Extravasation with methylthioninium chloride.

INTRODUCTION: Methylthioninium chloride is used for multiple treatment purposes and is sometimes administered through peripheral intravenous lines. We highlight the potential adverse effects of methylthioninium chloride extravasation during continuous peripheral intravenous administration. CASE SUMMARY: A 38-year-old woman presented to the emergency department with multifactorial hypovolemic and septic shock. She was treated with a continuous peripheral infusion of intravenous methylthioninium chloride for shock refractory to multiple vasopressors. IMAGES: One day after administration commenced, the patient developed blue staining of the left upper arm due to extravasation of methylthioninium chloride proximal to the site of infusion. Further images show its later spread. CONCLUSION: While reported cases of methylthioninium chloride extravasation are rare, it is our preference that methylthioninium chloride should be administered through a central line in cases of continuous infusion due to the risk of potential toxicity from extravasation.

Successful Treatment of Confirmed Severe Bupropion Cardiotoxicity With Veno-Arterial Extracorporeal Membrane Oxygenation Initiation Prior to Cardiac Arrest.

Bupropion is a substituted cathinone (ß-keto amphetamine) norepinephrine/dopamine reuptake inhibitor andnoncompetitive nicotinic acetylcholine receptor antagonist that is frequently used to treat major depressive disorder. Bupropion overdose can cause neurotoxicity and cardiotoxicity, the latter of which is thought to be secondary to gap junction inhibition and ion channel blockade. We report a patient with a confirmed bupropion ingestion causing severe cardiotoxicity, for whom prophylactic veno-arterial extracorporeal membrane oxygenation (ECMO) was successfully implemented. The patient was placed on the ECMO circuit several hours before he experienced multiple episodes of hemodynamically unstable ventricular tachycardia, which were treated with multiple rounds of electrical defibrillation and terminated after administration of lidocaine. Despite a neurological examination notable for fixed and dilated pupils after ECMO cannulation, the patient completely recovered without neurological deficits. Multiple bupropion and hydroxybupropion concentrations were obtained and appear to correlate with electrocardiogram interval widening and toxicity.

Common Factors Underlying Diverse Responses in Alcohol Use Disorder.

OBJECTIVE: Interindividual variation in responses to alcohol is substantial, posing challenges for medical management and for understanding the biological underpinnings of alcohol use disorders (AUD). It is important to understand whether diverse alcohol responses such as sedation, which is predictive of risk and partly heritable, occur concurrently or independently from responses such as blackouts and withdrawal. We hypothesized that latent factors accounting for sources of variance in diverse alcohol response phenotypes could be identified in a large, deeply phenotyped sample of patients with AUD. METHODS: We factor analyzed 17 alcohol response related items from the Alcohol Dependence Scale (ADS) in 938 individuals diagnosed with AUD via structured clinical interviews. Demographic, genetic, and clinical characteristics were tested as predictors of the latent factors by multiple indicators, multiple causes analysis. RESULTS: The final factor solution included three alcohol response factors: Physical Symptoms, Perceptual Disturbances, and Neurobiological Effects. Both gender and genetic ancestry were identified as variables influencing alcohol response. Major depressive disorder positively predicted physical symptoms and aggression negatively predicted physical symptoms. Barratt's Impulsivity Scale total score predicted the Physical and Perceptual domains. Family history, average drinks per drinking day, and negative urgency (an impulsivity measure) predicted all three domains. CONCLUSIONS: Diverse items from the ADS concurrently load onto three correlated alcohol response factors rather than loading independently. Genetic ancestry and clinical characteristics predicted the severity of items that define the alcohol response factors even after accounting for degree of alcohol consumption. Co-occurring phenotypes point towards an underlying shared physiology of diverse alcohol responses.

A retrospective analysis of treatment and retention outcomes of pregnant and/or parenting women with opioid use disorder.

AIM: To determine factors associated with positive outcomes of buprenorphine maintenance treatment for opioid use disorder among pregnant women and women with children under the age of five years. METHODS: This retrospective, de-identified electronic health record review of a cohort of 108 female patients at a suburban primary care outpatient clinic followed patients for one year of treatment at the clinic. Positive outcomes were defined as 1) treatment retention and 2) urine toxicology at 12 months free of all substances other than buprenorphine. This study also evaluated a variety of potential correlates of treatment retention and toxicology, including patient demographics, medical and social history, and clinical factors (i.e., participation in a women's group and assigned treatment provider). RESULTS: Patient retention was 73.2% at 12 months. Compared to those retained in treatment, patients not retained were more likely to have received past treatment for a psychiatric illness (65.4% vs. 38.2%; p < 0.02) or have prior criminal history of a misdemeanor conviction (56.0% vs. 27.9%; p < 0.02). There was a significant association between time in treatment and reduction in opiate use (p < 0.01). CONCLUSIONS: In this population, certain baseline characteristics were predictive of failure to be retained in treatment. As such, specific patients may need more intensive treatment. These findings have important public health and child welfare implications and may offer insight for providers to tailor treatment and refer for comprehensive services.