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1/6. Prolonged sedation requiring mechanical ventilation and continuous flumazenil infusion after routine doses of clorazepam for alcohol withdrawal syndrome.

    We report the cases of two patients who developed prolonged sedation after routine doses of clorazepam for alcohol withdrawal syndrome. They required prolonged mechanical ventilation (10 days for both patients) followed by continuous flumazenil infusion (16 days for one patient and 3 days for the other) to avoid reintubation. In the two patients, nordazepam accumulation (main active metabolite of clorazepam) was demonstrated as the cause of the coma. This accumulation could be attributed, in one case, to impaired hepatic cytochrome P 450 3A4 activity. Caution is required when prescribing benzodiazepines to alcoholic patients and the use of benzodiazepine which do not undergo hepatic oxidation by cytochrome P 450 such as oxazepam or lorazepam is suggested. ( info)

2/6. Emergency airway management in a case of lingual haematoma.

    A previously unreported cause of acute tongue swelling is presented and the airway issues discussed. Cases with different aetiology have been sporadically published however the consequent, and sometimes fatal, airway obstructions have been dealt with somewhat variably. The aetiogy of acute tongue swelling and modern emergency airway algorithms are discussed with reference to the literature. ( info)

3/6. bupropion seizure proportion among new-onset generalized seizures and drug related seizures presenting to an emergency department.

    bupropion is a relatively new and popular medication with seizures as its major side effect. This drug can produce seizures with an overdose. The purpose of this investigation was to determine the relative importance of this medication as the etiology of new-onset seizures relative to other drugs and new-onset seizures in general. The study design was a retrospective case series. All new onset generalized seizures were evaluated over a 4-year period in subjects 16 years of age and older. Etiologic diagnosis was determined from the neurology consultation and all patients with new-onset seizures were admitted to the hospital as per hospital policy and received a routine chemistry screening and a neuroimaging study as a minimum. The results indicate that 17 of 279 or 6.1% of the new-onset seizures were drug related. After cocaine intoxication (6/279 or 2.2%) and benzodiazepine withdrawal (5/279 or 1.8%) seizures, bupropion (4/279 or 1.4%) was the third leading cause of drug related seizures. In addition, all the bupropion related seizures occurred in patients taking what was considered to be a therapeutic dose or 450 mg/day or less. sleep deprivation, previous history of attention deficit disorder and bulimia, and previous heavy alcohol use were associated in three of the patients taking bupropion who had seizures. We conclude that although drug related new-onset seizures are not a common cause of seizures overall, bupropion might be a more common cause of drug related new-onset generalized seizures presenting to the Emergency Department than previously thought, occurring in more than one-fifth of this subgroup of cases. Possibly, greater exclusion criteria are needed than currently recommended for the use of bupropion at therapeutic doses. ( info)

4/6. Alcohol and other drug use in later life.

    BACKGROUND: Problem alcohol and other drug use is rarely suspected in the elderly. However, the elderly are more susceptible to problems related to drug use at lower doses because of age related changes, comorbidities and polypharmacy. Like other age groups, the elderly sometime seek the use of alcohol and other drugs, to help them feel better or to avoid negative feelings such as loneliness and depression. Drug use in the elderly is associated with significant morbidity anid can be masked by other medical problems. OBJECTIVE: This article demonstrates a gradual onset alcohol problem in a longstanding elderly patient, in whom changes in drug or alcohol use may not be easily detected. It also highlights some key differences in drug related presentations in the elderly. DISCUSSION: Some health professionals consider intervention for problem alcohol or other drug use in the elderly ineffective. However, because of the high prevalence of polypharmacy and comorbid pathology, intervention is more likely to result in a significant health improvement. general practitioners have a high level of contact with and are trusted by the elderly, giving them an unparalleled opportunity among health professionals to intervene in problem alcohol and other drug use. ( info)

5/6. Evaluation of a distal pericallosal aneurysm visualized with 3-dimensional digital subtraction angiography: case report and treatment implications.

    BACKGROUND: Digital subtraction angiography (DSA) is considered the gold standard in the evaluation of cerebrovascular structures. Recently, 3-dimensional DSA (3D-DSA) has been increasingly used to obtain detailed information about the morphology and dimensions of intracranial aneurysms. We report the case of a patient who presented with a distal pericallosal artery aneurysm, which appeared by 2D imaging to be a fusiform, possible mycotic aneurysm. This was then revealed to be a saccular bifurcation aneurysm by 3D-DSA. This additional information changed the treatment plan for this patient from medical management to a surgical approach. CASE DESCRIPTION: The patient is a 56-year-old man with a history of hypertension and alcohol abuse with withdrawal seizures, who presented with a large intracranial hemorrhage on initial computed tomography scan. After stabilization with intracranial pressure management, the patient underwent magnetic resonance angiography and 4-vessel DSA. These initial studies showed a distal, fusiform pericallosal aneurysm consistent with a mycotic aneurysm. Rotational DSA was then used to generate 3D images of the structure that revealed a saccular bifurcation aneurysm. This enabled the decision to offer operative treatment rather than conservative medical management. DISCUSSION: This report highlights the value of 3D-DSA in establishing the appropriate treatment plan for patients with unique cerebral aneurysms. The higher resolution images used in this case provided information that was crucial in shifting the treatment focus from medical management, for what appeared to be a mycotic aneurysm by traditional DSA, to surgical intervention, for a clear hemodynamic aneurysm at a vessel bifurcation seen with 3D-DSA. Accurate pre-interventional evaluation and differential diagnosis are critical to designing the most effective lowest risk treatment plan. The standard method in the diagnosis of cerebral aneurysms has been DSA. Yet, higher resolution images of unclear or high-risk aneurysms are often required to guide clinical decision making. The emergence of new, less invasive endovascular techniques for securing intracranial aneurysms has placed greater emphasis on precisely defining the shape and dimensions of an aneurysm. Three-dimensional DSA is currently the highest resolution imaging modality available for the evaluation of intracranial aneurysms. CONCLUSION: 3D-DSA was used to evaluate a small, distal pericallosal artery aneurysm and revealed a saccular bifurcation aneurysm not visualized with magnetic resonance angiography and conventional DSA. This additional resolution permitted the team to consider a surgical approach for a patient who would otherwise have been treated medically. This high-resolution technique is particularly useful in guiding clinical decision making in the context of aneurysms that carry a relatively broad differential diagnosis, potentially high interventional risk, and unclear morphology. ( info)

6/6. Delayed hypokalemic paralysis following a convulsion due to alcohol abstinence.

    We encountered three patients with hypokalemic paralysis following a convulsion in the early stages of alcohol abstinence. The transtubular potassium gradient was less than 2.0, suggesting intracellular potassium shift. Hypokalaemic paralysis may result from retention of intracellular cationic potassium bound by anionic phosphorylated compounds, precipitated by an acceleration of the (Na )-(K ) pump in alcohol withdrawal and convulsions. These findings warn of the lethal hypokalemia that may occur after convulsions, particularly soon after alcohol abstinence associated with moderate withdrawal symptoms. ( info)

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