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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">&#8216;Jamaican Stone&#8217;&#44; also known &#8216;Love Stone&#8217; or &#8216;Chan Su&#8217;&#44; is a kind of cardioactive steroid &#40;CAS&#41; derived from toad venom&#46; In western countries&#44; poisoning caused by ingestion of this substance is very uncommon&#46; Thus&#44; when it occurs&#44; an early and accurate diagnosis represents a critical challenge for clinicians&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A previously healthy 32-year-old male presented with abdominal pain&#44; nausea&#44; weakness and vomiting after accidental ingestion of &#8216;Jamaican Stone&#8217;&#44; a topical remedy applied direct to the penis for delaying ejaculation&#46; On arrival at the hospital he was somnolent&#46; Initial blood pressure was 85&#47;30 mmHg and the electrocardiogram showed complete atrioventricular block with diffuse ST-segment depression &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Treatment with dopamine was initiated&#46; Transthoracic echocardiography revealed a hyperdynamic left ventricle and potassium was within normal limits&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Five minutes later he developed a 130 bpm regular wide QRS tachycardia that subsequently progressed to ventricular fibrillation treated by a shock&#46; After defibrillation&#44; asystole was observed&#44; and advanced cardiopulmonary resuscitation was performed&#46; Multiple recurrences of ventricular arrhythmias &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#44; including bidirectional ventricular tachycardia &#40;VT&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#44; were recorded&#44; followed by ventricular fibrillation&#46; Likewise&#44; transcutaneous pacing resulted in VT&#44; and lidocaine infusion was therefore started&#46; There was no recurrence of ventricular arrhythmias but he remained in complete atrioventricular block&#46; A transvenous pacemaker was then successfully implanted&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Although intensive care treatment was performed&#44; the patient&#39;s condition gradually worsened and he finally died 24 hours after ingestion&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">CASs consist of a steroid nucleus and an unsaturated 5-membered &#40;cardenolide&#41; or 6-membered &#40;bufadienolide&#41; lactone ring&#46; Most cardenolides are derived from plants &#40;such as <span class="elsevierStyleItalic">Digitalis lanata</span>&#44; <span class="elsevierStyleItalic">Nerium oleander</span> or <span class="elsevierStyleItalic">Thevetia peruviana</span>&#41;&#46; By contrast&#44; bufadienolides are derived mainly from mammals and amphibians &#40;such as toad venom&#44; used to produce Jamaican Stone&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Cardenolides have been more often described in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Digoxin&#44; a well-known cardenolide&#44; is commonly used to treat atrial fibrillation and congestive heart failure&#44; and the clinical effects and symptoms of overdose are well recognized&#46; Toxicity due to other CASs is similar to digoxin poisoning&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Presentation as vomiting and abdominal pain is commonest&#44; and neurological manifestations are also frequent in more severe cases&#46; Bradyarrhythmias are the most common manifestation &#40;conduction defects affecting the sinus node&#44; the atrioventricular node or both&#41;&#44; but tachyarrhythmias&#44; atrial &#40;usually atrial fibrillation&#41; or ventricular&#44; may also occur&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Clinical suspicion is the key&#44; and positivity of serum immunoassays for digoxin &#40;cross-reactivity with CASs&#41; may corroborate diagnosis&#46; Because of partial cross-reactivity&#44; the concentration by itself is not relevant or predictive of clinical outcome&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Treatment in severe cases is very difficult and mortality associated with exposure to nonpharmaceutical CASs is high&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A systematic review of 924 cases of CAS poisoning by Barrueto et al&#46; found overall mortality of 6&#46;7&#37;&#44; and bufadienolides &#40;3&#37; of cases&#41; were five times more lethal than cardenolides &#40;29&#46;6&#37; vs&#46; 6&#37;&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Prevention of gastrointestinal absorption of further toxin by emesis&#44; gastric lavage&#44; administration of activated charcoal and cathartics is intuitive&#44; may be useful and is harmless&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">When significant bradyarrhythmia is present&#44; pacemaker therapy is recommended&#46; Use of atropine is frequently reported in the literature&#44; but opinion diverges about its potential to induce tachyarrhythmia&#46; Catecholamines&#44; although there are references to beneficial effects&#44; are not advised because they may potentiate ventricular arrhythmias&#44; as the electrophysiologic effects underlying CAS toxicity seem to be related to delayed afterdepolarizations &#40;DADs&#41; and triggered arrhythmias secondary to Ca<span class="elsevierStyleSup">2&#43;</span> overload&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Serum potassium concentration is frequently altered and has prognostic implications&#46; Hyperkalemia results from the shift of potassium from inside to outside the cell&#44; so insulin-dextrose infusion is the best treatment&#59; calcium administration is not recommended as it may potentiate DADs&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Administration of digoxin-specific Fab antibody&#44; if available&#44; should always be attempted&#44; especially in the presence of severe rhythm disturbances&#46; Data from in vitro and animal models confirm that digoxin-specific Fab antibody cross-reacts with CAS&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5&#8211;7</span></a> Clinical data&#44; although not always demonstrating a clear benefit&#44; supports its use and lack of harm&#46; In a prospective study of CAS poisoning&#44; Eddleston et al&#46; found that its use decreased mortality by half when administered to patients exposed to yellow oleander &#40;<span class="elsevierStyleItalic">Thevetia peruviana</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Dosage should not be based on digoxin concentration because of partial cross-reactivity&#44; and large and repeated doses are recommended &#40;190-380 mg&#44; 30 min to 1 h intervals&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In our opinion&#44; given the high mortality rate and the increasing recreational use of these substances&#44; physicians working in the emergency department and intensive care should suspect CAS exposure when symptoms and electrocardiogram findings are reminiscent of digoxin toxicity&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">To the best of our knowledge&#44; this is the first fully electrocardiographically documented case of toxicity following intake of &#8216;Jamaican Stone&#8217;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Case report
‘Jamaican Stone’: A potentially lethal remedy for delaying ejaculation
«Pedra jamaicana»: um remédio potencialmente letal para retardar a ejaculação
Belén Díaz-Antón
Corresponding author
b.diazanton@gmail.com

Corresponding author.
, Guillermo Alonso-Deniz, Jose Luis Perez-Vela, Javier Molina-Martín de Nicolás, Belen Rubio-Alonso, Alfonso Jurado-Román, Ana Miguel-Gutierrez, Roberto Martin-Asenjo
Department of Cardiology, Hospital 12 octubre, Madrid, Spain
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  "doi" => "10.1016/j.repce.2017.02.012"
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  "fechaPublicacion" => "2017-02-01"
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  "copyright" => "Sociedade Portuguesa de Cardiologia"
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a topical remedy applied direct to the penis for delaying ejaculation&#46; On arrival at the hospital he was somnolent&#46; Initial blood pressure was 85&#47;30 mmHg and the electrocardiogram showed complete atrioventricular block with diffuse ST-segment depression &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Treatment with dopamine was initiated&#46; Transthoracic echocardiography revealed a hyperdynamic left ventricle and potassium was within normal limits&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Five minutes later he developed a 130 bpm regular wide QRS tachycardia that subsequently progressed to ventricular fibrillation treated by a shock&#46; After defibrillation&#44; asystole was observed&#44; and advanced cardiopulmonary resuscitation was performed&#46; Multiple recurrences of ventricular arrhythmias &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#44; including bidirectional ventricular tachycardia &#40;VT&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#44; were recorded&#44; followed by ventricular fibrillation&#46; Likewise&#44; transcutaneous pacing resulted in VT&#44; and lidocaine infusion was therefore started&#46; There was no recurrence of ventricular arrhythmias but he remained in complete atrioventricular block&#46; A transvenous pacemaker was then successfully implanted&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Although intensive care treatment was performed&#44; the patient&#39;s condition gradually worsened and he finally died 24 hours after ingestion&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">CASs consist of a steroid nucleus and an unsaturated 5-membered &#40;cardenolide&#41; or 6-membered &#40;bufadienolide&#41; lactone ring&#46; Most cardenolides are derived from plants &#40;such as <span class="elsevierStyleItalic">Digitalis lanata</span>&#44; <span class="elsevierStyleItalic">Nerium oleander</span> or <span class="elsevierStyleItalic">Thevetia peruviana</span>&#41;&#46; By contrast&#44; bufadienolides are derived mainly from mammals and amphibians &#40;such as toad venom&#44; used to produce Jamaican Stone&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Cardenolides have been more often described in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Digoxin&#44; a well-known cardenolide&#44; is commonly used to treat atrial fibrillation and congestive heart failure&#44; and the clinical effects and symptoms of overdose are well recognized&#46; Toxicity due to other CASs is similar to digoxin poisoning&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Presentation as vomiting and abdominal pain is commonest&#44; and neurological manifestations are also frequent in more severe cases&#46; Bradyarrhythmias are the most common manifestation &#40;conduction defects affecting the sinus node&#44; the atrioventricular node or both&#41;&#44; but tachyarrhythmias&#44; atrial &#40;usually atrial fibrillation&#41; or ventricular&#44; may also occur&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Clinical suspicion is the key&#44; and positivity of serum immunoassays for digoxin &#40;cross-reactivity with CASs&#41; may corroborate diagnosis&#46; Because of partial cross-reactivity&#44; the concentration by itself is not relevant or predictive of clinical outcome&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Treatment in severe cases is very difficult and mortality associated with exposure to nonpharmaceutical CASs is high&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A systematic review of 924 cases of CAS poisoning by Barrueto et al&#46; found overall mortality of 6&#46;7&#37;&#44; and bufadienolides &#40;3&#37; of cases&#41; were five times more lethal than cardenolides &#40;29&#46;6&#37; vs&#46; 6&#37;&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Prevention of gastrointestinal absorption of further toxin by emesis&#44; gastric lavage&#44; administration of activated charcoal and cathartics is intuitive&#44; may be useful and is harmless&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">When significant bradyarrhythmia is present&#44; pacemaker therapy is recommended&#46; Use of atropine is frequently reported in the literature&#44; but opinion diverges about its potential to induce tachyarrhythmia&#46; Catecholamines&#44; although there are references to beneficial effects&#44; are not advised because they may potentiate ventricular arrhythmias&#44; as the electrophysiologic effects underlying CAS toxicity seem to be related to delayed afterdepolarizations &#40;DADs&#41; and triggered arrhythmias secondary to Ca<span class="elsevierStyleSup">2&#43;</span> overload&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Serum potassium concentration is frequently altered and has prognostic implications&#46; Hyperkalemia results from the shift of potassium from inside to outside the cell&#44; so insulin-dextrose infusion is the best treatment&#59; calcium administration is not recommended as it may potentiate DADs&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Administration of digoxin-specific Fab antibody&#44; if available&#44; should always be attempted&#44; especially in the presence of severe rhythm disturbances&#46; Data from in vitro and animal models confirm that digoxin-specific Fab antibody cross-reacts with CAS&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5&#8211;7</span></a> Clinical data&#44; although not always demonstrating a clear benefit&#44; supports its use and lack of harm&#46; In a prospective study of CAS poisoning&#44; Eddleston et al&#46; found that its use decreased mortality by half when administered to patients exposed to yellow oleander &#40;<span class="elsevierStyleItalic">Thevetia peruviana</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Dosage should not be based on digoxin concentration because of partial cross-reactivity&#44; and large and repeated doses are recommended &#40;190-380 mg&#44; 30 min to 1 h intervals&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In our opinion&#44; given the high mortality rate and the increasing recreational use of these substances&#44; physicians working in the emergency department and intensive care should suspect CAS exposure when symptoms and electrocardiogram findings are reminiscent of digoxin toxicity&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">To the best of our knowledge&#44; this is the first fully electrocardiographically documented case of toxicity following intake of &#8216;Jamaican Stone&#8217;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Case report"
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              "titulo" => "Protection of human and animal subjects"
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            1 => "Cardenolides"
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            0 => "Pedra jamaicana"
            1 => "Cardenol&#237;deos"
            2 => "Bufadienol&#237;deos"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Poisoning by ingestion of &#8216;Jamaican Stone&#8217;&#44; a kind of cardioactive steroid&#44; is extremely rare&#46; However&#44; mortality is very high&#46; For this reason&#44; when it occurs&#44; an early and accurate diagnosis represents a critical challenge for clinicians&#46; We present an unusual case of electrical storm caused by this substance&#46;</p></span>"
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        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">O envenenamento por ingest&#227;o de &#171;pedra jamaicana&#187;&#44; um tipo de esteroide cardioativo&#44; &#233; extremamente raro&#46; Contudo&#44; dado esta situa&#231;&#227;o se associar a uma mortalidade muito elevada&#44; o diagn&#243;stico precoce e rigoroso desta situa&#231;&#227;o pode ser clinicamente crucial&#46; &#201; retratado um caso pouco comum de tempestade arr&#237;tmica causada por esta subst&#226;ncia&#46;</p></span>"
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Article information
ISSN: 21742049
Original language: English
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2017 November 35 15 50
2017 October 25 6 31
2017 September 21 8 29
2017 August 30 7 37
2017 July 19 6 25
2017 June 33 7 40
2017 May 37 14 51
2017 April 17 9 26
2017 March 65 15 80
2017 February 5 4 9
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Revista Portuguesa de Cardiologia (English edition)
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