Facial eschar following a single application of black salve.

A previously healthy 86-year-old male was transported by ambulance to the trauma bay of the emergency department (ED) for profuse bleeding from the left temple. The ambulance crew raised concern that the volume and force of the bleed may suggest arterial involvement. The patient reported having applied a natural topical remedy to a mole two weeks prior at the recommendation of a naturopath. The patient described progressive blackening and swelling of the area in the days following the single application of the product. After gaining control of the bleeding in the ED, the area was found to have a raised, 2 cm eschar.

Stability of high-dose insulin in normal saline bags for treatment of calcium channel blocker and beta blocker overdose.

CONTEXT: High-dose insulin has become a first-line therapy for treating severe calcium channel blocker and beta blocker toxicity. Insulin infusions used to treat other conditions (e.g., diabetic ketoacidosis) may be used, but this may lead to pulmonary compromise due to fluid volume overload. An obvious solution would be to use a more concentrated insulin infusion; however, data describing the stability of insulin in polyvinyl chloride bags at concentrations >1 unit/mL are not readily available. OBJECTIVE: To determine the stability of insulin at 16 units/mL in 0.9% saline solution. MATERIALS AND METHODS: Eight-hundred units of regular insulin (8 mL from a stock vial containing 100 units/mL) were added to 42 mL of 0.9% saline solution in a polyvinyl chloride bag to make a final concentration of 16 units/mL. Two bags were stored at 4 °C (refrigerated) and two at 25 °C (room temperature). Samples were withdrawn and tested for insulin concentration periodically over 14 days. RESULTS: Concentrated regular insulin in a polyvinyl chloride bag remained within 90% of equilibrium concentration at all time points, indicating the 16 units/mL concentration was sufficiently stable both refrigerated and at room temperature for 14 days. DISCUSSION: Administration of high-dose insulin can cause fluid volume overload when using traditional insulin formulations. The 16 units/mL concentration allows for the treatment of a patient with severe calcium channel blocker or beta blocker toxicity for a reasonable period of time without administering excessive fluid. CONCLUSION: Insulin at a concentration of 16 units/mL is stable for 14 days, the maximum timeframe currently allowed under US Pharmacopeia rules for compounding of sterile preparations. This stability data will allow institutions to issue beyond-use dating for intravenous fluids containing concentrated insulin and used for treating beta blocker and calcium channel blocker toxicity.

The effect of grape seed extract on cardiovascular risk markers: a meta-analysis of randomized controlled trials.

Recent animal studies have suggested that grape seed extract has beneficial effects on the cardiovascular system. Randomized trials in human beings have yielded conflicting results. The objective of this systematic review was to assess the effect of grape seed extract on changes in blood pressure, heart rate, lipid levels, and C-reactive protein (CRP) levels. We searched MEDLINE (January 1, 1950, through October 31, 2010), Agricola (January 1, 1970, through October 31, 2010), Scopus (January 1, 1996, through October 31, 2010), and the Cochrane Central Register of Controlled Trials (through October 31, 2010) for randomized controlled trials in human beings of grape seed extract reporting efficacy data on at least one of the following end points: systolic or diastolic blood pressure, heart rate, total cholesterol, low-density or high-density lipoprotein cholesterol, triglycerides, or CRP. A manual search of references from primary and review articles was performed to identify additional relevant trials. For all endpoints except CRP, the mean change in each parameter from baseline was treated as a continuous variable and the effect size was calculated as the weighted mean difference between the means in the grape seed extract and control groups. Data on CRP were pooled as a standardized mean difference. Nine randomized, controlled trials (N=390) met the inclusion criteria, and a meta-analysis was conducted. Upon meta-analysis, grape seed extract significantly lowered systolic blood pressure (weighted mean difference -1.54 mm Hg (95% confidence interval -2.85 to -0.22, P=0.02]), and heart rate (weighted mean difference -1.42 bpm (95% confidence interval -2.50 to -0.34, P=0.01]). No significant effect on diastolic blood pressure, lipid levels, or CRP was found. No statistical heterogeneity was observed for any analysis (I(2)<39% for all). Egger's weighted regression statistic suggested low likelihood of publication bias in all analysis (P>0.05 for all), except for the effect on diastolic blood pressure (P=0.046). Based on the currently available literature, grape seed extract appears to significantly lower systolic blood pressure and heart rate, with no effect on lipid or CRP levels. Larger randomized, double-blinded trials evaluating different dosages of grape seed extract and for longer follow-up durations are needed.