ABSTRACT
Background: Vertatrum viride (false hellebore) is a perennial commonly found in eastern North America. The most common cause of exposure is misidentification when foraging for wild onion, or skunk cabbage. One regional poison center saw an increase in foraging-related poisonings during initial COVID-19 restrictions. The case report highlights severe delayed cardiac effects after ingestion of Veratrum viride in an otherwise healthy, young, female athlete. Case report: A 24-year-old female presented to an emergency room alongside family with complaints of nausea and vomiting that started 30 min after a meal consisting of foraged wild onion (Allium triccocum). Five others ate the same meal and noted similar symptoms. Vitals upon arrival (3 h post ingestion) are as described: HR 51, BP 88/52, Temp 36.7, RR 18 and O2 sat 100% on room air. The patient had no previous cardiac history and was athletic. Management included D5LR with K replacement, and dopamine infusion at 10mcg/kg/min. Dopamine was tapered slowly, down to 6 mcg/kg/min at 16.5 h. Vitals continued to be stable at 17.5 h post ingestion and dopamine was discontinued. The patient developed severe bradydysrhythmia 15 min later, consisting of complete heart block leading to prolonged sinus pause. She responded to 10 s of CPR with return of spontaneous circulation with a junctional escape rhythm which reverted back to sinus bradycardia. A repeat EKG was unremarkable. The dopamine infusion was reinstituted at 4 mcg/kg/min and continued until 26.5 h post ingestion. She was monitored an additional 9.5 h, and remained in sinus rhythm with mild complaints of dizziness that resolved before discharge. Discussion(s): Veratrum spp. toxicity is due to alkaloids found throughout the plant which cause sodium channel opening when bound to type 2 sodium channels. By increasing sodium ion influx during the resting potential and delaying inactivation to create a late sodium current, these alkaloids increase automaticity in conductive cells. This mechanism, paired with the Bezold-Jarisch reflex, is likely responsible for increased vagal tone leading to bradycardia, hypotension, sinus arrhythmia, and junctional escape rhythm. It is noteworthy that even 18 h post ingestion in a relatively stable patient with no significant cardiac history, cardiac arrest occurred just after treatment tapering. Clinicians should consider prolonged observation time in the setting of discontinuation of vasopressors. Conclusion(s): Both clinicians and amateur foragers should be aware of the risks associated with ingestion of Veratrum viride, especially during early spring when it more closely resembles wild onion. While uncommon, significant delayed cardiac effects are possible. Mistaking the plant for edible wild onions can be the difference between a delectable dinner, and a night in the ICU.
ABSTRACT
Introduction and Aim: Bhramari pranayama (Humming bee breath) is the most common slow pranayama practice involving inhalation through both nostrils followed by exhalation which produces sound of humming bee. Practicing pranayama reduces the effects of stress on different systems by increasing the vagal tone. With the ongoing COVID-19 pandemic, there are heightened feelings of stress, anxiety and depression and pranayama can be an effective way to improve our mental and emotional well-being. This study has been chosen to assess the effect of Bhramari pranayama on autonomic functions and to compare the immediate and training effects of Bhramari pranayama in the study group. Materials and Methods: An observational study was conducted in a medical college among 110 students aged between 18-22 years for a period of 2 months. The participants were instructed to do 9 rounds of Bhramari pranayama every day for 3 weeks. The immediate and training effect of pranayama practice on HRV (Heart Rate Variability) was assessed. The parameters of HRV (time and frequency domains) were assessed by PHYSIOPAC-PP4 (MEDICAID SYSTEMS, Chandigarh). Results: After training of Bhramari pranayama for 3 weeks, there was a decrease in Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP) and PNN50 and a decrease in frequency domain parameters, LFnu and LF/HF ratio were observed significantly. Conclusion: The study shows the possibility that Bhramari pranayama has a beneficial effect on HRV in medical students, as the autonomic balance produces the improvement of parasympathetic tone.
ABSTRACT
CASE: An 84-year-old woman with atrial fibrillation on Digoxin presented with acute onset of confusion associated with a week history of abdominal pain, vomiting, and poor fluid intake. A few days prior, Amiodarone was added to her drug regimen which included Lasix. Additionally, she received the COVID-19 booster vaccine which led to a viral-like syndrome resulting in dehydration. The patient was afebrile, normotensive, but bradycardic. EKG showed a prolonged PR interval and scooped ST segments. Labs showed hyperkalemia, pre-renal acute kidney injury (AKI), and a Digoxin level of 4.3 ng/mL (therapeutic range: 0.8-2.0 ng/mL). Digoxin and Lasix were held and Digoxin antidote, Digibind, was administered with normalizing heart rate, potassium, and clinical improvement. IMPACT/DISCUSSION: Digoxin is used to slow conduction in atrial fibrillation and increase cardiac contractility in heart failure. It inhibits the membrane sodium-potassium-adenosine triphosphatase pump (Na/K ATPase), resulting in increased cytosolic calcium and subsequent cardiac contractility and automaticity. In turn, this can also cause premature ventricular contractions and tachycardia. In the carotid sinus, increased baroreceptor firing and subsequent increased vagal tone occurs which can cause bradycardia, atrioventricular blocks, hypotension, and GI symptoms. In skeletal muscle, hyperkalemia can result due to the abundance of Na/K ATPase pumps. Digoxin has a narrow therapeutic index with serum levels easily affected by many commonly prescribed drugs by way of decreasing renal clearance, inhibiting P-glycoprotein, and inducing secondary electrolyte disturbances. That said, drug dosing should be individualized with close monitoring to avoid potentially life-threatening effects that may result with even mildly increased digoxin levels. Acute toxicity manifests as non-specific GI, and neurologic symptoms (confusion, lethargy, visual changes), hyperkalemia, and brady or tachy-arrhythmias. Treatment is with digoxin specific fragment antigen binding (Fab) antibody, Digibind, which binds digoxin, inactivating it within 6-8 hours. Postadministration, digoxin serum testing cannot distinguish free verse bound drug;therefore, drug levels remain elevated for days to weeks until the FabDigoxin complex is excreted. In the case above, the viral-like-syndrome after the booster vaccine with subsequent AKI secondary to dehydration likely precipitated Digoxin toxicity. Accompanying drug interactions of diuretics causing dehydration and hypokalemia, P-glycoprotein inhibitors (Amiodarone, Verapamil, Diltiazem, Quinidine), and ACE inhibitors can further worsen renal clearance and culminate in Digoxin toxicity. CONCLUSION: Given Digoxin's narrow therapeutic index, small clinical changes such as post COVID-19 vaccine flu-like symptoms, dehydration, and medication changes can manifest drug toxicity. Therefore, attentive monitoring of accompanying comorbidities and drug interactions is imperative at preventing catastrophic toxic effects.
ABSTRACT
Methods: In this ongoing randomized waitlist-controlled trial, we assessed changes in sleep,HRV & vitals, recorded overnight using a Ballistocardiography based health monitoring device. Outcomes were measured before (Day 0) & after (Day 4) a four-day online breath meditation workshop (OBMW) involving Sudarshan Kriya Yoga. 90 MPs from a tertiary care hospital in northern India were randomized equally (1:1) (45 participants each) to experimental (mean age 27.4±3.6) & waitlist-control (28.8±3.48) groups using computer-generated sequentially numbered opaque sealed envelopes. Results: All outcomes were found comparable at baseline. The between-groups analysis showed a highly significant increase in total sleep duration (p=0.000), duration of deep sleep (p=0.034), light sleep (p=0.000) & rapid eye movement sleep (p=0.000) with a significant reduction in respiration rate (p=0.015) for the Experimental group when compared to Controls. Within-group analysis showed highly significant improvements in HRV outcomes of SDNN (p=0.000) & RMSSD (p=0.000) & reduction in heart rate (p=0.006) for the experimental group alone. Background: Medical professionals (MPs) are facing tremendous stress, sleep deprivation & burnout due to COVID related high patient inflow& continuouswork shifts. Lowheart rate variability (HRV) & poor sleep regimes are associated with cardiomyopathy & diabetes in the long run. Yoga has strong evidence for its multifold mental & physical health benefits, yet no previous study has determined its acute effects on objective sleep measures & HRV among MPs during a pandemic. Conclusion: Maintaining a good sleep routine & high HRV result in greater cardiovascular fitness & vagal tone. Four days of OBMW might help induce psycho-physical relaxation & prove to be a feasible, cost-effective, & well-accepted tool to help build stress resilience. As the stakeholders in patient care i.e., MPs are healthy, it might further improve patient care & reduce the chance of medical errors. Further research is warranted to determine long-term effects in this regard.