bluuebunny/crossref_metadata_2025_split huggingface dataset:
Myoclonus Due to Chlorambucil in Two Adults with Lymphoma
Authors: Wyllie Andrew Rj , Bayliff Charles D , Kovacs Michael J 
Published: May 2017

ObjectiveTo report myoclonus due to chlorambucil therapy in two adults with lymphoma, and to review the literature of chlorambucil neurotoxicity in adults.Case SummariesCase 1: An 81-year-old man with lymphoma being treated with chlorambucil developed jerking movements and stiffness that persisted for 3 days and intensified at night. The dosage of chlorambucil was decreased with a subsequent decrease in symptomatology. Resolution of the myoclonus occurred with discontinuation of the chlorambucil. Rechallenge evoked a return of tremors the next day that later became constant and again resolved on discontinuation of chlorambucil. Case 2: A 75-year-old woman with lymphoma being treated with chlorambucil developed jerking movements in her limbs, particularly in her arms and right hip. The symptoms were so severe they prevented the patient from leaving her house. All symptoms resolved within 2–3 days after the cycle was completed and did not return. She was diagnosed as having had chlorambucil-induced myoclonus.Data SourcesSearches were performed on MEDLINE, CancerLit, and Science Citation Index Review to identify reports and articles discussing chlorambucil-induced neurotoxicity, particularly myoclonus.DiscussionChlorambucil-induced myoclonus has been described in overdose situations and in the treatment of nephrotic syndrome in children. Three cases of reversible myoclonic activity associated with high-dose chlorambucil in adults have also been described. In each case, the myoclonus resolved following discontinuation of the drug. Only one other conclusive case of low-dose chlorambucil-induced myoclonus in an adult has been described. The two cases presented here are unique in that the myoclonus occurred in adults receiving low-dose chlorambucil who had no myoclonus before or after treatment with the drug.ConclusionsFrom the cases reviewed, it appears that chlorambucil may induce myoclonus in adults receiving therapeutic dosages of chlorambucil. The neurologic status of patients receiving chlorambucil should be followed closely during treatment. If myoclonus develops, drug-induced myoclonus should be considered, as well as discontinuation of the drug.
Hypoprothrombinemia Associated with Cefmetazole
Authors: Breen Gail A , Peter Wendy L St 
Published: May 2017

Objective To report a case of hypoprothrombinemia associated with the use of cefmetazole sodium, define patients at risk for this adverse effect, and identify options to prevent this problem. Case Summary A malnourished patient with endstage renal disease received cefmetazole following a below-the-knee amputation of the right leg. Three days later, a prothrombin time (FT) and an international normalized ratio (INR) were obtained and were markedly elevated from baseline; however, the patient had no clinical symptoms of bleeding. Cefmetazole was discontinued. Vitamin K and fresh frozen plasma were administered. The PT and INR normalized within 24 hours and remained normal throughout the remainder of hospitalization. Discussion The incidence of hypoprothrombinemia associated with cefmetazole reported in the literature is conflicting and not consistent. There are three proposed mechanisms of cephalosporin-associated hypoprothrombinemia, two of which involve the N-methylthiotetrazole (NMTT) chain. The most plausible mechanism is NMTT inhibition of vitamin K epoxide reductase in the liver. Patients at an increased risk for this adverse event include those with low vitamin K stores, specifically patients who are malnourished, with low albumin concentrations and poor food intake. The elderly and patients with liver or renal dysfunction are examples of populations at risk. Conclusions Hypoprothrombinemia may occur with cephalosporins and is especially problematic with those containing an NMTT side chain. Clinicians need to identify patients at risk for developing antibiotic-associated hypoprothrombinemia, monitor them closely, and give vitamin K as prophylaxis accordingly.
Nonnarcotic Analgesics: Prevalence and Estimated Economic Impact of Toxicities
Authors: Mcgoldrick M Donald , Bailie George R 
Published: May 2017

Objective To review and compare the risks of nonnarcotic analgesic toxicities in adults and estimate the relative healthcare costs of these toxicities, since direct comparison of costs is not possible. Data Sources A MEDLINE search of the literature from 1969 to 1995 was used to identify pertinent data. Additional references were identified from articles obtained in the search. Information was obtained from prospective, retrospective, controlled, and uncontrolled studies; case reports; and review articles. Data Extraction Estimates of annual US costs of toxicities were extrapolated and synthesized from data from diagnosis-related groups, published information about the incidence of toxicity, or local data. Data Synthesis Chronic use of nonsteroidal antiinflammatory drugs (NSAIDs) is associated with a high incidence of acute renal toxicity and gastrointestinal toxicity. The most common problems associated with acetaminophen use are hepatotoxicity after acute ingestion of large doses (>10 g) or habitual use of smaller doses (<4 g), particularly in alcoholic patients, and chronic analgesic nephropathy. Aspirin use is associated with a high incidence of gastrointestinal and acute renal toxicity in certain patient groups. Available data suggest that acetaminophen, used intermittently, remains the nonnarcotic analgesic of choice in many patient populations, including those with impaired renal function, gastrointestinal disease, and bleeding disorders. Estimated annua] US costs associated with the toxicities of acetaminophen (excluding hepatotoxicity), aspirin (acute upper gastrointestinal bleeding only), and NSAIDs (excluding non-upper gastrointestinal hemorrhagic complications and hepatotoxicity) are about $51.5 million, $458.6 million, and $1.35 billion, respectively. Conclusions Intermittent use of most nonnarcotic analgesics produces a small risk of chronic renal or hepatic toxicity. Gastrointestinal toxicity, especially upper gastrointestinal bleeding, remains a significant problem with NSAIDs and aspirin. Acetaminophen remains the nonnarcotic analgesic of choice for intermittent use by most patient groups. The toxicities associated with NSAIDs constitute about 72.6% of the total toxicities (costs $1.86 billion) caused by NSAIDs, acetaminophen, and aspirin.
New Approaches to Using Antiretroviral Therapy for the Management of Hiv Infection
Authors: Doran Cynthia M 
Published: May 2017

Objective To review the changes that have occurred in the past 2 years in the management of HIV infection with antiretroviral agents by contrasting the 1994 with the 1996 Guidelines. Data Sources Conference proceedings, clinical experience of the author and her colleagues, and English-language articles from the body of scientific literature identified via MEDLINE, AIDSLINE, and Current Contents served as data sources. Data Synthesis Current antiretroviral management strategies include movement away from using zidovudine monotherapy, institution of combination antiretroviral therapy earlier in HIV disease, the use of newer agents such as lamivudine, protease inhibitors (i.e., saquinavir, ritonavir, indinavir), and nonnucleoside reverse transcriptase inhibitors (i.e., nevirapine, delavirdine), prevention of vertical transmission with zidovudine, and use of HIV-1 RNA determinations (viral load) to guide the initiation and alteration of antiretroviral therapy. These strategies represent a dramatic change from the 1994 Guideline, which recommended zidovudine monotherapy in nonpregnant and pregnant individuals whose CD4 cell counts were less than 500 cells/mm3, when many of the newer agents were not available and the assays to determine viral load were strictly investigational. Conclusions The difference between the 1994 and 1996 Guidelines is substantial. It is likely that within a year's time, newer information on pathogenesis and antiretroviral agents in development will be known and further management strategies will need to be disseminated. Until then, the International AIDS Society — USA Guidelines for 1996 should be followed as the standard of care.
Vancomycin-Induced Thrombocytopenia: A Challenge and Rechallenge
Authors: Howard Carol E , Adams Lorie A , Admire Jennifer L , Chu Mary A , Alred Ginger L 
Published: May 2017

Objective To report a case of thrombocytopenia apparently associated with vancomycin use. Case Summary A 58-year-old white man was admitted to the hospital with chronic osteomyelitis of the foot due to methicillin-resistant Staphylococcus aureus that later spread hematogenously to the cervical vertebrae. During the first course of therapy with vancomycin, his platelet count decreased from 397 × 103/mm3 to 22 × 103/mm3. After discontinuation of the drug, it increased to 310 × 103/mm3. During the second course of vancomycin, the platelet count decreased to 77 × 103/mm3, and increased to 404 × 103/mm3 after discontinuation of the drug. Discussion Vancomycin has been reported as a rare cause of thrombocytopenia. Thrombocytopenia can occur as an adverse drug reaction by the following three mechanisms: direct toxic effect, drug absorption (hapten) formation, and an “innocent bystander” immune response. Conclusions We suspect that the thrombocytopenia in this patient, which involved an increased number of megakaryocytes in the bone marrow, was due to vancomycin.
Zolpidem for Dementia-Related Insomnia and Nighttime Wandering
Authors: Shelton Penny S , Hocking Leslie B 
Published: May 2017

Objective To describe two elderly patients with dementia and severe nighttime wandering in whom Zolpidem restored normal sleep patterns. Case Summaries A 90-year-old African-American woman (case 1) and an 87-year-old African-American man (case 2) presented with nighttime wandering associated with the progression of Alzheimerlike dementia. Both patients had previously not responded to bedtime regimens of benzodiazepines, trazodone (an antidepressant used for its sedative properties), and neuroleptics. Both patients averaged 2–3 hours of sleep each night. Low-dose Zolpidem (5 mg hs) was initiated with only partial response. The dosage was titrated in 5-mg increments until the optimum dosage was reached for case 1 (15 mg hs) and case 2 (10 mg hs). These dosages have proven to be effective over a period of 3 months, with both patients averaging 7–8 hours of sleep each night with no apparent adverse effects. Discussion Dementia produces inversion of the circadian sleep/ wake cycle, leading to daytime sedation and nighttime wandering. Zolpidem, a nonbenzodiazepine hypnotic with proven safety and efficacy in older patients with insomnia, was well tolerated and improved sleep patterns in two patients with dementia and severe nighttime wandering. Conclusions Zolpidem appears to be useful for restoring normal sleep patterns in elderly patients with dementia and nighttime wandering.
Enoxaparin-Associated Dermal Necrosis: A Consequence of Cross-Reactivity with Heparin-Mediated Antibodies
Authors: Tonn Michael E , Schaiff Robyn A , Kollef Marin H 
Published: May 2017

Objective To describe a patient with enoxaparin-induced dermal necrosis and to review previously reported cases of skin manifestations associated with low-molecular-weight heparins. Case Summary A 43-year-old white woman with adult respiratory distress syndrome developed localized dermal necrosis and thrombocytopenia secondary to subcutaneous administration of unfractionated heparin. Upper extremity thrombi that had developed after administration of subcutaneous heparin at an outside hospital were treated with subcutaneous enoxaparin. Although platelet counts remained stable during enoxaparin therapy, dermal necrosis developed at the injection site. Parenteral anticoagulant therapy was discontinued and the necrotic lesions secondary to enoxaparin resolved with minimal local care. Discussion Numerous cases of dermal necrosis secondary to heparin administration have been reported while this reaction secondary to enoxaparin use has been reported only briefly. It has been postulated that dermal necrosis secondary to heparin is associated with heparin-induced thrombocytopenia and is a result of heparin-mediated thrombosis in the microvasculature. Antibodies to heparin have cross-reactivity with enoxaparin; therefore, dermal necrosis secondary to enoxaparin may occur by a similar mechanism. Conclusions Although enoxaparin-associated dermal necrosis appears to be a rare occurrence, we advise against the use of enoxaparin or other low-molecular-weight heparins in patients with a previous history of heparin-associated thrombocytopenia or heparin-induced dermal necrosis.
Infectious Diseases: Interferon Alfa in the Treatment of Chronic Viral Hepatitis B and C
Authors: Woo Michael H , Burnakis Thomas G 
Published: May 2017

Objective To review the indications, efficacy, and toxicity of interferon alfa in the treatment of chronic hepatitis B and C. Data Sources English-language literature pertaining to chronic hepatitis B and C and their management with interferon reported between 1980 and June 1995 was identified through computer searches using MEDLINE and through extensive searching of bibliographies and identified articles. Data Synthesis Two major causes of chronic hepatitis are hepatitis B virus and hepatitis C virus (HBV and HCV). Worldwide, HBV infection is a major cause of cirrhosis and hepatocellular carcinoma, but in the US it is mainly a disease of high-risk groups. In the US, and particularly the southern portion, HCV is more common. Like HBV, HCV also may cause cirrhosis and hepatocellular carcinoma. Except for interferon therapy, the ability to effectively treat chronic hepatitis is limited. Interferon has antiviral, antiproliferative, and immunomodulatory activity. This agent is indicated in patients who have histologic evidence of chronic hepatitis and ongoing viral replication. Thirty percent to 40% of patients with HBV achieve loss of serum HBV e antigen and HBV DNA after treatment with interferon alfa 5 million units/d or 10 million units three times weekly for 16 weeks. Fifty percent of patients with chronic HCV respond to interferon 3 million units three times weekly for 6 months, but half of these relapse within the next 6 months. Prolonged use (18 months) may provide longer term responses in HCV. Adverse effects are common, often dose-dependent, and usually transient. A flu-like syndrome occurs early in the treatment, but fatigue is the most common adverse effect and persists throughout therapy. Long-term interferon treatment has not been extensively evaluated and the impact on survival rates is not known. Conclusions Interferon is the only agent to have shown a consistent therapeutic effect on chronic hepatitis. Response of HBV to interferon is usually sustained, while a recurrence of HCV occurs in 50% of those who initially respond. Despite the benefits of interferon, its adverse effects and impact on hepatitis must be considered before treatment can be freely advocated.
Hypocalcemia and Hypomagnesemia after Ibuprofen Overdose
Authors: Al-Harbi Naffaa N , Domrongkitchaiporn Somnuek , Lirenman David S 
Published: May 2017

Objective To report a case of hypocalcemia and Hypomagnesemia after ibuprofen overdose. Case Summary A 21-month-old boy developed acute renal failure with severe metabolic acidosis after ingestion of ibuprofen 8 g. The infant developed tonic–clonic seizures 46 hours after ingestion, with significant hypocalcemia and hypomagnesemia that required electrolyte replacement to control the seizures. Discussion To our knowledge this is the first case report of hypocalcemia, hypomagnesemia, and seizures in a patient after ibuprofen overdose. The mechanism is unclear; the situation was probably aggravated by the use of sodium polystyrene sulfonate and furosemide. Conclusions In patients with ibuprofen overdose, serum calcium and magnesium concentrations should be evaluated since seizures may be associated with a deficiency of these cations. The management of these patients should include calcium and/or magnesium supplementation when required and furosemide should be avoided.
Potential Interaction between Clarithromycin and Warfarin
Authors: Recker Mark W , Kier Karen L 
Published: May 2017

Objective To report a possible drug interaction between clarithromycin and warfarin in a patient with chronic atrial fibrillation. Case Summary A patient with chronic atrial fibrillation was placed on warfarin therapy. International normalized ratios (INRs) ranged from 1.61 to 3.99 while the dosage was being adjusted during the first 5 months of warfarin therapy. The dosage was titrated to 20 mg/wk; laboratory tests obtained 2 weeks after this dosage was started indicated an INR of 2.1. The same dosage was continued. Clarithromycin 500 mg bid was started for an acute exacerbation of bronchitis 10 days after the last INR was obtained and was continued for 14 days of therapy. An INR obtained 3 days after completion of the clarithromycin therapy was 16.8. The warfarin was withheld and vitamin K 20 mg im was administered. The INR obtained the next day was 1.52. The warfarin was restarted and the dosage was titrated to between 22.5 and 25 mg/wk, with INRs ranging from 0.85 to 3.14. Discussion Many factors influence the metabolism of warfarin, including disease states, medications, age, and diet. Data collected in this case suggested clarithromycin may have contributed to the increase in the effect of warfarin. Inhibition of the cytochrome P450 oxidizing system appears to be the reason for the increase. Numerous drugs and disease states affect the rate at which this system metabolizes drugs. Conclusions The potential interaction between clarithromycin and warfarin warrants prudent monitoring of the INR during concurrent administration of these drugs. Warfarin dosages may need to be reduced during concurrent clarithromycin therapy to prevent bleeding complications. Further controlled clinical trials are needed to substantiate the interaction between clarithromycin and warfarin.
Enhancement of Warfarin Response in a Patient Receiving Etoposide and Carboplatin Chemotherapy
Authors: Le Alyssa T , Hasson Noelle K , Lum Bert L 
Published: May 2017

Objective To report a case of a possible drug interaction between warfarin, carboplatin, and etoposide resulting in a marked increase in a patient's response to warfarin, and to outline monitoring strategies for this interaction. Case Summary A 74-year-old white man receiving warfarin (average dose 42.5 mg/wk) for atrial fibrillation was diagnosed with a right testicular non-seminoma mixed germ cell tumor. Mediastinal metastases were subsequently discovered, and the patient was treated with a chemotherapy regimen including carboplatin and etoposide. Sixteen days after the first course of chemotherapy, the international normalized ratio (INR) was increased to 12.6 from a baseline range of 1.15–2.11 that was observed over the previous 8 months of therapy, indicating a clinically significant alteration in the pharmacodynamic response to warfarin. Discussion This patient had no concomitant disease or dietary changes to explain the altered response to warfarin. Carboplatin and etoposide have not been reported to inhibit warfarin metabolism. However, previous reports have suggested that etoposide may displace warfarin from its protein binding sites, resulting in an early elevation in prothrombin time following chemotherapy. The late elevation of INR observed in our patient suggests that his response to warfarin may have been due to the displacement of warfarin by elemental platinum, which has a long plasma half-life. Conclusions This case report suggests a possible drug interaction between carboplatin, etoposide, and warfarin. Because of the risk associated with an increased response to warfarin, we recommend close monitoring of the INR, perhaps twice weekly, early and later in the time course following chemotherapy with these agents. Appropriate dosage adjustments of warfarin should be performed if an altered response to warfarin is observed.
Ibuprofen-Induced Aseptic Meningitis in Rheumatoid Arthritis
Authors: Horn Amy C , Jarrett Steven W 
Published: May 2017

Objective To report a case of aseptic meningitis related to ibuprofen ingestion. Case Summary We discuss the case of a 56-year-old white man with a history of rheumatoid arthritis and hypertension who became confused, nauseated, and began to vomit within 2 hours of the ingestion of ibuprofen. A diagnosis of ibuprofen-induced aseptic meningitis was made based on the patient's physical and laboratory findings, the quick onset and resolution of symptoms, and his medical history. Discussion Ibuprofen-induced aseptic meningitis has been most frequently reported in patients with systemic lupus erythematosus. However, there have been reports of this reaction in patients with other underlying disease states. Various nonsteroidal antiinflammatory drugs have been reported to cause this reaction, but ibuprofen is the most common offending agent. A drug-related cause should be considered in any patient who presents with typical meningitis symptoms, such as fever, headache, and stiff neck, that occur within hours of ingesting a drug. Conclusions Although persons with systemic lupus erythematosus appear to have an increased risk for this type of reaction, the development of signs and symptoms in other patients warrants the consideration of nonsteroidal antiinflammatory drugs as the cause of aseptic meningitis.
Perioperative blood glucose concentrations in kittens following overnight fasting and gonadectomy
Authors: Semick Danielle N , Shaver Stephanie L , Cornell Heather N , Bradley Nancy C , Kreisler Rachael E 
Published: May 2017

Objectives The objective of this study was to determine if hypoglycemia is an effect of overnight fasting and gonadectomy in kittens, as well as to determine predictors of baseline and postoperative blood glucose. Methods This was a prospective observational study. Seventy-five kittens between the age of 8 and 16 weeks undergoing routine castration or ovariohysterectomy at an animal shelter were included. Two blood glucose measurements were analyzed per kitten after an overnight fast: a baseline reading prior to preoperative examination, and a reading immediately postoperatively. Predictors of the baseline and postoperative blood glucose levels were determined using multi-level mixed-effects linear regression. Results Kittens, when fasted overnight, were not hypoglycemic (<60 mg/dl). No kittens exhibited clinical signs consistent with hypoglycemia. No kittens had a blood glucose <70 mg/dl postoperatively. Postoperative hyperglycemia (>150 mg/dl) was observed in 44% of kittens. The only predictor of fasted blood glucose levels was body condition score. The only predictor of postoperative blood glucose levels was the fasting blood glucose value. Conclusions and relevance Overnight fasting prior to elective sterilization in 8- to 16-week-old kittens did not result in hypoglycemia. Concern regarding hypoglycemia after a prolonged fast in kittens may be unwarranted for short procedures in healthy animals.