Ergotism and factitious hypotension associated with interaction of ergotamine with CYP3A4 inhibitors

Background. Although uncommon, severe ergotism continues to occur. The purpose of this study is to describe causes and clinical effects of ergotism in recent years. Methods. This is an observational case series with data obtained retrospectively from all patients with ergotism referred to Ramathibodi Poison Center in Bangkok, Thailand from January 2006 to August 2013. Result. Twelve cases of ergotism were identified. All cases involved ergotamine 1 mg/caffeine 100 mg combination tablets. Nine cases (75%) were precipitated by drug–drug interactions with CYP3A4 inhibitors. The other cases involved suicidal attempt (2 cases) and pediatric unsupervised ingestion (1 case). Ten patients (83%) had signs of peripheral vascular insufficiency. Five of these patients initially had factitiously low or unmeasurable blood pressure using non-invasive technique and had paradoxical increase following intravenous vasodilator administration. Two patients required partial foot amputations due to gangrene. Two patients, including a 15-month-old boy with an unsupervised ingestion, died. Discussion. In this series, most cases of severe ergotism were associated with interaction with CYP3A4 inhibitors, which increase ergotamine bioavailability. Factitious low blood pressure in these cases was likely caused by severe vasospasm. Conclusion. Critical ergotism continues to occur in Thailand, most commonly associated with the drug–drug interactions.     

Evaluation of Border Entry Screening for Infectious Diseases in Humans

In response to the severe acute respiratory syndrome (SARS) pandemic of 2003 and the influenza pandemic of 2009, many countries instituted border measures as a means of stopping or slowing the spread of disease. The measures, usually consisting of a combination of border entry/exit screening, quarantine, isolation, and communications, were resource intensive, and modeling and observational studies indicate that border screening is not effective at detecting infectious persons. Moreover, border screening has high opportunity costs, financially and in terms of the use of scarce public health staff resources during a time of high need. We discuss the border-screening experiences with SARS and influenza and propose an approach to decision-making for future pandemics. We conclude that outbreak-associated communications for travelers at border entry points, together with effective communication with clinicians and more effective disease control measures in the community, may be a more effective approach to the international control of communicable diseases.     

Using scorecards to achieve facility improvements for maternal and newborn health

The Government of Sierra Leone launched the Free Health Care Initiative in 2010, which contributed to increased use of facility based maternity services. However, emergency obstetric and neonatal care (EmONC) facilities were few and were inadequately equipped to meet the increased demand. To ensure provision of EmONC in some priority facilities, the Ministry of Health and Sanitation undertook regular facility assessments. With the use of assessment tools and scorecards it is possible to make improvements to the services provided in the period after assessment. The exercise shows that evidence that is shared with providers in visually engaging formats can help decision-making for facility based improvements.     

Is Subjective Outcome Evaluation Related to Objective Outcome Evaluation? Insights from a Longitudinal Study in Hong Kong

Study ObjectivesEmpirical studies investigating the inter-relationships among subjective outcomes and objective outcomes are sparse in the scientific literature. This study examined the relationship between these 2 forms of outcome evaluation data in Chinese adolescents, utilizing longitudinal data.DesignIn Wave 3 and Wave 4 of a randomized group trial, 2,784 Chinese secondary school students responded to the Chinese Positive Youth Development Scale (CPYDS) assessing objective outcome at pretest (Wave 3) and posttest (Wave 4). Students in the experimental schools also responded to a measure of client satisfaction assessing the subjective outcome of a positive youth development program at posttest (Wave 4).ResultsSubjective outcome evaluation measures (eg, process, program, and effectiveness) at Wave 3 were significantly correlated with CPYDS scores at Wave 4 and difference scores. Subjective outcome evaluation measures also predicted changes in the objective outcome evaluation measures scores across time.ConclusionsThe present findings replicated the previous findings that subjective outcome and objective outcome evaluation findings were intimately related, and subjective outcome measures predicted posttest measures and their changes over time. The present study suggests that subjective outcome evaluation findings may yield useful information regarding program effectiveness in youth work settings.     

Multiple variants in UGT1A1 gene are factors to develop indirect hyper-bilirubinemia

Most Taiwanese patients with hyper-bilirubinemia have genetic abnormalities in the uridine diphosphoglucuronate-glucuronosyltransferase 1A1 (UGT1A1) gene beyond the variants in the TATA box upstream of UGT1A1 associated with Gilbert’s syndrome. To investigate the role of UGT1A1 in the pathogenesis of indirect hyper-bilirubinemia, we prospectively studied 97 consecutive patients with indirect hyper-bilirubinemia for genotypes of promoter [(TA)₆TAA6, (TA)₇TAA7] and coding region [nucleotide (nt)-211, nt-686, nt-1,091 and nt-1,456] of UGT1A1. Thirty-six of the patients (45.6%) were found to have Gilbert’s syndrome with 7/7 genotype; among them, 14 also carried variants at nt-686. Forty-two patients (43.3%) had the 6/7 genotype; among them, 36 patients were found to have one or more variants in the coding region. Patients with higher serum total bilirubin are associated with higher likelihood of carrying Gilbert’s syndrome genotype: 60.0% (P=0.007) patients with serum total bilirubin level ≥2.5 mg/dL carried the Gilbert’s syndrome genotype, while only 23.9% of patients with serum total bilirubin level <2.5 mg/dL carry the same genotype (P=0.0006). Forty-one of the 61 non-Gilbert’s patients had one homogenous variants or two or more heterozygous variants in UGT1A1. Further studies are necessary to confirm the role of one homo-zygous variant or two or more hetero-zygous variants in UGT1A1 gene as factors for indirect hyper-bilirubinemia.     

Role of ciclosporin in steroid-responsive sudden sensorineural hearing loss

Conclusions. A subgroup of patients with idiopathic sensorineural hearing loss (SNHL) will have steroid-dependent symptoms which can be confirmed using pure-tone audiometry. Long-term treatment with high-dose corticosteroids exposes patients to potentially serious adverse effects. Immunosuppression with ciclosporin can be an effective and well-tolerated treatment for steroid-responsive sudden SNHL. Objective. To highlight ciclosporin as a therapeutic option in the treatment of steroid-responsive sudden SNHL. Material and methods. A 39-year-old male with idiopathic sudden SNHL that was responsive to corticosteroids was treated with ciclosporin for 18 months. Results. Steroid-dependent SNHL was confirmed on audiological evaluation. Ciclosporin was administered, allowing corticosteroid therapy to be discontinued. Ciclosporin was effective at controlling all symptoms of SNHL. Remission was confirmed objectively with pure-tone audiometry.     

猪抗淋巴细胞免疫球蛋白联合环孢素治疗重型再生障碍性贫血疗效观察

目的探讨猪抗淋巴细胞免疫球蛋白与环孢素联合应用于治疗重型再生障碍性贫血(再障)的临床疗效及临床转归。方法 50例重型再障患者作为研究资料,治疗组给予猪抗淋巴细胞免疫球蛋白与环孢素联合治疗,对照组给予猪抗淋巴细胞免疫球蛋白治疗,观察并对比两组患者疗效、起效时间以及不良反应。结果治疗组总有效率明显高于治疗组,基本治愈率、明显缓解率以及有所改善率均高于对照组。经过治疗后两组患者白细胞(WBC)、血红蛋白(HGB)以及血小板(PLT)均明显升高,但治疗后治疗组WBC、HGB以及PLT均明显高于对照组。治疗组平均起效时间、牙龈增生出现例数明显高于对照组,另出现5例手颤,3例继发性糖尿病,而对照组未发现此类不良反应。结论猪抗淋巴细胞免疫球蛋白与环孢素联合应用于治疗重型再障疗效优于单用猪抗淋巴细胞免疫球蛋白治疗,但不良反应较单用猪抗淋巴细胞免疫球蛋白治疗更多,可以推荐应用,如何防治并发症仍值得思考。