First Case of Acute Poisoning with Amiodarone and Flecainide in Attempted Suicide Successfully Managed with Lipid Emulsion Therapy in the Emergency Department: Case Report and Literature Review

Acute antiarrhythmics poisoning represents a challenge in the Emergency Department (ED). These patients often develop malignant arrhythmias in need of exceptional therapeutic measures in the ICU. We report a 47-year-old patient admitted to the ED 5 h after the ingestion of a large dose of amiodarone and flecainide in a suicide attempt. During their ED stay, the patient developed signs of cardiotoxicity evidenced by electrocardiogram and ventricular arrhythmias. The toxicological results showed a level of 4.8 mg/L amiodarone and 2.98 mg/L flecainide. He was successfully treated in the ED using a large dose of sodium bicarbonate and lipid emulsion therapy. After hospital admission, he remained stable, with no need for exceptional therapeutic measures such as mechanical circulatory support, cardiac pacing or ECMO. We emphasize the importance of an early start of pharmacological therapies in the ED, which might improve the outcome in antiarrhythmic acute poisoning.

Effectiveness of Adding a Large Dose of Shoulder Strengthening to Current Nonoperative Care for Subacromial Impingement: A Pragmatic, Double-Blind Randomized Controlled Trial (SExSI Trial)

Background: A strong recommendation against subacromial decompression surgery was issued in 2019. This leaves nonoperative care as the only treatment option, but recent studies suggest that the dose of strengthening exercise is not sufficient in current nonoperative care. At this point, it is unknown if adding more strengthening to current nonoperative care is of clinical value. Purpose: To assess the effectiveness of adding a large dose of shoulder strengthening to current nonoperative care for subacromial impingement compared with usual care alone. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: In this double-blinded, pragmatic randomized controlled trial, we randomly allocated 200 consecutive patients referred to orthopaedic shoulder specialist care for long-standing shoulder pain (>3 months), aged 18 to 65 years and diagnosed with subacromial impingement using validated criteria, to the intervention group (IG) or control group (CG). Outcome assessors were blinded, and participants were blinded to the study hypothesis as well as to the treatment method in the other group. The CG received usual nonoperative care; the IG underwent the same plus an add-on intervention designed to at least double the total dose of shoulder strengthening. The primary outcome was the Shoulder Pain and Disability Index (SPADI; 0-100) at 4-month follow-up, with 10 points defined as the minimal clinically important difference. Secondary outcomes included shoulder strength, range of motion, health-related quality of life, and the Patient Acceptable Symptom State (PASS). Results: Intention-to-treat and per-protocol analyses showed no significant or clinically relevant between-group differences for any outcome. From baseline to 4-month follow-up, SPADI scores improved in both groups (intention-to-treat analysis; IG, –22.1 points; CG, –22.7 points; between-group mean difference, 0.6 points [95% CI, –5.5 to 6.6]). At 4 months after randomization, only 54% of the IG and 48% of the CG ( P = .4127) reached the PASS. No serious adverse events were reported. Conclusion: Adding a large dose of shoulder strengthening to current nonoperative care for patients with subacromial impingement did not result in superior shoulder-specific patient-reported outcomes. Moreover, approximately half of all randomized patients did not achieve the PASS after 4 months of nonoperative care, leaving many of these patients with unacceptable symptoms. This study showed that adding more exercise is not a viable solution to this problem. Registration: NCT02747251 ( ClinicalTrials.gov identifier)

Protective potential of Cynara scolymus extract in thioacetamide model of hepatic injury in rats

Hepatic injury is a worldwide health problem. This study aimed to evaluate the possible hepatoprotective potential of Artichoke (Cynara scolymus) extract (CSE) in albino rats using the thioacetamide (TAA) a model of liver injury. Acclimatized 42 rats were divided randomly into seven groups, each consists of six rats, and subjected to different treatments. Hepatic injury model was induced by administration of TAA at a dose of 100 mg per kg, intraperitoneally, twice weekly for 8 weeks (+ve control); test groups rats received CSE at doses of 100 or 200 mg/kg BW, orally, daily for 8 weeks adjunct with TAA; standard group rats received Silymarin at a dose of 100 mg per kg, orally, daily for 8 weeks adjunct with TAA; other 2 groups of rats received only CSE at the same dose levels; while -ve control rats received only the vehicles. Blood and liver tissue samples were collected at the end of the experimental course for different assessments. Results revealed that CSE exhibited dose-dependent hepatoprotection indicated by nearly normalized parameters, including enzymatic liver function parameters (AST, ALT, GGT & ALP with potential % of 94.06, 86.96, 85.93, 64.85, respectively, after large dose when standardized by Silymarin); non-enzymatic parameters (total protein, albumin, globulins, total bilirubin, conjugated bilirubin, unconjugated bilirubin, TAGs, Cholesterol, HDL, LDL & VLDL with potential % of 83.42, 85.9, 83.44, 98.1, 77.41, 91.5, 97.51, 97.46, 81.41, 88.52 & 89.4, respectively, after large dose when standardized by Silymarin). The underlying mechanism of the observed hepatoprotection of CSE was attributed to impeding the oxidative stress-mediated by TAA, indicated by reduced hepatocyte lipid peroxidation product MDA (95.96 % of Silymarin), and improved antioxidative enzymes in liver homogenate, namely, GPx, Catalase & SOD with potentials of 95.44, 87.02 & 81.48 % of Silymarin, respectively. Macroscopic and microscopic pathological pictures were supportive to the biochemical findings, where the pathological lesions caused by TAA as congestion and dilatation of central and portal veins with perivascular fibrous connective tissue proliferation admixed with few mononuclear leukocytes plus necrotic hepatocytes and hyperplastic biliary epithelium, were ameliorated dose-dependently when CSE was administered together with TAA. The present study's data may suggest CSE as a natural source for promising hepatoprotective and antioxidant drug preparations.

Potential Role of Vitamins and Zinc on Acute Respiratory Infections Including Covid-19

Background. Vitamin C, E, D, A, zinc are considered to be essential in preventing and treating of acute respiratory infections (ARI) including COVID-19. Methods. We reviewed published studies evaluating the potential roles of these vitamin and zinc for ARIs and COVID-19 using Medline database, medRxiv, and bibliographic references. Results. Vitamins C, D, and E did not reduce incidence of common cold in general, but vitamin C reduced by half in population with physical and environment stresses. Vitamins C and E shortened duration and reduced severity of common cold. A large-dose vitamin A had no effect on recovery from pneumonia. Zinc improved clinical deterioration and pneumonia duration in under five. The effect on preventing COVID-19 morbidity and related-death was lacking. Conclusions. Although the effects of vitamins and zinc on ARIs including COVID-19 were inconclusive, taking these for a short period during pandemic may be beneficial when there is risks of deficiency.

The Protection Effect of Ulinastatin on Freshwater Instillation-Induced Acute Lung Injury in Rabbits

Background: Drowning is an important cause of accidental death in humans. The main cause of death following drowning is pulmonary oedema or lung injury, eventually leading to acute respiratory distress syndrome. The present study aimed to determine the protective effects of Ulinastatin on freshwater-induced acute drowning lung injury. Methods: Rabbits were randomly divided into a control, freshwater, freshwater + small-dose Ulinastatin, freshwater + medium-dose Ulinastatin, freshwater + large-dose Ulinastatin group. The arterial blood gas analysis was performed before modelling (baseline) and at various time points after freshwater instillation. And then, the wet-to-dry weight ratio lung permeability index were measured to detect the effect of Ulinastatin on lung endothelial permeability. Furthermore, histopathological staining and ELISAs were used to analyse the histological changes and inflammatory cytokines expression resulted from lung injury, respectively. Western blotting and Quantitative real-time polymerase chain reaction were used to measure the protein and mRNA levels of Hypoxia inducible factor-lα (HIF-1α)/ Vascular endothelial growth factor (VEGF) in the lung tissues. Results: By inhibiting the HIF-1α/VEGF pathway, treatment with Ulinastatin at a large dose could markedly attenuate changes in the PaO2/FiO2 (P/F), lung endothelial permeability, histopathology, and the expression of inflammatory cytokines induced by freshwater instillation. Conclusion: Ulinastatin is a potential candidate treatment for freshwater drowning-induced acute lung injury that targets the HIF-1α/VEGF pathway.

The effect of a large dose of intravenous immunoglobulin on general paresis of the insane

General paresis of the insane (GPI) remains the form of neurosyphilis most closely associated with dementia, even after the advent of penicillin. Penicillin remains the top treatment choice for syphilis, but treatment failure is not rare. Although the neurological symptoms of GPI can be alleviated by antibiotic treatment, mental symptoms may continue. A 60-year-old man was admitted to hospital due to rapidly progressive dementia. He was diagnosed as GPI. With the patient’s informed consent, we treated him with a large dose of intravenous immunoglobulin (IVIG) (0.4 g/kg/day) for 5 days, as well as penicillin (24 million units daily divided into six doses) for 14 days. A near-immediate improvement in his emotions and orientation occurred on the 17th day in hospital. The patient made an excellent recovery 6 weeks after treatment, his psychotic and mood symptoms improved significantly. Therefore, we hypothesize that patients with GPI treated with IVIG and penicillin G would have better outcomes than those treated with penicillin G alone. IVIG may be introduced as a necessary treatment for GPI.