P. De Paepe

Is vitreous humour useful for the interpretation of 3,4-methylenedioxymethamphetamine (MDMA) blood levels?

Abstract As drug instability and redistribution are factors known to affect the interpretation of post-mortem blood levels, we questioned whether post-mortem vitreous humour concentrations could be useful as predictors for the MDMA load at the time of death. In a first series of in vivo experiments using rabbits, 3,4-methylenedioxy-methamphetamine (MDMA) concentrations in plasma, blood and vitreous humour were studied as a function of time after intravenous (iv) administration of MDMA. Equilibration between the vascular compartment and vitreous humour was attained about 1 h after iv MDMA administration. In a second series of experiments, the post-mortem stability of MDMA in vitreous humour in relation to ambient temperature was investigated. Post-mortem MDMA concentrations in vitreous humour were closer to the ante-mortem blood levels when compared to cardiac blood samples. These preliminary investigations in the rabbit model indicate that measurements of vitreous humour concentrations could also be of interest for predicting the blood concentration at the time of death in humans.

A survey on alcohol and illicit drug abuse among emergency department patients.

Abstract Alcohol and illicit drug abuse are major health care problems frequently leading to emergency department admission. The aims of this survey were (1) to determine for the Ghent University Hospital how frequently substance abuse contributed to emergency department admissions, (2) to describe the most important clinical features of these patients and (3) to determine how frequently these patients were referred to appropriate psychiatric services. All 1,941 patients attending the emergency department during the month of September 2003 were registered by the attending emergency department personnel. After exclusion of 8 cases, 1,933 patients were included: 198 (10%) with substance abuse leading to the emergency department admission (= INTOX group) and 1,735 (90%) in the NON-INTOX group. Males and the 21-50 years age group were overrepresented in the INTOX group. Patients with substance abuse were also overrepresented during the night, but not during the weekend. Among the patients from the INTOX group the most frequent reason for the emergency department visit was a psychiatric problem (102/198; 51%). Traumatic lesions related to a fight (n=19), to a traffic accident (n=17) and to leisure time activities (n=30) were also frequent. In most patients, only alcohol was abused (144/198; 73%), most frequently chronically (102/144; 71%). In 13% (26/198), there was only illicit drug use, and in 14% (28/198) alcohol abuse was combined with illicit drug use. Among the 54 patients with illicit drug use (with or without alcohol abuse) the most frequently reported drugs were cannabis (54%), cocaine (41%), amphetamines (39%) and opiates (39%). With regard to referral to appropriate psychosocial services it was striking that 53% (19/36) of trauma patients with chronic substance abuse were not offered that type of help. We conclude that abuse of alcohol – and to a much lesser degree illicit drugs – is a frequent cause of emergency department admissions. Our data may help to convince and/or reinforce health care policy makers, emergency department medical directors and the public that alcohol consumption (much more than illicit drugs) is responsible for avoidable morbidity and mortality, and that well-co-ordinated strategies against unhealthy alcohol use are urgently needed. In this respect, the importance of detection and referral of emergency department patients with unhealthy alcohol use should be stressed.

Drug interactions and adverse drug reactions in the older patients admitted to the emergency department

Abstract Purpose: The aim of this study was to prospectively evaluate drug interactions and adverse drug reactions (ADRs) in the older patients admitted to the emergency department (ED) and to characterize risk factors. Methods: In 80 patients aged 65 years and older medication history and ED drug administration were analysed. Medical records were analysed for ADRs by an expert panel which also evaluated their avoidability and causality. An interaction program was used to search for potential drug interactions followed by assessment for clinical significance. Data were analysed using a logistic regression model. The significance level was set at α = 0.05. Results: Eighty seven ADRs were identified in 37 patients; 18 were the result of an interaction (15 patients). Causality was assessed as definite (n = 1), probable (n = 62) and possible (n = 24). The reason for admission was definitely and probably related to an ADR in 6 and 18 patients respectively. Only 17 (20%) of the ADRs were assessed as unavoidable, while 23 (26%) and 47 (54%) were classified as definitely and possibly avoidable, respectively. ADRs were related with female gender (p = 0.023) and number of drugs (p = 0.004), but not with high age (p = 0.151). Clinically relevant interactions were related with older age (p = 0.032) and number of drugs (p = 0.003), but not with gender (p = 0.380). None of the interactions with ED initiated medications were considered unjustified. Conclusions: ADRs frequently occur in the older patients admitted to the ED and are an important cause of hospital admissions with a substantial contribution of adverse drug interactions.

PHARMACOTHERAPY OF DEPRESSION IN OLD AGE

Abstract This review addresses the pharmacotherapy of antidepressants in the elderly. We performed a search based on Medline and the Cochrane Library. In addition to a meta-analysis of 17 randomised controlled studies, 36 randomised controlled trials of patients over the age of 60 published between 1980 and 2005 in English met the selection criteria and were included. Existing evidence suggests that no one class of antidepressant drugs has been found to be more effective than another in the treatment of depression in the elderly. Although newer antidepressants are not more effective than older ones, they are better tolerated and are safe especially in overdose. The adverse effect data suggest modest superiority of selective serotonin reuptake inhibitors over tricyclic antidepressants. The evidence available indicates that antidepressant treatment of four weeks has a beneficial effect compared to placebo. As to prevention of relapse and recurrence, antidepressants should be continued for at least six months after good initial response. In patients with high risk of relapse, treatment should be continued for at least two years. Long-term efficacy has been shown for dosulepin, nortriptyline and citalopram. In patients with dementia with persistent and significant symptoms antidepressant treatment may be indicated. At present, clomipramine, citalopram and sertraline have been reported as being superior to placebo. There is a paucity of data on the use of antidepressants in very elderly individuals, patients with significant comorbidity and patients with dementia. More data on the effect of antidepressants in the elderly, especially in the over 80-age group are needed.

Nursing home residence is the main risk factor for increased mortality in healthcare-associated pneumonia

Healthcare-associated pneumonia (HCAP) is considered to represent a category of disease distinct from community-acquired pneumonia (CAP). We describe the incidence and characteristics of HCAP compared with CAP in patients hospitalised through the emergency department (ED). Pneumonia diagnosed at the ED of Ghent University Hospital from 1 November 2006 to 31 October 2007 was retrospectively categorised as CAP or HCAP according to the definition of the American Thoracic Society/Infectious Diseases Society of America. We categorised 287 episodes of pneumonia, diagnosed in 269 patients, as CAP [159 (55%)] or HCAP [128 (45%)]. Patients with HCAP were older [75 years (range: 64-83) vs 68 (41-78); P < 0.001], had more comorbidity, and had more severe pneumonia [CURB-65: 2 (1-3) vs 1 (0-2); P < 0.001] in comparison to patients with CAP. Patients with HCAP had more frequently an unfavourable clinical course (27% vs 15%; P < 0.01) and a longer hospital stay (12 days vs 9 days; P<0.001) compared with patients with CAP. In multivariate regression analysis, nursing home residence (odds ratio: 2.96; 95% confidence interval: 1.12-7.84; P = 0.03) but not HCAP was an independent predictor for in-hospital mortality. In conclusion, a high percentage (45%) of patients hospitalised with pneumonia through the ED was classified as HCAP. Classification as HCAP was associated with an unfavourable clinical course. Nursing home residence was an independent predictor for increased mortality.

Hepatotoxicity of N,N-dimethylformamide (DMF) in acute poisoning with the veterinary euthanasia drug T-61

1 We report on a patient who was resuscitated after a suicide attempt with the veterinary euthanasia pro duct T-61 and treated with N-acetylcysteine (NAC) to prevent hepatotoxicity from N,N-dimethylformamide (DMF), the solvent of T-61. 2 Serum concentrations of DMF were high as compared with values published on occupational exposure. 3 The patient showed only a transient increase in liver enzymes with eventually a full recovery. 4 The hepatoprotective effect of NAC was studied in a rat model using the rise in serum sorbitol dehydrogenase (SDH) as a marker for DMF-induced hepatotoxicity. 5 Four series of randomized, controlled and double- blind experiments were carried out and consistently showed a lower increase in SDH in NAC-treated animals in each series. The difference was statistically significant only when the data of the 4 series were pooled. This is probably due to the large interindivi dual variations in the effect of DMF. 6 We hypothesize that in the rat NAC may have a protective effect. Whether NAC is also protective in patients, in which it is administered after exposure to DMF, cannot be concluded from the present experi ments.

Late Kibaran magmatism in Burundi

Abstract The Late Kibaran magmatism in Burundi is represented by 2 magmatic associations. Small alkaline granitoid plutons constitute the first one. In Central Burundi, they form a N-S alignment of 40 km. A new RbSr 7 WR age of 1137 ± 39 M.a. (Ro = 0.7027 ± 0.0011; MSWD = 2.0), considered to date the emplacement of the granitoids, confirms a preliminary age of 1125 M.a. In Burundi and NW Tanzania, the second association is represented by an alignment of mafic and ultramafic intrusive bodies which form a prominent structure 350 km long and at least 25 km wide. The plutons have developed thermal aureoles. In Central Burundi, the granitoids, as well as the mafic and ultramafic rocks, occur on both sides of a major N-S trending Late Kibaran shear zone. This suggests a genetic relationship, not only between the shear and the magmatism, but also between both magmatic associations. Recent fieldwork confirms this hypothesis as both mafic rocks and granitoids have been observed in continuity within a single massif. More field observations and laboratory research, however, are needed before we can propose a coherent geodynamic model.

Acrylonitrile exposure in the general population following a major train accident in Belgium: A human biomonitoring study

BACKGROUND On Saturday May 4, 2013, a train transporting chemicals derailed in the village of Wetteren (Belgium) and caused a leak of acrylonitrile (ACN). OBJECTIVES To assess the human exposure to acrylonitrile in the local population with the highest suspected exposure. METHODS Between May 18-25, 242 residents participated in the study. N-2-cyanoethylvaline (CEV), a biomarker that is highly specific for ACN exposure, was measured in the blood. To account for potential influence by smoking, cotinine was determined in the urine. Participants also filled in a short questionnaire. RESULTS In the evacuated zone, 37.3% of the non-smokers and 40.0% of the smokers had CEV concentrations above the reference values of 10 and 200 pmol/g globin, respectively, at the time of the train accident. Spatial mapping of the CEV concentrations depending on the residential address showed a distribution pattern following the sewage system. DISCUSSION AND CONCLUSION The train derailment resulted in a highly atypical sequence-of-events. In addition to exposure in the direct vicinity of the site of the train derailment, exposure also occurred via the sewage system, into which acrylonitrile had entered shortly after the accident.

Use of out-of-hours services : the patient's point of view on co-payment: a mixed methods approach

Abstract Introduction: In many countries out of hours (OOH) care is offered by different health care services. General practitioners (GP) tend to offer services in competition with emergency departments (ED). Patients behaviour depends on a number of factors. In this study, we highlight the knowledge and ideas of patients concerning the co-payment system. Methods: We used a mixed methods design, combining quantitative and qualitative research. During two weekends in January 2005, all patients using the ED or the GP OOH service, were invited for an interview with a structured questionnaire. A stratified random sample of patients participated in a semi-structured interview. Both methods add complementary data to answer the research questions. Results: Most mentioned reasons for seeking help at the ED are: accessibility (15.0%), proximity (6.4%) and competence of the staff (5.6%). Reasons for choosing the GP are: GP is easy to find, minor medical problem or anxiety and confidence in the GP. The odds of not knowing the co-payment system are significantly higher in patients visiting the ED (OR 1.783; 95% CI: 1.493-2.129). Mostly GP users recognize the problem of ED overuse. They suggested especially to provide clear information about the tasks of the different services and about the payment system, to reduce ED overuse. Conclusion and discussion: When intending to shift from ED to GP services for minor medical problems, aiming at just one measure is no option. Information campaigns aiming to address the entire population, can clarify the role of each player in out-of-hours care.

External artifacts by advanced life support providers misleading automated external defibrillators

BACKGROUND The ECG analysis algorithm of automated external defibrillators (AEDs) shows reduced sensitivity and specificity in the presence of external artifacts. Therefore, ECG analyses are preceded by voice prompts. We investigated if advanced life support (ALS) providers follow these prompts, and the consequences if they do not. METHODS In a two-tiered EMS system all 510 ECG analyses from 135 resuscitation attempts with a Laerdal FR2 AED (applied by emergency medical technicians [EMTs] and subsequently used by ALS providers) were prospectively evaluated. The ALS data were compared with data before arrival of ALS providers (EMT data) using Mc Nemar test. RESULTS In the presence of ALS providers, 286 ECG rhythm analyses were performed. In the 96 analyses with shockable rhythms, artifacts were detected in 35 (36%), leading to a wrongful no shock decision in 19 (20%). Corresponding EMT data were 67 analyses with shockable rhythms, with artifacts in 18 (27%; p<0.001) but a wrongful no shock decision in only 3 (4%; p<0.001). ALS providers also failed to deliver the AED shock in 7 of the 77 analyses with an appropriate shock decision (9%). This was never found in the EMT data. In the 190 analyses of a non-shockable rhythm in the presence of ALS providers, artifacts were detected in 120 (63%) leading to one spurious shock (0.5%). Corresponding EMT data were 157 analyses, with artifacts in 87 (55%; p=0.20) but no spurious shocks. CONCLUSIONS External artifacts were frequently found, sometimes leading to important errors. Consequently, more training is needed, especially for ALS providers.