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Background: Medication organizers increased compliance, but they do not contain child protective packaging. Medications organizers have been involved in some pediatric exposures; however, previous reports do not describe if “one pill can kill” (1PCK) medications were involved in the exposures. 1PCK medications may cause toxicity even with a single tablet. Objective: The purpose of this study is to describe the type and presence of 1PCK medications dispensed in medication organizers at a single center. Methods: Adult patients who received blister packed medications from September 1, 2017 to September 30, 2017 were included in this retrospective review. Medications were excluded if dispensed traditionally during this time. The primary outcome described included 1PCK medications (quantity and type). Secondary outcomes included total number of tablets dispensed, delayed- (DR) and extended-release (ER) formulations, average age of those dispensed 1PCK medications versus those without. Results: A total of 450 patients received 486 blister packs and 75.5% of which found to include 1PCK medications. Most commonly included 1PCK medications were beta-blockers and calcium channel blockers (42.4 and 49.4%, respectively). Patients receiving 1PCK medications were older (69.1 ± 12.6 vs 62.6 ± 16.7 years old, p < 0.0001) and included more medications (8.5 ± 2.9 vs 5.7 ± 2.9 medications, p < 0.0001). DR and ER formulations were in 150 packs. Conclusion: The majority of dispensed medication organizers included 1PCK medications. Upon dispensing, patients should be questioned for possible proximity exposures. Additionally, they should receive education on medication safety for children that may be in proximity of the medications during home, work, or social activities.

Article: Schiele F, van Ryn J, Newsome C, et al. A specific antidote for dabigatran: functional and structural characterization. Blood. 2013;121: 3554-3562.Keywords: Dabigatran, Fab antidote, Preclinical research. Background: Advances in anticoagulation for patients at risk for thromboembolic disorders have led from the use of indirect thrombin inhibitors (like warfarin) to direct inhibitors including dabigatran. Dabigatran therapy is more convenient for patients and has less reported complications than warfarin in large studies. However, when bleeding occurs during dabigatran therapy or a need for emergent surgery arises, there is no effective reversal modality and mortality in these circumstances is seemingly high.Research objective: Characterize the structure and test the ability of a novel anti-dabigatran fab to reverse anticoagulant effects x and in vivo.Methods: Antibodies were cloned after dabigatran exposure in mice, purified, and then humanized. The antidabigatran fab was then tested in vitro for the ability to reverse dabigatran anticoagulation, structurally characterized via crystallography, and examined for intrinsic coagulant effect. The derived fab was also tested in vivo in dabigatrananticoagulated rats.Results: Intact mouse antibodies, purified mouse antibodies, and humanized fab bound dabigatran as measured via ELISA. These antibodies also reversed prolonged plasma thrombin time in a dose dependent manner. Detailed crystallography revealed that the final humanized fab is composed of two variable light and heavy chain domains and two constant domains. The dabigatran binding site is a polar pocket surrounded by a hydrophobic area. Dabigatran binds at the polar pocket in a similar manner to thrombin binding. In the third phase of the study, investigators performed further assays to investigate fab binding to thrombin and other thrombin substrates. There was no observed binding nor procoagulant effects. Lastly, a single fab dose reversed prolonged thrombin time in rats despite continuous infusion of dabigatran.Conclusion: The derived anti-dabigatran fab bound with high affinity, reversed anti-coagulant effects in vitro/in vivo, and lacked intrinsic thrombin-like procoagulant effects.Critique: This is an elegant study that demonstrates the ability to produce a novel fab that specifically binds to dabigatran and reverses its anticoagulant effect without untoward procoagulant activity. All investigators are employees of the manufacturer of dabigatran.Implication for toxicologists: This report is promising in that we may have an effective and safe therapy for direct thrombin inhibitor in the reasonable future.Article: Manini AF, Stimmel B, Vlahov D. Racial susceptibility for QT prolongation in acute drug overdose. J Electrocardiol. 2014 (in press).

Background and Objectives: The aim of this quality improvement project was to decrease the percentage of emergency department (ED) patients admitted with blood glucose (BG) level above 250 mg/dL to less than 20%. Methods: A work group comprised physicians, pharmacists, and endocrinologists collaborated to standardize management of ED hyperglycemia. Plan-Do-Study-Act cycles included education, monitoring of patients with BG level above 200 mg/dL, and development of an ED-specific insulin protocol. Results: Following the initiative, 24.8% fewer patients were admitted with BG level above 250 mg/dL. The average admission BG level was reduced by 65.8 mg/dL, creating a significant shift toward improved average BG level. No difference was seen in hospital mortality, hospital length of stay, ED length of stay, hypoglycemia, or inhospital diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome. Conclusion: Implementation of a standardized hyperglycemia treatment protocol along with pharmacist interventions reduced average admission BG and the percentage of patients with BG level above 250 mg/dL on admission.