Loperamide abuse cardiotoxicity. Should loperamide still be an over the counter medication?

Loperamide is an over-the-counter anti-diarrheal medication that is inexpensive, easily accessible, and widely used. It is generally thought to be safe and effective without the potential for abuse. However, recent discovery of its ability to treat opioid withdrawal symptoms at high doses has led to not only its abuse, but also the need to recognize its cardiotoxicity due to the ability to prolong the QTc interval. We report a case of a 33 year old female with a history of opioid dependence who presented to the emergency department with acute onset shortness of breath and generalized weakness who was subsequently found to be in ventricular tachycardia. Electrocardiogram showed prolongation of the QTc and the patient later admitted to ingestion of 70 loperamide pills daily for the past year in order to alleviate her opioid withdrawal symptoms. Due to increased loperamide abuse and toxicity displayed within the last several years, public and health provider awareness should be optimized to fully understand its lethality, and stricter regulations on its availability to the general population should be considered. Even in asymptomatic patients with ECG abnormalities, emergency medicine physicians should admit them for further monitoring and aggressive medical therapy.

Facelift Practice Evolution: Objective Implementation of New Surgical Techniques.

BACKGROUND: Facial rejuvenation is an elective procedure commonly performed to combat the consequences of normal aging. The senior author's practice initially consisted of traditional facelifts with superficial muscular apopneurotic system plication and/or superficial muscular apopneurotic system flap. After the development of the minimal access cranial suspension (MACS) technique by Tonnard et al., the senior author transitioned to an almost exclusive MACS facelift practice. The purpose of this study was to determine the efficacy of the MACS technique versus the traditional facelift approach and objectively incorporate these results into practice. METHODS: A retrospective cohort study design was performed to identify all patients who underwent a facelift by the senior author between January 1, 2013, and December 31, 2015. Patient demographics, comorbidities, type of procedure, complications, revision surgery, and objective surgeon satisfaction were among the parameters recorded. This was compared with an historical cohort of the senior author's earlier experience. RESULTS: There was a statistically significant decrease in the use of the MACS facelift procedure between this study and the senior authors' seminal study. Within this study cohort, compared with conventional facelift, the MACS technique was done on younger patients, proved to have significantly shorter operative time, mean follow up, and allowed for additional concurrent non-facial procedures when compared with the traditional approach (all comparisons significant at P < 0.05). However, continued postoperative neck laxity, submental pleating, and periocular pleating were seen with the MACS technique. CONCLUSIONS: The current study shows that the MACS technique is better suited for young patients with lesser cervical bulk or laxity and provides an opportunity for concurrent nonfacial procedures. Objective assessment with recognition of the limitations of the MACS technique versus the traditional facelift approach has led to a change in the senior author's practice. Although the MACS lift incurs shorter procedure time and quicker recovery, it does demonstrate limitations when it comes to marked skin laxity and bulky necks/platysmal banding. Both techniques are used with in line with the respective limitations and advantages.

Effects of Temperature and pCO2 on Population Regulation of Symbiodinium spp. in a Tropical Reef Coral.

This study tested the bleaching response of the Pacific coral Seriatopora caliendrum to short-term exposure to high temperature and elevated partial pressure of carbon dioxide (pCO2). Juvenile colonies collected from Nanwan Bay, Taiwan, were used in a factorial experimental design in which 2 temperatures (∼27.6 °C and ∼30.4 °C) and 2 pCO2 values (∼47.2 Pa and ∼90.7 Pa) were crossed to evaluate, over 12 days, the effects on the densities and physiology of the symbiotic dinoflagellates (Symbiodinium) in the corals. Thermal bleaching, as defined by a reduction of Symbiodinium densities at high temperature, was unaffected by high pCO2. The division, or mitotic index (MI), of Symbiodinium remaining in thermally bleached corals was about 35% lower than in control colonies, but they contained about 53% more chlorophyll. Bleaching was highly variable among colonies, but the differences were unrelated to MI or pigment content of Symbiodinium remaining in the coral host. At the end of the study, all of the corals contained clade C Symbiodinium (either C1d or C15), and the genetic variation of symbionts did not account for among-colony bleaching differences. These results showed that high temperature causes coral bleaching independent of pCO2, and underscores the potential role of the coral host in driving intraspecific variation in coral bleaching.

Extreme dNTP pool changes and hypermutability in dcd ndk strains.

Cells lacking deoxycytidine deaminase (DCD) have been shown to have imbalances in the normal dNTP pools that lead to multiple phenotypes, including increased mutagenesis, increased sensitivity to oxidizing agents, and to a number of antibiotics. In particular, there is an increased dCTP pool, often accompanied by a decreased dTTP pool. In the work presented here, we show that double mutants of Escherichia coli lacking both DCD and NDK (nucleoside diphosphate kinase) have even more extreme imbalances of dNTPs than mutants lacking only one or the other of these enzymes. In particular, the dCTP pool rises to very high levels, exceeding even the cellular ATP level by several-fold. This increased level of dCTP, coupled with more modest changes in other dNTPs, results in exceptionally high mutation levels. The high mutation levels are attenuated by the addition of thymidine. The results corroborate the critical importance of controlling DNA precursor levels for promoting genome stability. We also show that the addition of certain exogenous nucleosides can influence replication errors in DCD-proficient strains that are deficient in mismatch repair.