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Metformin overdose may result in vasodilatory shock, lactic acidosis and death. Hemodialysis is an effective means of extracorporeal elimination, but may be insufficient in the shock setting. We present a case of a 39 yo male who presented with hypotension, coma, hypoglycemia, and lactate of 6.5 mmol/L after ingesting an unknown medication. Metformin overdose was suspected, and he was started on hemodialysis. He developed profound vasoplegia refractory to high doses of norepinephrine, vasopressin, epinephrine and phenylephrine. Venoarterial extracorporeal membrane oxygenation (VA ECMO) was initiated and he had full recovery. Serum analysis with high resolution liquid chromatography mass spectrometry revealed a metformin level of 678 μg/mL and trazodone level of 2.1 μg/mL. This case is one of only a handful of reported cases of metformin overdose requiring ECMO support, and we report the highest serum metformin levels in the literature to date. We recommend early aggressive hemodialysis and vasopressor support in all suspected cases of metformin toxicity as well as VA ECMO if refractory to these therapies.ObjectiveWe present a case of vasodilatory shock secondary to metformin overdose requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) support. This case is one of only a handful of reported cases of metformin overdose requiring ECMO support, and we report the highest serum metformin levels in the literature to date.Data sourcesUniversity of San Francisco, Fresno.Study designCase report.Data extractionClinical records and high resolution liquid chromatography mass spectroscopy analysis.Data synthesisNone.ConclusionsVenoarterial ECMO provided an effective means of hemodynamic support for a patient with severe metformin toxicity.

Aims: Population‐wide, person‐level, linked electronic health record data are increasingly used to estimate epidemiology, guide resource allocation, and identify events in clinical trials. The accuracy of data from NHS Digital (now part of NHS England) for identifying hospitalization for heart failure (HHF), a key HF standard, is not clear. This study aimed to evaluate the accuracy of NHS Digital data for identifying HHF. Methods and results: Patients experiencing at least one HHF, as determined by NHS Digital data, and age‐ and sex‐matched patients not experiencing HHF, were identified from a prospective cohort study and underwent expert adjudication. Three code sets commonly used to identify HHF were applied to the data and compared with expert adjudication (I50: International Classification of Diseases‐10 codes beginning I50; OIS: Clinical Commissioning Groups Outcomes Indicator Set; and NICOR: National Institute for Cardiovascular Outcomes Research, used as the basis for the National Heart Failure Audit in England and Wales). Five hundred four patients underwent expert adjudication, of which 10 (2%) were adjudicated to have experienced HHF. Specificity was high across all three code sets in the first diagnosis position {I50: 96.2% [95% confidence interval (CI) 94.1–97.7%]; NICOR: 93.3% [CI 90.8–95.4%]; OIS: 95.6% [CI 93.3–97.2%]} but decreased substantially as the number of diagnosis positions expanded. Sensitivity [40.0% (CI 12.2–73.8%)] and positive predictive value (PPV) [highest with I50: 17.4% (CI 8.1–33.6%)] were low in the first diagnosis position for all coding sets. PPV was higher for the National Heart Failure Audit criteria, albeit modestly [36.4% (CI 16.6–62.2%)]. Conclusions: NHS Digital data were not able to accurately identify HHF and should not be used in isolation for this purpose. [ABSTRACT FROM AUTHOR]

This article applies the concept of legitimacy to reinterpret collective bargaining as a war of words instead of an institutional arrangement of negotiations and power struggles between employers and trade unions. The case study investigates trade union discourse by collecting and analysing campaign materials about academic wages across British universities over 18 years. The results suggest trade unions tried to stigmatize British universities for not engaging in consultation and negotiation; acting with honesty and good faith; or being transparent and equitable. However, none of these management practices puts economic framing at the forefront, which is at odds with financialization and the essence of wages being about money and performance. This article concludes that embracing economics and reducing plurality within trade union discourse may help legitimize academic wages to match economic growth in the sector. [ABSTRACT FROM AUTHOR]

Wildlife professionals routinely use potent sedatives and anesthetics when chemically immobilizing wildlife and zoo species in remote environments. Accidental exposure to these prescription veterinary drugs is rare but could be rapidly fatal. Commonly used agents include opioids and α2 adrenoreceptor agonists. These drugs can be reversed with specific antagonists; however, they are often not approved for human use. The protocol created here can be used by wildlife health professionals in a field setting with basic human emergency medical response training in coordination with local Emergency Medical Services (EMS). Key components include, building local relationships between EMS and wildlife professionals, focused EMS training, administering opioid and α2 adrenergic antagonists off label, and local evacuation procedures. This framework could allow wildlife management agencies or zoos to mitigate the risk of human exposures to these commonly used drugs, significantly improving occupational safety in an otherwise high-risk environment. [ABSTRACT FROM AUTHOR]

Summary: The World Checklist of Vascular Plants (WCVP) is an extremely valuable resource that is being used to address many fundamental and applied questions in plant science, conservation, ecology and evolution. However, databases of this size require data manipulation skills that pose a barrier to many potential users. Here, we present rWCVP, an open‐source R package that aims to facilitate the use of the WCVP by providing clear, intuitive functions to execute many common tasks. These functions include taxonomic name reconciliation, geospatial integration, mapping and generation of multiple different summaries of the WCVP in both data and report format. We have included extensive documentation and tutorials, providing step‐by‐step guides that are accessible even to users with minimal programming experience. rWCVP is available on cran and GitHub. This article is part of the Special Collection 'Global plant diversity and distribution'. See https://www.newphytologist.org/global-plant-diversity for more details. [ABSTRACT FROM AUTHOR]