John Fowler

Urginea Maritima (Squill) Toxicity

A 55 year-old female ingested two bulbs of Urginea maritime (squill) plant as a folk remedy for her arthritic pains. Her past history was significant for Hashimoto thyroiditis and she was hypothyroid upon presentation. Subsequent effects resembling those seen with cardiac glycoside intoxication included nausea, vomiting, seizures, hyperkalemia, atrioventricular block and ventricular arrhythmias resembling digitalis toxicity. A serum digoxin level by an enzyme immunoassay method was 1.59 ng/mL. Despite supportive treatment and pacing, the patient expired from ventricular arrhythmias 30 h after ingestion. Squill has been recognized since antiquity for the clinical toxicity of its cardiac glycosides, but this appears to be the first report of a fatality since 1966.

Syrian rue tea: A recipe for disaster

Peganum harmala, commonly called “Syrian rue,” is native to countries around the Mediterranean sea and western United States. Known for its sedative effects when consumed by farm animals, its seeds have stimulant and hallucinogenic effects at low doses (3–4 g when eaten) in humans. Its active ingredients harmaline and harmine have monoamine oxidase inhibitor properties. A 41-year-old female prepared a hot drink by boiling approximately 100 g of P. harmala seeds in water (10–20 times the recommended dose for “calming ones nerves”). Upon presentation to the emergency department, she was unconscious and had hypertension, tachycardia, and tachypnea. Hepatic and renal function markers were grossly elevated. After intubation, she improved with supportive care over the course of five days. Her level of consciousness, renal and hepatic markers gradually returned to normal. Poisoning with high doses of Peganum harmala can be life-threatening, although patients usually recover with supportive therapy alone.

Predictors of success in the conversion of new-onset atrial fibrillation using oral propafenone.

We have investigated the relationship of clinical variables to successful cardioversion of atrial fibrillation (AF) to sinus rhythm using an oral loading dose of propafenone. Fifty consecutive patients with recent onset (< 72 hours) atrial fibrillation of various aetiologies were included in the study cohort. All patients were given the study medication while in the emergency department and then monitored for 8 hours. All patients converting to sinus rhythm (39 out of 50, 78%) were discharged and re-evaluated at 24 hours and 30 days. We investigated the effect of clinical factors such as age, sex, presence of hypertension (HT), chronic obstructive lung disease (COPD), diabetes mellitus (DM), mitral stenosis (MS), congestive heart failure (CHF), coronary artery disease (CAD) and the duration of atrial fibrillation on conversion to sinus rhythm. Of these factors, univariate and multivariate analysis showed that only the duration of atrial fibrillation was a significant predictor of conversion (p = 0.002). Our results suggest that most patients with new-onset AF can be converted successfully to sinus rhythm with a low incidence of adverse reactions using oral propafenone in the emergency department.

Toxicity Following Unintentional DDT Ingestion

Introduction: Dichlorodiphenyltrichloroethane (DDT) ingestion is an uncommon cause of poisoning worldwide. To date, no cases of renal impairment after oral intake of DDT in humans have been reported. We describe the clinical course and management of two patients presenting after DDT ingestion, one of whom developed acute oliguric renal failure. Case Report: A father and son mistook DDT powder for flour while preparing fish for a meal, and after eating they developed symptoms compatible with acute organochlorine insecticide poisoning. Both were intubated endotracheally due to recurrent convulsions and loss of consciousness followed by admission to the intensive care unit. Both cases developed severe metabolic acidosis. Acute oliguric renal failure (ARF) was diagnosed in the son in the second day, with a blood urea nitrogen level of 47 mg/dl and creatinine 6.4 mg/dl. Urinalysis disclosed abundant RBCs on the third day. Vigorous fluid resuscitation and strict monitoring helped reverse its clinical course by the tenth day. Both patients recovered within two weeks and were discharged without sequelae. Conclusion: Clinicians should not overlook the possibility of DDT poisoning in the differential diagnosis of acute renal failure and seizures. More strict measures should be taken to prohibit misidentification of DDT and similar products, particularly in the developing world.

In Vitro Adsorption of Dichlorvos and Parathion by Activated Charcoal

Accidental and suicidal ingestions of organophosphate compounds continue to be a common occurrence in Turkey. Activated charcoal administration without gastric emptying has been advocated as primary therapy in most acute poisoning cases, although some references do not recommend activated charcoal use in organophosphate poisoning. This study was performed to determine the in vitro adsorption of dimethyl dichlorovinyl phosphate (dichlorvos) and parathion by activated charcoal over a wide range of charcoal:organophosphate ratios (1:1, 2.5:1, 5:1, 10:1 and 20:1, g:g). The charcoal binding ability of dichlorvos and parathion were studied in both pH 1.2 and pH 7 environments. The supernatant was extracted with n-hexane and then analyzed by gas chromatography. Each incremental increase in charcoal dose increased the percent adsorption of dichlorvos and parathion. At the 20:1 ratio, 82.8 +/- 2.0/87.3 +/- 2.9% (pH 1.2/7.0) of dichlorvos and 59.3 +/- 4.5/64.5 +/- 6.1% (pH 1.2/7.0) of parathion were bound by activated charcoal. There were no significant differences in amounts of compound bound in the acid and neutral solutions. Large doses of activated charcoal effectively bind dichlorvos and parathion in vitro. In vivo research should be performed to determine activated charcoals role in organophosphate poisoning cases.

Ondansetron versus diclofenac sodium in the treatment of acute ureteral colic: A double blind controlled trial

The aim of this study is to compare the effectiveness of the 5-HT3 antagonist, ondansetron and a non-steroidal anti-inflammatory agent, diclofenac sodium, as a pain reliever in the treatment of acute ureteral colic. Sixty four patients with severe or moderate pain who were clinically diagnosed as having ureteral colic associated with microscopic or gross hematuria were included in the study. Thirty three patients were administered ondansetron and 31 patients were administered diclofenac sodium. Exclusion critera were known kidney or liver disease causing dysfunction, known hypersensitivity to ondansetron or diclofenac sodium, pregnancy, lactation, duodenal ulcer or bleeding. After pain assessment with a verbal scale and a visual analog scale (VAS), we randomized patients and administered 8 mg ondansetron intravenously to 33 patients and 75 mg diclofenac sodium intramuscularly to 31 patients and pain scores were recorded every 15 minutes. If significant pain relief was not achieved within 60 minutes, IV meperidine was given as rescue pain medication. Ondansetron was effective as a primary pain reliever in 14 (42.4%) patients, whereas 19 patients required additional medication. Diclofenac sodium was effective as a primary pain reliever in 24 (77.4%) patients, whereas 7 patients required additional medication. Ondansetron was not superior to diclofenac sodium in relieving pain in patients with acute ureteral colic.

Modified hair apposition technique as the primary closure method for scalp lacerations

OBJECTIVE The aim of this study is to report the usability of our modified hair apposition technique (modHAT) in repairing scalp lacerations. METHODS Data were collected prospectively over a 36-month period regarding our routine repair of scalp lacerations: those in areas with hair 1 cm or longer were repaired with our modHAT technique (10-15 hairs bundled and twisted with clamps) using cyanoacrylate glue, whereas wounds in areas with hair less than 1 cm long, with irregular wound edges, or which continued to bleed after pressure, were repaired with sutures or staples. Two days later, a wound check was performed. At least 30 days later, all patients were contacted again by telephone to assess satisfaction with care, preference regarding the method of repair in the future, and occurrence of any complication, infection, or need for additional health care. RESULTS One hundred two consecutive patients (ages 2-92 years) with scalp lacerations (mean length, 24 mm; range, 4-100 mm) presented for care. Wound closure was accomplished with the modHAT technique in 66%. Sutures were used in 32% and staples in 2% because of baldness/short hair in 6% and continued bleeding after pressure in 28%. Satisfaction in both hair apposition technique and suture groups was high, and no patient sought further health care. CONCLUSION Most scalp lacerations can be repaired with the modHAT technique primarily. Care should be taken to apply the glue to the twist of hair only and avoid excess glue running onto the scalp or into the wound. Wider use of this inexpensive, quick technique should be encouraged.

Age-related digoxin-alprazolam interaction

A case report of dramatic increases in serum digoxin levels after alprazolam administration prompted our investigation. Twelve inpatients receiving long‐term digoxin (0.25 mg daily) randomly received oral administration of either 1.0 or 0.5 mg alprazolam per day for 7 days. In each dosage group, three patients were older than and three were younger than 65 years of age. The area under the concentration‐time curve for serum digoxin increased significantly in patients receiving 1 mg alprazolam daily, and this increase was more pronounced in patients older than 65 years of age. Clinical digoxin toxicity developed in one elderly patient who was receiving 1 mg/day alprazolam.

Prevention of Oral Dichlorvos Toxicity by Different Activated Charcoal Products in Mice

STUDY OBJECTIVE To determine whether immediate treatment with oral activated charcoal (AC) products of differing surface areas prevents clinical toxicity of a lethal oral dose of dichlorvos in mice. DESIGN An in vivo, prospective, randomized, placebo-controlled study using 75 male albino mice. INTERVENTIONS Fasting mice were administered 57.5 mg/kg of a 0.55% dichlorvos solution via feeding tube. One minute later, groups of 15 mice each received 1 or 2 g/kg of Actidose-Aqua AC or 1 or 2 g/kg of Sigma AC or sterile water by feeding tube. In this way, all mice received 15 mL/kg of an AC suspension or sterile water. The animals were observed for 24 hours for seizures or death. RESULTS In all treatment groups, mice were found to have significantly fewer seizures and deaths (P < .05) than the control group when compared by chi 2 and Fishers exact tests. No statistical difference was found between the death and seizure rates when treatment groups were compared with each other. The group sizes were too small, however, to rule out significant type II error (beta > .2). CONCLUSION In this in vivo mouse model, all AC products tested decreased the incidence of seizures and death. Further studies should be done to investigate the clinical effects of AC products with different surface areas.