2020 Volume 22 Issue 4 Published: 28 April 2020
  

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  • Attention should be paid to monitoring of adverse reactions to new antitumor drugs
    Jiang Shuai, Cai Haodong, Dong Mei
    2020, 22(4): 217-220. https://doi.org/10.3760/cma.j.cn114015-20200225-00169
    Abstract ( ) PDF ( )
    With the continuous deepening of the research on tumor pathogenesis, more and more innovative oncology drugs have been approved on the market, mainly including targeted antitumor drugs and immune checkpoint inhibitors. These new antitumor drugs have the advantages of high specificity, precise targeting, good efficacy, and low toxicity to greatly improve the patient quality of life and prognosis. However, because of the different types and monitoring methods of their adverse drug reactions from those of the traditional chemotherapy ones, the research on these drugs from aspects of prediction of adverse drug reactions, the relationship between adverse drug reactions and gene polymorphisms, and the therapeutic drug monito- ring are still necessary to be further researched.
  • Cardiotoxicity of programmed cell death 1 receptor/programmed cell death ligand 1 inhibitors: a meta-analysis
    Qiu Xuejia, Cao Gexi, Tian Dongdong, Zhang Yue, Lian Yufei
    2020, 22(4): 221-226. https://doi.org/10.3760/cma.j.cn114015-20190212-00136
    Abstract ( ) PDF ( )
    Objective To systematically evaluate cardiotoxicity of programmed cell death 1 receptor (PD-1)/programmed cell death ligand 1 (PD-L1) inhibitors.　Methods Clinical trials of PD-1/PD-L1 inhibitor alone or in combination with other treatments for tumors were collected by searching related databases at home and abroad (up to March 2, 2019). The methodological quality of studies was evaluated using the internationally accepted Cochrane collaboration′s risk of bias assessment tool. A meta-analysis was performed using RevMan 5.3 software to compare the incidences of cardiotoxicity between PD-1/PD-L1 inhibitors (trial group) and placebo or other antineoplastic agents(control group).　Results A total of 10 randomized controlled trials (RCTs) were enrolled, 9 of which were about PD-1 inhibitor alone or in combination with other antineoplastic agents, and 1 of which was about PD-L1 inhibitor monotherapy. There were a total of 5-291 patients, including 3-022 in the trial group and 2-269 in the control group. Evaluation of the methodological quality for studies showed that 4 RCTs were at high risk of bias and the other 6 were at low risk of bias. The meta-analysis showed that the incidence of cardiotoxicity in the trial group was significantly higher than that in the control group, and the difference was statistically significant［1.13% (34/3-022) vs. 0.22% (5/2-269), RR=2.38, 95%CI: 1.19-4.78, P=0.01］.　Conclusion PD-1/PD-L1 inhibitors have the risk of causing heart related adverse events, which should be paid attention to in clinical application.
  • Risk analysis of regorafenib related hepatobiliary system injury based on the US Food and Drug Administration Adverse Event Reporting System
    Long Xia, Zeng Xiaohuan, Gan Xiaohong
    2020, 22(4): 227-232. https://doi.org/10.3760/cma.j.cn114015-20190615-00491
    Abstract ( ) PDF ( )
    Objective To explore the risks and influencing factors of regorafenib related hepatobiliary system injury.　Methods Reports of regorafenib related hepatobiliary system adverse events received from 4th quarter, 2012 to 3rd quarter, 2018 in the US Food and Drug Administration Adverse Event Reporting System (FAERS) database were collected. The signal intensity of hepatobiliary system adverse events related to regorafenib was screened and statistically analyzed by report odds ratio (ROR) and proportional report ratio (PRR), and their influencing factors were analyzed by logistic regression analysis.　Results A total of 26-013 adverse event reports related to regorafenib were retrieved, and 28 preferred terms were screened as suspicious hepatobiliary system related adverse event signals. Results from sorting the signal intensity of adverse events using ROR, PRR and their lower limit of 95% confidence interval (CI) showed that elevation of jaundice and bilirubin had the strongest signal (ROR=8.56, 95%CI lower limit: 7.66; PRR=8.46, 95%CI lower limit: 7.58), followed by other laboratory abnormalities (ROR=6.05, 95%CI lower limit: 4.95; PRR=6.03, 95%CI lower limit: 4.94) and then liver related diseases (ROR=5.46, 95%CI lower limit: 4.71; PRR=5.43, 95%CI lower limit: 4.69). Logistic regression analysis showed that the risk of hepatobiliary system adverse events was higher when the regorafenib dose was>80~<160-mg/d, compared with the dose of ≤80-mg/d (OR=1.702, 95%CI: 1.230-2.356, P=0.001), and was lower in patients with gastrointestinal stromal tumors, compared with other tumors (OR=0.436, 95%CI: 0.240-0.792, P=0.006).　Conclusion Regorafenib has the risk of hepatobiliary system injury, and a higher dose may be related to the increased risk.
  • Clinical and literature case analysis of hand-foot syndrome induced by apatinib
    Han Mei, Ge Ming, Liu Yuee
    2020, 22(4): 233-238. https://doi.org/10.3760/cma.j.cn114015-20190409-00348
    Abstract ( ) PDF ( )
    Objective To explore the clinical characteristics of hand-foot syndrome（HFS） induced by apatinib.　Methods Case reports of HFS induced by apatinib were collected through sear- ching PubMed, VIP, CNKI, and Wanfang databases (up to March 20, 2019). The clinical characteristics of HFS induced by apatinib were analyzed according to the literature above and the information from 2 related patients admitted to Kailuan General Hospital.　Results A total of 16 patients were enrolled in the study, including 9 males and 7 females, aged (62±16) years. Apatinib was applied for gastric cardia cancer in 4 patients, lung cancer in 4 patients, ovarian cancer in 2 patients, thyroid cancer in 2 patients, and other malignant tumors in 4 patients. And it was used alone in 11 patients and in combination with other antineoplastic agents in 5 patients. Dosages of apatinib included 850-mg/d in 3 patients, 500-mg/d in 6 patients, 425-mg/d in 1 patient, and 250-mg/d in 6 patients (the dose was increased to 500-mg/d in 2 patients after 1 and 2 weeks of administration, respectively). According to the severity, HFS was classified as grade 1 in 2 patients (12.5%), grade 2 in 6 patients (37.5%), and grade 3 in 8 patients (50.0%). Except that the time from application of apatinib to HFS occurrence was not known in 1 patient, the median time from medication to HFS occurrence was 3 (1-11) weeks in other 15 patients, and 10 (66.7%) of them developed HFS within 3 weeks of administration. In addition to the skin lesions of HFS, the skin/mucous membrane damage also appeared on perianal area, genital, axillary fossa, groin, and mouth in 5 patients. Among the 16 patients, 13-had other adverse events, including hypertension in 10 patients (62.5%). The symptoms of 8 patients with HFS of grade 1-2 mostly improved or were tolerable after symptomatic treatments. And in detail, 3 patients′ symptoms had no effect on the treatment of apatinib, 4 patients could tolerate a reduced dose or re-medication after a pause, and 1 patient stopped medication. Symptomatic treatment effects were poor in 8 patients with grade 3 HFS, 4 of whom stopped apatinib because of the serious HFS and 3 of whom died.　Conclusions The HFS induced by apatinib usually occurs within 3 weeks after administration, which can involve many parts of the body except for the skin of hands and feet, and are accompanied with hypertension mostly. HFS symptoms can be relieved by symptomatic treatments, reasonable dose reduction, or drug withdrawal in most patients.
  • Analysis on risk factors of myelosuppression caused by nedaplatin in patients with lung cancer
    Li Xiaoli, Wu Kunrong, Yin Ying, Li Rui, Zhang Shufang, Guan Ziwan, Li Yan
    2020, 22(4): 239-246. https://doi.org/10.3760/cma.j.cn114015-20190327-00292
    Abstract ( ) PDF ( )
    Objective To explore the risk factors of myelosuppression caused by nedaplatin in patients with lung cancer.　Methods The medical records of postoperative patients with advanced lung cancer and receiving nedaplatin-based chemotherapy in Shandong Provincial Qianfoshan Hospital from June 2015 to August 2018 were searched using hospital information system and analyzed retrospectively. Accor- ding to sex, age (<60 years old, ≥ 60 years old), glutathione mercaptotransferase (GSTP) 1A313G genotype (AA or AG), pathological classification (non-small cell lung cancer, small cell lung cancer), having smoking history or not, being with or without liver injury and kidney injury, the patients were divided into 2 groups, respectively. The overall myelosuppression incidence and incidences of myelosuppression with different manifestations and different degrees were compared respectively between each 2 groups of patients with above-mentioned 7 different clinical features. The risk factors of nedaplatin-induced myelosuppression were analyzed using logistic regression.　Results A total of 46 patients were enrolled, including 34 males and 12 females. Among the 46 patients, 30 cases developed myelosuppression after administration of nedaplatin, and the overall incidence of myelosuppression was 65.2%, including 20 cases of grade Ⅰ-Ⅱ (43.5%) and 10 cases of grade Ⅲ-Ⅳ (21.7%). After administration of nedaplatin, the incidence of severe myelosuppression in patients with small cell lung cancer （3/5）was higher than that with non-small cell lung cancer (17.1%) (P<0.05), showed by the univariate analysis; the overall incidence of leukopenia in males was higher than that in females (58.8% vs. 25.0%); the overall incidence of leukopenia and neutropenia was higher in patients with smoking history than that in patients without previous smoking history (68.0% vs. 28.6%, 0.01%, P=0.01; 64.0% vs. 33.3%, P=0.04); the overall incidence of thrombocytopenia in patients with small cell lung cancer was higher than that with non-small cell lung cancer (4/5 vs. 9.8%, P<0.01); the differences in the incidences of different degrees of neutropenia in patients with and without smoking history were statistically significant (P=0.03); the differences in the incidences of different degrees of leukopenia, neutropenia, and thrombocytopenia in patients with different pathological classification were statistically significant (P<0.01 for all). The binary logistic regression analysis showed that the risk of thrombocytopenia in patients with small cell lung cancer was higher than that with non-small cell lung cancer (OR=25.00, 95%CI:2.20-284.61, P=0.01). The orderial logistic regression analysis showed that a pathological classification of small cell lung cancer was a risk factor for severe myelosuppression, leukopenia, neutropenia, and thrombocytopenia（OR=13.20, 95%CI: -4.67-0.49, P=0.02; OR=22.20, 95%CI: -5.37-0.83, P=0.01; OR=19.49, 95%CI: -5.11- 0.82, P=0.01; OR=13.87, 95%CI: -4.89-0.38, P=0.02).　Conclusions A pathological classification of small cell lung cancer is an independent risk factor for severe myelosuppression in lung cancer patients after taking nedaplatin. Male patients with a history of smoking are more likely to have leukopenia/neutropenia.
  • Drug-induced acute kidney injury in hospitalized patients: a retrospective study
    Liu Chen, Gai Di, Yan Suying, Wang Yuqin, Cui Xiaohui, Zhang Yangxin
    2020, 22(4): 247-251. https://doi.org/10.3760/cma.j.cn114015-20190910-00753
    Abstract ( ) PDF ( )
    Objective To investigate the occurrence of drug-induced acute kidney injury (AKI) in adult hospitalized patients in Xuanwu Hospital, Capital Medical University.　Methods All medical records of adult inpatients who were discharged from January 1, 2014 to December 31, 2014 and whose diagnosis were in accordance with AKI during their hospitalization in Xuanwu Hospital, Capital Medical University were collected. The patients were divided into drug-induced AKI group and non-drug-induced AKI group according to whether AKI was caused by drugs. Basic information, comorbidity, change in serum crea- tinine (Scr), disease outcome, nephrotoxic medication exposure, and evaluation of the relationship between drugs and AKI of the patients were collected and retrospectively analyzed.　Results A total of 592 patients enrolled in the study, including 138 (23.31%) in the drug-induced AKI group and 454 (76.69%) in the non-drug-induced AKI group. The differences in gender, age, days in hospital, comorbidity, Scr level on admission, time for Scr level to peak after admission, and outcome between the patients in the 2 groups were not statistically significant, respectively (P>0.05 for all). Peak value of Scr during hospitalization and at discharge in patients in the drug-induced AKI group (178-μmol/L, 116-μmol/L) were obviously higher than those in the non-drug-induced AKI group (129-μmol/L, 103-μmol/L), and the differences were statistically significant (P<0.001，P=0.001). A total of 231 times of suspected drugs were involved in the 138 patients in the drug-induced AKI group. The top 6 types of drugs in turn were anti-infectious agents (35.06%, 81/231), diuretics (17.32%, 40/231), contrast agents (13.42%, 31/231), plasma substitutes (9.96%, 23/231), angiotensin converting enzyme inhibitors/angiotensinⅡreceptor blocker (8.23%, 19/231), and non-steroidal anti- inflammatory drugs (NSAIDs) (6.93%, 16/231). Contrast agents and plasma substitutes had the shortest (range: 1-3 days) but anti-infectious agents had the longest time (range: 1-12 days) from medication to AKI occurrence. Peak values of Scr in AKI inpatients caused by NSAIDs and contrast agents were lower ［median value: 118 (103, 300) μmol/L, 133 (90, 243) μmol/L］, but in those caused by anti-infectious agents was the highest ［median value: 223 (138, 396) μmol/L］. Multivariate logistic regression analysis showed that hypoproteinemia (OR=8.369, 95%CI: 3.379-20.724, P<0.001) and advanced age (OR=1.689, 95%CI: 1.206-2.365, P=0.002 for every 10 years of aging) were independent risk factors related to the death of patients with drug-induced AKI.　Conclusions The patients with AKI induced by drugs accounts for 23.31% of all AKI adult inpatients in Xuanwu Hospital, Capital Medical University. Anti-infectious agents, diuretics, and contrast agents are the most common suspected pathogenic drugs. Hypoproteinemia and advanced age are independent risk factors for hospital deaths in drug-induced AKI patients.
  • Survey and analysis of the cognition and behavioral intention of the public on adverse drug reactions
    Pan Daiyong, Jiang Baoyu, Huang Xiuyun
    2020, 22(4): 252-256. https://doi.org/10.3760/cma.j.cn114015-20190202-00115
    Abstract ( ) PDF ( )
    Objective To understand the condition of the cognition and behavioral intention of the public on adverse drug reactions (ADRs).　Methods On-the-spot questionnaire survey was conducted, using self-designed paper and WeChat questionnaires, on patients or their family members who were waiting to see a doctor or get medicine in the outpatient department in the First Affiliated Hospital of Guangxi University of Science and Technology from September to December, 2018. The respondents filled in the questionnaires anonymously and the on-site questionnaire recovery was conducted. Qualified questionnaires were screened out by 2 pharmacists. A score and its percentile one were given for each question about the cognition and behavioral intention of ADRs in the questionnaires, and the results were statistically analyzed.　Results A total of 519 questionnaires were collected, of which 508 were qualified, and the effective recovery rate was 97.9%. The median scores of the cognition and behavioral intention of respondents on ADRs were 50 (0, 100) and 86 (36, 100), respectively. Both the scores of cognition and behavioral intention on ADRs in the elderly respondents ≥60 years of age were lower than those in the respondents with 20-39 and 40-59 years of age (P>0.05 for all). Both the scores of cognition and behavioral intention on ADRs in the respondents with college/university degree were significantly higher than those in the respondents with middle school/secondary professional degree (P>0.05 for all). Both the scores of cognition and behavioral intention on ADRs in the urban respondents were significantly higher than those in the suburban and rural respondents (P>0.05 for all). Only 55.9% (284/508) of the respondents knew the right answer to the definition of ADRs, 44.1% (224/508) of the respondents thought that ADRs were caused by medication errors, drug quality, or medical errors, and 62.6% (318/508) of the respondents thought that hospitals, drug manufacturers, and drug regulatory departments should be responsible for the ADRs. After the occurrence of ADRs, 91.9% (467/508) of the respondents expressed their willingness to report it to the relevant departments, but 25.6%(130/508) of them did not know which department the ADRs should be reported to or how to fill in the report form.　Conclusions The cognition of the public on ADRs was relatively lower. Although there was an intention to report ADRs, it was limited by the lower cognition and the lack of know- ledge of ADRs reporting departments and channels.
  • Research progress in the regulation of programmed cell death 1 receptor and its ligand pathway and the strategies against tumor drug resistance
    Xie Aqing, Wang Lin
    2020, 22(4): 257-261. https://doi.org/10.3760/cma.j.cn114015-20190516-00422
    Abstract ( ) PDF ( )
    The overexpression of programmed cell death 1 receptor (PD-1) on the surface of T cells and programmed cell death 1 ligand 1 (PD-L1) secreted by tumor cells in tumor tissue inhibits the cellular immune response to a certain degree, so that the growth of tumor cells can escape the surveillance and clearance of the immune system. PD-1/PD-L1 inhibitors are specific protein antibodies designed for the expression of PD-1 or PD-L1, which can prevent the interaction between PD-1 and PD-L1 on tumor cells, thus partially restore T cell function and enhance tumor cell killing by T cells. However, because of the increasingly prominent drug resistance of PD-1/PD-L1 inhibitors in clinical applications, their efficacy cannot be sustained or even there were non-response to drugs in some patients. Recent studies have found that the expression of PD-1 and PD-L1 is regulated by many immune factors, and the transport and degra-  dation processes of PD-L1 are also affected by many factors, such as glycosylation, phosphorylation, ubiquitination, and so on. The researches on the regulatory factors that may interfere in the PD-1/PD-L1 pathway will help to develop new treatment strategies to overcome drug resistance of PD-1/PD-L1 inhibitors in tumor, thereby improving the efficacy of tumor immunotherapy.
  • Cardiotoxicity due to oxcarbazepine in 3 patients with epilepsy Chu Min, Liu Aihua
    Chu Min, Liu Aihua
    2020, 22(4): 262-264. https://doi.org/10.3760/cma.j.cn114015-20190327-00295
    Abstract ( ) PDF ( )
    Three patients with epilepsy (patient 1, a 60-year-old female with a history of heart disease; patient 2, a 29-year-old male; patient 3, an 18-year-old male) received oxcarbazepine orally for epileptic seizures (patient 1 received 0.3 g twice daily; patient 20.45 g twice daily; patient 3-0.6 g twice daily). Intermittent syncope or palpitations occurred in patient 1, 2, and 3 on day 4, 5, and 1 after medications, respectively. All 3 patients showed arrhythmias in electrocardiograms. Patient 1 developed atrial fibrillation, cardiac arrest, degree III sinoatrial block, degree II type II atrioventricular block; patient 2 and 3 deve- loped different degrees of atrioventricular block. Above-mentioned arrhythmias were considered to be cardiotoxicity caused by oxcarbazepine. In patient 1, the number of syncope was reduced from 2 to 3 times per day to 1 time per day after 3 days of oxcarbazepine withdrawal, but the electrocardiogram still showed degree II type II atrioventricular block. Then no syncope recurred after implantation of heart pacemaker. In patient 2, no syncope recurred after 5 days of oxcarbazepine withdrawal. In patient 3, no palpitations recurred after reduction of oxcarbazepine to 0.45 g twice daily and addition of other antiepileptic drugs for 2 days.
  • Sodium phosphates oral solution-induced acute attack of gout: report of 3 cases
    Gao Weina, Xie Yihong
    2020, 22(4): 264-265. https://doi.org/10.3760/cma.j.cn114015-20181221-01272
    Abstract ( ) PDF ( )
    Three Tibetan male patients (patient 1, 64-year-old; patient 2, 51-year-old; patient 3, 39-year-old) with previous history of gout received sodium phosphates oral solution 90-ml in intestinal preparation for endoscopic examination or treatment. The patients all developed typical gout attack on day 2 after their medications, but their blood uric acid levels were lower than those before taking the medicine (patient 1, from 526-μmol/L to 417-μmol/L; patient 2, from 566-μmol/L to 374-μmol/L; patient 3, from 465-μmol/L to 379-μmol/L), respectively. The acute attack of gout in the 3 patients was considered to be related with sodium phosphates oral solution, but whether it was related with phosphate crystallization was not determined.
  • Torsades de Pointes and Aspen syndrome due to levosimendan
    Sun Yue, Liu Jia, Liao Qingchi
    2020, 22(4): 266-267. https://doi.org/10.3760/cma.j.cn114015-20200103-00005
    Abstract ( ) PDF ( )
    A 72-year-old female patient received intravenous injection of furosemide injection and oral metoprolol succinate sustained-release tablets, furosemide tablets, spironolactone tablets, digoxin tablets, and isosorbide mononitrate sustained release tablets for heart failure. Continuous intravenous pumping of levosimendan 12.5-mg dissolved in 0.9% sodium chloride 45-ml at a speed of 1.5-ml/h was additionally given because of her unimproved symptoms of heart failure. After 20-hours of intravenous pumping, the patient developed unconsciousness, no response to voice stimuli, and bilateral mydriasis suddenly. The electrocardiogram monitoring showed heart rate 200 beats per minute, prolonged QT interval, and QTc period 520-ms. The laboratory tests showed serum potassium 3.02-mmol/L. She was diagnosis as Torsades de Pointes and Aspen syndrome, which were considered to be related with levosimendan. Levosimendan was stopped immediately. The treatments such as closed-chest cardiac massage, electric defibrillation, and potassium supplementation were given. Four days later, the reexamining results showed her serum potassium 4.60 mmol/L, heart rate 80 beats per minute, and QTc period 450-ms.
  • Acute liver injury induced by Yinaoning tablets （益脑宁片）
    Shen Changlong, Fu Shuangnan, Zhou Kun, Gong Man, Yu Li, He Tingting
    2020, 22(4): 268-269. https://doi.org/10.3760/cma.j.cn114015-20180813-00787
    Abstract ( ) PDF ( )
    A 52-year-old male patient received self-purchased Yinaoning tablets (益脑宁片) (3 tablets, trice daily) orally for health care. On day 18 of medication, the patient developed jaundiced skin and sclera and dark urine. On day 24, he developed fatigue and anorexia. Laboratory tests showed alanine aminotransferase (ALT) 1-132-U/L, aspartate aminotransferase (AST) 953-U/L, total bilirubin (TBil) 80.0-μmol/L, direct bilirubin (DBil) 73.4-μmol/L, alkaline phosphatase (ALP) 203-U/L, and gamma-glutamyltransferase (γ-GT) 155-U/L. Acute liver injury induced by Yinanning tablets was considered. Then the drug was discontinued and liver-protective therapy and drugs for anti-jaundice were given. On day 6 of drug withdrawal, the laboratory tests showed ALT 192-U/L, AST 158-U/L, TBil 51.0-μmol/L, DBil 39.9-μmol/L, ALP 178-U/L, and γ-GT 149-U/L, his appetite recovered, and the yellowish skin and sclera improved mar- kedly. On day 13 of drug withdrawal, his yellowish skin and sclera disappeared, and the laboratory tests showed ALT 56-U/L, AST 62-U/L, TBil 30.7-μmol/L, DBil 22.4-μmol/L, ALP 164-U/L, and γ-GT 142-U/L. At 6 months of follow-up, there were no abnormalities in his liver function.
  • Electrolyte disorder, metabolic acidosis, and hyponatremia encephalopathy  caused by polyethylene glycol electrolytes powder (Ⅳ)
    Xing Man, Shi Shiqiang, Gao Jing, Wang Na
    2020, 22(4): 270-271. https://doi.org/10.3760/cma.j.cn114015-20181216-01249
    Abstract ( ) PDF ( )
    A 61-year-old female patient underwent intestinal preparation before electronic colonoscopy. She took polyethylene glycol electrolytes powder (Ⅳ) in 6 times (dissolved content A 24 bags and B 24 bags in warm water 3-000-ml and then took 500-ml orally per 30-minutes). During the intestinal preparation, the patient′s urine output was about 4-500-ml, diarrhea occurred 8 times, and she vomited 2 times within 5.5-hours. The patient fell into a coma at 14:00 on the day, accompanied by limb convulsion and trismus. Laboratory tests showed that the serum sodium and potassium decreased from 140-mmol/L and 4.0-mmol/L to 120-mmol/L and 2.7-mmol/L before and after treatment, respectively. In addition, his chloride was 87.2-mmol/L and bicarbonate was 11.5-mmol/L. Blood gas analysis showed pH 7.29-mmHg, partial pressure of carbon dioxide 31-mmHg, partial pressure of oxygen 105-mmHg, and base excess -10.4-mmol/L. Metabolic acidosis was diagnosed. Head CT and MRI showed no abnormalities. Electrolyte disorder, metabolic acidosis, and hyponatremia encephalopathy due to hyponatremia caused by polyethylene glycol electrolytes powder (Ⅳ) was considered. Oxygen inhalation, continuous ECG monitoring, correction of electrolyte disorders, correction of acidosis, rehydration, and other symptomatic and supportive treatments were given immediately. After 4 hours of treatments, the vital signs of the patient were gradually stable but she was still in a coma. On the third day of treatments, the patient was conscious, her serum electrolytes returned to normal, and no seizures occurred.
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