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Clin Toxicol (Phila) ; 56(9): 841-845, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29490507


INTRODUCTION: Steroidal alkaloids are found in plants of the genus Veratrum. Their toxicity manifests as gastrointestinal symptoms followed by a Bezold-Jarisch reflex: hypopnea, hypotension, and bradycardia. Some Veratrum steroidal alkaloids are also teratogens interfering with the hedgehog-2 signaling pathway, which causes cyclopsia and holoprosencephaly. We present a case of accidental poisoning from Veratrum parviflorum mistaken for the edible Allium tricoccum (ramps, wild leek). CASE HISTORY: A 27-year-old man and his 25-year-old wife presented to the emergency department with nausea, vomiting, hypotension, and bradycardia after foraging and ingesting plants that they believed to be a local native species of wild leek. METHODS: We collected and analyzed the implicated fresh plant material and both patients' serum/plasma. We used liquid chromatography-mass spectroscopy and high-resolution electrospray ionization time of flight tandem mass spectrometry to extract and characterize steroidal alkaloids from the foraged plant and patients' serum. RESULTS: Our V. parviflorum samples contained verazine, veratramine, veratridine, and cyclopamine. DISCUSSION: Steroidal alkaloids have been previously isolated from Veratrum viride and Veratrum album and toxicity has been reported mainly from V. album species. CONCLUSION: V. parviflorum toxicity manifests with gastrointestinal and cardiac symptoms. Treatment is symptomatic and supportive as with previous case reports of toxicity with other Veratrum species.

Antieméticos/uso terapêutico , Gastroenteropatias/tratamento farmacológico , Intoxicação por Plantas/tratamento farmacológico , Intoxicação por Plantas/fisiopatologia , Alcaloides de Veratrum/envenenamento , Veratrum/envenenamento , Vômito/tratamento farmacológico , Adulto , Feminino , Gastroenteropatias/etiologia , Georgia , Humanos , Masculino , Resultado do Tratamento , Vômito/etiologia
J Emerg Med ; 53(4): 520-523, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28756934


BACKGROUND: Scopolamine is a potent anticholinergic compound used commonly for the prevention of postoperative nausea and vomiting. Scopolamine can cause atypical anticholinergic syndromes due to its prominent central antimuscarinic effects. CASE REPORT: A 47-year-old female presented to the emergency department (ED) 20 h after hospital discharge for a right-knee meniscectomy, with altered mental status (AMS) and dystonic extremity movements that began 12 h after her procedure. Her vital signs were normal and physical examination revealed mydriasis, visual hallucinations, hyperreflexia, and dystonic movements. Laboratory data, lumbar puncture, and computed tomography were unrevealing. The sustained AMS prompted a re-evaluation that revealed urinary overflow with 500 mL of retained urine discovered on ultrasound and a scopolamine patch hidden behind her ear. Her mental status improved shortly after patch removal and physostigmine, with complete resolution after 24 h with discharge diagnosis of scopolamine-induced anticholinergic toxicity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although therapeutically dosed scopolamine transdermal patches rarely cause complications, incomplete toxidromes can be insidiously common in polypharmacy settings. Providers should thoroughly evaluate the skin of intoxicated patients for additional adherent medications that may result in a delay in ED diagnosis and curative therapies. Our case, as well as rare case reports of therapeutic scopolamine-induced anticholinergic toxicity, demonstrates that peripheral anticholinergic effects, such as tachycardia, dry mucous membranes, and hyperpyrexia are often not present, and incremental doses of physostigmine may be required to reverse scopolamine's long duration of action. This further complicates identification of the anticholinergic toxidrome and diagnosis.

Síndrome Anticolinérgica/diagnóstico , Antagonistas Colinérgicos/envenenamento , Síndrome Anticolinérgica/etiologia , Antagonistas Colinérgicos/uso terapêutico , Distonia/etiologia , Serviço Hospitalar de Emergência/organização & administração , Feminino , Alucinações/etiologia , Humanos , Meniscectomia/efeitos adversos , Meniscectomia/normas , Pessoa de Meia-Idade , Midríase/etiologia , Período Pós-Operatório , Escopolamina/envenenamento , Escopolamina/uso terapêutico , Adesivo Transdérmico
Am J Health Syst Pharm ; 72(12): 1059-64, 2015 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-26025998


PURPOSE: The development of eligibility criteria and use of tranexamic acid in conjunction with a massive transfusion protocol (MTP) are described. SUMMARY: The trauma surgery and pharmacy departments collaborated to operationalize tranexamic acid administration in trauma patients for whom an MTP was activated. The MTP at Boston Medical Center, an urban, tertiary, academic medical center, is activated by the attending physician when the patient is expected to require at least 10 units of packed red blood cells in 24 hours. Tranexamic acid was considered in MTP trauma patients who arrived at the medical center within 8 hours of traumatic injury, were 15 years of age or older, and weighed at least 40 kg. Eligible patients were to receive a loading dose of tranexamic acid 1 g i.v. over 10 minutes followed by a maintenance dose of 1 g infused over 8 hours. To ensure that tranexamic acid use was limited to trauma patients, both its location of use and physician-ordering privileges were restricted by the pharmacy department. A 16-month assessment revealed that 16 patients received tranexamic acid, 13 (81%) of whom met all criteria for use. Tranexamic acid was used in 13 (38%) of 34 eligible MTP patients. Barriers to the use of tranexamic acid include a lack of familiarity with the medication among staff, drug availability, the complexity of administration, and the critical setting of MTP activation. CONCLUSION: Multidisciplinary collaboration and standardization of tranexamic acid use in conjunction with an MTP promoted use of the drug within a trauma population.

Antifibrinolíticos/administração & dosagem , Transfusão de Eritrócitos/métodos , Ácido Tranexâmico/administração & dosagem , Ferimentos e Lesões/terapia , Centros Médicos Acadêmicos , Adolescente , Adulto , Boston , Comportamento Cooperativo , Feminino , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Adulto Jovem
J Oncol Pharm Pract ; 18(4): 394-401, 2012 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22357638


PURPOSE: To determine the cost-effectiveness of fulvestrant 250 mg compared to 500 mg in postmenopausal women with estrogen receptor-positive metastatic breast cancer and disease progression after antiestrogen therapy. METHODS: A Markov model was constructed to find the incremental cost-effectiveness of fulvestrant 250 mg monthly when compared with the 500 mg monthly in patients with progression after antiestrogen therapy. The model duration was 24 months. Clinical efficacy data inputs were derived from a phase III clinical trial demonstrating a statistically significant increase in progression-free survival in patients receiving 500 mg versus 250 mg. Cost data utilized were all relevant Ambulatory Payment Classification payment rates from the 2011 Medicare Outpatient Prospective Payment System. A Monte Carlo simulation was performed to test the model at various willingness to pay thresholds. RESULTS: The incremental cost-effectiveness ratio as determined by the Markov model was US$10,972 per month of progression-free survival for the 500 mg dose compared with the 250 mg dose. Using a Monte Carlo simulation, it was found that 500 mg monthly was cost-effective at and above the willingness to pay threshold of US$15,000 per month. A series of one-way sensitivity analyses showed this result is robust to geographical practice variations in costs of drug administration and physician examination. CONCLUSION: From a third party payer perspective, the value of fulvestrant 500 mg monthly is dependent on the willingness to pay threshold. Despite a labeling change for fulvestrant in September 2010, fulvestrant 250 mg monthly appears to be a viable option in the target population.

Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/economia , Estradiol/análogos & derivados , Antagonistas de Estrogênios/administração & dosagem , Antagonistas de Estrogênios/economia , Neoplasias da Mama/metabolismo , Ensaios Clínicos Fase III como Assunto/economia , Análise Custo-Benefício , Progressão da Doença , Intervalo Livre de Doença , Relação Dose-Resposta a Droga , Esquema de Medicação , Estradiol/administração & dosagem , Estradiol/economia , Feminino , Fulvestranto , Humanos , Cadeias de Markov , Modelos Econômicos , Método de Monte Carlo , Pós-Menopausa , Receptores Estrogênicos/metabolismo , Estados Unidos