The sweet cake that reaches parts other cakes can't!

This is a case report of a previously healthy woman of 56 years who presented with a life threatening tetraparesis, severe hypokalaemia, hypertension, and raised muscle enzymes. The cause of was finally found to be unusual and very much "local". Initial inquiry into her drug history was negative until she was made aware that herbal remedies could cause serious adverse reactions. She then mentioned that she had been eating a large number of "Pontefract cakes" (a liquorice sweet) for the management of her chronic constipation. This case highlights the importance of asking about herbal remedies when taking a drug history in all patients, including those admitted as medical emergencies.

Fludrocortisone in the treatment of hypotensive disorders in the elderly.

OBJECTIVE: To evaluate tolerance of fludrocortisone in older patients with hypotensive disorders. DESIGN: Prospective case series. SETTING: Syncope clinic. PATIENTS: 64 Consecutive patients over 65 years (mean age 80 years) with one or more hypotensive disorders (orthostatic hypotension, vasodepressor carotid sinus syncope, and/or vasodepressor neurocardiogenic syncope. INTERVENTIONS: Fludrocortisone in daily doses of 100 micrograms [corrected] (72%), 50 micrograms [corrected] (27%), and 200 micrograms [corrected] (one patient). MAIN OUTCOME MEASURES: Adverse events, treatment withdrawal. RESULTS: During follow up 13 patients died of unrelated causes. Of the remainder 33% discontinued fludrocortisone at a mean of five months. Reasons for discontinuing treatment were hypertension, five; cardiac failure, four; depression, three; oedema, three; and unspecified, two. In those who continued treatment supine systolic and diastolic blood pressure did not differ significantly from baseline (follow up two to 21 months). Hypokalaemia developed in 24% at a mean of eight months; in no case was treatment withdrawn because of hypokalaemia. CONCLUSION: Fludrocortisone, even in low doses, is poorly tolerated in the long term in older patients with hypotensive disorders.

Effect of oxybutynin on the QTc interval in elderly patients with urinary incontinence.

1. Terodiline, an anticholinergic drug with calcium antagonist properties, is associated with QT prolongation and ventricular arrhythmias. It is not known if oxybutynin, a drug with a similar pharmacological profile, causes QT prolongation. ECGs were obtained before and at least 4 weeks after commencement of oxybutynin (mean daily dose 7.6, range 2.5-10 mg), in 21 elderly (mean age 75, range 58-88 years) patients treated for urinary incontinence. Heart rate, (mean +/- s.d.) 74 +/- 11 vs 69 +/- 11 beats min-1, -6 (-13,2), before vs during oxybutynin therapy, mean difference (95% confidence intervals); PR interval, 168 +/- 27 vs 156 +/- 27 ms, -11 (-26,3); QTc 454 +/- 27 vs 447 +/- 31 ms1/2, -9 (-23,5), and QTc dispersion, QTc max-QTc min, 68 +/- 24 vs 63 +/- 26 ms1/2, -1 (-15,14) were all unaltered by oxybutynin therapy. The lack of an effect on resting heart rate suggests that oxybutynin has little anticholinergic action at cardiac M2 receptors at usually administered doses. Oxybutynin therapy is not associated with QTc interval prolongation and is unlikely to produce ventricular arrhythmias.