings with <150 mL of gastric residuals every 6 hours for >72 hours. RESULTS Fifty-seven patients were induced into a barbiturate coma. All were victims of blunt-force trauma. Forty-two of 57 (74%) patients were men, with a mean age of 37+/-12 years and a mean injury severity score of 24+/-10. Thirty-eight of the 57 (67%) patients had an isolated traumatic brain injury. All 57 patients failed enteral nutrition via the nasogastric route after the first 48 hours of nutrition initiation after barbiturate coma was fully achieved by protocol criteria. Prokinetic agents demonstrated no improvement in feeding tolerance after the subsequent 48-72 hours. Of the 12 patients who had a postpyloric feeding tube placed, only 25% tolerated enteral nutrition for >48 hours. CONCLUSIONS Patients with traumatic brain injury induced into barbiturate coma develop a significant ileus that is refractory to prokinetic agents. Only a marginal improvement is seen when the postpyloric route is obtained. Early parenteral nutrition should be considered in this patient population.
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Affiliation(s)
- Grant V Bochicchio
- R. Adams Cowley Shock Trauma Center, Division of Clinical and Outcomes Research, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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Hirata Y, Kamei S, Tatsumi F, Shimoda M, Tanabe A, Sanada J, Fushimi Y, Irie S, Mune T, Kaku K, Kaneto H. Hypoglycemic Coma Induced by the Use of Succinic Acid Cibenzoline in Frail Late-stage Elderly Subjects. Intern Med 2017. [PMID: 28626178 PMCID: PMC5505908 DOI: 10.2169/internalmedicine.56.8120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Succinic acid cibenzoline (CZ) is an antiarrhythmic agent often used for the treatment of tachyarrhythmia. However, hypoglycemia should be avoided in the treatment of diabetes. We herein report two late-stage elderly subjects who experienced a severe and prolonged hypoglycemic coma after the usage of CZ. These cases suggest that, when CZ is administered to elderly subjects with renal dysfunction and/or frailty, we should be aware of the possibility that this medicine may induce hypoglycemia and should adjust the dose as appropriate and monitor the concentration of CZ to avoid severe hypoglycemia.
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Affiliation(s)
- Yurie Hirata
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Shinji Kamei
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Fuminori Tatsumi
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Masashi Shimoda
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Akihito Tanabe
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Junpei Sanada
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Yoshiro Fushimi
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Shintaro Irie
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Tomoatsu Mune
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Kohei Kaku
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Hideaki Kaneto
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
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An J, Jonnalagadda D, Moura V, Purdon PL, Brown EN, Westover MB. Spatial variation in automated burst suppression detection in pharmacologically induced coma. Annu Int Conf IEEE Eng Med Biol Soc 2016; 2015:7430-3. [PMID: 26738009 DOI: 10.1109/embc.2015.7320109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Burst suppression is actively studied as a control signal to guide anesthetic dosing in patients undergoing medically induced coma. The ability to automatically identify periods of EEG suppression and compactly summarize the depth of coma using the burst suppression probability (BSP) is crucial to effective and safe monitoring and control of medical coma. Current literature however does not explicitly account for the potential variation in burst suppression parameters across different scalp locations. In this study we analyzed standard 19-channel EEG recordings from 8 patients with refractory status epilepticus who underwent pharmacologically induced burst suppression as medical treatment for refractory seizures. We found that although burst suppression is generally considered a global phenomenon, BSP obtained using a previously validated algorithm varies systematically across different channels. A global representation of information from individual channels is proposed that takes into account the burst suppression characteristics recorded at multiple electrodes. BSP computed from this representative burst suppression pattern may be more resilient to noise and a better representation of the brain state of patients. Multichannel data integration may enhance the reliability of estimates of the depth of medical coma.
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Richards JR, Davis MT, Curry MR, Tsushima JH, McKinney HE. Doxapram reversal of suspected gamma-hydroxybutyrate-induced coma. Am J Emerg Med 2016; 35:517.e1-517.e3. [PMID: 27641247 DOI: 10.1016/j.ajem.2016.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 09/06/2016] [Indexed: 11/16/2022] Open
Affiliation(s)
- John R Richards
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA.
| | - M Thais Davis
- Department of Emergency Medicine, Division of Toxicology, University of California Davis Medical Center, Sacramento, CA
| | - Mark R Curry
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA
| | - John H Tsushima
- Department of Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, CA
| | - Howard E McKinney
- Department of Pharmacy, University of California Davis Medical Center, Sacramento, CA
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Abstract
The aim of this study was to assess the clinical and laboratory factors in methanol poisoned patients to determine the prognosis of their toxicity. This survey was done as a prospective cross-sectional study in methanol-poisoned patients in Loghman-Hakim hospital poison center during 9 months from October 1999—June 2000. During this time 25 methanol-poisoned patients were admitted. The mortality rate was 12 (48%). Amongst survivors, three (23%) of the patients developed blindness due to their poisoning and the other 10 (77%) fully recovered without any complication. The mortality rate in comatose patients was nine (90%) while in non-comatose patients it was three (20%) ( P < 0.001). There was a significant difference in mean pH in the first arterial blood gas of patients who subsequently died (6.82 ± 0.03) and survivors (7.15 ± 0.06) ( P < 0.001, M-W). The mean time interval between poisoning and ED presentation in deceased patients were (46 ± 15.7) hours, in survived with sequelae were (16.7 ± 6.7) and in survived without sequelae were (10.3 ± 7.2) hours ( P < 0.002, K-W). We found no significant difference between the survivors versus the patients who died regarding methanol. Simultaneous presence of ethanol and opium affected the outcome of the treatment for methanol intoxication favourably and unfavourably, respectively. In our study, poor prognosis was associated with pH < 7, coma on admission and >24 hours delay from intake to admission. Human & Experimental Toxicology (2007) 26: 583—586.
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Affiliation(s)
- H Hassanian-Moghaddam
- Poison Control Center, Loghman-Hakim Hospital, School of Medicine, Shaheed Beheshti Medical University, Tehran, Iran.
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Caksen H, Odabaş D, Akbayram S, Cesur Y, Arslan S, Uner A, Oner AF. Deadly nightshade (Atropa belladonna) intoxication: an analysis of 49 children. Hum Exp Toxicol 2016; 22:665-8. [PMID: 14992329 DOI: 10.1191/0960327103ht404oa] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Deadly nightshade (Atropa belladonna) intoxication has been infrequently reported in both children and adults in the literature. In this article, the clinical and laboratory findings of 49 children with acute deadly nightshade intoxication are reviewed. Our purpose was to enlighten the findings of deadly nightshade intoxication in childhood. The most common observed symptoms and signs were meaningless speech, tachycardia, mydriasis, and flushing. None of the children required mechanical ventilation or died in our series. The patients were categorized into two groups, mild/moderate and severe intoxication. Children with and without encephalopathy were accepted as severe and mild/moderate intoxication, respectively. While 43 children were placed in the group of mild/moderate intoxication, six were in severe intoxication group. We found that meaningless speech, lethargy, and coma were more common, but tachycardia was less common in the severe intoxication group (children with encephalopathy) (P B-0.05). In the treatment, neostigmine was used in all children because of no available physostigmine in our country. In conclusion, our findings showed that the initial signs and symptoms of acute deadly nightshade intoxication might be severe in some children, but no permanent sequel and death were seen in children. We also showed that meaningless speech, lethargy, coma, and absence of tachycardia were ominous signs in deadly nightshade intoxication in childhood. Lastly, we suggest that neostigmine may be used in cases of deadly nightshade intoxication if physostigmine cannot be available.
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Affiliation(s)
- Hüseyin Caksen
- Yüzüncü Yil University, Faculty of Medicine, Department of Pediatrics, 65200, Van, Turkey.
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Abstract
As valpromide is a prodrug of valproic acid (valproate), the clinical presentation of overdoses with either valpromide or valproate sodium is generally considered similar. Whereas plasma peak levels and signs of central nervous system depression occur within a few hours after the acute ingestion of regular-release forms of valproate sodium, delayed toxicity and time to peak levels following valpromide ingestion can be seen as shown by the three reported cases. They were initially considered as mild because patients presented with no or only moderate symptoms and serum valproate levels were below or at therapeutic levels on admission more than 3 hours post-ingestion in two of the three patients. Serum valproate levels were not monitored until marked deterioration more than 10 hours after ingestion. At the time of deterioration, serum valproate was at toxic level in the three reported cases. Therefore, large intake of valpromide should be closely monitored because no or moderate symptoms together with low plasma levels in the first few hours after ingestion do not exclude a subsequent severe intoxication. Despite the usual favourable outcome and the poor correlation between plasma levels and toxic symptoms, patients should not be discharged until plasma levels are documented to remain at low levels for at least 10 hours after the ingestion of valpromide and the patient asymptomatic.
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Affiliation(s)
- C Payen
- Centre Antipoison, 162 Avenue Lacassagne, 69424 Lyon cedex 03, France.
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48
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Abstract
1–Butanol is a colourless organic solvent with a rancid sweet odour. 1–Butanol ingestion may result in vomiting, abdominal pain, headache, drowsiness and unconsciousness. We present a 47–year–old male with no previous medical history, who was found comatose and soiled after having vomited while unconscious. On arrival, he had a Glasgow coma scale of 3, tachycardia, hypotension, shallow tachypnoic breathing, hypotonic muscles, absent myotatic reflexes and aromatic odour. The patient was intubated and treated with oxygen, dopamine and volume replacement therapy. Gastric lavage was performed and activated charcoal was given. His initial laboratory test revealed hypokaliemia, renal failure, acidosis with elevated lactate and hypercapnic respiratory insufficiency. Twelve hours after admission, the patient started to respond to a painful stimulus and 4 h later he was conscious. He was extubated 23 h after admission. All pathological laboratory results gradually returned within normal limits. The subsequent toxicological examination of gastric content and urine sample by gas chromatography revealed 1–butanol. On awakening, he confirmed ingestion of a solvent stored in an airport hangar. In conclusion, we describe a patient who ingested an unknown dose of 1–butanol. Symptoms were headache, vomiting, abdominal pain, coma, muscular hypotonus, hypotension, respiratory insufficiency and mixed acidosis. The patient totally recovered after supportive therapy over 30 h. In future cases, intravenous administration of ethanol or even hemodialysis can be considered analogous to the treatment of methanol and ethylene glycol poisoning.
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Affiliation(s)
- M Bunc
- Medical Faculty, Institute for Pathophysiology, Zaloska, Ljubljana, Slovenia
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Küçükardali Y, Acar HV, Ozkan S, Nalbant S, Yazgan Y, Atasoyu EM, Keskin O, Naz A, Akyatan N, Gökben M, Danaci M. Accidental Oral Poisoning Caused by Rdx (Cyclonite): A Report of 5 Cases. J Intensive Care Med 2016; 18:42-6. [PMID: 15189666 DOI: 10.1177/0885066602239123] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The explosive RDX (hexogen, cyclonite) is usually used for the production of C-4 explosive. The rare occurrence of accidental and intentional RDX intoxications has been reported during manufacturing process or in wartime. In this article, the authors report 5 cases of accidental oral RDX poisoning. On admission, observed signs and symptoms included repetitive generalized tonic-clonic convulsions, postictal coma, lethargy, confusion, hyperreflexia, postictal amnesia, nausea, vomiting, abdominal tenderness, sinusal tachycardia, dysrhythmia with frequent ventricular premature beats, generalized muscle spasms, and myoclonus. Leukocytosis, mild anemia, methemoglobinemia, elevated levels of blood glucose, serum aspartate transaminase, alanine transaminase, lactic dehydrogenase, creatine phosphokinase, amilase, hypokalemia, metabolic acidosis, proteinuria, glucosuria, and myoglobinuria were also noted. Plasma RDX concentrations were 268 to 969 ng/mL at 3 hours of ingestion. For management, supportive and symptomatic measures were taken. Whole-bowel irrigation might have been an effective therapeutic procedure due to probable slow gastrointestinal absorption of RDX. Three patients who developed severe metabolic acidosis underwent urgent hemodialysis. All patients were discharged 7 to 21 days after admission without any sequelae. Plasma RDX levels were strongly correlated with the clinical and laboratory manifestations. The available toxicological data on this rare accidental poisoning are reviewed in light of the literature.
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Alsukhni RA, Ghoubari MS, Farfouti M, Aboras YA. Status epilepticus following local anesthesia in a previously healthy adult. BMC Res Notes 2016; 9:300. [PMID: 27287503 PMCID: PMC4901442 DOI: 10.1186/s13104-016-2100-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 05/24/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Local anesthesia could result in lethal complications if injected in highly vascularized area. Dentist should take care to avoid such complications. CASE PRESENTATION We present a case of 15 year old girl with a coma following convulsive status epilepticus which developed after inferior alveolar nerve blockade by a dentist. The patient was admitted to the intensive care unit ICU and recovered within several days. CONCLUSION This case is reported to tell both of dentists and medical staff that although it is uncommon, such complications of local anesthesia should be in mind to be avoided and managed promptly if happened.
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Affiliation(s)
- Rana Alnasser Alsukhni
- />Division of Neurology, Department of Internal Medicine, Aleppo University Hospital, Aleppo, Syria
| | | | - M.Taher Farfouti
- />Head of Neurology Unit, Aleppo University Hospital, Aleppo, Syria
| | - Yasmin Adib Aboras
- />Division of Neurology, Department of Internal Medicine, Aleppo University Hospital, Aleppo, Syria
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