Intravenous methylphenidate: an unusual way to provoke ST-elevation myocardial infarction.

Acute ST-T elevation is a sign of myocardial ischemia or infarction usually due to coronary artery atherosclerosis or coronary spasm. Coronary spasm may be spontaneous or can occur as a result of a drug that causes arterial spam. Ritalin, Novartis Pharmaceut. Corporation, USA (methylphenidate hydrochloride), a dopamine reuptake inhibitor,is an oral drug used to treat attention-deficit/hyperactivity disorder and narcolepsy. Sudden deaths, stroke, and myocardial infarction have been reported in adults taking stimulant drugs at usual dose for attention-deficit/hyperactivity disorder [1]. This drug is not supplied as solution for injection [2]. We report here, what we believe to be, the first case report of a 40-year-old male patient who was admitted for acute chest pain and ST-elevation myocardial infarction after intravenous self-injection of Ritalin. His coronary angiogram demonstrated nonobstructive coronary disease.

Acute transient phlebitis during eptifibatide intravenous injection: case report.

We present a 56-year-old man who developed acute transient phlebitis of the right cephalic vein during an intravenous injection of eptifibatide (Integrilin, Schering Plough, Kenilworth, NJ). The eptifibatide injections were discontinued, and signs of phlebitis disappeared within minutes. The patient's course was uneventful, and he was discharged home after 8 days. As far as we know, this is the first report of acute transient phlebitis during intravenous eptifibatide injections in the English-language medical literature.

Single-dose quinolone treatment in acute gastroenteritis.

BACKGROUND: Acute diarrhea is a common disease worldwide and in Israel, a Mediterranean country. Acute bacterial gastroenteritis (ABGE) is the leading cause of severe diarrhea in Israel in summer and early autumn. Although there are some reports showing some benefit from empiric antibiotic therapy in acute gastroenteritis, most are old reports using nondefinitive diagnostic criteria and using 5-day antibiotic regimens. AIMS: 1. To examine the efficiency of antibiotic therapy in relatively severe ABGE in general. 2. To check the efficiency of the different types of quinolones in the treatment of ABGE. 3. To compare various therapy regimens. METHODS: All patients admitted to the Barzilai Medical Center emergency room during the period June to October in 2002-2004 who were defined by protocol as having relatively severe gastroenteritis and required hospitalization in the Department of Internal Medicine were included in the study. All were randomized either to a supportive treatment only group (STG) or to the antibiotic treatment group (ATG) of ofloxacin or levofloxacin with a single dose or BID for 5 days in addition to STGs. All patients were interviewed a week later about their medical history and duration of symptomatology. RESULTS: One hundred thirty-nine patients were found eligible for the study in the above-mentioned period. Abdominal pain resolved 1.3 days earlier in the ATG in comparison to the STG whereas vomiting and diarrhea disappeared 1.0 and 0.8 days earlier, respectively, in the ATG versus the STG. In terms of fever abatement there was no difference between the regimens and no significant difference in symptomatology disappearance between various types of quinolones used or between the single antibiotic dose regimen and the 5-day antibiotic regimen groups. CONCLUSIONS: 1. Antibiotic therapy was found to shorten duration of symptoms in patients with relatively severe gastroenteritis. 2. Single-dose therapy is as effective and certainly significantly more cost effective in comparison to the 5-day antibiotic treatment regimen.

Rizatriptan RPD for severe migraine in the emergency department--a multicenter study.

Many patients with severe migraine come to the Emergency Department (ED) due to failure of different drug regimens to stop their headache. We treated 98 patients with severe migraine who were seen in three different EDs. We used rizatriptan RPD wafers 10 mg and observed the patients for 2 h. We found that at 2 h, 92.9% (91/98) of the patients had pain relief, and 73.5% were pain free. The mean time to pain relief was 26.9 +/- 29.6 min with a median of 15 min, and the time to pain free was 70.2 +/- 47.3 min with a median of 75 min. Eighty-five percent of the patients were free of associated symptoms, such as nausea and vomiting, at 2 h with a mean time to symptom free of 55 +/- 47.5 min and a median of 45 min. Rizatriptan was reported to be much better than other drugs by 74.4% of the patients. Side effects were minor and transient. Recurrence of migraine occurred part of the day in 17.1% of the patients and all day or almost all day in 8.6% of the patients only. The results were consistent in all three EDs. We conclude that rizatriptan RPD is very effective and reliable as a first-line therapy for acute migraine in the ED. It dissolves immediately in the mouth without the inconvenience of an injection. It works fast and has few side effects and low headache recurrence.

Severe dyspnea due to jellyfish envenomation.

During the summer, jellyfish stings are the most common envenomation situations encountered by humans in the marine environment. The more people swim, scuba dive, or snorkel, the more necessary it is to know what should be done immediately, how life can be saved, how to prevent early and late complications, and how to facilitate convalescence in the event of jellyfish envenomation. We describe an atypical case of a 14-year-old boy with severe dyspnea due to upper airway obstruction caused by a jellyfish sting to the face and outline a practical approach to the treatment of jellyfish stings.

BiPAP ventilation as assistance for patients presenting with respiratory distress in the department of emergency medicine.

BACKGROUND: Noninvasive ventilatory support (NIVS) is intended to provide ventilatory assistance for a wide range of respiratory disturbances. The use of NIVS for treatment of respiratory distress may be applicable in the emergency department (ED). It may prevent endotracheal intubation and, likewise, may favorably influence the course of the patient's hospitalization, depending on the primary disease or ventilatory disturbance. OBJECTIVE: To evaluate the efficacy of bilevel positive airway pressure (BiPAP) ventilation in patients with acute respiratory distress presenting in the ED. METHODS: A prospective, uncontrolled, nonrandomized, nonblind study enrolled 30 patients. They were cooperative and hemodynamically stable, aged over 18 years, and presented with acute respiratory distress as defined by predetermined criteria. They were connected to a BiPAP machine through a face mask, using an initial pressure of 8/3 cm H(2)O, which was gradually raised to 12/7 cm H(2)O inspiratory positive airway pressure/expiratory positive airway pressure. Standard drugs, inhalation and oxygen therapies were administered as needed. The BiPAP was disconnected either upon relief of respiratory distress or on deterioration of the patient's condition. RESULTS: Of the 30 patients in the study, 19 had cardiogenic pulmonary edema, four had acute asthma, three had exacerbation of COPD, three had pneumonia and one had malignant pleural effusion. BiPAP was instituted subsequent to failure of standard therapies. Twenty-six patients were classified as responders to the BiPAP ventilation and four as nonresponders (three patients were intubated after 1 hour and one patient 24 hours, post BiPAP). The total length of stay (LOS) in the ED was 3-5 hours and the mean LOS in hospital was 4.1 +/- 1.5 days, versus 6.5 +/- 1.2 days in LOS reports of similar patients in the same hospital during 1999, who did not undergo BiPAP ventilation. No other complications were observed. CONCLUSIONS: We found BiPAP ventilation simple, safe, effective and well tolerated by patients in respiratory distress. The rate of endotracheal intubation after successful BiPAP ventilation was low. In carefully selected patients with respiratory distress, BiPAP ventilation may successfully replace endotracheal intubation.

Fatal hyperkalemia related to combined therapy with a COX-2 inhibitor, ACE inhibitor and potassium rich diet.

We describe the case of a 77-year old mildly hypertensive woman with no underlying renal disease who was admitted to the Emergency Department (ED) in a comatose state with fever. The patient had been on low dose enalapril and a potassium rich diet. Five days before admission, rofecoxib, a new selective COX-2 inhibitor nonsteroidal anti-inflammatory drug (NSAID), was added for leg pain. She was found to have severe hyperkalemia and died 90 min after her arrival. We cannot absolutely determine whether the COX-2 inhibitor was the dominant contributor to the development of hyperkalemia or the combination itself, with an intercurrent infection and some degree of dehydration. Physicians should be aware of this possible complication and only prescribe NSAIDs, including the new COX-2 drugs, to the elderly under close monitoring of kidney function and electrolyte tests.