S.B. Gunatilake

Multiple-dose activated charcoal for treatment of yellow oleander poisoning: a single-blind, randomised, placebo-controlled trial

BACKGROUND Deliberate self-poisoning with yellow oleander seeds is common in Sri Lanka and is associated with severe cardiac toxicity and a mortality rate of about 10%. Specialised treatment with antidigoxin Fab fragments and temporary cardiac pacing is expensive and not widely available. Multiple-dose activated charcoal binds cardiac glycosides in the gut lumen and promotes their elimination. We aimed to assess the efficacy of multiple-dose activated charcoal in the treatment of patients with yellow-oleander poisoning. METHODS On admission, participants received one dose of activated charcoal and were then randomly assigned either 50 g of activated charcoal every 6 h for 3 days or sterile water as placebo. A standard treatment protocol was used in all patients. We monitored cardiac rhythm and did 12-lead electocardiographs as needed. Death was the primary endpoint, and secondary endpoints were life-threatening cardiac arrhythmias, dose of atropine used, need for cardiac pacing, admission to intensive care, and number of days in hospital. Analysis was by intention to treat. FINDINGS 201 patients received multiple-dose activated charcoal and 200 placebo. There were fewer deaths in the treatment group (five [2.5%] vs 16 [8%]; percentage difference 5.5%; 95% CI 0.6-10.3; p=0.025), and we noted difference in favour of the treatment group for all secondary endpoints, apart from number of days in hospital. The drug was safe and well tolerated. INTERPRETATION Multiple-dose activated charcoal is effective in reducing deaths and life-threatening cardiac arrhythmias after yellow oleander poisoning and should be considered in all patients. Use of activated charcoal could reduce the cost of treatment.

Twenty-seven venous cutdowns to treat pseudostatus epilepticus

Pseudoseizures are often misdiagnosed. We report a patient with pseudostatus epilepticus who has had 27 venous cutdowns on different occasions when she was admitted to hospital with repeated seizures.

Yellow oleander poisoning in Sri Lanka: outcome in a secondary care hospital

Cardiac toxicity after self-poisoning from ingestion of yellow oleander seeds is common in Sri Lanka. We studied all patients with yellow oleander poisoning (YOP) admitted to a secondary care hospital in north central Sri Lanka from May to August 1999, with the objective of determining the outcome of management using currently available treatment. Patients with bradyarrhythmias were treated with intravenous boluses of atropine and intravenous infusions of isoprenaline. Temporary cardiac pacing was done for those not responding to drug therapy. During the study period 168 patients with YOP were admitted to the hospital (male:female=55:113). There were six deaths (2.4%), four had third-degree heart block and two died of undetermined causes. They died soon after delayed admission to the hospital before any definitive treatment could be instituted. Of the remaining 162 patients, 90 (55.6%) patients required treatment, and 80 were treated with only atropine and/or isoprenaline while 10 required cardiac pacing in addition. Twenty-five (14.8%) patients had arrhythmias that were considered life threatening (second-degree heart block type II, third-degree heart block and nodal bradycardia). All patients who were treated made a complete recovery. Only a small proportion of patients (17%) admitted with YOP developed life-threatening cardiac arrhythmias. Treatment with atropine and isoprenaline was safe and adequate in most cases.

Juvenile myoclonic epilepsy: a study in Sri Lanka

Juvenile myoclonic epilepsy (JME) has a distinct clinical profile. Often JME is not recognized, with the result that proper treatment is not instituted, leading to poor control of seizures. This study is an attempt to identify the factors that contribute to the delay in diagnosing this condition. During a period of 3 years 40 patients (21 females) with JME were identified and all were included in a prospective follow-up study. The age range was 12-58 years. Twenty-seven patients (67%) had already seen at least one specialist; however, diagnosis had not been made despite the presence of characteristic features. The duration of delay in diagnosis varied from months to years with a mean of 11 years. Myoclonic jerks were the most characteristic feature, but only six volunteered this information spontaneously. The response to treatment with sodium valproate was excellent, although only three were taking it when first seen. As a result of treatment with other drugs all patients were having recurrent seizures. The main reasons for the delay in diagnosis found in our study were that the physicians were unaware of the condition, the occurrence of myoclonic jerks were overlooked either because the patients were not directly questioned about them or because the patients did not volunteer the information.

Parasuicide by self-injection of an organophosphate insecticide

Parasuicide by ingestion of organophosphate (OP) insecticides is common in Sri Lanka, but the use of the parateral route to self administer the poison is extremely rare. We report a patient who deliberately injected herself intramuscularly with an OP compound with suicidal intent. The clinical manifestations of OP poisoning were unpredictable and posed a therapeutic problem.

Medial Temporal Lobe Atrophy, Apolipoprotein Genotype, and Plasma Homocysteine in Sri Lankan Patients with Alzheimer's Disease

ABSTRACT The authors studied the association of Alzheimers disease (AD) with total plasma homocysteine (tHcy) and apolipoprotein E (apoE) genotype, and the usefulness of measuring medial temporal lobe thickness (MTL) thickness for the diagnosis of AD in Sri Lankan patients. Using criteria of the NINCDS-ADRDA, 23 AD patients and 21 controls were recruited. All underwent MTL-oriented computed tomographic (CT) scans, measurement of plasma tHcy, and apoE genotyping. Mean plasma tHcy was significantly higher in AD patients than controls (p = .001). This association was independent of age, sex, body mass index (BMI), serum folate and vitamin B12, and serum creatinine. The frequency of apoE4 allele was significantly higher (p = .003) in AD patients, and the adjusted odds ratio of AD for the presence of one or more apoE4 alleles compared with none was 10.39 (95% CI 1.77–61.10; p = .010). The mean minimum MTL thickness was significantly higher in control subjects compared to that of AD patients (p < .001). This first report of apoE4, plasma tHcy, MTL thickness, and AD from Sri Lanka shows that high plasma tHcy, the presence of apoE4 allele, and MTL atrophy are associated with AD.

Self-limiting cerebellar ataxia following organophosphate poisoning

Deliberate self-harm by ingestion of organophosphate insecticides is a common health problem in Sri Lanka. The poisoning results in an initial life-threatening cholinergic crisis and several intermediate and late neurological and psychiatric manifestations. A patient who developed self-limiting cerebellar signs 8 days after ingestion of dimethoate, an organophosphorous insecticide, is reported on.

Use of early aspirin in suspected acute myocardial infarction by General Practitioners in Sri Lanka

Early low dose aspirin therapy is beneficial in myocardial infarction (MI). This study investigated the use of early aspirin therapy in patients with suspected MI by General Practitioners (GP). Patients with MI who were referred to our unit by GPs were studied to see whether aspirin therapy had been initiated before referral. A questionnaire was sent to GPs to test their attitudes and practices regarding early aspirin therapy in suspected MI. Our results indicate that few patients with MI had been given early aspirin therapy. Only a minority of GPs were aware of the benefits of early aspirin therapy in MI, and very few prescribed it. Even when it was prescribed, the dose and route of administration were wrong in most instances.

Multidose activated charcoal for yellow oleander poisoning

Sir—H A de Silva and colleagues (June 7, p 1935) report that multipledose activated charcoal (MDAC) confers a survival advantage over a single dose in patients with yellow oleander poisoning. We commend the researchers for addressing a serious health concern endemic to Sri Lanka. However, certain aspects of their study merit additional comment. The comparison of groups at baseline would benefit from additional specification. Because of the prognostic implications of varying degrees of depressed atrioventricular conduction and enhanced ventricular automaticity in such poisonings, a breakdown of arrhythmias and baseline heart rate would be more informative than simply categorising ventricular fibrillation and seconddegree atrioventricular block together. The early death rate for individuals with yellow oleander poisoning (one of 422 at 6 h, or 0·2%) in this study is remarkably low. Moreover, premonitory arrhythmias were reported in fewer than half of the deaths. The same researchers and others have previously suggested that deaths from yellow oleander poisoning often occur shortly after hospital admission, and are usually preceded by third degree atrioventricular block or ventricular tachyarrhythmias. Many of the deaths in this study are, therefore, unusual, yet they are essential to the study’s interpretation because the absolute number of events in the two groups are sufficiently low as to render the study’s conclusions statistically fragile. Another puzzling aspect of the trial is the sample size calculation, which is not straightforward. De Silva and colleagues estimate a 10% death rate for controls, citing previous work by Eddleston and colleagues, involving patients treated at remote hospitals often without the benefits of pacing or digoxin immune Fab. Why did the group not rely on their own previous research, reporting a death rate of 2·4%. Moreover, de Silva and co-workers anticipated a 75% reduction in the risk of death in patients treated with MDAC. The basis for such optimism is unclear, since MDAC has not been shown to improve clinical outcomes associated with cardiac glycoside toxicity. Two other aspects of the trial deserve comment. Although controversial, routine use of gastric lavage is difficult to justify, especially for late presentations (averaging 10 h in this study) after ingestion of a highly emetogenic substance. Finally, digoxin immune Fab should be standard care for patients with serious cardiac glycoside toxicity. Only seven of at least 21 patients (33%) with an absolute indication for the drug (lifethreatening arrhythmias) received it. Notwithstanding its limited availability and cost, withholding this essential antidote affects this study’s conclusions and generalisability. *David N Juurlink, Marco L A Sivilotti