Moxifloxacin is a rare but important cause of drug-induced immune thrombocytopenia (DIT). We describe a patient who presented with an acute onset of severe thrombocytopenia complicated by petechial rash, epistaxis, and melena. Recent new drug exposures included moxifloxacin and two proton pump inhibitors. On presentation to the hospital, all recently initiated medications were discontinued and the patient's thrombocytopenia was treated with platelet transfusions, intravenous immunoglobulin, and high-dose corticosteroids. Her thrombocytopenia improved over the next seven days and she was discharged on hospital day 8. Serologic testing revealed strongly positive moxifloxacin-dependent IgM and IgG antiplatelet antibodies, confirming a diagnosis of moxifloxacin-induced immune thrombocytopenia. DIT has been reported with other fluoroquinolone antibiotics, especially ciprofloxacin. This case documents a rare but potentially fatal complication of exposure to moxifloxacin and is the first to demonstrate objective evidence of acute sensitization with IgM antibody positivity. It highlights the need to consider this potential reaction when choosing antibiotic therapy, particularly in patients who are at high risk for bleeding, have hematologic disorders, or are receiving myelosuppressive therapies, and perhaps in those with a history of multiple drug allergies.

The isolated working guinea-pig heart was used to compare the cardiostimulatory effects of acetylcholine and nicotine observed in the presence of atropine. Both agonists increased aortic pressure, left ventricular pressure, left ventricular dP/dt, cardiac output, and ventricular cyclic AMP levels. These responses were qualitatively and quantitatively similar to the effects of exogenous norepinephrine. Hexamethonium treatment abolished the responses to acetylcholine and to nicotine. However, several differences in the responses of the two agonists were also observed with respect to: 1) the effect of propranolol pretreatment, 2) selective effects on coronary and aortic flow rates, 3) coefficients of correlation between ventricular cyclic AMP and changes in dP/dt, and 4) the "autoinhibition" effect. The results support the view that the cardiostimulatory effects of acetylcholine are due entirely to endogenous catecholamine release, but that the effects of nicotine may involve an additional action.

Introduction Since the introduction of a venous thromboembolism (VTE) risk assessment tool in 2011 there has been an increase in the workload of the combined Obstetric-Haematology clinic. In view of this increase a retrospective review of the size and composition of clinics during the first 12 weeks of 2011 and 2012 was carried out. Method Clinic lists for the relevant weeks were obtained and the letters reviewed. New referrals were categorised as VTE risk assessment or other. The type of clinic and number of antenatal visits was obtained from the patient activity summary. Results The total number of new referrals to the clinic increased by 51.4% when the first 12 weeks of 2011 and 2012 were compared. The number of referrals for VTE risk increased by 40%. 51.4% (18/35) of the VTE risk assessment new referrals made in 2012 were women with a family history of VTE, compared with 16% (4/25) in 2011. In 2012 of the women referred for a family history of VTE 61.1% (11/18) were reviewed at one further follow up appointment in the combined clinic. Conclusions The introduction of the VTE risk assessment tool has contributed to the increase in new referrals. Many of the women reviewed do not require further Consultant input and may be suitable for review by a Specialist Midwife. The development of a Specialist Midwife role may increase Consultant clinic capacity and provide midwifery input for women who are reviewed frequently and may miss out on holistic care from their community Midwife.

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