- Treatment of Ventricular Fibrillation Due to Ammonium Bifluoride Poisoning With Hemodialysis. [Journal Article]
- PedPediatrics 2018 Aug 15
- Ammonium bifluoride is an inorganic, fluoride-containing compound found in glass and metal etching products, as well as wheel cleaners. Fluoride toxicity is a common cause of preventable poisoning an...
Ammonium bifluoride is an inorganic, fluoride-containing compound found in glass and metal etching products, as well as wheel cleaners. Fluoride toxicity is a common cause of preventable poisoning and has been reported to cause life-threatening ventricular dysrhythmias. Here, we report a case of recurrent ventricular fibrillation secondary to ingestion of ammonium bifluoride. The patient presented with vomiting and coma. She was intubated for altered mental status and respiratory failure and subsequently had 5 episodes of ventricular fibrillation, each resolving with a single defibrillation. She developed metabolic acidosis and hypocalcemia, which were treated with sodium bicarbonate and calcium gluconate, respectively. During transfer to a tertiary care children's hospital, ventricular fibrillation recurred despite electrolyte correction. Hemodialysis (HD) was initiated emergently. No further dysrhythmia occurred after initiation of HD. The result of a basic urine drug screen was negative, and a comprehensive drug screen (gas chromatography and mass spectroscopy) revealed only a nonsignificant peak for diphenhydramine. Subsequent laboratory evaluation revealed an elevated serum fluoride level. Diagnostic laryngoscopy and upper endoscopy did not reveal evidence of caustic injury. She was successfully extubated on hospital day 2 and discharged from the hospital on day 4 with no neurologic sequelae. With this example, we demonstrate a potential therapeutic approach to this potentially lethal poisoning. Fluoride toxicity is typically treated with calcium. However, dysrhythmia may result from calcium-independent direct myocardial toxicity. The kinetics of fluoride are amenable to HD, and renal clearance is slow. The potential use of HD in cases of fluoride poisoning refractory to other therapies warrants further study.
- Gold Nanoparticles for Enhanced Ionization and Fragmentation of Biomolecules using LDI-MS. [Journal Article]
- JMJ Mass Spectrom 2018 Aug 14
- New applications for gold nanoparticles (AuNPs) in Laser Desorption Ionization Mass Spectrometry (LDI-MS) are presented here. This work expands on previous biomolecule studies and introduces carbohyd...
New applications for gold nanoparticles (AuNPs) in Laser Desorption Ionization Mass Spectrometry (LDI-MS) are presented here. This work expands on previous biomolecule studies and introduces carbohydrates, steroids, bile acids, and other small molecules as a focus. Broad trends in ionization are observed and specifically of interest are new species that have not previously been reported from AuNPs (e.g., [M+Au]+ ). Interesting fragmentation effects have been observed for diphenhydramine, including similarity to Electron Impact mass spectra and possible radical driven reactions, providing insight into the mechanism of ionization when using AuNPs.
- The feasibility of dexamethasone omission in weekly paclitaxel treatment for breast cancer patients. [Journal Article]
- SCSupport Care Cancer 2018 Aug 01
- CONCLUSIONS: Dexamethasone withdrawal from W3 to W12 in early stage breast cancer patients treated with weekly paclitaxel is feasible. The incidence of all grades of HSRs was comparable to that reported in trials with dexamethasone for 12 consecutive weeks, and no serious events (G3/G4) occurred. Studies with larger sample sizes are needed to confirm our results which are important, especially for patients for whom corticosteroids are contraindicated.
- Emergency Department Use of Intravenous Prochlorperazine for Acute Migraine. [Journal Article]
- AEAdv Emerg Nurs J 2018 Jul/Sep; 40(3):148-154
- The Research to Practice Column is designed to improve translational research critique skills of nurse practitioners (NPs). In this issue, the article "Randomized study of IV prochlorperazine plus di...
The Research to Practice Column is designed to improve translational research critique skills of nurse practitioners (NPs). In this issue, the article "Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine" is discussed in the context of a patient with an acute headache presenting to the emergency department (ED). The study was designed to assess the efficacy of intravenous prochlorperazine and diphenhydramine as compared with intravenous hydromorphone for patients with acute migraine in the ED. With the growing trend to avoid the use of opiates to curb potential addiction and increased ED length of stay, NPs need to be aware of efficacious, evidence-based treatments for acute migraines, a common ED presentation.
- Insomnia in Elderly Patients: Recommendations for Pharmacological Management. [Review]
- DADrugs Aging 2018 Jul 30
- Chronic insomnia affects 57% of the elderly in the United States, with impairment of quality of life, function, and health. Chronic insomnia burdens society with billions of dollars in direct and ind...
Chronic insomnia affects 57% of the elderly in the United States, with impairment of quality of life, function, and health. Chronic insomnia burdens society with billions of dollars in direct and indirect costs of care. The main modalities in the treatment of insomnia in the elderly are psychological/behavioral therapies, pharmacological treatment, or a combination of both. Various specialty societies view psychological/behavioral therapies as the initial treatment intervention. Pharmacotherapy plays an adjunctive role when insomnia symptoms persist or when patients are unable to pursue cognitive behavioral therapies. Current drugs for insomnia fall into different classes: orexin agonists, histamine receptor antagonists, non-benzodiazepine gamma aminobutyric acid receptor agonists, and benzodiazepines. This review focuses on Food and Drug Administration (FDA)-approved drugs for insomnia, including suvorexant, low-dose doxepin, Z-drugs (eszopiclone, zolpidem, zaleplon), benzodiazepines (triazolam, temazepam), and ramelteon. We review the indications, dosing, efficacy, benefits, and harms of these drugs in the elderly, and discuss data on drugs that are commonly used off-label to treat insomnia, and those that are in clinical development. The choice of a hypnotic agent in the elderly is symptom-based. Ramelteon or short-acting Z-drugs can treat sleep-onset insomnia. Suvorexant or low-dose doxepin can improve sleep maintenance. Eszopiclone or zolpidem extended release can be utilized for both sleep onset and sleep maintenance. Low-dose zolpidem sublingual tablets or zaleplon can alleviate middle-of-the-night awakenings. Benzodiazepines should not be used routinely. Trazodone, a commonly used off-label drug for insomnia, improves sleep quality and sleep continuity but carries significant risks. Tiagabine, sometimes used off-label for insomnia, is not effective and should not be utilized. Non-FDA-approved hypnotic agents that are commonly used include melatonin, diphenhydramine, tryptophan, and valerian, despite limited data on benefits and harms. Melatonin slightly improves sleep onset and sleep duration, but product quality and efficacy may vary. Tryptophan decreases sleep onset in adults, but data in the elderly are not available. Valerian is relatively safe but has equivocal benefits on sleep quality. Phase II studies of dual orexin receptor antagonists (almorexant, lemborexant, and filorexant) have shown some improvement in sleep maintenance and sleep continuity. Piromelatine may improve sleep maintenance. Histamine receptor inverse agonists (APD-125, eplivanserin, and LY2624803) improve slow-wave sleep but, for various reasons, the drug companies withdrew their products.
- Autism Spectrum Disorder and Mental Health Comorbidity Leading to Prolonged Inpatient Admission. [Journal Article]
- JDJ Dev Behav Pediatr 2018 Jul/Aug; 39(6):523-525
- Sam is a 6-year-old boy with a diagnosis of autism spectrum disorder (ASD) who recently relocated and has an appointment with you, his new pediatric clinician, to establish care. He was previously fo...
Sam is a 6-year-old boy with a diagnosis of autism spectrum disorder (ASD) who recently relocated and has an appointment with you, his new pediatric clinician, to establish care. He was previously followed by a psychiatrist for 2 years for additional diagnoses of insomnia, bipolar disorder, anxiety, attention deficit hyperactivity disorder, and intellectual disability. He has tried and (apparently) failed multiple psychotropic trials including stimulants, nonstimulants, mood stabilizers, atypical antipsychotics, and nonbenzodiazepine hypnotics. He has a delayed sleep onset and frequent night awakenings each night for the past 3 months, during which he "screams, cries, and thrashes and can stay up for over an hour." His behaviors are described as irritable, self-injurious, and aggressive with no clear pattern of triggers according to his mother. He is nonverbal and communicates by leading and rarely pointing. The patient's current medication regimen includes clonidine 0.2 mg at night, lorazepam 1.5 mg as needed at night, olanzapine 5 mg twice daily, and diphenhydramine as needed for sleep/agitation. His mother is concerned that he is developing "tolerance" to the regimen and wants to wean him off some of the medications. His mother is struggling to take care of the patient given his worsening behavior and body habitus (body mass index >99%; z = 3.41).There is a family history of depression, anxiety, bipolar disorder, and autism. He has a 3-year-old sister, who is also diagnosed with ASD, though she is not as severely impacted. His mother's partner recently moved in along with 2 children of his own, aged 3 and 4 years. Sam attends a specialized school, where he receives behavior therapy and occupational therapy. He has undergone inpatient pediatric hospitalization twice, 1 time for 3 weeks and the other for 6 days, for aggressive behavior, and in both instances, he was discharged before inpatient psychiatric placement because of a lack of available beds.After urgent consultation with your local developmental and behavioral pediatrician, a slight reduction was made in the lorazepam because of concerns about tolerance and side effects. However, within a week of this, he was brought to the emergency department for continued self-injurious behavior and increased trouble with sleeping. His mother voiced concerns about his safety in the home, which were particularly related to aggression toward his younger sister. He was admitted to the pediatric inpatient floor for observation, and medication adjustment (increasing olanzapine), which was initially helpful in improving behavior, but mostly behavioral/environmental strategies were used to soothe him, including frequent wagon rides through the hospital corridors.Despite the patient being stable from the medical standpoint, Sam's mother did not feel comfortable taking him home. Social work contacted local community mental health services to pursue outpatient resources and respite care options and sought inpatient pediatric psychiatry. After several failed attempts to find placement, he remained in pediatric inpatient care for 1 and a half months with no acute medical interventions other than his oral medications.He was finally accepted to the in-state pediatric psychiatric facility when a bed was available. During his week-long stay, he had further medication adjustments with a decrease in olanzapine and optimization of his clonidine dose. During his psychiatric hospital stay, care coordination succeeded in arranging center-based applied behavior analysis interventions and respite care and parent training for his family. Sam began to show improvement in his overall agitation and aggression, requiring less clonazepam, and his mother then maintained outpatient follow-up.The day before discharge, you visit him in the hospital, and a medical student asks you why he was in the hospital for so long. How would you answer the question?
- Fundamental study of the ultrasonic induced degradation of the popular antihistamine, diphenhydramine (DPH). [Journal Article]
- WRWater Res 2018 Jul 17; 144:265-273
- Diphenhydramine (DPH) the active ingredient in Benadryl, has been detected in streams, rivers and other surface water sources. As a bioactive compound, DPH impacts human health even at low concentrat...
Diphenhydramine (DPH) the active ingredient in Benadryl, has been detected in streams, rivers and other surface water sources. As a bioactive compound, DPH impacts human health even at low concentrations. Ultrasonic irradiation at 640 kHz leads to the rapid degradation of DPH in aqueous solution. Radical scavenging experiments and detailed product studies indicate the DPH degradation involves direct pyrolysis and degradation reactions mediated by the hydroxyl radicals produced during cavitation. The degradation can be modeled by pseudo-first order kinetics yielding rate constants k of 0.210, 0.130, 0.082, 0.050, 0.035, 0.023 min-1 at the initial concentrations of 2.8, 5.2, 13.9, 27.0, 61.0, 160.0 μmol L-1, respectively. The degradation process follows the Langmuir-Hinshelwood (heterogeneous) model with a partition coefficient, KL-H = 0.06 μmol·L-1and reactivity constant kr = 1.96 μmol min-1·L-1. A competition kinetic study conducted employing the hydroxyl radical trap, coumarin, illustrates that DPH was degraded primarily by hydroxyl radical mediated processes. Computational studies employing Gaussian 09 basis set provide fundamental insight into the partitioning of the reaction pathways and the degradation mechanisms. The study demonstrates the ultrasonic degradation of DPH is rapid, follows simple kinetic expressions and is accurately modeled using computational methods.
- Spatio-temporal bioaccumulation and trophic transfer of ionizable pharmaceuticals in a semi-arid urban river influenced by snowmelt. [Journal Article]
- JHJ Hazard Mater 2018 Jul 20; 359:231-240
- Bioaccumulation of pharmaceuticals in aquatic organisms is increasingly reported in the peer-reviewed literature. However, seasonal instream dynamics including occurrence and bioaccumulation across t...
Bioaccumulation of pharmaceuticals in aquatic organisms is increasingly reported in the peer-reviewed literature. However, seasonal instream dynamics including occurrence and bioaccumulation across trophic positions are rarely studied, particularly in semiarid streams with flows influenced by seasonal snowmelt and municipal effluent discharges. Thus, we selected East Canyon Creek in Park City, Utah, USA to examine spatio-temporal bioaccumulation of select ionizable pharmaceuticals across trophic positions using trophic magnification factors calculated at incremental distances (0.15, 1.4, 13 miles) downstream from a municipal effluent discharge during spring (May), Summer (August), and fall (October). Nine target analytes were detected in all species during all sampling events. Trophic dilution was consistently observed for amitriptyline, caffeine, diphenhydramine, diltiazem, fluoxetine, and sertraline, regardless of seasonal instream flows or distance from effluent discharge. Calculated TMFs ranged from 0.01-0.71 with negative slopes observed for all regressions of chemical residue in tissue and trophic position. We further presents the first empirical investigation of normalizing pharmaceutical concentrations to lipid, phospholipid or protein fractions using pair matched fish samples. Empirical results identify that normalization of ionizable pharmaceutical residues in aquatic tissues to neutral lipids, polar lipids, or the total protein fraction is inappropriate, though bioaccumulation studies examining influences of internal partitioning (e.g., plasma proteins) are needed.
- Preparation, Characterization, and Formulation Development of Drug-Drug Protic Ionic Liquids of Diphenhydramine with Ibuprofen and Naproxen. [Journal Article]
- MPMol Pharm 2018 Aug 06
- Diphenhydramine (DPH) has been used with ibuprofen (IBU) or naproxen (NAP) in combined therapies to provide better clinical efficacy as an analgesic and sleep aid. We discovered that DPH can form pro...
Diphenhydramine (DPH) has been used with ibuprofen (IBU) or naproxen (NAP) in combined therapies to provide better clinical efficacy as an analgesic and sleep aid. We discovered that DPH can form protic ionic liquids (PILs) with IBU and NAP, which opens the opportunity for a new delivery mode of these combination drugs. [DPH][IBU] and [DPH][NAP] PILs exhibit low ionicity, as confirmed by Fourier transform infrared and 1H NMR spectroscopy, and accompanied by low diffusivity, high viscosity, and poor ionic conductivity. Evaluation of pharmaceutical properties of the two PILs showed that these PILs, despite high solubility and good wettability, exhibited low dissolution rates, owing to the poor dispersion of the PIL drops and the resultant small surface area during dissolution. However, when loaded into a mesoporous carrier, the PIL-carrier composites exhibited improved dissolution rates along with excellent flow properties and easy handling. Oral capsules of both PILs were developed using such composites. Such capsule products exhibited acceptable drug release and bioavailability as demonstrated by a predictive artificial stomach-duodenum dissolution test.
New Search Next
- Multicomponent Interventions Reduce High-Risk Medications for Delirium in Hospitalized Older Adults. [Journal Article]
- JAJ Am Geriatr Soc 2018 Jul 23
- Delirium threatens the functional independence and cognitive capacity of patients. Medications, especially those with strong anticholinergic effects, have been implicated as a preventable cause of de...
Delirium threatens the functional independence and cognitive capacity of patients. Medications, especially those with strong anticholinergic effects, have been implicated as a preventable cause of delirium. We evaluated the effect of multicomponent interventions aimed at reducing the use of 9 target medications in hospitalized older adults at risk of delirium. This continuous quality improvement program was undertaken at a tertiary care facility and 4 community hospitals in a hospital system. We included 21, 541 hospital admissions with patients aged 70 and older on acute care medical or surgical units from the preintervention (2012) period, and 27,764 from the postintervention (2015) period. Implemented interventions include formulary and policy changes, technology-assisted medication review, age-conditional order set modifications, best practice alerts, and education. The proportion of hospital admissions with individual's receiving at least 1 target medication declined from 45.6% to 31.3% (relative reduction (RR)=31.4%) from before to after the intervention, meaning that target medication exposure was avoided in approximately 4,000 older adults. The greatest effect was observed for zolpidem (11.2% to 5.3%, RR=52.6%) and diphenhydramine (12.9% to 7.1%, RR=45%). Furthermore, the mean number of doses administered during all hospital admissions was reduced for 7 of 9 medications. Multicomponent interventions implemented in our hospital system were effective at reducing exposure to target medications in hospitalized older adults at risk of delirium. These systematic changes applied throughout the medication use process are sustained today.