Low serum level and chronic toxicity for methotrexate. Case Report.

INTRODUCTION: Methotrexate (MTX) is a folic acid antagonist used to treat different immunological or proliferative illnesses because of its anti-proliferative and anti-inflammatory effects. MTX Toxicity is considered a severe problem. Although acute toxicity related to high-dose administration (doses ≥500 mg/m2) can be predicted based on the given dose, chronic toxicity still has no specific factors to predict it, so treatment depends on the history and symptoms of toxicity. MTX was initially used for oncology indications with high cyclic doses, then expanded to non-oncology indications with different low doses and frequencies. This significant change in doses resulted in dosing errors that contributed to MTX toxicity reports. Measures to prevent the toxicity of MTX should be implemented. CASE: A 66-year-old female patient ingested 10 mg of MTX daily for one month instead of the once-toxicity symptoms. The serum level of MTX was requested, and treatment with folinic acid was initiated until the patient improved with the discontinuation of MTX. DISCUSSION: There is limited literature about the lack the total cumulative dose, duration of intake, or serum level of MTX. All this information was provided in this case report, but drug-drug interactions were not reviewed, although aspirin and pantoprazole were identified as having interactions with methotrexate in this patient. Minimum total cumulative dose identification may help assess the toxicity risk in such patients. CONCLUSION: Low-dose MTX chronic toxicity still needs further information to guide the patient's risk of toxicity and when to initiate treatment. Safety-practical measures should be implemented to prevent such administration errors.

What adult patients prefer for reporting their pain levels, and frequency of reassessment when in the emergency department.

OBJECTIVES: This study interviewed adult patients presenting to the emergency department (ED) for various pain conditions enquiring about their preferred tool for reporting pain severity and preferred time interval between initial assessment and subsequent pain reassessments. METHODS: A prospective observational (cross-sectional) study was conducted in adult patients with acute pain in a tertiary care hospital ED setting. Patients' initial pain score was recorded using NRS (numerical rating scale) pain scale, and appropriate analgesia offered. Once the patient had been evaluated by an attending physician, a research team member interviewed the patient regarding the pain reassessment time and preferred pain assessment tool. The pain assessment tools evaluated in this study were NRS, PS (picture scale or face pain scale), VRS (verbal rating scale), and VAS (visual analogue scale). The patients were presented with the four pain assessment tools (in their primary language) through an audio-visual on an electronic tablet display. RESULTS: 200 (138 male, mean age 36.5 ± 11.17) patients participated in the study. With increasing age, pain reassessment interval increased by 0.19 min (95% CI 0.03-0.36 min). Males requested pain reassessment 6.7 min (95% CI 2.2-10.8) faster than females. In this study, the preferred interval for pain reassessment was reported as a mean of 22.8 (SD + -13.6) minutes. There was no relationship reported between time reassessment and pain severity (P = 0.22). Out of 200 subjects, irrespective of the initial pain scores, 100 preferred NRS. NRS was preferred by patients with mild to moderated pain due to the perception of being faster. However, patients with severe pain choose a non-NRS scale to prioritize accuracy. CONCLUSION: There was no influence found between the initial pain severity scores and the desired frequency of pain reassessment. However, associations were identified between the time for pain reassessment interval and age, sex, and geographical region. Patients with severe pain preferred PS or VRS while patients with mild/moderate pain preferred the NRS.

Azathioprine induced acute sialadenitis: A case report.

Key clinical message: Patients presenting with acute sialadenitis need careful review of their medications. Azathioprine is one of such drugs, which can rarely induce acute sialadenitis. Prompt discontinuation of the medication leads to reversal of the patient condition. Abstract: Acute sialadenitis is one of the rare adverse effects of azathioprine. We report a case of acute submandibular sialadenitis following initiation of azathioprine which resolved upon discontinuation of the drug.

Acute Myocardial Infarction (AMI) Treated with Snake Antivenom.

Cardiac complications following snakebites are uncommon but fatal. Here, we discuss a case of a snakebite that led to acute myocardial infarction (AMI). Forty-five-year-old male presented to the emergency room with snakebite on the right middle finger. He was given symptomatic treatment and admitted for observation. His vital signs and initial investigations were normal except for the white blood count that was high. During observation, he developed vomiting and bradycardia. He was diagnosed with a right bundle branch block on ECG. The patient developed chest pain after a few hours and was diagnosed with AMI on ECG. The toxicology team started antivenom therapy. His troponin kept rising initially but later started coming down without percutaneous intervention (PCI). He was treated successfully with antivenom therapy and discharged.