BackgroundTricyclic antidepressants (TCA) are becoming one of the most frequently used substances in self poisoning. Significant morbidity and mortality associated with TCA overdose are often related to and refractory hypotension. We report the first case of survival after severe amitriptyline poisoning, leading to prolonged cardiac arrest and ventricular tachycardia (VT), resuscitated with 3 h of uninterrupted cardiac massage and Direct current (DC) shocks.Case presentationA 25 year old girl presented with severe amitriptyline poisoning causing pulseless VT and prolonged cardiac arrest. After 3 h of uninterrupted external cardiac massage, together with nine DC shocks and intra venous bicarbonate injections the rhythm reverted to a nodal tachycardia, initial 2D echocardiogram showed left ventricular dysfunction, which recovered to normal after 2 weeks and the patient had a complete recovery subsequently.ConclusionOur case highlights the importance of continued resuscitation in patients presenting with TCA poisoning and resistant arrhythmia, especially in young and otherwise healthy patients.

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Purpose: In recent years interest has grown in the investigation and clinical application of intensity modulated radiation therapy (IMRT) for adjuvant treatment of early stage breast cancer. A review of the current literature was conducted to establish if IMRT can reduce doses delivered to the heart and potentially minimise the likelihood of cardiac toxicities for early stage left‐sided breast cancer patients. Methods: A literature review was undertaken to identify recent studies (1999–2009) that compared IMRT with three‐dimensional conformal radiation therapy (3D CRT) techniques for left‐sided breast patients. Results: Based on the five reviewed articles, IMRT reduces the cardiac volume treated to high doses; however this is at the expense of an increase in the volume treated to low/intermediate doses. The maximum dose to the coronary arteries and left ventricle can be reduced with IMRT. Using radiobiological modelling some studies found a reduced risk of normal tissue complication probability (NTCP) for cardiac mortality with IMRT. Conclusion: The evidence provided in this review encourages the use of IMRT approaches in the treatment of early stage left‐sided breast cancer in order to minimise morbidity specifically to cardiac tissue. However, in order to ensure optimal use of resources, thought needs to be given as to which women will benefit most from complex treatment approaches.

Background: Bone is a common metastatic site of primary lung carcinoma. But bone metastasis being the initial presentation of primary lung malignancy is rare and only a few cases are reported in literature. We report a case of a primary lung cancer with extensive bone metastasis to skull and long bones, with no clinically or radiologically evident primary tumor.