Citalopram overdose: Late presentation of torsades de pointes (TdP) with cardiac arrest

Introduction

Citalopram overdose may produce bradycardia, QT prolongation, and torsades de pointes (TdP). A cardiotoxic metabolite may be responsible for the delayed onset of cardiotoxicity. Although some authorities recommend a minimum of 24 hours of observation following citalopram overdose, a recent analysis suggested that dysrhythmias rarely occur beyond 13 hours post-ingestion. We present a case of citalopram overdose with a substantially delayed onset of cardiac toxicity.

Case Report

A 36-year-old woman complained of shakiness, numbness in the arms, and palpitations that began approximately 32 hours after ingesting 50 (20-mg) tablets of citalopram. Her initial vital signs were: blood pressure, 84/44 mmHg; pulse, 102–150/minute; respirations, 17/min; temperature, 99.3° F (37.3° C). Her initial ECG showed sinus rhythm with a prolonged corrected QT interval (572 msec) with paroxysmal, self-limited runs of wide-complex tachycardia that appeared multifocal in nature. Approximately 20 minutes after presentation, she experienced self-terminating TdP, with transient hypotension and loss of consciousness. Her serum citalopram concentration (33 hours post-ingestion) was 477 ng/mL (therapeutic: 40–110 ng/mL); desmethylcitalopram concentration was 123.2 ng/mL (therapeutic: 14–40 ng/mL). She was treated with magnesium and lidocaine, and her corrected QT interval remained abnormal for 24 hours after presentation.

Discussion

Citalopram overdose can produce life-threatening cardiac toxicity with a clinical onset that may be delayed beyond a routine observation period of 6 hours. Once the QT interval is prolonged, it seems prudent to prolong the observation period.     

Development and evaluation of a required patient safety course

Objectives

To develop, implement, and assess a required patient safety course for second-year doctor of pharmacy students.

Design

A patient safety course was developed that included didactic lectures, case studies, in-class activities, and reading assignments. Written examinations and essays were used to evaluate student learning. In addition, a modified minute paper and a pre- and post-intervention student self-assessment survey were used to assess course outcomes.

Assessment

Results examining the utility of the course teaching format and the relevance of the material in meeting the course outcomes are presented and discussed. The self-assessment course survey indicated major improvements in the students'' knowledge and skills, readiness for knowledge application, and commitment to improve patient safety.

Conclusion

The course provided pharmacy students with an increased level of understanding of the principles and concepts of patient safety.     

Expression, purification, and characterization of the immunological response to a 40-kilodalton Plasmodium vivax tryptophan-rich antigen

We describe here an approximately 40-kDa Plasmodium vivax tryptophan-rich antigen (PvTRAg40) which contains 321 amino acids and 11.4% tryptophan residues. This protein shows 65% homology (35% identity) with the previously described PvTRAg, besides sharing 23 of 27 positionally conserved tryptophan residues and similar genomic organization. The nucleotide sequence of the entire tryptophan-rich domain of PvTRAg40 was identical among 35 P. vivax clinical isolates. The protein is expressed by ring, trophozoite, and schizont stages of the parasite. The cDNA covering exon 2 of PvTRAg40 was cloned and expressed in the pPROEXHTa vector, and recombinant protein was purified. A high humoral immune response (90.7% seropositivity; n = 43) against this recombinant protein was detected in humans during the course of natural P. vivax infection. Eighty percent of the total of 20 P. vivax-exposed individuals exhibited lymphoproliferative responses against this antigen. The T cells of these individuals produced larger amounts of interleukin-12 (IL-12), IL-4, and IL-10 than gamma interferon and tumor necrosis factor alpha cytokines in response to the recombinant protein. Production of Th2-biased cytokines, conserved T- and B-cell epitopes, and an enhanced humoral immune response indicate that PvTRAg40 could possibly induce antibody-mediated immune protection against infection.     

Blood-Based Next-Generation Sequencing in Adrenocortical Carcinoma

BackgroundAdrenocortical carcinoma (ACC) is a rare and heterogeneous malignancy with poor prognosis. We aimed to evaluate the feasibility of next-generation sequencing (NGS) testing of circulating cell-free tumor DNA (ctDNA) in patients with ACC, to characterize the genomic landscape of alterations, and to identify potential clinically actionable mutations.MethodsRetrospective analysis of genomic data from 120 patients with ACC who had ctDNA testing between 12/2016 and 10/2021 using Guardant360 (Guardant Health, CA) was performed. ctDNA NGS analysis interrogated single nucleotide variants, fusions, indels, and copy number amplifications of up to 83 genes. The frequency of genomic alterations, landscape of co-occurring mutations, and pathogenic/likely pathogenic alterations with potential targeted therapies was identified. The prevalence of alterations identified in ctDNA was compared to those detected in tissue using a publicly available database (cBioPortal).ResultsThe median age of this cohort was 53 years (range 21-81), and 56% of patients were female. Ninety-six patients (80%) had ≥1 somatic alteration detected. TP53 (52%), EGFR (23%), CTNNB1 (18%), MET (18%), and ATM (14%) were found to be the most frequently altered genes in ACC samples. Pathogenic and/or likely pathogenic mutations in therapeutically relevant genes were observed in 56 patients (47%) and included EGFR, BRAF, MET, CDKN2A, CDK4/6, and ATM. The most frequent co-occurring mutations were EGFR + MET (9%), MET + CDK4 (7%), EGFR + CDK4 (7%), and BRAF + MET (7%). The frequencies of mutations detected in ctDNA were similar to those detected in tissue.ConclusionsUtilizing blood-based NGS to characterize genomic alterations in advanced ACC is feasible in over 80% of patients. Almost half of the patients had actionable mutations with approved therapies in other cancers. This approach might inform the development of personalized treatment options or identify clinical trials available for this aggressive malignancy.     

Photocatalysis and perovskite oxide-based materials: a remedy for a clean and sustainable future

The massive use of non-renewable energy resources by humankind to fulfill their energy demands is causing severe environmental issues. Photocatalysis is considered one of the potential solutions for a clean and sustainable future because of its cleanliness, inexhaustibility, efficiency, and cost-effectiveness. Significant efforts have been made to design highly proficient photocatalyst materials for various applications such as water pollutant degradation, water splitting, CO₂ reduction, and nitrogen fixation. Perovskite photocatalyst materials are gained special attention due to their exceptional properties because of their flexibility in chemical composition, structure, bandgap, oxidation states, and valence states. The current review is focused on perovskite materials and their applications in photocatalysis. Special attention has been given to the structural, stoichiometric, and compositional flexibility of perovskite photocatalyst materials. The photocatalytic activity of perovskite materials in different photocatalysis applications is also discussed. Various mechanisms involved in photocatalysis application from wastewater treatment to hydrogen production are also provided. The key objective of this review is to encapsulate the role of perovskite materials in photocatalysis along with their fundamental properties to provide valuable insight for addressing future environmental challenges.

Photocatalytic reaction for CO₂ reduction in presence of co-catalyst.     

阈值法在肝包虫病CT图像分割中的应用

目的 探讨阈值法在肝包虫病CT图像分割中的应用价值.方法 选择20张患有肝包虫病的病患CT图像,对CT图像进行归一化预处理,然后对其进行阈值法分割.结果 成功分割17 张,分割失败3张,分割成功率为85%,过度分割和漏分割情况较少,分割的结果 图像比较清晰饱满,光滑连通性好,基本没有线条缺损的现象.结论 阈值法适合肝包虫病CT图像的分割,基本能达到比较准确的判断.能很好地帮助肝包虫病CT图像的纹理特征、形状特征及其他特征的提取,较理想地将目标与背景分开来实现分割.     

Intracerebral transplantation of marrow stromal cells cultured with neurotrophic factors promotes functional recovery in adult rats subjected to traumatic brain injury

This study was designed to examine the effects of bone marrow stromal cells (MSCs) cultured in vitro with or without neurotrophic factors transplanted into adult male Wistar rats after traumatic brain injury (TBI). MSCs harvested from donor Wistar rats were cultured with either the culture medium containing brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) or the same culture media without these factors. Control and experimental animals were then traumatized by a controlled cortical impact. One day after the impact, either the placebo or the washed MSCs (1 x 10(6)) cultured with or without NGF and BDNF were transplanted adjacent to the site of injury. In addition, a nontreated group of rats was employed. Motor function of the animals was evaluated by the Rotarod test both before and after the injury. All animals were sacrificed 8 days after TBI, and the brain sections were stained by H&E as well as for immunohistochemistry. MSCs survived and migrated toward the injury site. The group treated with MSCs cultured with BDNF and NGF had a significantly higher number of engrafted cells than the group treated with MSCs cultured without BDNF and NGF (6.3 x 10(4) +/- 4250 compared to 4.1 x 10(4) +/- 3684; p < 0.05). In both groups, some transplanted MSCs showed positive staining for astrocytic (GFAP) and neuronal markers (Neu N and MAP-2). The groups treated with MSCs had better motor function than the groups receiving no treatment or receiving the placebo (PBS; p < 0.05); however, the improvement reached statistical significance only in the group treated with MSCs cultured with neurotrophic factors. These data suggest that more robust motor function described in rats subjected to TBI and treated with intracerebral transplantation of MSCs was achieved by the use of MSCs cultured with neurotrophic factors.     

Validation of the Finnvasc score in infrainguinal percutaneous transluminal angioplasty for critical lower limb ischemia

The aim of the present study was to validate the Finnvasc score for prediction of immediate outcome after infrainguinal percutaneous transluminal angioplasty (PTA) for critical lower limb ischemia (CLI). Our registry included prospective data on 512 patients who underwent isolated infrainguinal PTA revascularization procedures for CLI. The Finnvasc score herein evaluated was calculated by assigning one point each to diabetes, coronary artery disease, foot gangrene, and urgent operation. Early mortality and major limb amputation rates after PTA revascularization were 2.5% and 12.3%, respectively. Seventy-two patients (14.1%) died and/or had lower limb amputation. Diabetes (p = 0.001), foot gangrene (p = 0.047), urgent operation (p < 0.0001), and preoperative renal failure (p = 0.001) were independent predictors of postoperative mortality and/or major limb amputation. Finnvasc score was predictive of major lower limb amputation (p = 0.003), mortality (p < 0.0001), and mortality and/or major amputation (p < 0.0001) after PTA. Mortality, major lower limb amputation, and combined end point rates in patients with a Finnvasc score of 3-4 were 12.8%, 25.6%, and 35.9%, respectively. The Finnvasc score is a simple risk scoring method which can be useful to estimate the risk of immediate postprocedural mortality and/or major lower limb amputation also in patients undergoing infrainguinal PTA for CLI.