William O. Robertson

Zolpidem-Associated Hallucinations and Serotonin Reuptake Inhibition: A Possible Interaction

BACKGROUNDnZolpidem (Ambien) is a sedative believed to act exclusively at the benzodiazepine omega 1 receptor. Sporadic case reports of zolpidem-associated hallucinations have appeared over the past 5 years, and over the past 2 years, the Washington Poison Center received five reports of prolonged visual hallucinations associated with zolpidem.nnnCASE REPORTSnAll five patients reported experiencing visual hallucinations lasting from 1-7 hours soon after taking zolpidem. Most had been taking zolpidem for less than a week and all five were concurrently taking an antidepressant: sertraline, desipramine, fluoxetine, bupropion, or venlafaxine; two sought assistance at a hospital.nnnDISCUSSIONnThe precise mechanism of zolpidem-associated hallucinations remains unknown. In some previously published cases, the zolpidem-associated hallucinations have been short in duration, lasting at most 30 minutes. In contrast, the five patients in our series and in five previously reported cases, the hallucinations were more persistent, lasting up to 7 hours. Of these ten cases with persistent symptoms, nine were concurrently taking antidepressants that inhibit serotonin-reuptake, despite the fact that zolpidem has no known serotonin-mediated mechanisms.nnnCONCLUSIONSnThese cases, plus prior case reports, suggest that a pharmacodynamic interaction between serotonin reuptake inhibition and zolpidem may lead to prolonged zolpidem-associated hallucinations in susceptible individuals.

Misrepresentation of authorship by applicants to pediatrics training programs

PURPOSE: To determine whether applicants to pediatrics residency and fellowship programs misrepresented authorship of publications. METHOD: The authors sampled 1995 applications to the University of Washington School of Medicines pediatrics residency program and pediatrics pulmonary fellowship program. They submitted all publications claimed in the submitted applications to extensive efforts to authenticate both their existence and authorship. RESULTS: Among the 404 pediatrics residency program applications studied, 147 claimed authorship of publications; 29 (19.7%) of these contained at least one unverifiable publication. Of the 401 publications claimed in the 147 applications, 41 (10.2%) could not be confirmed. Among 31 fellowship applications, 14 claimed publications. At least one citation was unverifiable for each of the 14 applications. Of the total 77 publications claimed, 31 (40%) could not be confirmed. CONCLUSION: Misrepresentation occurs on graduate medical education applications; solutions are needed to address this problem.

Fumigant-Related Illnesses: Washington State's Five-Year Experience

Objective: Exposure to fumigants may have severe or persistent health effects. Washington States fumigant-related illnesses were reviewed to better understand the circumstances surrounding exposure and resultant health effects. Methods: Fumigant-related illnesses reported to and investigated by the Washington State Department of Health were reviewed. Illnesses considered by Department of Health to be definitely, probably, or possibly related to pesticide exposure were then analyzed. Results: From 1992–1996, 39 (3.3%) of 1192 definite, probable, or possible cases of pesticide-related illnesses involved exposures to fumigants. Fumigant exposures during this period were to aluminum phosphide (15), methyl bromide (12), metam-sodium (9), and zinc phosphide (3). Symptoms included respiratory problems and eye and/or skin irritation for the majority of exposures, and no deaths were reported. The nature of exposure for these cases included exposure to applicators (17), reentry into a fumigated structure (9), improper storage or disposal (6), reentry into treated agricultural fields (4), drift from treated fields (2), and other (1). Conclusions: Review of fumigant exposures should be used to prevent future events through continued enforcement of established regulations and training of applicators.

Hazardous materials incidents: the Washington Poison Center experience and approach to exposure assessment.

Hazardous materials incidents include gas and vapor releases, spills, explosions, and fires. Incidents involving human exposure are challenging for most health care providers because of the vast number of potential chemicals involved, frequently incomplete incident information, and limited experience in exposure assessment. To facilitate improved evaluation and treatment of patients with chemical exposures, the Washington Poison Center established the Hazardous Materials Exposure Information Service in 1994. During the first 33 months of operation, this service has provided information on 70 incidents, involving a total of 1120 exposed individuals, including 501 patients treated in medical facilities. This paper reviews these incidents, the process used to collect information from the incidental scene, and selected techniques for evaluating the extent of individual chemical exposure.

Hazardous Materials Exposure Information Service: Development, Analysis, and Medical Implications

The Hazardous Materials Exposure Information Service (HMEIS) was established at the Washington Poison Center (WPC) to rapidly provide information to medical professionals who treat victims of hazardous-materials exposure. Incident description and exposure information is collected from on-site hazardous-materials teams and immediately analyzed by WPC medical toxicologists. Diagnostic and treatment recommendations are provided to prehospital personnel and receiving physicians. Over the first 22 months of operation, 50 calls were received that met HMEIS criteria. Of the 466 individuals exposed, 256 (55%) were transported to a medical facility for treatment. When the WPC was contacted before the decision to transport a patient to a medical facility, 28 of 185 exposure victims (15%) were transported, compared with a transport rate of 81% of exposure victims (66% change; 95% confidence interval [CI], 60% to 72%) in all other concurrent incidents and a historical transport rate of 63% (25% change; 95% CI, 14% to 36%) before the establishment of the HMEIS. These findings, although preliminary and subject to potential confounding, suggest that the HMEIS reduces health care costs through more efficient use of medical resources.

Risk factors for adverse health effects following hazardous materials incidents

Toidentify risk factors for persistent morbidity, we conducted a prospectivestudy of individuals involved in hazardous materials incidents reported to theWashington Poison Center. Between December 1997 and October 1999, 202 subjectsin 87 incidents were surveyed by telephone. Medical symptoms persisting for aminimum of 8 days after the incident were reported in 51 (25%) subjects, and18 (9%) left work or school for more than 2 days because of the exposure.Medical intervention was reported in 46 (58%) of 79 subjects for whom medicalrecords were available, and objective abnormalities were found in 57 (72%).Multiple logistic regression analysis indicated that subjects with dermalexposures, three or more alcoholic drinks per week, and previous use ofpsychiatric medications were more likely to report persistent symptoms.Divorced, widowed, or separated subjects, asthmatic subjects, and those havinginitial dermal symptoms were more likely to miss work or school for more than2 days. Of patients evaluated at a health care facility, subjects withpreexisting hypertension were more likely to receive medical treatment or haveobjective medical findings, whereas those with inhalation exposures and thosedecontaminated at the scene were less likely to be treated or haveabnormalities. In our study, both incident and individual factors werepredictive of adverse health effects, and these findings should be consideredin planning the care of patients involved in hazardous materialsincidents.

Continuing medical education: Potential role of tertiary care centers in the education of community physicians

&NA; To take advantage of the medical practitioners “teachable moment” for continuing medical education (CME) we accompanied “discharge summaries” with selected clinical abstracts focusing on the patients individual discharge diagnosis. A mail survey of 253 recipients brought a 45% return strongly supportive of such efforts for the future. We conclude that, for minimal costs, the technique holds promise as a CME method on the one hand, and as a potential marketing tool for the institution and its medical staff on the other. We are planning to attempt to quantify clinical behavior changes—if any—among the recipients.