Common pitfalls in the use of hypertonic sodium bicarbonate for cardiac toxic drug poisonings

BACKGROUND

Hypertonic sodium bicarbonate is advocated for the treatment of sodium channel blocker poisoning, but its efficacy varies amongst different sodium channel blockers. This Commentary addresses common pitfalls and appropriate usage of hypertonic sodium bicarbonate therapy in cardiotoxic drug poisonings.

SODIUM BICARBONATE WORKS SYNERGISTICALLY WITH HYPERVENTILATION

Serum alkalinization is best achieved by the synergistic effect of hypertonic sodium bicarbonate and hyperventilation (PCO2 ∼ 30-35 mmHg [0.47-0.6 kPa]). This reduces the dose of sodium bicarbonate required to achieve serum alkalinization (pH ∼ 7.45-7.55) and avoids adverse effects from excessive doses of hypertonic sodium bicarbonate.

VARIABILITY IN RESPONSE TO SODIUM BICARBONATE TREATMENT

Tricyclic antidepressant poisoning responds well to sodium bicarbonate therapy, but many other sodium channel blockers may not. For instance, drugs that block the intercellular gap junctions, such as bupropion, do not respond well to alkalinization. For sodium channel blocker poisonings in which the expected response is unknown, a bolus of 1-2 mmol/kg sodium bicarbonate can be used to assess the response to alkalinization.

SODIUM BICARBONATE CAN EXACERBATE TOXICITY FROM DRUGS ACTING ON MULTIPLE CARDIAC CHANNELS

Hypertonic sodium bicarbonate can cause electrolyte abnormalities such as hypokalaemia and hypocalcaemia, leading to QT interval prolongation and torsade de pointes in poisonings with drugs that have mixed sodium and potassium cardiac channel properties, such as hydroxychloroquine and flecainide.

THE GOAL FOR HYPERTONIC SODIUM BICARBONATE IS TO ACHIEVE THE ALKALINIZATION TARGET (∼PH 7.5), NOT COMPLETE CORRECTION OF QRS COMPLEX PROLONGATION

Excessive doses of hypertonic sodium bicarbonate commonly occur if it is administered until the QRS complex duration is < 100 ms. A prolonged QRS complex duration is not specific for sodium channel blocker toxicity. Some sodium channel blockers do not respond, and even when there is a response, it takes a few hours for the QRS complex duration to return completely to normal. In addition, QRS complex prolongation can be due to a rate-dependent bundle branch block. So, no further doses should be given after achieving serum alkalinization (pH ∼ 7.45-7.55).

MAXIMAL DOSING FOR HYPERTONIC SODIUM BICARBONATE

A further strategy to avoid overdosing patients with hypertonic sodium bicarbonate is to set maximum doses. Exceeding 6 mmol/kg is likely to cause hypernatremia, fluid overload, metabolic alkalosis, and cerebral oedema in many patients and potentially be lethal.

RECOMMENDATION FOR THE USE OF HYPERTONIC SODIUM BICARBONATE IN SODIUM CHANNEL BLOCKER POISONING

We propose that hypertonic sodium bicarbonate therapy be used in patients with sodium channel blocker poisoning who have clinically significant toxicities such as seizures, shock (systolic blood pressure < 90 mmHg, mean arterial pressure <65 mmHg) or ventricular dysrhythmia. We recommend initial bolus dosing of hypertonic sodium bicarbonate of 1-2 mmol/kg, which can be repeated if the patient remains unstable, up to a maximum dose of 6 mmol/kg. This is recommended to be administered in conjunction with mechanical ventilation and hyperventilation to achieve serum alkalinization (PCO2∼30-35 mmHg [4-4.7 kPa]) and a pH of ∼7.45-7.55. With repeated bolus doses of hypertonic sodium bicarbonate, it is imperative to monitor and correct potassium and sodium abnormalities and observe changes in serum pH and on the electrocardiogram.

CONCLUSIONS

Hypertonic sodium bicarbonate is an effective antidote for certain sodium channel blocker poisonings, such as tricyclic antidepressants, and when used in appropriate dosing, it works synergistically with hyperventilation to achieve serum alkalinization and to reduce sodium channel blockade. However, there are many pitfalls that can lead to excessive sodium bicarbonate therapy and severe adverse effects.

Home Therapies to Neutralize Button Battery Injury in a Porcine Esophageal Model

STUDY OBJECTIVE

Button battery ingestion can cause alkaline esophageal injury. There is interest in first-aid household products to neutralize the injury. The objective was to investigate which household products are effective at reducing button battery injury.

METHODS

Two cadaveric porcine experiments were performed. Experiment 1 utilized esophageal mucosal segments. A button battery (3VCR2032) was placed onto the mucosa, and substances (saline control, honey, jam, orange juice, yogurt, milk, and cola) were applied every 10 minutes for 6 applications. Tissue pH was measured every 10 minutes, and macroscopic ulceration size was assessed at 120 minutes. Experiment 2 used an intact esophageal model with a battery inserted into the lumen and jam, honey, and saline irrigation as per experiment 1. Tissue pH, macroscopic and histopathology changes were evaluated at 60, 90 and 120 minutes.

RESULTS

In experiment 1, only honey and jam had a lower mean tissue pH at 120 minutes (8.0 [standard deviation [SD] 0.9, n=12] and 7.1 [SD 1.7, n=12], respectively) compared to saline solution 11.9 (SD 0.6, n=6, P<.0001). Both honey (0.24 cm2, SD 0.17) and jam (0.37 cm2, SD 0.40) had smaller mean areas of ulceration compared to saline solution (3.90 cm2, SD 1.03, P<.0001). In experiment 2, honey and jam had significantly lower mean tissue pH at all timepoints compared to saline solution. Histologic changes were evident at 60 minutes in the saline group, whereas honey and jam exhibited no or minimal changes until 120 minutes.

CONCLUSIONS

Honey and jam were able to neutralize injury caused by a button battery resulting in a smaller area of ulceration. Jam should be further explored as a possible first-aid option as an alternative to honey in suspected button battery ingestion prior to definitive management.

Cognitive impairment following sedative overdose

INTRODUCTION

Patients with sedative overdose may have residual cognitive impairment at the time they are deemed medically cleared for discharge. Impairment could affect the performance of high-risk activities, including driving. The Trail Making Test is an alpha-numeric assessment that can be performed at the bedside to assess cognitive function. We examined whether there were differences in cognitive function when medically cleared between patients that overdosed on sedative and non-sedative drugs.

METHODS

A prospective, observational study assessed cognitive function using the Trail Making Test between 2018 and 2021. Patients (16 years and greater) completed testing upon medical clearance if they spoke English and had no previous neurological injury. Continuous covariates were compared using t-tests or Mann-Whitney U tests and multiple linear regression; binary variables were modelled using logistic regression.

RESULTS

Of 171 patients enrolled, 111 (65 per cent) had sedative overdose; they were older (median 32.1 versus 22.2 years) and more likely to be male (58.6 per cent versus 36.7 per cent). Benzodiazepines and paracetamol were the commonest drug overdoses. Patients with sedative overdose performed worse on Trail Making Test part A (37.0 versus 33.1 seconds, P = 0.017) and Trail Making Test part B (112.4 versus 81.5 seconds, P = 0.004). Multiple linear regression analysis indicated that patient age (P < 0.001, 1.7 seconds slower per year, 95 per cent confidence interval: 0.9-2.6 seconds) and perception of recovery (P = 0.006, 36.4 seconds slower if perceived not recovered, 95 per cent confidence interval: 10.8-62.0 seconds) were also associated with Trail Making Test part B times. Patients with sedative overdose were more likely to be admitted to the intensive care unit (Odds Ratio: 4.9, 95 percent confidence interval: 1.1-22.0; P = 0.04).

DISCUSSION

Our results are broadly in keeping with previously published work, but include a wider range of drug overdose scenarios (polypharmacy and recreational drugs). While patients demonstrated some perception of their cognitive impairment, our model could not reliably be used to provide individual discharge advice. The study design did not allow us to prove causation of cognitive impairment, or to make comparison between the strength of an overdose to the trail making test time.

CONCLUSIONS

Trail Making Test results suggested that patients who had sedative drug overdoses may have significant cognitive deficits even when medically cleared. Risk of harm may be minimised with advice to avoid high-risk activities such as driving. More profound impacts seen on the Trail Making Test part B than A may mean higher-order thinking is more affected than simple cognitive function.

Case series profile of olanzapine post-injection delirium/sedation syndrome

Olanzapine pamoate is an intramuscular depot injection for the treatment of schizophrenia. Approximately 1.4% of patients develop a serious adverse event called post-injection delirium/sedation syndrome (PDSS), characterised by drowsiness, anticholinergic and extrapyramidal symptoms. The objective is to investigate olanzapine PDSS presentations including clinical features and treatment approach. This is a retrospective review of olanzapine PDSS patients from three toxicology units and the NSW Poisons Information Centre between 2017 and 2022. Adult patients were included if they had intramuscular olanzapine then developed PDSS criteria. Clinical symptoms, treatment, timing and length of symptoms were extracted into a preformatted Excel database. There were 18 patients included in the series, with a median age of 49 years (interquartile range [IQR]: 38-58) and male predominance (89%). Median onset time post injection was 30 min (IQR: 11-38). PDSS symptoms predominate with drowsiness, confusion and dysarthria. Median length of symptoms was 24 h (IQR: 20-54). Most common treatment included supportive care without any pharmacological intervention (n = 10), benzodiazepine (n = 4) and benztropine (n = 3). In one case, bromocriptine and physostigmine followed by oral rivastigmine were given to manage antidopaminergic and anticholinergic symptoms respectively. This proposed treatment combination could potentially alleviate some of the symptoms but needs further studies to validate the findings. In conclusion, this case series supports the characterisation of PDSS symptomology predominantly being anticholinergic with similar onset (<1 h) and duration (<72 h). Bromocriptine is proposed to manage PDSS if patients develop severe dopamine blockade and physostigmine followed by rivastigmine for anticholinergic delirium.

Prescribing Trend of Tapentadol in a Sydney Local Health District

BACKGROUND

Tapentadol, an opioid with mu-opioid receptor agonism and noradrenaline reuptake inhibition, has been increasingly used in Australia since 2011. However, data on hospital prescribing trends and indications are scarce.

OBJECTIVES

To investigate hospital prescribing trends of tapentadol, oxycodone and tramadol in a Sydney Local Health District (LHD) and the indications for tapentadol hospital prescriptions in an Australian tertiary hospital.

METHODS

Firstly, we analysed 5-year patient dispensing for tapentadol, oxycodone and tramadol from four hospitals in a Sydney LHD with data expressed as oral morphine equivalents (OME). Secondly, a retrospective review of 140 and 54 patients prescribed tapentadol at a tertiary hospital's surgical and spinal units in 2020 was conducted.

RESULTS

Over 5 years in the Sydney LHD, there was a 19.5% reduction in total dispensing of these opioids from 1,225,210 to 986,477.5 OME milligrams. Decreases were specifically for oxycodone(-37.8% immediate-release, -65.2% sustained-release) and tramadol(-74.6% immediate-release, -70.1% sustained-release). Contrastingly, hospital prescriptions of tapentadol immediate-release increased by 223.2% between 2018-19 and 2020-21 while sustained-release increased by 17.9% from 2016-17 to 2020-21. By 2020-21, tapentadol overtook oxycodone to become the most prescribed opioid in the Sydney LHD(51.4%). At the hospital's surgical units, 137(97.9%) patients were prescribed tapentadol for acute post-operative pain with majority(54.0%) prescribed both immediate-release and sustained-release tapentadol, while 71.1% were prescribed for neuropathic pain in the spinal units.

CONCLUSION

In a Sydney LHD, tapentadol prescriptions increased significantly to become the preferred opioid analgesic. At the hospital's surgical units, off-label prescriptions of tapentadol sustained-release for acute post-operative pain were observed.

Tapentadol exposures and poisonings in Australia

INTRODUCTION

Tapentadol is an atypical opioid with mu-receptor affinity and noradrenaline reuptake inhibition approved for use in Australia in 2011. However, data on tapentadol poisoning are scarce.

OBJECTIVES

To investigate tapentadol poisonings and related deaths in Australia.

METHODS

We performed a retrospective review of tapentadol poisonings from New South Wales Poisons Information Centre (NSWPIC) and three toxicology units in Australia. The National Coronial Information System (NCIS) database was searched to determine the number of tapentadol-related deaths.

RESULTS

Between 2016 and 2020, 220 tapentadol calls were made to NSWPIC, with a 4.5-fold increase in tapentadol exposure calls. The median dose ingested was 575 mg (IQR: 300-1163 mg). Most overdoses included co-ingestions (75%), especially benzodiazepines (26%) and opioids (25%). From Jan 2016 to Dec 2021, 107 patients presented to the three toxicology units with tapentadol poisoning. The median dose ingested was 500 mg (IQR: 200-1400 mg). Most patients took co-ingestants (84%), including benzodiazepines (40%) and opioids (32%). Naloxone was administered in 39 patients (36%), 10 (9%) were intubated and the median length of stay was 18 h (IQR: 9-30). Thirty-five tapentadol-related deaths were recorded within NCIS between Jan 2015 and Oct 2021 with a median age of 51 years (IQR: 42-61 years).

CONCLUSION

There are increasing tapentadol poisonings and deaths reported to the NSWPIC, three toxicology units, and NCIS in Australia. Most tapentadol poisonings were taken with benzodiazepines and/or other opioids.

Clinical experience with titrating doses of digoxin antibodies in acute digoxin poisoning. (ATOM-6)

INTRODUCTION

For acute digoxin poisoning, it has been recommended to give bolus doses of 10-20 vials or potentially larger than needed doses calculated from dose ingested or the measured concentration. However, a recent revision of internal Poisons Information Centre guidelines prompted a change of our recommendations, specifically instead of large boluses, to use titrating repeated low doses of digoxin antibodies(Digoxin-Fab) based on bedside assessment of cardiac toxicity.

METHODS

This is a prospective observational study of patients with acute digoxin poisoning identified through two Poisons Information Centres and three toxicology units. Patient demographics, signs and symptoms of digoxin toxicity, doses and response to Digoxin-Fab, free and bound serum digoxin concentrations. Outcomes were recorded and analysed.

RESULTS

From September 2013 to September 2020, 23 patients with 25 presentations (median age 56 years, females 56%) were recruited. Median dose ingested was 13 mg(IQR: 9.5-25). Median heart rate (HR) was 41 beats/min before treatment. Initial median digoxin and potassium concentrations were 14.5 nmol/L (IQR: 10.9-20) [11.2 µg/L(IQR: 8.4-15.4)] and 5 mmol/L (IQR: 4.5-5.4 mmol/L), respectively. Gastrointestinal symptoms and acute kidney injury were present in 22 patients (88%) and 5 patients (20%), respectively. Four patients received an initial bolus dose of Digoxin-Fab of 5-20 vials. Twenty-one patients received repeated titrated doses (1-2 vials) of Digoxin-Fab and the median total dose was 4 vials (IQR: 2-7.5). Median maximal change in HR post-Digoxin-Fab was 19 beats/min. The median potassium concentration decrease post-Digoxin-Fab was 0.3 mmol/L. Total dose used in the titration group was 25% and 35% of the predicted doses based on the amount of digoxin ingested or measured serum concentration, respectively. Twelve had free digoxin concentrations measured. Free digoxin concentrations dropped to almost zero after any dose of Digoxin-Fab. Ten patients had a rebound of digoxin >2.6 nmol/L (2 µg/L). There were no deaths from acute digoxin toxicity.

CONCLUSIONS

The new practice of using small, titrated doses of Digoxin-Fab led to a considerable reduction in total usage and major savings. The clinical response to titrated doses was safe and acceptable in acute digoxin poisoning.

Optimising alkalinisation and its effect on QRS narrowing in tricyclic antidepressant poisoning

AIMS

The objectives were to determine the effect of NaHCO₃ and/or mechanical ventilation on the biochemical profile and serum alkalinisation in tricyclic antidepressant (TCA) poisoning and investigate the impact of effective alkalinisation therapy on the QRS interval in TCA poisoning.

METHODS

This was a retrospective review of TCA poisonings from three Australian toxicology units and a poisons information centre (Jan 2013 to Jan 2019). We included patients with TCA toxicity who ingested>10 mg/kg or had clinically significant toxicities consistent with TCA poisoning, and analysed patients' clinical, electrocardiogram and biochemical data.

RESULTS

Of 210 patients, 84 received NaHCO₃ and ventilation (dual therapy), 12 NaHCO₃ , 46 ventilation and 68 supportive care treatment. When compared with single/supportive groups, patients who received dual therapy had taken a significantly higher median dose of TCA (1.5 g vs1.3 g, P < .001), a longer median maximum QRS interval (124 ms, interquartile ranges [IQR] 108-138 vs106 ms, IQR 98-115, P < .001) and were more likely to have seizures (14% vs3%, P = .006) and arrhythmias (17% vs1%, P < .001). The dual therapy group demonstrated greater increases in serum pH (median 0.11, IQR 0.04-0.17) compared to the single/supportive therapy group (median 0.03, IQR -0.01-0.09, p < .001). A greater proportion of patients reached the target pH 7.45-7.55 in the dual therapy group (59%) compared to the single/supportive therapy group (10%) (P < .001). For each 100 mmol bolus of NaHCO₃ given, the median increase in serum sodium was 2.5 mmol/L (IQR 1.5-4.0). QRS narrowing occurred twice as quickly in the dual therapy vs single/supportive therapy group.

CONCLUSIONS

A combination of NaHCO₃ and mechanical ventilation was most effective in achieving serum alkalinisation and was associated with a more rapid narrowing of the QRS interval. We advise that the maximal dose of NaHCO₃ should be <400 mmol (6 mmol/kg).

A cluster of lysergic acid diethylamide (LSD) poisonings following insufflation of a white powder sold as cocaine

OBJECTIVE

Adulteration, substitution or contamination of illicit substances can have clinically significant implications when other illicit substances are included. Such circumstances can present as clusters of poisonings, including severe toxicity and death following exposure to unexpected illicit substances. We report a cluster of laboratory-confirmed lysergic acid diethylamide (LSD) in a powder that was sold as cocaine and used recreationally.

METHODS

The Prescription, Recreational and Illicit Substance Evaluation (PRISE) program established by the New South Wales Ministry of Health includes State-based hospital toxicology services, Poisons Information Centre, Forensic & Analytical Science Service and emergency services to identify clusters of severe and unusual toxicity associated with substance use. PRISE criteria include a known cluster (geographically or situationally related) of people with acute severe toxicity, especially when accompanied by a toxidrome that is inconsistent with the history of exposure. A timely comprehensive drug screen and quantification is performed in eligible cases and the results are related to the clinical features. The need for a public health response is then considered. Four individuals inhaled a white powder that was sold as cocaine and developed severe toxicity that was not consistent with cocaine which prompted transfer to hospital for further management.

RESULTS

LSD was confirmed in four subjects, and the concentrations in 3 of the individuals were 0.04-0.06 mg/L which are among the highest reported in the literature. Common clinical features were hallucinations, agitation, vomiting, sedation, hypertension, and mydriasis. One subject required intubation and admission to the intensive care unit, two required overnight admission, and the fourth was discharged following oral diazepam after observation. No subject suffered persistent injury.

CONCLUSIONS

A close working relationship between pre-hospital emergency services, hospital-based clinical services, public health authorities, and analytical laboratories appears to be advantageous. Favourable clinical outcomes are observed from LSD poisoning despite high exposures with good supportive care.

Association between shift work and cognitive performance on the Trail Making Test in emergency department health officers

OBJECTIVE

Shift work has been proposed to disturb alertness and decrease cognitive efficiency. However, studies so far have had varied findings. The aim of the present study was to compare cognitive function following shifts at different times of the day in an Australian ED context.

METHODS

A prospective, self-controlled observational study was conducted on medical and nursing staff at a tertiary referral centre and regional hospital ED. Participants were required to complete the Trail Making Test (TMT), a neurocognitive test consisting of two parts (TMT-A and TMT-B), at baseline (at the start of the day) and at the end of their shift (day, evening or night). Related samples Wilcoxon signed-rank tests were used to compare post-shift TMT performance to baseline in medical and nursing staff.

RESULTS

Over a 5-month period, 140 ED staff were recruited including 109 doctors and 31 nurses. After a night shift, medical staff (n = 85) and nursing staff (n = 29) took longer to complete the TMT-B by 3.4 s (P < 0.001) and 7.1 s (P = 0.01), respectively, compared to baseline. Post-evening shift, medical staff (n = 59) took longer to complete the TMT-A by 0.3 s (P = 0.02).

CONCLUSIONS

Night shift work was associated with a longer TMT time. This may indicate a decrease in cognitive performance, in particular, visual attention, processing speed, task switching and executive function and may implicate the quality of care for patients and worker safety.

Angiotensin axis antagonists increase the incidence of haemodynamic instability in dihydropyridine calcium channel blocker poisoning

CONTEXT

Amlodipine, a dihydropyridine calcium channel blocker (CCB), is the leading cause of cardiovascular drug-related overdose deaths in the USA. In contrast, angiotensin-II receptor blockers (ARBs) and angiotensin converting enzyme inhibitors (ACEIs) cause minimal toxicity in overdose. ACEIs/ARBs are often combined with dihydropyridines in hypertension treatment. Co-ingested ARBs/ACEIs may significantly contribute to the toxicity of dihydropyridine, but this has not been investigated.

OBJECTIVE

To investigate the clinical outcomes from dihydropyridine overdoses with ARBs/ACEIs versus dihydropyridine overdoses alone.

METHODS

This was a retrospective study of patients reported to the New South Wales Poisons Information Centre (NSW PIC) and 3 toxicology units (Jan 2016 to Jun 2019) in Australia. Patients >14 years who took an overdose of dihydropyridines (amlodipine, felodipine, lercanidipine, nifedipine) were included. Concurrent overdoses with non-dihydropyridine CCBs, alpha-blockers and beta-blockers were excluded. Patient demographics, drugs exposure details, serial vital signs, treatments and outcome were collected.

RESULTS

There were 100 patients. 68 took mixed overdoses of dihydropyridines with ARBs/ACEIs and 32 took single overdoses of dihydropyridines without ARBs/ACEIs. The mixed group had lower median nadir mean arterial pressures (62 vs 75 mmHg, p < 0.001), more frequently had hypotension (OR 4.5, 95%CI: 1.7-11.9) or bradycardia (OR 8.8, 95%CI: 1.1-70). Multivariable analysis indicated the mixed overdoses had an 11.5 mmHg (95%CI: 4.9-18.1) lower minimum systolic blood pressure (SBP) compared with the single group; other factors associated with a lower minimum SBP were higher doses [2.3 mmHg (95%CI: 1.1-3.5) lower per 10 defined daily doses] and younger age [2.2 mmHg (95%CI: 0.3-4.2) higher per decade]. A larger proportion of the mixed ingestion group received intravenous fluids (OR 5.7, 95%CI: 1.8-18.6) and antidotes and/or vasopressors (OR 2.9, 95%CI: 1.004-8.6).

CONCLUSION

Combined overdoses of dihydropyridines with ARBs/ACEIs caused more significant hypotension and required more haemodynamic support than overdoses of dihydropyridines alone.

Seasonal and temperature effect on serum lithium concentrations

BACKGROUND

Lithium remains the gold standard treatment for bipolar disorder. However, it has a very narrow therapeutic index (0.6-0.8 mmol/L). It has been suggested that high environmental temperature can lead to dehydration, elevated plasma lithium concentration and then lithium toxicity.

OBJECTIVES

We aimed to investigate the effect of seasonal and short-term changes in temperature on serum lithium concentrations in Sydney, Australia.

METHODS

We retrospectively analysed data from all patients who had serum lithium concentrations taken from the Prince of Wales and Sutherland Hospitals between 2008 and 2018. Temperature data came from the Bureau of Meteorology. We examined correlations between lithium concentrations and the preceding 5 days maximum temperatures, month and season. We also performed a longitudinal analysis of the effect of temperature and seasons within selected patients who had repeated levels.

RESULTS

A total of 11,912 serum lithium concentrations from 2493 patients were analysed. There was no significant association between higher lithium concentration and preceding higher temperatures (r = -0.008, p = 0.399). There was also no important seasonal or monthly variation, across all patients or in the smaller cohort with longitudinal data (n = 123, r = 0.008, 95% confidence interval: [-0.04, 0.06]).

CONCLUSION

There were no clinically important differences in serum lithium concentration related to seasons, months or temperatures, which suggests that patients on lithium are able to adequately maintain hydration during hot weather in Sydney.

Effect of age on the severity of chronic lithium poisoning

Objectives: Severe lithium toxicity is commonly observed in older people. We aimed to determine the extent to which age is associated with increased severity of chronic lithium poisoning and of which a range of possible factors might explain the associations.Method: We did a retrospective review of patients aged ≥15 years old with serum lithium concentrations ≥1.3 mmol/L from three hospitals. Clinical details, treatment and outcomes were recorded. eGFR, creatinine and lithium clearance were calculated. The severity of lithium toxicity was graded into five categories (Amdisen score). ANOVA was used to quantify the association between age and severity. Spearman correlation coefficient was used to explore relationships between age and different factors expected to alter severity. Ordinal regression analysis was used to determine the interdependence of age and these factors and age on severity of lithium toxicity.Results: From 2008-2018, there were 242 patients with a median age of 56.5 years (IQR: 41-69). There were 156 females (64%). There was a statistically significant association between Amdisen severity scores and age (p = .0004). The median calculated eGFR was 65 mL/min/1.73 m² (IQR: 41-91) with a corresponding estimated lithium clearance of 18 mL/min (IQR: 13.8-22.8). There was no correlation of age with initial serum lithium concentration (p = .76). There was a strong correlation between age and estimated lithium clearance (r = -0.72, 95% CI: -0.78 to -0.66, p < .001), lithium daily dose (r = -0.65, 95% CI: -0.72 to -0.57, p < .0001) and lithium concentration/dose (r = 0.62, 95% CI: 0.53-0.69, p < .0001). There was a weak correlation between age and infection (r = 0.18, 95% CI: 0.04-0.31, p = .009) and drug interactions (r = 0.25, 95% CI: 0.11-0.37, p = .0003). Ordinal regression indicated the independent predictors for severity of lithium toxicity were lithium concentration (p < .0001) and lithium clearance (p = .03) adjusted for age and dose.Conclusions: Despite lower lithium doses, older patients had more severe toxicity. Increased severity of lithium toxicity in the elderly is largely explainable by decreased lithium clearance from multiple factors such as age-related decline in renal function, drug interactions and infection.

Haemodialysis for lithium poisoning: Translating EXTRIP recommendations into practical guidelines

OBJECTIVES

This study aimed to determine the impact on practice of applying the Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup criteria to lithium toxicity.

METHOD

We retrospectively examined the medical records of patients from three hospitals who presented with chronic or acute on chronic lithium poisoning with a lithium concentration ≥1.3 mmol/L (2008-2018). We determined which criteria were met by patients and their subsequent course. We developed and validated a method to predict if lithium concentration would be >1mmol/L at 36 hours.

RESULTS

There were 111 acute on chronic and 250 chronic lithium toxic patients. Nine patients (2.5%) were treated with haemodialysis. Six chronic patients had neurological sequelae. The "estimated lithium concentration at 36 hours > 1 mmol/L" criterion required pharmacokinetic calculations. A simple nomogram was developed using Estimated Glomerular Filtration Rate (eGFR) and lithium concentration. For chronic toxicity, the nomogram would have correctly predicted lithium concentration >1.4 mmol/L at 36 hours in all except two patients. If EXTRIP criteria were followed, dialysis would have been instituted for 211 patients (58%). However, only 51 patients with chronic toxicity fulfilled both a concentration and a clinical criterion. Late neurological sequelae were observed in five out of six patients who fulfilled a concentration and a clinical criterion on admission, with the sixth meeting these criteria shortly after admission.

CONCLUSIONS

The EXTRIP criteria are too broad, but minor modifications allow haemodialysis to be targeted to those most at risk of sequelae. Most acute on chronic poisonings do not need haemodialysis, but it might shorten hospital stay in those with very high concentrations. The nomogram accurately predicts the fall in lithium concentration for chronic poisoning.

Clinical decision rule for non-traumatic computed tomography of the brain

OBJECTIVE

The aims of the present study were to derive and validate a clinical decision rule (CDR) to rule out the need for computed tomography of the brain (CTB) in non-traumatic patients who present to the ED.

METHODS

This is a retrospective review of non-traumatic patients who presented to the EDs in two urban hospitals and received CTB from January 2014 to December 2016. Data from one hospital were used to develop a CDR for clinically significant CTB findings. Clinically significant CTB findings were defined as acute infarction, intracranial neoplasm, intracranial haemorrhage, acute hydrocephalus, cerebral oedema and intracranial infection. Patients from another hospital were used as a validation cohort to evaluate the CDR and compare it to four previously derived CDRs.

RESULTS

There were 5296 cases in the derivation cohort, with 345 (6.5%) clinically significant CTB findings. Identified risk factors were: focal neurological deficit (adjusted odds ratio [OR] 3.4, 95% confidence interval [CI] 2.6-4.4), Glasgow Coma Scale <15 (adjusted OR 3.5, 95% CI 2.6-4.6), history of malignancy (adjusted OR 3.2, 95% CI 2.4-4.2), nausea and/or vomiting (adjusted OR 1.6, 95% CI 1.1-2.1), headache (adjusted OR 1.1, 95% CI 0.9-1.5) and coagulopathy (adjusted OR 9.2, 95% CI 2.1-41.5). These criteria and four pre-existing CDRs were applied to the validation cohort of 5098 patients from the second hospital, which had 338 (6.6%) clinically significant CTB findings. Our criteria were found to have a sensitivity of 99.7% (95% CI 99.1-100.0) and a specificity of 11.0% (95% CI 10.1-11.9). The risk of having a clinically significant CTB finding is 0.3% if patients do not meet any of the criteria.

CONCLUSION

The CDR derived in the present study achieved the highest sensitivity and a moderate specificity when compared with four other pre-existing CDRs for non-traumatic brain injury patients.

Vasoplegic Shock Treated with Methylene Blue Complicated by Severe Serotonin Syndrome

INTRODUCTION

Management of severe vasoplegic shock in overdose can be very challenging. We describe a case of severe refractory vasodilatory shock in poisoning where methylene blue (MB) was used with success. However, the patient subsequently developed severe Serotonin Syndrome (SS) as a result of an interaction between serotonergic drugs and MB.

CASE REPORT

A 15-year-old male developed severe vasoplegic shock 1.5 hours after overdosing on several different medications including quetiapine slow release, quetiapine immediate release, desvenlafaxine slow release, venlafaxine, amlodipine, ramipril, fluoxetine, promethazine and lithium. His vasoplegic shock was resistant to high doses of noradrenaline and vasopressin. MB was administered 6.5 hours post ingestion and within 1 hour there was an improvement in his hemodynamic status and reduction of catecholamine requirements. Twelve hours post ingestion, he developed severe Serotonin Syndrome that lasted 5 days as a result of interaction between MB, a reversible monoamine oxidase inhibitor (MAO-I), and the antidepressants taken in overdose. MB had a calculated half-life of 38 hours.

CONCLUSION

MB is a useful additional strategy for severe drug induced vasodilatory shock and may be potentially life-saving. Clinicians should be aware that it can interact with other drugs and cause life-threatening Serotonin Syndrome. Lower doses or shorter durations may be wise in patients at risk of this interaction.

Modern Intermittent Haemodialysis (IHD) is an Effective Method of Removing Salicylate in Chronic Topical Salicylate Toxicity

INTRODUCTION

There are limited data on modern intermittent hemodialysis (IHD) efficacy on salicylate elimination from topical poisoning.

CASE REPORT

A 54-year-old male sought treatment for dyspnea but was then diagnosed with salicylate toxicity from topical application of Dencorub Extra Strength Heat Gel® for 1 week. Each tube contained 100 g with 26 % methylsalicylate (26 g). Laboratory workup was remarkable for an elevated anion gap of 30 and salicylate concentration of 78.7 mg/dL [5.7 mmol/L (N < 0.4 mmol/L)]. Treatment with urinary alkalinization was followed by hemodialysis for 5 h. Extraction ratios were 0.44 with clearance rates of 78.5 mL/min. Salicylate concentrations fell rapidly following initiation of hemodialysis with no rebound observed.

DISCUSSION

Modern high flux IHD is an effective method of removing salicylates in the treatment of chronic topical poisoning.

Pharmacological treatment of cardiac glycoside poisoning

Cardiac glycosides are an important cause of poisoning, reflecting their widespread clinical usage and presence in natural sources. Poisoning can manifest as varying degrees of toxicity. Predominant clinical features include gastrointestinal signs, bradycardia and heart block. Death occurs from ventricular fibrillation or tachycardia. A wide range of treatments have been used, the more common including activated charcoal, atropine, β-adrenoceptor agonists, temporary pacing, anti-digoxin Fab and magnesium, and more novel agents include fructose-1,6-diphosphate (clinical trial in progress) and anticalin. However, even in the case of those treatments that have been in use for decades, there is debate regarding their efficacy, the indications and dosage that optimizes outcomes. This contributes to variability in use across the world. Another factor influencing usage is access. Barriers to access include the requirement for transfer to a specialized centre (for example, to receive temporary pacing) or financial resources (for example, anti-digoxin Fab in resource poor countries). Recent data suggest that existing methods for calculating the dose of anti-digoxin Fab in digoxin poisoning overstate the dose required, and that its efficacy may be minimal in patients with chronic digoxin poisoning. Cheaper and effective medicines are required, in particular for the treatment of yellow oleander poisoning which is problematic in resource poor countries.

High-yield expression of fully bioactive N-terminal parathyroid hormone analog in Escherichia coli

A fully active analog of human parathyroid hormone (hPTH) has been produced by recombinant expression in Escherichia coli. Initially, a nucleotide sequence encoding hPTH(1-34)-Asp-Pro was ligated to a proinsulin gene in the plasmid pUC8, for the eventual expression of a fusion protein of 137 amino acids. Unexpectedly, the proinsulin gene and 340 bp downstream were deleted by an unknown mechanism during transformation of the E. coli. This resulted in a new plasmid encoding a small (72-amino acid) fusion product of hPTH(1-34)-Asp35-Pro36-X, where X is a 36-residue "arbitrary" downstream sequence of pUC8. The fusion product was efficiently expressed and the hPTH analog, [Asp35]hPTH-(1-35), was readily released by acid cleavage, with a yield of 100 mg/L. This analog had an effective concentration for half-maximal adenylyl cyclase stimulation (EC50) in rat osteosarcoma cells of 14 nM, which was identical to that for hPTH-(1-34). In the ovariectomized rat model of osteoporosis, [Asp35]hPTH-(1-35) was fully active as a bone anabolic agent.

Mapping the substrate binding site of the prostaglandin transporter PGT by cysteine scanning mutagenesis

We have identified a cDNA, PGT, that encodes a widely expressed transporter for prostaglandin (PG) E(2), PGF(2alpha), PGD(2), 8-iso-PGF(2alpha), and thromboxane B(2). To begin to understand the molecular mechanisms of transporter function, we have initiated a structure-function analysis of PGT to identify its substrate-binding region. We have found that by introducing the small, water-soluble, thiol-reactive anion Na(2-sulfonatoethyl)methanethiosulfonate (MTSES) into the substrate pathway, we were able to cause inhibition of transport that could be reversed with dithiothreitol. Importantly, co-incubation with PGE(2) protected PGT from this inhibition, suggesting that MTSES gains access to the aqueous pore pathway of PGT to form a mixed disulfide near the substrate-binding site. To identify the susceptible cysteine, we mutated, one at a time, all six of the putative transmembrane cysteines to serine. Only the mutation of Cys-530 to serine within putative transmembrane 10 became resistant to inhibition by MTSES. Thus, Cys-530 is the substrate-protectable, MTSES-inhibitable residue. To identify other residues that may be lining the substrate-binding site, we initiated cysteine-scanning mutagenesis of transmembrane 10 using Cys-530 as an entry point. On a C530S, MTSES-resistant background, residues in the N- and C-terminal directions were individually mutated to cysteine (Ala-513 to His-536), one at a time, and then analyzed for MTSES inhibition. Of the 24 cysteine-substituted mutants generated, 6 were MTSES-sensitive and, among these, 4 were substrate-protectable. The pattern of sensitivity to MTSES places these residues on the same face of an alpha-helix. The results of cysteine-scanning mutagenesis and molecular modeling of putative transmembrane 10 indicate that the substrate binding of PGT is formed among its membrane-spanning segments, with 4 residues along the cytoplasmic end of helix 10 contributing to one surface of the binding site.

Cloning of the human kidney PAH transporter: narrow substrate specificity and regulation by protein kinase C

Conserved from fish to mammals, renal proximal tubule organic anion secretion plays an important role in drug and xenobiotic elimination. Studies with the model substrate p-aminohippurate (PAH) have suggested that a basolateral PAH/alpha-ketoglutarate exchanger imports diverse organic substrates into the proximal tubule prior to apical secretion. cDNAs encoding PAH transporters have been cloned recently from rat and flounder. Here we report the cloning of a highly similar human PAH transporter (hPAHT) from human kidney. By Northern blot analysis and EST database searching, hPAHT mRNA was detected in kidney and brain. PCR-based monochromosomal somatic cell hybrid mapping placed the hPAHT gene on chromosome 11. When expressed transiently in vitro, hPAHT catalyzed time-dependent and saturable [3H]PAH uptake (Km of approximately 5 microM). Preincubation with unlabeled alpha-ketoglutaric or with glutaric acid stimulated tracer PAH uptake, and preincubation with unlabeled PAH stimulated tracer alpha-ketoglutarate uptake, results that are consistent with PAH/alpha-ketoglutarate exchange. Several structurally diverse organic anions cis-inhibited PAH uptake. Like rat OAT1 organic anion transporter, hPAHT was inhibited by furosemide, indomethacin, probenecid, and alpha-ketoglutarate. Unlike OAT1, hPAHT was not inhibited by prostaglandins or methotrexate (MTX). Moreover, tracer PGE2 and MTX were not transported, indicating that the substrate specificity for transport by hPAHT is not broad. PAH uptake was inhibited by phorbol 12-myristate 13-acetate (PMA) in a dose- and time-dependent fashion, but not by the inactive 4alpha-phorbol-12,13 didecanoate. PMA-induced inhibition was blocked by staurosporine. Thus the protein kinase C-mediated inhibition of basolateral organic anion entry previously reported in intact tubules is likely due, at least in part, to direct modulation of the PAH/alpha-ketoglutarate exchanger.

Serotonin syndrome resulting from drug interactions

We describe six patients diagnosed with serotonin syndrome after exposure to drugs with serotonergic activity. Drug interactions occurred as a result of a combination of tricyclic antidepressants, selective serotonin reuptake inhibitors, selective noradrenaline reuptake inhibitors or monoamine oxidase inhibitors. Management included supportive care and the use of non-specific serotonin antagonists (cyproheptadine, benzodiazepines and chlorpromazine). All patients made uneventful recoveries.

The renal excretory mechanisms and the role of organic cations in modulating the renal handling of paraquat

Paraquat (PQ), a cationic herbicide, is predominantly excreted by the kidneys, but it is also nephrotoxic. It is thought to cause damage to proximal renal epithelial cells, which results in acute renal failure. The precise mechanism by which PQ is excreted by the kidney has not been fully elucidated, although current evidence indicates that it is actively secreted via a cation transport system. This review examines the renal cytotoxic effect and excretory mechanisms of PQ, and the role of organic cations in modulating the renal handling of PQ.

Mechanism of prostaglandin E2 transport across the plasma membrane of HeLa cells and Xenopus oocytes expressing the prostaglandin transporter "PGT"

We recently identified a novel prostaglandin transporter called PGT (Kanai, N., Lu, R., Satriano, J. A., Bao, Y., Wolkoff, A. W., and Schuster, V. L. (1995) Science 268, 866-869). Based on initial functional studies, we have hypothesized that PGT might mediate the release of newly synthesized prostaglandins (PG), epithelial transport of PGs, or metabolic clearance of PGs. Here we examined the mechanism of PGT transport as expressed in HeLa cells and Xenopus oocytes, using isotopic PG influx and efflux studies. In both native HeLa cells and oocytes, cell membranes were poorly permeable to PGs. In contrast, in oocytes injected with PGT mRNA, the PG influx permeability coefficient was 90-157 times that of oocytes injected with water. The rank order substrate profile was PGF2alpha approximately PGE2 > TXB2 >> 6 keto-PGF1alpha. PG influx displayed an overshoot with rapid accumulation of tracer PGE2, followed by a gradual return to baseline. Based on estimated oocyte volumes, the PGT-mediated accumulation of PGE2 reached steady state at intra-oocyte concentrations 25-fold higher than the external media. The accumulation of PG was not due to intracellular binding or metabolism. PGT-mediated uptake was ATP- and temperature-dependent, but not sodium-dependent, and was inhibited by disulfonic stilbenes, niflumic acid, and the thiol reactive anion MTSES (Na(2-sulfonatoethyl)methanethiosulfonate). [3H]PGE2 efflux from PGT-transfected HeLa cells was stimulated by external (trans) PGE2 in a dose-dependent fashion and was inhibited by bromcresol green and 4,4'-diisothiocyanatostilbene-2,2'-disulfonate. Membrane depolarization inhibited uptake of [3H]PGE2, consistent with a model of net outward movement of negative charge during the translocation event. These findings suggest that PGT mediates [3H]PGE2 accumulation via obligatory, electrogenic anion exchange.

Transport of paraquat by a renal epithelial cell line, MDCK

Transport of paraquat (PQ), a herbicidal cation, was previously investigated in a proximal (LLC-PK1), renal epithelial cell line using permeable collagen-coated filters. PQ was actively transported from the basolateral side via a cation transport system by the LLC-PK1 cells. In the present study, the transport of PQ was investigated in a distal renal epithelial cell line, MDCK. PQ was predominantly transported from the basolateral to apical (B to A) side. The basolateral transport of PQ in MDCK cells was not saturable with increasing concentrations and not energy dependent. The flux and uptake of PQ was much lower in the MDCK than LLC-PK1 cells. It is concluded that MDCK, a distal renal tubular cell line, does not have an active transport system for PQ.

The mechanism of excretion of paraquat in rats

Paraquat (PQ)(1,1'-dimethyl-4,4'-bipyridinium) is a toxic herbicidal cation. The renal excretory mechanisms of PQ and its interactions with organic cations and anions were investigated in anaesthetised rats. The renal clearance of PQ was studied in male Wistar rats using inulin as the marker of glomerular filtration rate. The fractional excretion of paraquat (FEpq) decreased from 2.1+/-0.01 to 1.2+/-0.03 as the plasma concentration rose from 0.4+/-0.02 to 21.2+/-1.6 microM. These results demonstrated that the excretion of PQ was greater than glomerular filtration, concentration dependent and saturable, indicating that it was secreted by an active transport system. The excretion of PQ was dependent predominantly on the glomerular filtration rate with a small secretory component (Km = 8.5+/-3.1 microM, Vmax = 114+/-19 nmol/kg per min). The clearance of PQ was not inhibited by high doses of cimetidine, or p-aminohippurate. However, quinine (P = 0.001) and N-methylnicotinamide (NMN) (P = 0.03) reduced the FEpq, suggesting that they share a similar cation transport system with PQ. In summary, PQ is actively secreted by the rat kidney via a cation transport system.

Survival after a massive hydrofluoric acid ingestion

BACKGROUND

Hydrofluoric acid ingestion is known to have a very high mortality rate secondary to the rapid development of hypocalcemia and fatal arrhythmias.

CASE REPORT

A 33-year-old man ingested an estimated dose of hydrofluoric acid 6 times that considered to be lethal. The patient survived with minimal morbidity despite having multiple ventricular fibrillation arrests. His survival is attributed to early, high dose calcium therapy given via the nasogastric and intravenous routes.

Characterisation and uptake of paraquat by rat renal proximal tubular cells in primary culture

1 Uptake of the herbicide paraquat (PQ), by rat proximal tubular cells (PTC) in primary culture grown on a collagen coated support was investigated. 2 The uptake of PQ by PTC was predominantly from the basolateral side. The basolateral uptake of PQ was saturable with time and increasing concentrations, energy dependent and could be inhibited by certain organic cations. Using Michaelis Menten kinetics, the apparent K(m) was 778 +/- 241 microM and Vmax was 0.97 +/- 0.24 pmol/microgram protein/15 min for the basolateral uptake of PQ. Cimetidine (5.7 +/- 0.4 pg/microgram protein/ 30 min, P < 0.001) was the most potent inhibitor of PQ uptake, followed by quinine (6.5 +/- 0.4 pg/microgram protein/30 min, P < 0.01) and then tetraethylammonium (8.2 +/- 0.5 pg/microgram protein/30 min, P < 0.05) when compared with control (11 +/- 1 pg/microgram protein/30 min). N-methylnicotinamide, p-aminohippurate and putrescine did not inhibit the basolateral uptake of PQ. The sodium hydrogen exchange inhibitors, amiloride and its analogue, 5-(N,N hexamethylene) amiloride (HMA) inhibited both the apical and basolateral uptake of PQ. 3 The apical uptake of PQ was not saturable with increasing concentrations and was not inhibited by 2,4-dinitrophenol, but it was reduced by cimetidine (P < 0.01), quinine (P < 0.05) and a sodium potassium ATPase inhibitor, ouabain (P < 0.01). 4 It is concluded that PQ was taken up from the basolateral side of primary cultured rat PTC by an energy dependent transport system.

Transport of paraquat in a renal epithelial cell line LLC-PK1

Transport of paraquat (PQ), a cationic herbicide, was investigated in a proximal renal epithelial cell line, LLC-PK1. Collagencoated permeable filters were used to study the direction of PQ transport. PQ was transported predominantly from the basolateral to apical (B-->A) membrane of these cells. The B-->A flux and uptake of PQ were saturable with time and increasing concentrations, energy dependent and inhibited by several cations. Quinine was the most potent inhibitor of basolateral PQ uptake, followed by cimetidine and then tetraethylammonium acetate (P < .0001). The noninhibitable basolateral uptake of PQ has an apparent K(m) of 357 microM and a Vmax of 1.47 pmol/micrograms protein/2 min. For flux studies, only quinine inhibited the B-->A flux of PQ (P = .02). Putrescine, p-aminohippurate, probenecid, N-methylnicotinamide and choline did not inhibit the flux or uptake of PQ. 5-N,N-Hexamethylene amiloride, a cationic amiloride analog and a potent inhibitor of the Na/H exchanger, significantly inhibited the uptake of PQ from either side (P < .0001). Acidic pH in the apical medium inhibited the uptake of PQ from either side. The studies demonstrated that PQ was actively transported by the LLC-PK1 cells. PQ shared a similar transport system with several cations, which appeared to have a more significant inhibition on the transcellular uptake than the flux of PQ.

Effect of base-mismatch in the cohesive ends of oligonucleotide in gene cloning

The tolerance of mismatched nucleotides between the cohesive ends of insert and target DNAs in gene cloning has been investigated. An oligonucleotide duplex with a cohesive end GGCC-5' or variation was ligated to the 5'-CCGG end of a linearized plasmid. The ligation mixture was used in the transformation of E. coli. A single-base mismatch, such as 5'-CCGG/AGCC-, GACC-, GGAC- or GGCA-5' (mismatch underlined), was well tolerated in the cloning of the oligonucleotide duplex, with efficiency lower than the fully complementary ends. Double-base mismatch 5'-CCGG/AACC- or GGAA-5' resulted in further decrease of cloning efficiency. Via a similar approach, a tetracycline resistance gene was successfully inserted into a pUC-type plasmid.

Structural aspects of a higher order nucleoprotein complex: induction of an altered DNA structure at the Mu-host junction of the Mu type 1 transpososome

The Mu in vitro strand transfer reaction proceeds via two stable higher order nucleoprotein complexes, the Type 1 and Type 2 transpososomes. The Mu A protein is responsible for the structural and functional integrity of the Type 1 transpososome. We have investigated the quaternary structure of the Mu A protein within this complex by chemical cross-linking experiments and found that the basic structural unit is an A tetramer. Three Mu A binding sites in the transpososome are protected by DNase I footprinting: the outermost A binding sites L1 and R1, as well as R2. Genetic evidence is also presented which corroborates this result. Efficient formation of Type 1 complexes occurs in mini-Mus with the L3 or R3 sites deleted or when the L2 site has been substituted; but no reaction occurs in the absence of R2. The protection at the L1 and R1 sites extends 12-13 bp beyond the Mu-host junctions as seen by DNase I and methidiumpropyl-EDTA.Fe(II) [MPE.Fe(II)] foot-printing, indicating Mu A contacts with the flanking host sequences in the transpososome but not on linear DNA; furthermore, hydroxyl radical footprinting shows an unprecedentedly large enhancement on the continuous strand, 2 bp beyond the nick site outside the Mu right end, which suggests that an altered DNA structure is induced upon Type 1 complex formation.

The kalilo linear senescence-inducing plasmid of Neurospora is an invertron and encodes DNA and RNA polymerases

The nucleotide sequence of kalilo, a linear plasmid that induces senescence in Neurospora by integrating into the mitochondrial chromosome, reveals structural and genetic features germane to the unique properties of this element. Prominent features include: (1) very long perfect terminal inverted repeats of nucleotide sequences which are devoid of obvious genetic functions, but are unusually GC-rich near both ends of the linear DNA; (2) small imperfect palindromes that are situated at the termini of the plasmid and are cognate with the active sites for plasmid integration into mtDNA; (3) two large, non-overlapping open-reading frames, ORF-1 and ORF-2, which are located on opposite strands of the plasmid and potentially encode RNA and DNA polymerases, respectively, and (4) a set of imperfect palindromes that coincide with similar structures that have been detected at more or less identical locations in the nucleotide sequences of other linear mitochondrial plasmids. The nucleotide sequence does not reveal a distinct gene that codes for the protein that is attached to the ends of the plasmid. However, a 335-amino acid, cryptic, N-terminal domain of the putative DNA polymerase might function as the terminal protein. Although the plasmid has been co-purified with nuclei and mitochondria, its nucleotide composition and codon usage indicate that it is a mitochondrial genetic element.

Delayed diagnosis in subarachnoid haemorrhage

OBJECTIVE

To determine the outcome in patients with subarachnoid haemorrhage from a ruptured aneurysm, particularly in those in whom the diagnosis was delayed.

DESIGN

A two-year retrospective study of medical records of patients admitted to Westmead Hospital between July 1988 and June 1989.

SETTING

A tertiary level teaching hospital.

PATIENTS

Ninety-four patients treated for subarachnoid haemorrhage. In 15 cases the diagnosis was delayed.

MAIN OUTCOME MEASURES

Death, disability, or functional recovery.

RESULTS

Overall, 40 (42.5%) patients died, 14 (15%) were disabled, and 40 made a functional recovery. Of the 62 patients who were treated surgically 38 (61%) made a functional recovery compared with two of the 32 (6%) who were not. Of the 15 in whom the diagnosis was delayed seven (47%) made a functional recovery. Confirmation of the diagnosis was delayed in four of the latter group because a cranial computed tomography scan showed no abnormalities.

CONCLUSIONS

Earlier diagnosis, allowing early definitive surgical treatment, may improve the outcome in aneurysmal subarachnoid haemorrhage. The results of a computed tomography scan are diagnostic only if they are positive--a negative result must be interpreted in conjunction with the clinical picture.

Urban trauma: an analysis of 1,116 paediatric cases

Over a 2-year period 1,116 children admitted to an urban teaching hospital were studied prospectively. The overall group was analysed as to the nature of the injury and a subgroup of seriously injured children was identified and further analysed. All deaths were examined as to their cause and possible preventable as well as salvageable factors. The predictive value of the Trauma Score (T.S.) and Method of Injury (M.O.I.) were evaluated for their prospective prediction of serious injury as determined by the Injury Severity Score and outcome. Most of the children were not seriously injured, with the most common injury being due to a fall (57%) and involving a single injury to the upper limb. With the subgroup of 143 children (13% of the total) who suffered serious injuries, the cranial cavity (90%) was the most common site of injury, occurring most often in pedestrians (31% of the total injured). There were 16 deaths in the series, representing 1.4% of all paediatric trauma admissions and 11% of the admissions who were seriously injured. All deaths were related to motor vehicle accidents and associated with serious head injury. A Trauma Score less than or equal to 12 accurately included all deaths but when correlated with the I.S.S., the Trauma Score had a specificity of 99% and a positive predictive value of 86%; its sensitivity was only 27%. The Method of Injury was associated with an overtriage rate of 300% in relation to the I.S.S.. Of children admitted following pedal cycle accidents only 9% were wearing helmets. Of car occupants injured, 39% were unrestrained.(ABSTRACT TRUNCATED AT 250 WORDS)

Insertion of a foreign nucleotide sequence into mitochondrial DNA causes senescence in Neurospora intermedia

The kalilo variants of Neurospora contain a cytoplasmic genetic factor that causes senescence. This factor is a 9.0 kb transposable element (kalDNA) that lacks nucleotide sequence homology with mtDNA and is inserted into the mitochondrial chromosome, often at sites located within the open reading frame in the intron-DNA of the mitochondrial 25S-rRNA gene. Genomes containing the "foreign" DNA insert accumulate during growth, and death occurs as the cells become deficient in functional large and small subunits of mitochondrial ribosomes. The kalDNA transposon may be an "activator" element that causes breaks in mtDNA. Nonsenescing [+] strains of Neurospora do not contain kalDNA.

Observations on the discharged granules from guinea-pig bone marrow basophils following anaphylaxis

Degranulation of basophils took place in sensitized guinea-pigs when challenged with specific antigen, regardless of whether the animals had received a mepyramine maleate (anti-histamine) injection or not. The degranulation was most pronounced in the first 5 minutes following challenge. The discharged basophil granules were taken up by the neutrophils, the macrophages, and the monocytes in the bone marrow; the neutrophils, however, responded much more promptly and actively than the other phagocytes. Phagocytosis of the discharged basophil granules was most active 10–15 minutes following challenge, during which varying numbers of phagocytic vacuoles were found in the phagocytes.

Stages of changes were observed in the phagocytic vacuoles and their granule contents, which consisted of: (1) diminution or disappearance of the perigranular clear space with subsequent adhesion of the limiting membrane of the vacuole to the granule content; (2) disintegration or dissolution of the granule content and the limiting membrane of the vacuole; and (3) incorporation of the granule content into the cytoplasmic matrix of the phagocyte. In addition, a depletion of neutrophil granules in the cytoplasm surrounding the phagocytic vacuole was also observed in association with the above changes, and was suggested to be related to the digestion of the ingested granules.

The discharged basophil granules disappeared completely from the bone marrow by 1 hour after challenge. The removal of the granules was by digestion while they were in the bone marrow as well as by dispersal of the granules through the bone marrow sinusoids into the circulation.