Use of a Nerve Agent Antidote-Dosing Tool for Mass Casualty Incident Emergency Preparedness.

OBJECTIVE: Nerve agent attacks pose a serious threat worldwide and ensuring optimal readiness is essential to management. We review a mass casualty incident (MCI) drill in a busy urban New York City Emergency Department incorporating an antidote-dosing tool. METHODS: Emergency Management and Preparedness planned an MCI drill involving a nerve agent exposure and engaged the pharmacy department to participate on a more comprehensive level. The clinical pharmacist prepared a treatment tool with antidote dosing recommendations to distribute to team members participating in the drill. RESULTS: During the launch of the exercise, all clinicians involved reviewed the antidote-dosing tool with the pharmacy team members. Because of the ease of use, limited time was necessary to review the dosing tool before the start of the exercise. After the exercise, feedback regarding the use of the tool was very positive and participants appreciated the tool for use in a theoretical emergency that they have had limited experience managing. CONCLUSIONS: Optimizing team preparedness with accessible and practical dosing tools may be a helpful addition to emergency preparedness for chemical and biological events with the potential for many casualties.

Low-dose oral propranolol for treatment of thyrotoxic periodic paralysis with hypokalaemia in the emergency department: A case report.

WHAT IS KNOWN AND OBJECTIVE: Thyrotoxic periodic paralysis (TPP) with hypokalaemia is a rare acute phenomenon. Reports of the use of high-dose non-selective ß-blockers describe symptom resolution, but often administration does not occur promptly enough in the treatment course and patients may experience overcorrection and hyperkalaemia. CASE DESCRIPTION: A 37-year-old Hispanic male developed TPP. Patient was successfully treated with low-dose oral propranolol and potassium supplementation with no overcorrection. WHAT IS NEW AND CONCLUSION: Delay in the administration of non-selective ß-blockers may lead to overcorrection of potassium with exogenous supplementation. Low-dose propranolol administered in the Emergency Department was successful in preventing overcorrection of potassium.

A Review and Clinical Understanding of Tenofovir: Tenofovir Disoproxil Fumarate versus Tenofovir Alafenamide.

HIV is a serious chronic medical condition. Significant improvements in antiretroviral therapy have led to a transformation in its management. No curative treatment is available for HIV, and lifelong therapy is required with a combination of agents to control viral replication and prevent complications. Some of the older agents are notorious for many side effects, making patient compliance difficult, which is critical to preventing HIV resistance. Tenofovir is one of the newer, more tolerable, nucleotide reverse transcriptase inhibitors on the market; is a mainstay of many antiretroviral therapy combinations; and is now available in 2 different formulations, tenofovir disoproxil fumarate (TDF) and, the more recent, tenofovir alafenamide (TAF). These 2 formulations have very different pharmacokinetics, which seem to affect their efficacy and safety. This manuscript provides insight into the history of TDF and TAF development, their unique pharmacokinetics and pharmacology, clinically important adverse effects, monitoring, interactions, resistance, review of clinical studies, and guideline recommendations and clinical applications for tenofovir's various indications.

Management of Patients with Candida auris Fungemia at Community Hospital, Brooklyn, New York, USA, 2016-20181.

Candida auris is an emerging fungus that can cause invasive infections. It is associated with high mortality rates and resistance to multiple classes of antifungal drugs and is difficult to identify with standard laboratory methods. We describe the management and outcomes of 9 patients with C. auris fungemia in Brooklyn, New York, USA.

Iatrogenic Adrenal Insufficiency Secondary to Combination Therapy with Elvitegravir/Cobicistat/Tenofovir Disoproxil Fumarate/Emtricitabine and Interlaminar Triamcinolone Injection in an AIDS Patient.

We report the first identified case of suspected iatrogenic adrenal insufficiency after an interlaminar injection of triamcinolone acetonide while on concomitant Stribild (elvitegravir 150 mg/cobicistat 150 mg/tenofovir disoproxil fumarate 300 mg/emtricitabine 200 mg [EVG/c/TDF/FTC]). A 49-year-old female with HIV on EVG/c/TDF/FTC therapy presented to our endocrinology clinic to be evaluated for suspected Cushing syndrome. Prior to presentation, the patient had been given 2 interlaminar spinal injections of triamcinolone. Thereafter, she developed a swollen face, had unexplained weight gain, and fatigue. Cosyntropin stimulation test was positive for adrenal insufficiency. By applying the Naranjo Nomogram for Causality and the Drug Interaction Probability Scale to this drug-drug interaction, we calculated a score of 6 ( probable) and 5 ( probable), respectively. Symptoms resolved without further intervention. The EVG/c/TDF/FTC contains cobicistat, a strong cytochrome P450 3A4 (CYP3A4) inhibitor, which can potentiate drug interactions involving metabolizing of medications via this pathway. Clinicians are reminded to be vigilant while assessing the potential pharmacokinetic drug interactions not mentioned by the manufacturer.