A - 143 Factor Structure of the Beck Anxiety Inventory in Mild Traumatic Brain Injury

OBJECTIVE

The Beck Anxiety Inventory-II (BAI) is a widely used screening instrument for anxiety symptoms in clinical and medical populations. The factor structure of the BAI remains unknown for people with mild traumatic brain injury (mTBI), despite common anxiety symptoms in this group. This study compared one, two, and four-factor models of the BAI in an mTBI sample.

DATA SELECTION

A sample of 141 individuals diagnosed with an mTBI were evaluated. All subjects were administered the BAI screening measure during a comprehensive neuropsychological evaluation in a private practice setting. Confirmatory factor analysis was used to test whether items loaded on a single anxiety factor, a two-factor structure with a somatic-affective and cognitive component of anxiety (based on original BAI), or a four-factor structure derived from studies in other populations with cognitive impairments.

DATA SYNTHESIS

The sample was predominantly female (63%), with a mean age of 46.93 (SD = 13.28) and a mean education level of 15.08 (SD = 2.65). Consistent with prior literature, 69% of our sample reported at least mild symptoms of anxiety (BAI > 8). Confirmatory factor analysis (CFA) results indicated the best fit was the model with four factors consisting of cognitive, autonomic, neuromotor, and panic symptoms, CFI = 0.92; RMSEA = 0.067, 90% CI (0.053,0.081).

CONCLUSION

These results suggest that instead of the two-factor model posited by original creators of the BAI, clinicians and researchers should attend to four clusters of anxiety symptoms in mTBI populations. Anxiety symptoms following mTBI can be evaluated based on cognitive, autonomic, neuromotor, and panic components.

Garnet, the archetypal cubic mineral, grows tetragonal

Garnet is the archetypal cubic mineral, occurring in a wide variety of rock types in Earth’s crust and upper mantle. Owing to its prevalence, durability and compositional diversity, garnet is used to investigate a broad range of geological processes. Although birefringence is a characteristic feature of rare Ca–Fe³⁺ garnet and Ca-rich hydrous garnet, the optical anisotropy that has occasionally been documented in common (that is, anhydrous Ca–Fe²⁺–Mg–Mn) garnet is generally attributed to internal strain of the cubic structure. Here we show that common garnet with a non-cubic (tetragonal) crystal structure is much more widespread than previously thought, occurring in low-temperature, high-pressure metamorphosed basalts (blueschists) from subduction zones and in low-grade metamorphosed mudstones (phyllites and schists) from orogenic belts. Indeed, a non-cubic symmetry appears to be typical of common garnet that forms at low temperatures (<450 °C), where it has a characteristic Fe–Ca-rich composition with very low Mg contents. We propose that, in most cases, garnet does not initially grow cubic. Our discovery indicates that the crystal chemistry and thermodynamic properties of garnet at low-temperature need to be re-assessed, with potential consequences for the application of garnet as an investigative tool in a broad range of geological environments.

Impact of hospital transfer on surgical outcomes of intestinal atresia

BACKGROUND

Examine effects of hospital transfer into a quaternary care center on surgical outcomes of intestinal atresia.

METHODS

Children <1 yo principally diagnosed with intestinal atresia were identified using the Kids' Inpatient Database (2012). Exposure variable was patient transfer status. Outcomes measured were inpatient mortality, hospital length of stay (LOS) and discharge status. Linearized standard errors, design-based F tests, and multivariable logistic regression were performed.

RESULTS

1672 weighted discharges represented a national cohort. The highest income group and those with private insurance had significantly lower odds of transfer (OR:0.53 and 0.74, p < 0.05). Rural patients had significantly higher transfer rates (OR: 2.73, p < 0.05). Multivariate analysis revealed no difference in mortality (OR:0.71, p = 0.464) or non-home discharge (OR: 0.79, p = 0.166), but showed prolonged LOS (OR:1.79, p < 0.05) amongst transferred patients.

CONCLUSIONS

Significant differences in hospital LOS and treatment access reveal a potential healthcare gap. Post-acute care resources should be improved for transferred patients.

Health behaviours associated with indoor tanning based on the 2012/13 Manitoba Youth Health Survey

INTRODUCTION

Although indoor tanning causes cancer, it remains relatively common among adolescents. Little is known about indoor tanning prevalence and habits in Canada, and even less about associated behaviours. This study explores the prevalence of adolescent indoor tanning in Manitoba and its association with other demographic characteristics and health behaviours.

METHODS

We conducted secondary analyses of the 2012/13 Manitoba Youth Health Survey data collected from Grade 7 to 12 students (n = 64 174) and examined associations between indoor tanning (whether participants had ever used artificial tanning equipment) and 25 variables. Variables with statistically significant associations to indoor tanning were tested for collinearity and grouped based on strong associations. For each group of highly associated variables, the variable with the greatest effect upon indoor tanning was placed into the final logistic regression model. Separate analyses were conducted for males and females to better understand sex-based differences, and analyses were adjusted for age.

RESULTS

Overall, 4% of male and 9% of female students reported indoor tanning, and prevalence increased with age. Relationships between indoor tanning and other variables were similar for male and female students. Binary logistic regression models indicated that several variables significantly predicted indoor tanning, including having part-time work, being physically active, engaging in various risk behaviours such as driving after drinking for males and unplanned sex after alcohol/drugs for females, experiencing someone say something bad about one's body shape/size/appearance, identifying as trans or with another gender, consuming creatine/other supplements and, for females only, never/rarely using sun protection.

CONCLUSION

Indoor tanning among adolescents was associated with age, part-time work, physical activity and many consumption behaviours and lifestyle risk factors. Though legislation prohibiting adolescent indoor tanning is critical, health promotion to discourage indoor tanning may be most beneficial if it also addresses these associated factors.

The effects of acidification on human milk's cellular and nutritional content

OBJECTIVE

Fortification of human milk for preterm infants is necessary and a common newborn intensive care practice. Currently, acidified human milk as part of a human milk fortifier is being fed to preterm infants. However, there are little data on the acidification effects on mother's milk. The aim of this study is to determine the effects of acidification on human milk's cellular and nutritional composition.

STUDY DESIGN

One hundred milk samples were collected from eight mothers who had infants in the neonatal intensive care unit. All milk samples were frozen at 4 °C. The frozen samples were thawed and divided into two equal aliquots, control and acidified. The control milk sample had its pH determined while the other sample was acidified to pH 4.5. Each milk sample was examined for pH, white cells, total protein, creamatocrit, lipase activity and free fatty acids.

RESULT

Mean pH of the human milk control was 6.8 ± 0.1 (M ± s.d.) with the acidified milk at 4.5 ± 0.1. Acidification caused a 76% decrease in white cells, a 56% decrease in lipase activity and a 14% decrease in the total protein but a 36% increase in the creamatocrit.

CONCLUSION

Acidification of human milk causes significant changes of the milk's cellular and nutritional components that may not be beneficial to preterm infants.

The impact of a rural emergency department rotation on applicant ranking of a US emergency medicine residency program

INTRODUCTION

Few US emergency medicine (EM) residency programs have been located in rural states due to program requirements for emergency department (ED) patient volume. Recent revision to the program requirements now permits 'educationally justifiable exceptions' to the patient population requirement, 'such as clinical sites in a rural setting', and some EM residency programs now plan to offer rural ED clinical experiences as a required curricular component. The impact of a required rural EM rotation on the ranking decisions of applicants is important to residency programs seeking to attract the most desirable applicants.

OBJECTIVE

To assess the impact of a required rural ED rotation on applicant ranking of an EM residency program in the US National Resident Matching Program (NMRP).

METHODS

All applicants to the study's EM residency program completing the interview portion of the application process received a mailed and emailed survey following the release of the 2004 NMRP results. The survey included questions addressing the rural/non-rural classification of the location of the applicants' childhood home, medical school, and anticipated future practice.

RESULTS

Of 46 eligible subjects, 32 (69.6%) completed the survey. Of subjects with a rural childhood, 73.3% reported a positive impact on rank order (95% CI 50.9-95.7%) and 26.7% reported no impact (CI 4.3-49.1%); 81.3% of subjects with non-rural backgrounds reported no impact (CI 62.2-100%), 12.5% higher rank (CI 0-28.7%), and 6.3% lower (CI 0-18.2%). If planning a future practice in a rural community, 83.3% reported positive impact (CI 62.2-100%) and 16.7% no impact (CI 0-37.8%); 78.9% of subjects anticipating future practice in non-rural communities reported no impact (CI 60.6-97.3%), 15.8% higher rank (CI 0-32.2%), and 5.3% lower (CI 0-15.4). Of the subjects attending medical school in rural states, 52.2% reported a positive impact (CI 31.8-72.6%) and 47.8% no impact (CI 27.4-68.2%), while 75% of graduates of medical schools in non-rural states reported no impact (CI 32.6-100%) and 25% (CI 0-67.4%) a negative impact.

CONCLUSION

The presence of a rural ED rotation did not adversely impact EM residency applicants' ranking of the program.

Self-help and minimal-contact therapies for anxiety disorders: Is human contact necessary for therapeutic efficacy?

Self-help materials, brief therapies, and treatments involving minimal therapist contact have all been proposed as effective and low-cost interventions for anxiety disorders. However, research also suggests that the therapeutic alliance is a central predictor of therapy outcome. Interestingly, amounts of therapist contact within and across "self-help" interventions vary greatly. It is therefore unclear how much therapist contact is necessary for a positive anxiety disorder treatment outcome. The present article reviews the literature on anxiety disorder treatments using self-help, self-administered, and decreased therapist-contact interventions. Treatment studies are grouped together by anxiety diagnosis as well as amount of therapist contact. It is concluded that self-administered treatments are most effective for motivated clients seeking treatment for simple phobias. Predominantly self-help therapies are efficacious for panic disorder and mixed anxiety samples. On the other hand, minimal-contact therapies have demonstrated efficacy for the greatest variety of anxiety diagnoses.

Multiple virulence factors of Cryptococcus neoformans are dependent on VPH1

Acidification of vesicular compartments plays an important role in a number of cellular transport processes, including protein secretion, metal cofactor insertion, glycosylation and pH stability. In the present study, we identify and characterize a component of the vesicular proton pump, Vph1p, to determine its role in the virulence of the AIDS-related fungal pathogen Cryptococcus neoformans. Insertional mutagenesis and plasmid rescue were used to identify the VPH1 gene by screening for mutants defective in laccase activity. Disruption of VPH1 resulted in defects in three virulence factors (capsule production, laccase and urease expression), as well as a growth defect at 37 degrees C, but only a small growth reduction at 30 degrees C. These effects were duplicated by the vacuolar (H+)-ATPase inhibitor bafilomycin A1. Furthermore, the vph1 insertional mutant was also avirulent in a mouse meningo-encephalitis model. Complementation of the insertional mutant with wild-type VPH1 resulted in a recovery of virulence factor expression, normal growth at 37 degrees C and restoration of full virulence. These studies establish the importance of the VPH1 gene and vesicular acidification in the virulence of C. neoformans.

Planning a successful women's health and wellness conference in your community

Planning a woman's health conference in your community requires knowledge of the audience's interests and the compilation of a diversified planning committee.

Trends in a decade of drug abuse presentation to an inner city ED

Temporal factors on the periodic presentations has been described for many diseased states (ie, asthma, seizures, coronary attacks). We now report an analysis of factors that could affect the periodic character regarding emergency department (ED) presentation of drugs of abuse. All drugs presentations consistent with the Drug Abuse Warning Network (DAWN) reporting program from January 1988 through December 1997 were categorized. Data collection was based on daily chart review of ED medical records from Rush-Presbyterian-St. Luke's Hospital (Chicago, IL). Data were computer analyzed using SPSS and Pharmfit programs and analyzed for time, age, disposition, sex, and reasons for presentation and taking the drugs. During the above period, the Rush ED saw 369,770 patients of which 2,561 (0.7%) presented with a drug-related problem. The average age of men was 33. 7 + 0.29 and women 30.5 + 0.37 years. One hundred thirty-nine patients (5.4%) were under 17 years of age whereas only 72 patients (2.8%) were over 55 years of age. Cocaine was the most common drug presentation with a total of 859 visits. Seven hundred sixty-one (29. 7%) presented with an unexpected reaction, 754 (29.4%) experienced an over dosage, 135 (5.3%) had a drug withdrawal, 546 (21.3%) experienced chronic effects, 1,380 (53.9%) were drug dependent, 218 (8.5%) were suicide attempts, and the remaining 2.7% were unknown. There were 1,078 (42.2%) patients who were treated and released, 1, 394 (54.6%) who were admitted into the hospital, 74 (2.9%) left against medical advice whereas 9 patients (0.4%) died. Peak time for presentation was 5:03 PM (P =.00002). Suicide intent presentations were more likely to be women (P <.0001), older (P <.001), and present at a later time that of recreational drug use (acrophase 18:49 versus 16:39; P =.00011). Almost 90% of patients presenting to our urban ED over past 10 years with drug-related problems arrive because of drug abuse or dependency issues. ED staff should be most prepared to deal with these issues in the late afternoon.

Determining the optical constants of read-write sliders during flying-height testing

Flying-height testers for rigid disk drives employ a transparent glass substrate in place of the magnetic disk and use optical interferometry to measure the flight properties of the read-write slider. Because of the material phase change on reflection, the effective optical constants n and k of the slider play an important role in the measurement. We describe an instrument that determines the optical constants simultaneously with flying height, using polarization interferometry. This in situ analysis of n and k obviates the need for independent ellipsometry, while avoiding the problematic retract calibration characteristic of traditional flying-height test equipment. The rms uncertainty for n and k are 0.04, resulting in height uncertainties that range from 3 nm for 250-nm flying heights down to 0.5 nm at contact. We verify these results by use of a variety of experimental techniques on both laboratory samples and actual read-write sliders.

Implementing means restriction education in urban EDs

This study evaluated the impact of a mail information campaign on emergency department (ED) professionals' knowledge about the lethal role of firearms in suicide, knowledge of appropriate strategies for warning caregivers of adolescents who have attempted suicide about firearms, and practices with respect to the delivery of such warnings. Responses obtained from physicians and nurses working in ED sites within the targeted city (Chicago) were compared with responses from ED professionals employed in a comparison city (Detroit). In Chicago, the percentage of respondents recommending firearm removal strategies increased from 60% at pretest to 76% at posttest. Individual reports of caregiver warnings per adolescent suicide exposure showed a significant decline in Chicago and a marginally significant decline in Detroit. Gains in knowledge about firearm warning strategies persisted in multivariate analyses controlling for subject demographic characteristics. The pattern of results suggests that the intervention may have effected changes in knowledge while having little impact on behavior. More intensive, interactive educational strategies may be needed to effect behavioral changes among ED professionals.

High sensitivity detection of HPV-16 in SiHa and CaSki cells utilizing FISH enhanced by TSA

Detection of integrated human papillomavirus type 16 (HPV-16) DNA in SiHa and CaSki cells was used as a model system to demonstrate sensitivity and resolution of a well defined target. Using 293- to 1987-base polymerase chain reaction (PCR)-synthesized probes to the E6 and E7 open reading frames of HPV-16, several fluorescent in situ hybridization (FISH) detection methods, enhanced with tyramide signal amplification (TSA), were compared. The synthetic probes were biotin labeled by a nick translation method and the hybridized probes were detected by various fluorescent TSA methods using cyanine 3 tyramide, biotinyl tyramide and a biotin TSA Plus reagent. High sensitivity detection in SiHa cells was demonstrated using a 619-base probe to detect two single copies of integrated HPV-16 DNA. In CaSki cells, which contain up to 600 copies of HPV-16 DNA, a 293-base probe was used for detection. The results of these comparisons show that with refinement of TSA methods and reagents, increasing levels of high sensitivity detection can be achieved and that these methods allow subnuclear localization as well.

A case of paraquat poisoning and subsequent fatality presenting to an emergency department

Paraquat (1,1'-dimethyl-4,4'-dipyridylium) is an herbicide associated with both accidental and intentional ingestion, leading to severe and often fatal toxicity. Prognosis is largely dependent on the amount of paraquat absorbed. Rapid identification of the symptoms of paraquat toxicity (burns or ulceration at the site of ingestion or injection, acute respiratory distress, and renal failure) can facilitate early treatment intervention to limit absorption. We report a case of a 71-year-old man with a suicidal ingestion of paraquat 2 days prior to presentation. Serum paraquat levels, time elapsed since ingestion, and clinical symptoms all indicated poor prognosis. The patient developed severe respiratory distress and progressive renal failure, and died 6 days after admission to the hospital.

Anticholinergic toxicity from nightshade berry poisoning responsive to physostigmine

The woody nightshade, Solanum dulcamara, belongs to the genus Solanum and its primary toxin is solanine. We report a large nightshade ingestion in a 4-yr-old girl who presented to the emergency department in acute anticholinergic crisis. The child was given 0.2 mg of intravenous physostigmine (0.02 mg/kg). Within 50 min, the patient received two additional equal doses with complete resolution of symptoms. After 36 h of observation, the child was discharged. Our patient presented with symptoms more suggestive of the deadly nightshade species, Atropa belladonna, which is native to Europe; however, a detailed laboratory analysis of the suspect berries revealed no atropine or hyoscyamine. Analysis did reveal sterols consistent with solanine. This is a unique case presentation of woody nightshade, S. dulcamara, poisoning presenting with anticholinergic crisis and responding to physostigmine.

Lionfish envenomations in an urban wilderness

Marine envenomations are commonly encountered along coastal regions of the United States. Although less frequent, marine bites and stings do occur in landlocked locales, such as the Midwest, because of an increased interest in keeping these exotic creatures as pets. We report 33 cases of envenomations by captive lionfish (Pterois volitans) called to a regional Chicago poison control center over a 2-year period. All stings were accidental, and 10 (30%) were treated in an emergency department. The wounds were uniformly on the hand, and all presented with local, intense pain. The majority of envenomations were responsive to prompt immersion in nonscalding water within 90 min, and all were advised on tetanus prophylaxis and local wound care. Two patients (6%) required hospitalization. In all cases, those patients envenomated recovered without permanent sequelae. As a result of increasing encounters with lionfish as pets, health care providers. regardless of their locale, should be familiar with the current treatment recommendations.

Chloral hydrate toxicity from oral and intravenous administration

BACKGROUND

Overdose from enteric chloral hydrate results in cardiovascular and central nervous system symptoms.

CASE REPORTS

This case series compares and contrasts two cases of oral chloral hydrate overdose with two cases of accidental i.v. administration. Whereas ingestion of 219 mg/kg of chloral hydrate resulted in transient bigeminy, ingestion of up to 960 mg/kg caused torsades de pointes and ventricular fibrillation which were effectively treated with defibrillation and a beta blocker. I.V. administration in humans does not appear previously documented. Two cases of i.v. administration of a therapeutic chloral hydrate dose resulted in central nervous system depression and minimal local effects at the injection site.

CONCLUSIONS

Given the high bioavailability of oral chloral hydrate the major determinant of cardiotoxicity may be the dose rather than the route of administration. Cardiac arrhythmias due to chloral hydrate appear to be responsive to beta blocker therapy.

Emergency department poison advice telephone calls

STUDY OBJECTIVE

Requests for medical advice regarding treatment of poisonings are common in emergency departments. Although there are designated poison centers (PCs), most EDs are recognized by the community and medical staff as a poison information resource. The purpose of this study was to evaluate the accuracy and consistency of poison information given by ED personnel.

DESIGN

A prospective, stratified-sample, telephone survey over a 6-month period of requests for medical advice about simulated poison ingestions.

PARTICIPANTS

Fifty-two hospital EDs in urban and rural Illinois, all three PCs in Illinois, and three PCs from Indiana, Wisconsin, and Michigan.

RESULTS

Hospital EDs responded correctly to only 100 of 156 calls (64.2%). PCs responded correctly to 17 of 18 calls (94.4%), whereas teaching hospitals responded correctly to 15 of 30 calls (50%, P = .002). ED night shift personnel were 5.5 times more likely to respond incorrectly than were personnel on other shifts (95% confidence interval, 2.72 to 11.12). Forty-eight percent of all calls to EDs resulted in advice to call the regional PC.

CONCLUSION

Poison advice by ED personnel proved to be inaccurate and inconsistent. As a result, patients may be better served if advice calls are redirected to regional PCs.

Fractional mercury levels in Brazilian gold refiners and miners

A field study survey of individuals residing in the region of Para, Brazil, was conducted to determine fractional mercury levels in individuals at risk for exposure in the Brazilian Amazon region. Subjects with a history of exposure to mercury either in the gold mining or refining industry, or exposure to these processes through proximity were included. Three groups were identified as either having recent (less than 2 d since last exposure), intermediate (less than 60 d), or remote (greater than 60 d) exposure to mercury vapors. Fractional blood and urinary mercury levels were assessed for these groups. Group I (recent) had the highest geometric mean blood 24.8 (SD 44.1, range 7.6-158.8) micrograms/L and urine 75.6 (SD 213.4, range 6.5-735.9) micrograms/g-cr (microgram mercury per gram of creatinine) mercury; intermediate (group II) geometric mean blood 7.6 (SD 5.5, range 2.2-19.4) micrograms/L and urine levels 23.8 (SD 84.0, range 7.8-297.0) micrograms/g-cr; the lowest levels in remote exposure (group III): geometric mean blood 5.6 (SD 3.3, range 3.1-14.3) micrograms/L and urine 7.0 (SD 9.8, range 3.1 to 32.9) micrograms/g-cr. The fraction of organic was lowest in group I (32.4%), higher in group II (65.7%), and highest in group III (72.2%). While the frequency of symptoms was comparable in the recent and intermediate groups (2.6 mean, SD 2.3, range 0-8, and 3.1 mean, SD 1.9, range 0-7, symptoms per patient), those with remote exposure demonstrated the highest rate of reporting (6.4 mean, SD 4.1, range 0-11, symptoms per patient). There is significant exposure to mercury for those working in or living near the mining and refining industry. Blood and urine levels are a better marker of recent than remote exposure. The fraction of organic mercury increases with time since exposure. Symptoms may be persistent and low levels of blood and urine mercury do not exclude remote or cumulative toxicity.

Acute bone marrow toxicity and pancytopenia following exposure to lead chromate, xylene, and ethylbenzene in a degloving injury

A case of unique acute bone marrow toxicity and pancytopenia following subcutaneous exposure to lead chromate, xylene, and ethylbenzene in a previously healthy patient is reported. The patient sustained an extensive degloving injury to his lower extremity. The wound was contaminated with traffic paint containing lead chromate pigment along with a large volume of xylene and ethylbenzene solvent. Consequences of the patient's clinical course and management of degloving injuries are discussed.

The toxic patient as a potential organ donor

The use of organs from poisoned victims for the purpose of transplantation has been poorly studied; criteria for organ donation is virtually non-existent in such cases. To further elucidate these indications, a retrospective review of all organ transplantation donated by poisoned victims in Northern and Central Illinois was undertaken. From January 1988 to December 1993, 17 poisoned victims were identified as having donated organs to 41 recipients. Eleven of the donors died as a direct result of drug toxicity, whereas six donors had drug-related deaths. The cases were reviewed for toxin involved, organ preoperative function and postoperative function (up to 1 year after transplant). Kidney transplants postoperative function was rated as good if creatinine was less than 1.9, fair if creatinine was 2 to 2.9, and poor if creatinine was 3. Donor age ranged from 2 years to 54 years. Toxins involved in donation included ethanol (n = 8), cocaine (n = 5), carbon monoxide (5), barbiturates (2) and lead (1), six patients had multiple drugs. Two of the nine recipients of livers died intraoperatively, both unrelated to organ function. Thirty-two kidneys were transplanted with 28 having good 10-day postoperative function, three having fair postoperative function, and one (cocaine donor) having poor postoperative function. One kidney transplanted from a cocaine donor had a thrombosed graft 5 days postoperatively. Deaths involving toxins in general does not seem to be a contraindication to donation of liver and kidney for transplantation.

Tricyclic antidepressants in red cells and plasma: correlation with impaired intraventricular conduction in acute overdose

OBJECTIVE

Tricyclic antidepressant levels in red blood cells and plasma in acute overdose and their association with cardiotoxicity were studied.

METHODS

This was a prospective study in 15 patients with acute tricyclic antidepressant overdose. Tricyclic antidepressant parent compounds and metabolites were measured in red blood cells and plasma, and tricyclic antidepressant levels were correlated with ECG indexes of toxicity.

RESULTS

Plasma levels of the parent compounds were higher than their red blood cell levels on admission (mean +/- SD, 691 +/- 409 and 337 +/- 220 ng/ml, respectively). Admission metabolite levels were higher in red blood cells than in plasma (264 +/- 180 and 190 +/- 164 ng/ml, respectively). QRS duration and the red blood cell levels of the metabolites were significantly correlated at the time of admission (r = 0.77, p < 0.01), as well as at 6 to 10 hours (r = 0.74, p < 0.01).

CONCLUSIONS

In acute overdose, a shift of tricyclic antidepressants from plasma to red blood cells and increased levels of red blood cell metabolites reflect tissue redistribution of the drug. Tricyclic antidepressant red blood cell metabolites are the best markers for impaired intraventricular conduction.

Toxicology training in US and Canadian medical schools

The objective was to determine the extent of toxicology training in US and Canadian Medical Schools. The authors took a phone survey of the medical schools in the United States and Canada. Questions asked included whether school had a required toxicology course, in what context toxicology was taught, whether basic poison management was taught, and whether a doctoral toxicologist was on staff. Quantitation of hours of toxicology instruction and toxicology-related questions was also sought. Of the 142 medical schools in the United States and Canada, 123 schools were contacted (85.4%); 107 of these schools were US schools while 16 were Canadian medical schools. One hundred two schools (82.8%) stated that toxicology was taught in pharmacology or pathology courses, while only six schools (4.9%) had separate formal toxicology courses. An average of 5.04 hours (+/- 4.6 hours) of toxicology was taught in US courses, while the Canadian average was 6.04 hours (+/- 5.2 hours). Basic poison management was taught in 75 of the schools (61%), while a toxicologist (holding either an MD or PhD degree) was on staff in 56 of the 110 schools responding to this question (51%). While no relationship existed between having a toxicologist on staff and whether poison management was taught in US schools, a significant relationship was noted in Canadian schools (P less than .05). The authors conclude that toxicology as a separate discipline (and poison management in particular) is not routinely taught in medical school.

The emergency management of moray eel bites

As human encounters with hazardous marine life increase, emergency physicians are more frequently confronted with the management of resultant injuries. We present three cases involving hand injuries inflected by moray eels. Each was managed with local wound care and subsequent outpatient treatment with either oral ciprofloxacin or cefuroxime. One patient had mild residual hand dysfunction, and no patient developed wound infection. To better assess the bacteriology of such injuries, oral cultures were taken from captive moray eels and surrounding aquarium water. Culture and sensitivity analyses showed Vibrio and Pseudomonas to be the predominant species, both sensitive to ciprofloxacin, cefuroxime, tetracycline, and trimethoprim-sulfamethoxazole. We conclude that moray eel bites can be managed successfully with aggressive, local wound care and antibiotic coverage that targets Vibrio and Pseudomonas species.

Acute oral hypoglycemic ingestions

We reviewed the poison center records of 48 consecutive reports of oral hypoglycemic exposure reported to the Rush Poison Control Center between January 1988 and December 1989. The average age of ingestion was 15.0 y (range 1 to 75 y). Twenty-three of the patients (48%) were male, while 25 (52%) were female. Twenty-nine patients ingested glyburide, 10 chlorpropamide, 6 glipizide, 2 tolbutamide, and 1 each for tolazamide and phenformin. One patient ingested both glyburide and tolbutamide. Sixteen cases (33%) involved coingestants. Accidental cause was the primary reason for ingestion in 33 cases (69%) with suicidal intent being mentioned in an additional 11 cases (23%). Thirteen patients (27%) were treated and released from a health care facility, while the same percentage of patients were admitted. There was no adverse effect in 24 patients (50%) while 9 patients (19%) had minor effects without residual disability. Only 2 patients (4%) experienced a major effect. No deaths were reported. We conclude that oral hypoglycemic ingestions generally have a successful outcome and there does not appear to be a significant difference whether a short/long acting agent or first/second-generation product was ingested.

Jack o'lantern mushroom poisoning

The cases of seven adults who ingested jack o'lantern mushrooms are presented. All patients experienced nausea and vomiting associated with abdominal cramping, and three reported diarrhea. Four of the seven complained of weakness and dizziness. Two were diaphoretic on physical examination. All seven were given IV fluids and oral activated charcoal in a local emergency department and admitted overnight for observation. Laboratory studies showed three of the seven patients to have mildly elevated liver function tests. One patient had hypokalemia requiring potassium supplementation. All were discharged the following day with normal follow-up examinations and laboratory studies. We recommend that all patients presenting with jack o'lantern mushroom poisoning be observed and rehydrated and have baseline liver function tests and potassium levels obtained.

Central nervous system manifestations of a valproic acid overdose responsive to naloxone

We report the case of a 22-year-old man who presented with a depressed level of consciousness after ingesting valproic acid. He responded to IV naloxone; over a nine-hour period, his serum valproic acid level decreased from 180.4 to 59.2 micrograms/ml with multiple-dose charcoal therapy. We recommend the use of both agents in the treatment of valproic acid overdose.

Oxygen consumption during sleep: influence of sleep stage and time of night

We measured oxygen consumption (VO2) in eight normal male volunteers during sleep, using the ventilated-hood method. Data were collected over 28 subject-nights. There was an overnight trend of gradually decreasing VO2 in the first 4 h, followed by a rise toward the morning. The minimum VO2 was 7.9% lower than that in the first hour. To examine the influence of sleep stages on the VO2, we compared the VO2 of a sleep stage (an overnight average of all epochs in that stage) with that of other stages. The results show that VO2 values in stages awake and 1 are significantly higher than all other stages. Stage rapid eye movement (REM) is significantly lower than stage 2, but stages 3 and 4 are not different from each other or from stages REM and 2. We also compared VO2 of sleep stages that occurred close to each other (within the same hour). VO2 in awake stage is again significantly higher than in all other stages, and stage 2 is higher than stages 3 and 4. However, no difference is found between stage 1 and stages 2, 3 and REM, nor is there any difference between REM and stages 2 and 3. The discrepancy between close-stage comparison and overnight-average comparison can be accounted for by the variation in VO2 of an individual stage with the time of night. Although there is a variation in time distribution of the stages overnight, this factor influences the overnight trend of VO2 in a minor fashion only.