Severe hypotension and hypothermia caused by acute ethanol toxicity

Syncope Secondary to Concomitant Ingestion of Tizanidine and Alcohol in a Patient With Alcohol Use Disorder

Syncope is the transient loss of consciousness due to cerebral hypoperfusion. A significant number of individuals experience a syncopal attack at one stage of their lives. The common causes of syncope include vasovagal syncope, orthostatic hypotension, and cardiac causes. Drugs are also associated with causing syncope. The drugs involved are mostly those that depress the central nervous system, and concomitant use of more than one of such drugs increases the risk of syncope even further. Tizanidine and alcohol individually can cause hypotension and combining both drugs is not advised due to heightened central nervous system depression and profound hypotension. We present a case of a 53-year-old female with alcohol use disorder who presented with a first-time syncopal attack due to postural hypotension after ingesting both tizanidine and alcohol concurrently. Co-administration of tizanidine and alcohol is not advised, however, cases of syncope have been rarely reported with concomitant use. This case will enlighten physicians to counsel patients about the need to abstain from alcohol consumption when taking tizanidine.

An epidermal patch for the simultaneous monitoring of haemodynamic and metabolic biomarkers

Monitoring the effects of daily activities on the physiological responses of the body calls for wearable devices that can simultaneously track metabolic and haemodynamic parameters. Here we describe a non-invasive skin-worn device for the simultaneous monitoring of blood pressure and heart rate via ultrasonic transducers and of multiple biomarkers via electrochemical sensors. We optimized the integrated device so that it provides mechanical resiliency and flexibility while conforming to curved skin surfaces, and to ensure reliable sensing of glucose in interstitial fluid and of lactate, caffeine and alcohol in sweat, without crosstalk between the individual sensors. In human volunteers, the device captured physiological effects of food intake and exercise, in particular the production of glucose after food digestion, the consumption of glucose via glycolysis, and increases in blood pressure and heart rate compensating for oxygen depletion and lactate generation. Continuous and simultaneous acoustic and electrochemical sensing via integrated wearable devices should enrich the understanding of the body's response to daily activities, and could facilitate the early prediction of abnormal physiological changes.

Cardiac Arrest Secondary to Accidental Hypothermia: The Physiology Leading to Hypothermic Arrest

Cardiac arrest secondary to accidental hypothermia is rare in the United Kingdom. However, some evidence suggests that it is under-reported; furthermore, recognizing hypothermia as the cause of death is difficult in the postmortem setting. Urban and rural residents are exposed to cold winter conditions both at home and while undertaking recreational activities. Understanding the physiology underpinning hypothermic cardiac arrest is crucial in order to make informed clinical decisions in regard to triage and management by air ambulance services and in prevention of this rare presentation. This article discusses the epidemiology and pathophysiology of accidental hypothermic to explain how personnel can survive after 8 hours 40 minutes of cardiac arrest.

Long-term Results after CT-Guided Percutaneous Ethanol Ablation for the Treatment of Hyperfunctioning Adrenal Disorders

OBJECTIVES:

To evaluate the safety and long-term efficacy of computed tomography-guided percutaneous ethanol ablation for benign primary and secondary hyperfunctioning adrenal disorders.

METHOD:

We retrospectively evaluated the long-term results of nine patients treated with computed tomography-guided percutaneous ethanol ablation: eight subjects who presented with primary adrenal disorders, such as pheochromocytoma, primary macronodular adrenal hyperplasia and aldosterone-producing adenoma, and one subject with Cushing disease refractory to conventional treatment. Eleven sessions were performed for the nine patients. The patient data were reviewed for the clinical outcome and procedure-related complications over ten years.

RESULTS:

Patients with aldosterone-producing adenoma had clinical improvement: symptoms recurred in one case 96 months after ethanol ablation, and the other patient was still in remission 110 months later. All patients with pheochromocytoma had clinical improvement but were eventually submitted to surgery for complete remission. No significant clinical improvement was seen in patients with hypercortisolism due to primary macronodular adrenal hyperplasia or Cushing disease. Major complications were seen in five of the eleven procedures and included cardiovascular instability and myocardial infarction. Minor complications attributed to sedation were seen in two patients.

CONCLUSION:

Computed tomography-guided ethanol ablation does not appear to be suitable for the long-term treatment of hyperfunctioning adrenal disorders and is not without risks.

Fatal intoxication with synthetic cannabinoid MDMB-CHMICA

MDMB-CHMICA is a synthetic cannabinoid that appeared on the European drug market in September 2014. This substance was found in Poland in the herbal mixture "Mocarz" ("Strongman"), which caused a large outbreak of intoxications at the beginning of July 2015. This paper describes the circumstances of death and toxicological findings in a fatal intoxication with MDMB-CHMICA (in combination with alcohol). Loss of consciousness and asystole occurred a few minutes after smoking the 'legal high'. The man died after 4 days of hospitalisation. The cause of death accepted by the medical examiner was multiple organ failure. MDMB-CHMICA was detected and quantified in blood (ante- and postmortem) and internal organs tissues. The samples were analysed using liquid chromatography with mass spectrometry (LC-MS/MS). The concentration of MDMB-CHMICA in antemortem blood was 5.6 ng/mL. Although the death occurred after 4 days from administration a relatively high concentration (2.6 ng/g) was estimated in the brain. Traces of this compound were also found in other postmortem materials (blood, stomach, liver, bile, and kidney). The presented case shows the health risks associated with MDMB-CHMICA use. The administration of this substance can lead to the number of organ failures, cardiac arrest and consequently death.

Mad Honey Poisoning-Related Hypothermia: A Case Series

BACKGROUND

Mad honey-related intoxication frequently leads to bradycardia, hypotension, and syncope. Hypothermia is a potentially life-threatening condition if not identified early and treated appropriately.

CASE REPORT

Three patients are reviewed. Patient 1 was a 66-year-old man who presented to the emergency department with nausea, vomiting, and faintness beginning 2 h after consuming honey. His temperature was 34°C, his blood pressure was 70/40 mm Hg, and his heart rate was 30 beats/min. Patient 2, a 57-year-old man, presented to the emergency department with headache, feeling cold, and faintness beginning 3 h after consuming honey. His temperature was 35°C, his blood pressure was 60/40 mm Hg, and his heart rate was 46 beats/min. Patient 3 was a 79-year-old woman who presented with nausea, vomiting, and headache 2 h after consuming honey. Her temperature was 35°C, her blood pressure was 70/40 mm Hg, and her heart rate was 40 beats/min. All 3 patients were discharged in good condition after appropriate therapy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Bradycardia and hypotension are frequently encountered in mad honey intoxication. However, intoxication accompanied by hypothermia has attracted little attention to date.

Effects of ethanol on systemic hemodynamics in a porcine model of accidental hypothermia

OBJECTIVES

Accidental hypothermia is frequently associated with ethanol intoxication. Each has independent effects on systemic hemodynamics, but their combined effects are poorly understood. We aimed to describe the hemodynamic effects of ethanol intoxication in a model of severe hypothermia and rewarming.

METHODS

Anesthetized pigs was assigned to control (n=8) or ethanol groups (ETOH) (n=7, 3 mg/kg of ethanol via an orogastric tube). Subjects were cooled to 25°C using ice packs and then warmed to baseline core temperature with passive external and active core rewarming.

RESULTS

In the ETOH group, peak serum ethanol concentration was 202 mg/dL at 25°C. Ethanol had no effect on time of cooling or rewarming. In both the control and ETOH, there were similar maximal decreases in mean arterial pressure (from 94±24 to 50±15 mm Hg and 100±27 to 31±12 mm Hg, respectively), ventricular contractility (rate of maximal left ventricular pressure rise from 5731±1462 to 2610±596 mm Hg/s and 6832±1384 to 1937±437 mm Hg/s, respectively), and cardiac output (from 2.14±0.8 to 0.53±0.3 L/min and 2.93±0.9, to 0.44±0.2 L/min, respectively; all P<.001). After rewarming, only in the ETOH group were persistent decreases in mean arterial pressure (59±14 mm Hg), contractility (3982±1573 mm Hg/s), and cardiac output (1.6±0.9 L/min, all P<.03) observed.

CONCLUSIONS

Hypothermia caused significant adverse effects on cardiac function and systemic hemodynamics, which returned to baseline with rewarming. Ethanol intoxication had no additional effects on systemic hemodynamics during cooling; however, it caused more prolonged depression of cardiac function and adverse effects on systemic hemodynamics during rewarming. These data may have implications for resuscitation of ethanol-intoxicated victims of accidental hypothermia.

Shifts in temperature within the physiologic range modify strand-specific expression of select human microRNAs

Previous studies have revealed that clinically relevant changes in temperature modify clinically relevant gene expression profiles through transcriptional regulation. Temperature dependence of post-transcriptional regulation, specifically, through expression of miRNAs has been less studied. We comprehensively analyzed the effect of 24 h exposure to 32°C or 39.5°C on miRNA expression profile in primary cultured human small airway epithelial cells (hSAECs) and its impact on expression of a targeted protein, protein kinase C α (PKCα). Using microarray, and solution hybridization-based nCounter assays, with confirmation by quantitative RT-PCR, we found significant temperature-dependent changes in expression level of only five mature human miRNAs, representing only 1% of detected miRNAs. Four of these five miRNAs are the less abundant passenger (star) strands. They exhibited a similar pattern of increased expression at 32°C and reduced expression at 39.5°C relative to 37°C. As PKCα mRNA has multiple potential binding sites for three of these miRNAs, we analyzed PKCα protein expression in HEK 293T cells and hSAECs. PKCα protein levels were lowest at 32°C and highest at 39.5°C and specific miRNA inhibitors reduced these effects. Finally, we analyzed cell-cycle progression in hSAECs and found 32°C cells exhibited the greatest G1 to S transition, a process known to be inhibited by PKCα, and the effect was mitigated by specific miRNA inhibitors. These results demonstrate that exposure to clinically relevant hypothermia or hyperthermia modifies expression of a narrow subset of miRNAs and impacts expression of at least one signaling protein involved in multiple important cellular processes.

Acute Alcohol Toxicity

Acute alcohol (ethanol) toxicity is a definition that encompasses both the metabolic toxicity of alcohol and the association of alcohol with traumatic deaths, suicide, and criminal activities. As with any postmortem measurement, there must be control of postmortem sampling, storage of specimens, and appropriate analysis to ensure that there is not artifactual alcohol production or incorrect measurement of other postmortem alcohols. It is almost unheard of for acute alcohol toxicity to cause death secondary to metabolic effects in a naïve individual, although there has been a recent trend in social media dares that have led to deaths due to isolated episodes of extreme alcohol consumption. However, in most cases, there will be evidence for chronic alcohol misuse at the postmortem examination.

Acute alcohol intoxication characteristics in children

AIMS

To describe clinical, mental and physical signs in children with different severity acute alcohol intoxication (AAI) determined either by serum alcohol concentration (SAC) or by blood alcohol concentration (BAC) to study the diagnostic performance characteristics of clinical assessment and to establish the ratio of SAC:BAC in children.

METHODS

Data were analysed from 256 children aged 8.4-17.9 years who were hospitalized at Estonia's two children's hospitals over a 3-year period. In each case, the on-call paediatrician completed a special form about the clinical, mental (consciousness, balance and speech) and physical (muscle tone, blood pressure, pulse and body temperature) signs of AAI. Blood samples were drawn for measurements of SAC and BAC. Diagnostic performance characteristics (sensitivity, specificity, efficiency) of the clinical assessments and the SAC:BAC ratio were calculated.

RESULTS

The most correctly described signs in children in different SAC groups were consciousness (rs = 0.16) and speech (rs = 0.13) (P < 0.0001). The severity of alteration of consciousness and degrees of disturbance in balance and speech were positively correlated with SAC (P < 0.001). The clinical judgment matched better with AAI determined by SAC rather than by BAC with the mean efficiency. The mean ratio between SAC and BAC was 1.19 ± 0.13 (P < 0.001) in children.

CONCLUSION

The level of consciousness is the leading sign in the clinical evaluation of children with AAI and correlates well with SAC. The severity of AAI judged by clinical assessment matched better with AAI severity stages determined by SAC than by BAC. For legal cases where BAC is required, the SAC:BAC ratio of 1.19:1 should be used in children regardless of their gender or age.

Alcohol and the older adult: a comprehensive review

Alcohol consumption in the older adult is of major concern with the advent of baby boomers coming into the over 65-age bracket. Alcohol consumption has been touted as beneficial for health, and while that may be accurate for moderate consumption in younger persons, there is considerable risk associated with increased alcohol intake in older adults. This increase is partially due to age-related physiological changes, existing diagnoses, number of comorbid conditions, and increased use of prescribed and/or over-the-counter medications, coupled with other concerns. This review addresses the current research regarding ethanol consumption in older adults and all-cause mortality as well as several conditions more frequently seen in the geriatric population. These conditions include vascular diseases, hypertension, type 2 diabetes, gastrointestinal disorders, hepatic disorders, dental and oro-facial problems, bone density decline, and falls and fractures. In addition, drug interactions and recent research into select vitamin and mineral considerations with increased alcohol intake in older persons are addressed. While recommendations for alcohol intake have not been specifically established for age ranges within the 65-year-and-older bracket, and practitioners do not routinely assess alcohol intake or ethanol related adverse events in this population, common sense approaches to monitoring will become increasingly important as the generation of "boomers" who believe that alcohol intake improves health comes of age.

Hypothermia in the geriatric population

Hypothermia is common in the geriatric population and its significance perhaps under-recognized. Hypothermia is associated with substantial morbidity and fatality, but to some extent is preventable provided caregivers and providers of healthcare to older adults adopt preventive measures to lower its occurrence. Hypothermia occurs in both cold and warm settings; its pathogenesis involves alterations in the age-related physiology of thermoregulation, along with a variable combination of environmental factors, disease processes and medications, many of which are recognizable. Once diagnosed, treatment must be prompt and aggressive, and must consider several options for rewarming. Education of healthcare providers regarding early recognition of hypothermia and a better understanding of preventive and treatment measures will undoubtedly lower complications of hypothermia in affected elderly.

Neuroexcitatory actions of Tamiflu and its carboxylate metabolite

Oseltamivir (Tamiflu) is now being stockpiled by several governments as a first line treatment for an anticipated outbreak of avian influenza caused by H5N1. However, abnormal behaviors and death associated with the use of Tamiflu have developed into a major issue in Japan where Tamiflu is often prescribed for seasonal influenza. Thus, it is critical to determine neuropsychiatric effects of oseltamivir and to establish methods for safe administration. Using juvenile rats and rat hippocampal slices, we investigated whether oseltamivir has adverse effects on the central nervous system. Systemic injection of oseltamivir (50mg/kg i.p.) produced no change in behavior within 2h. However, prior injection of oseltamivir significantly altered the duration of loss of lightning reflex following ethanol injection (3.3g/kg, i.p.). Ethanol injection in the presence of oseltamivir also resulted in enhanced hypothermia. In the CA1 region of hippocampal slices, oseltamivir (100 microM) induced paired-pulse facilitation in population spikes without changes in excitatory postsynaptic potentials. Similarly, 3 microM oseltamivir carboxylate, the active metabolite of oseltamivir, facilitated neuronal firing, though the facilitation did not involve GABAergic disinhibition. Moreover, oseltamivir carboxylate produced further facilitation following administration of 60mM ethanol. These findings indicate that oseltamivir has effects on the central nervous system, especially when combined with other agents.