Veterans Affairs Medical Center San Diego

San Diego, CA, United States

Veterans Affairs Medical Center San Diego

San Diego, CA, United States
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Nogar J.N.,University of California at San Diego | Nogar J.N.,Veterans Affairs Medical Center San Diego | Minns A.B.,University of California at San Diego | Savaser D.J.,University of California at San Diego | Ly B.T.,University of California at San Diego
Clinical Toxicology | Year: 2011

Background. Cardiac arrest due to lamotrigine (LTG) has been reported after co-ingestion with bupropion, but severe sodium channel blockade in the absence of other toxins has not been described. We report a case of cardiac arrest and status epilepticus following a massive LTG overdose. Case Report. A 48 year-old female was brought to the ED with seizure-like activity subsequent to ingesting 7.5 g of LTG. Vital signs were HR 131, BP 107/68, T 99.4°F, RR 16. She was intubated in the ED for a low GCS. Initial ECG demonstrated a narrow-complex normal sinus rhythm, and her labs were unremarkable. Three hours after intubation she developed status epilepticus, and a pulseless wide-complex tachycardia. She was aggressively resuscitated during which time pulses were periodically reestablished, but lost each time seizures recurred. She was not stabilized until the convulsions were terminated with vecuronium. Her post-resuscitation ECG demonstrated a junctional tachycardia with a 3 mm R-wave in aVR. The LTG level was 74.7 mcg/ml (therapeutic: 3-14 mcg/ml). Comprehensive LC-MS/MS drug screen was negative for all screened compounds. Discussion. This is the first report of cardiovascular collapse due to LTG with the highest drug concentration to date. Conclusion. The degree of neurologic and cardiovascular toxicity seen in this case are novel and illustrate the potential for severe sodium channel blockade after massive LTG poisonings. Drug levels are not clinically relevant in the acute setting due to the time delay in obtaining results, and recurrent seizure activity may be the only clinical finding that precedes severe cardiac toxicity. © 2011 Informa Healthcare USA, Inc.


Lee R.H.,University of California at Irvine | Lee R.H.,Veterans Affairs Long Beach Health Care System | Tang R.S.,University of California at San Diego | Muthusamy V.R.,University of California at Irvine | And 12 more authors.
Gastrointestinal Endoscopy | Year: 2011

Background: Studies suggest that endoscopist-related factors such as colonoscopy withdrawal time are important in determining the adenoma detection rate (ADR). Objective: To determine the importance of withdrawal technique in differentiating among endoscopists with varying ADRs. Design: Prospective, multicenter study. Setting: Five academic tertiary-care medical centers. Participants: This study involved 11 gastroenterology faculty endoscopists. Intervention: A retrospective review of screening colonoscopies was performed to categorize endoscopists into low, moderate, and high ADR groups. Video recordings were randomly obtained for each endoscopist on 20 (10 real, 10 sham) withdrawals during colonoscopies performed for average-risk colorectal cancer screening. Three blinded reviewers assigned withdrawal technique scores (total of 75 points) on 110 video recordings. A separate reviewer recorded withdrawal times. Main Outcome Measurements: Withdrawal technique scores and withdrawal times. Results: Mean (± standard deviation [SD]) withdrawal technique scores were higher in the moderate (62 ± 2.5) and high (59.5 ± 3) ADR groups compared with the low (40.8±3) ADR group (P = .002). Mean (± SD) withdrawal times were 6.3 ± 1.8 minutes (low ADR), 10.2 ± 1.5 minutes (moderate ADR), and 8.2 ± 1.8 minutes (high ADR) (P = .29). A comparison of the withdrawal times and technique scores of the two individual endoscopists with the lowest and highest ADRs did not find a significant difference in withdrawal times (6.6 ± 1.7 vs 7.4 ± 1.7 minutes) (P = .36) but did find a nearly 2-fold difference in technique scores (36.2 ± 9 vs 62.8 ± 9.9) (P = .0001). Limitations: Not adequately powered to detect small differences in withdrawal times. Conclusion: Withdrawal technique is an important indicator that differentiates between endoscopists with varying ADRs. It is possible that withdrawal technique is equal to, if not more important than, withdrawal time in determining ADRs. © 2011 American Society for Gastrointestinal Endoscopy.


Alexander T.H.,University of California at San Diego | Alexander T.H.,Veterans Affairs Medical Center San Diego | Harris J.P.,University of California at San Diego | Harris J.P.,Veterans Affairs Medical Center San Diego | And 2 more authors.
Otology and Neurotology | Year: 2015

Objective To compare outcomes in patients with idiopathic sudden sensorineural hearing loss (ISSNHL) treated with intratympanic (IT) dexamethasone (DEX) at either 10 mg/mL or 24 mg/mL. Study Design Retrospective case series. Setting Tertiary referral center. Patients Thirty-seven adults with ISSNHL. Interventions In addition to concurrent prednisone taper, patients received a series of IT DEX injections for 2 weeks with either 10 mg/mL or 24 mg/mL. Main Outcome Measure Greater than 30-dB improvement in pure-tone average (PTA). Results Baseline characteristics were similar between groups. Mean follow-up was 10 weeks. Ten (53%) of 19 patients treated with 24 mg/mL had greater than 30-dB improvement in PTA compared with 3 (17%) of 18 treated with 10 mg/mL (p = 0.0382, Fisher's exact test). There was a trend toward improved word recognition score outcome with 24 mg/mL. The interval between onset and initiation of IT DEX significantly affected outcome, with earlier treatment resulting in greater improvement in PTA and word recognition score. Multivariate logistic regression confirmed that IT DEX dose and interval to starting treatment were both independent predictors of PTA outcome. Change in PTA was not significantly affected by age, sex, pretreatment hearing levels, or concurrent treatment with hyperbaric oxygen. Conclusion To our knowledge, this is the first demonstration of superiority of IT DEX at 24 mg/mL for the treatment of ISSNHL, with significantly better recovery of PTA. Our data suggest that treatment should be initiated as soon as possible. A prospective randomized trial to confirm the optimal dose is warranted. © 2015, Otology & Neurotology, Inc.

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