Intravenous lipid emulsion (ILE) has been proposed as a rescue therapy for severe local anesthetic drugs toxicity, but experience is limited with other lipophilic drugs. An 18-year-old healthy woman was admitted 8 h after the voluntary ingestion of sustained-release diltiazem (3600 mg), with severe hypotension refractory to fluid therapy, calcium salts, and high-dose norepinephrine (6.66 μg/kg/min). Hyperinsulinemic euglycemia therapy was initiated and shortly after was followed by a protocol of ILE (intralipid 20%, 1.5 ml/kg as bolus, followed by 0.25 ml/kg over 1h). The main finding attributed to ILE was an apparent rapid decrease in insulin resistance, despite a prolonged serum diltiazem elimination half-life. Diltiazem is a lipophilic cardiotoxic drug, which could be sequestered in an expanded plasma lipid phase. The mechanism of action of ILE is not known, including its role in insulin resistance and myocardial metabolism in calcium-channel blocker poisoning.

nurses spend more time at bedside than do ED physicians, and may deliver contradictory information. Therefore, impact of nurses' involvement should be assessed to improve procedure efficacy. We acknowledge that our population was highly selected, and sample size was small and not calculated a priori. Consequently, translating results in other settings seems disputable. We observed that junior physicians informed nearly half the patients. Although this corresponds to real life, one could argue that the gold standard should be the information by senior physicians. However, junior physicians can provide valuable information [5]. Of note, patients from the control group more frequently received information from senior physicians. In addition, we could not assess whether the study questionnaire could have guided physicians' behavior and improved information quality. Finally, applying our procedure can be perceived as time-consuming. Therefore, providing diagnosis and severity may be sufficient if physicians give patients the opportunity to ask questions, and answer them.Herein we demonstrate that a standardized procedure to deliver basic information improves the understanding in complex ED patients. This makes sense as practice in ED exposes to detrimental communication gaps in severe patients [1,3]. Further investigations are needed to ascertain these promising results.

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Malagashanine has been isolated from indigenous madagascan Strychnos myrtoides alkaloids used traditionally to treat malaria. This alkaloid was found to enhance the action of chloroquine against chloroquine-resistant strains of Plasmodium falciparum when combined with classical antimalarial drugs (chloroquine, quinine). The present study was carried out in order to investigate by electrospray mass and tandem mass spectrometry and NMR spectroscopy the structure of two new metabolites isolated from rat urine and human liver microsomes. We were able to demonstrate the presence of two new metabolites of malagashanine corresponding to a malagashanine N-demethylated metabolite and to the oxidation of malagashanine in the alpha-position of the N-methyl group to produce a carbinolamine function. The latter metabolite may be subject to ring and open-chain tautomerism effects and dimeric species were detected in the electrospray mass spectrum.

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