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For decades, salicylates have been recognised as one of the leading causes of drug overdoses. Deaths attributable to salicylates alone can be as high as 20.6% per year of analgesic drug deaths.[1] The incidence of salicylate poisonings, especially those with a chronic component, is difficult to ascertain because of the under-reporting of such cases and the poor correlation with serum levels. However, it is perceived to be low and usually occurs in patients with chronic pain.[2] Classic signs and symptoms in mild cases of acute salicylate toxicity include tachypnoea, lethargy, vomiting and hyperthermia without overt acidosis. In severe cases, symptoms worsen and, in addition, the patient may have metabolic acidosis and/or coma.[3] These symptoms correlate with the Done nomogram, which is used to assess the severity of acute salicylate poisoning.[4] Unfortunately, the severity of chronic salicylate overdoses is difficult to determine since serum concentrations do not accurately correlate with the Done nomogram.[5] Data illustrating the clinical ramifications of mixed acute and chronic intoxication of salicylates are scarce. Pulmonary injury has been well documented with chronic salicylate toxicity. Animal lung biopsy studies of salicylate poisoning have demonstrated increased permeability of alveoli.[6] To the best of our knowledge, these findings have not been confirmed in humans other than at autopsy.[7] This case illustrates the magnitude of diffuse pulmonary damage resulting in respiratory failure from long-term salicylate use as well as histological evidence in an otherwise healthy individual.

Background Hemodialysis (HD) patients are at risk for medication-related problems (MRP). The MRP number, type, and appearance rate over time in ambulatory HD patients has not been investigated. Methods Randomly selected HD patients were enrolled to receive monthly pharmaceutical care visits. At each visit, MRP were identified through review of the patient chart, electronic medical record, patient interview, and communications with other healthcare disciplines. All MRP were categorized by type and medication class. MRP appearance rate was determined as the number of MRP identified per month/number of months in study. The number of MRP per patient-drug exposures were determined using: {[(number of patients) × (mean number of medications)]/(number of months of study)} /number of MRP identified. Results were expressed as mean ± standard deviation or percentages. Results Patients were 62.6 ± 15.9 years old, had 6.4 ± 2.0 comorbid conditions, were taking 12.5 ± 4.2 medications, and 15.7 ± 7.2 doses per day at baseline. Medication-dosing problems (33.5%), adverse drug reactions (20.7%), and an indication that was not currently being treated (13.5%) were the most common MRP. 5,373 medication orders were reviewed and a MRP was identified every 15.2 medication exposures. Overall MRP appearance rate was 0.68 ± 0.46 per patient per month. Conclusion MRP continue to occur at a high rate in ambulatory HD patients. Healthcare providers taking care of HD patients should be aware of this problem and efforts to avoid or resolve MRP should be undertaken at all HD clinics.