Acetaminophen poisoning: an evidence-based consensus guideline for out-of-hospital management

The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial management of patients with suspected ingestions of acetaminophen. An evidence-based expert consensus process was used to create this guideline. This guideline applies to ingestion of acetaminophen alone and is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care. The panel's recommendations follow. These recommendations are provided in chronological order of likely clinical use. The grade of recommendation is provided in parentheses. 1) The initial history obtained by the specialist in poison information should include the patient's age and intent (Grade B), the specific formulation and dose of acetaminophen, the ingestion pattern (single or multiple), duration of ingestion (Grade B), and concomitant medications that might have been ingested (Grade D). 2) Any patient with stated or suspected self-harm or who is the recipient of a potentially malicious administration of acetaminophen should be referred to an emergency department immediately regardless of the amount ingested. This referral should be guided by local poison center procedures (Grade D). 3) Activated charcoal can be considered if local poison center policies support its prehospital use, a toxic dose of acetaminophen has been taken, and fewer than 2 hours have elapsed since the ingestion (Grade A). Gastrointestinal decontamination could be particularly important if acetylcysteine cannot be administered within 8 hours of ingestion. Acute, single, unintentional ingestion of acetaminophen: 1) Any patient with signs consistent with acetaminophen poisoning (e.g., repeated vomiting, abdominal tenderness in the right upper quadrant or mental status changes) should be referred to an emergency department for evaluation (Grade D). 2) Patients less than 6 years of age should be referred to an emergency department if the estimated acute ingestion amount is unknown or is 200 mg/kg or more. Patients can be observed at home if the dose ingested is less than 200 mg/kg (Grade B). 3) Patients 6 years of age or older should be referred to an emergency department if they have ingested at least 10 g or 200 mg/kg (whichever is lower) or when the amount ingested is unknown (Grade D). 4) Patients referred to an emergency department should arrive in time to have a stat serum acetaminophen concentration determined at 4 hours after ingestion or as soon as possible thereafter. If the time of ingestion is unknown, the patient should be referred to an emergency department immediately (Grade D). 5) If the initial contact with the poison center occurs more than 36 hours after the ingestion and the patient is well, the patient does not require further evaluation for acetaminophen toxicity (Grade D). Repeated supratherapeutic ingestion of acetaminophen (RSTI): 1) Patients under 6 years of age should be referred to an emergency department immediately if they have ingested: a) 200 mg/kg or more over a single 24-hour period, or b) 150 mg/kg or more per 24-hour period for the preceding 48 hours, or c) 100 mg/kg or more per 24-hour period for the preceding 72 hours or longer (Grade C). 2) Patients 6 years of age or older should be referred to an emergency department if they have ingested: a) at least 10 g or 200 mg/kg (whichever is less) over a single 24-hour period, or b) at least 6 g or 150 mg/kg (whichever is less) per 24-hour period for the preceding 48 hours or longer. In patients with conditions purported to increase susceptibility to acetaminophen toxicity (alcoholism, isoniazid use, prolonged fasting), the dose of acetaminophen considered as RSTI should be greater than 4 g or 100 mg/kg (whichever is less) per day (Grade D). 3) Gastrointestinal decontamination is not needed (Grade D). Other recommendations: 1) The out-of-hospital management of extended-release acetaminophen or multi-drug combination products containing acetaminophen is the same as an ingestion of acetaminophen alone (Grade D). However, the effects of other drugs might require referral to an emergency department in accordance with the poison center's normal triage criteria. 2) The use of cimetidine as an antidote is not recommended (Grade A).     

Diphenhydramine and dimenhydrinate poisoning: an evidence-based consensus guideline for out-of-hospital management

In 2003, there were 28,092 human exposures to diphenhydramine reported to poison centers in the US. A related drug, dimenhydrinate, is a less frequent cause of poisonings. Between January 2000 and June 2004, there were 2,534 reported dimenhydrinate ingestions in children less than 6 years of age. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft was created by the primary author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial management of patients with a suspected ingestion of diphenhydramine or dimenhydrinate, or a dermal exposure to diphenhydramine. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. The panel's recommendations for dermal or oral exposures to diphenhydramine or oral exposures to dimenhydrinate follow. The grade of recommendation is in parentheses: 1) All patients with suicidal intent, intentional abuse, or in cases in which a malicious intent is suspected (e.g., child abuse or neglect) should be referred to an emergency department (Grade D). 2) In patients without evidence of self-harm, abuse, or malicious intent, poison center personnel should elicit additional information including the time of the ingestion or dermal exposure, determination of the precise dose ingested, and the presence of co-ingestants (Grade D). 3) Patients experiencing any changes in behavior other than mild drowsiness or mild stimulation should be referred to an emergency department. Examples of moderate to severe symptoms that warrant referral include agitation, staring spells, inconsolable crying, hallucinations, abnormal muscle movements, loss of consciousness, seizures, or respiratory depression (Grade D). 4) For patients referred to the emergency department, transportation via ambulance should be considered based on several factors including the condition of the patient and the length of time it will take the patient to arrive at the emergency department (Grade D). 5) If the patient has no symptoms, and more than 4 hours have elapsed between the time of diphenhydramine ingestion and the call to the poison center, referral to an emergency department is not recommended. For dermal exposures to diphenhydramine, if the patient has no symptoms and it has been more than 8 hours since the diphenhydramine was thoroughly removed from the skin, referral to an emergency department is not recommended (Grade D). 6) Patients with acute ingestions of less than a toxic dose of diphenhydramine, or chronic exposures to diphenhydramine and no or mild symptoms, can be observed at home with instructions to call the poison center back if symptoms develop or worsen. The poison center should consider making a follow-up call at approximately 4 hours after ingestion (Grade D). 7) Children less than 6 years of age who ingest at least 7.5 mg/kg of diphenhydramine should be referred to an emergency department (Grade D). 8) Patients 6 years of age and older who ingest at least 7.5 mg/kg or 300 mg of diphenhydramine (whichever is less), should be referred to an emergency department (Grade D). 9) If the patient has no symptoms, and more than 6 hours have elapsed between the time of dimenhydrinate ingestion and the call to the poison center, referral to an emergency department is not recommended (Grade D). 10) Patients with acute ingestions of less than a toxic dose of dimenhydrinate, or chronic exposures to dimenhydrinate and no or mild symptoms, can be observed at home with instructions to call the poison center back if symptoms develop or worsen. The poison center should consider making a follow-up call at approximately 6 hours after ingestion (Grade D). 11) Children less than 6 years of age ingesting at least 7.5 mg/kg of dimenhydrinate should be referred to an emergency department (Grade D). 12) Patients 6 years of age and older ingesting at least 7.5 mg/kg or 300 mg of dimenhydrinate (whichever is less), should be referred to an emergency department for evaluation (Grade D). 13) Following oral exposures of diphenhydramine or dimenhydrinate, do not induce emesis. Because of the potential for diphenhydramine or dimenhydrinate to cause loss of consciousness or seizures, activated charcoal should not be administered en route to an emergency department (Grade D). 14) For chronic dermal exposures of diphenhydramine, skin decontamination (with water or soap and water) should be attempted prior to transporting a patient to an emergency department unless moderate to severe symptoms are already present. In this circumstance, transportation should not be delayed, and EMS personnel should attempt skin decontamination en route to the emergency department (Grade D). 15) Intravenous sodium bicarbonate may be administered by EMS personnel if QRS widening (QRS >0.10 msec) is present and if authorized by EMS medical direction (Grade D). 16) Physostigmine should be reserved for administration in a hospital (Grade D). 17) Benzodiazepines may be administered by EMS personnel if agitation or seizures are present, and if authorized by EMS medical direction (Grade D).     

Solid phase radioimmunoassay for determination of conjugated cholic acid in serum.

A modified radioimmunoassay for conjugated cholates is presented. In this modification the antibody is chemically bound to Sepharose which enablproducibility (the coefficient of variation between samples is 4%). The whole procedure is carried out at room temperature and with a short incubation time (45 min). Serum can by analysed directly (no extractions or modifications needed). The assay is a suitable tool for liver function testing. A rough indication of total bile acid concentration in serum or bile can also be obtained with this assay.     

Value of coronary artery calcium scanning by computed tomography for predicting coronary heart disease in diabetic subjects

OBJECTIVE: The South Bay Heart Watch is a cohort study designed to determine the significance of coronary calcium in high-risk asymptomatic patients. This is a report of the relative risk (RR) for outcomes of coronary artery calcium in diabetic and nondiabetic subjects. RESEARCH DESIGN AND METHODS: A total of 1312 diabetic and nondiabetic subjects underwent risk factor screening and computed tomography testing for coronary calcium at baseline and were followed clinically for 6.3 +/- 1.4 years. End points were either 1). hard events of nonfatal myocardial infarction (MI) or coronary death or 2). any cardiovascular event (nonfatal MI, coronary death, coronary revascularization, or stroke). RESULTS: The incidence rates of a hard event and any cardiovascular event for diabetic and nondiabetic subjects were 14.5 and 6.1% and 23.8 and 12.2%, respectively (P < 0.001). Cox regression analyses of the combined risk relationship of diabetes status and calcium score demonstrated that relative to nondiabetic subjects with low calcium scores (<2.8), diabetic subjects with calcium scores >or=2.8 exhibited at least a fourfold increase in the risk of either a hard or any cardiovascular event (P < 0.001). Cox regression analyses conducted separately for nondiabetic and diabetic subjects revealed that coronary calcium score risk groups were significantly associated with events in nondiabetic subjects (RR >or= 2.6, P 0.05). CONCLUSIONS: The risk of coronary heart disease increases with increasing calcium scores and diabetes status. Calcium scores have less prognostic value in diabetic subjects.     

Ethylene glycol exposure: an evidence-based consensus guideline for out-of-hospital management

In 2002, poison centers in the US reported 5816 human exposures to ethylene glycol. A guideline that effectively determines the threshold dose for emergency department referral and need for pre-hospital decontamination could potentially avoid unnecessary emergency department visits, reduce health care costs, optimize patient outcome, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with a suspected exposure to ethylene glycol by (1) describing the process by which the exposure might be evaluated, (2) identifying the key decision elements in managing the case, (3) providing clear and practical recommendations that reflect the current state of knowledge, and (4) identifying needs for research. This guideline is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care, considering all of the circumstances involved. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. (1) A patient with exposure due to suspected self-harm, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the dose reported (Grade D). (2) Patients with inhalation exposures will not develop systemic toxicity and can be managed out-of-hospital if asymptomatic (Grade B). Patients with clinically significant mucous membrane irritation should be referred for evaluation (Grade D). (3) Decontamination of dermal exposures should include routine cleansing with mild soap and water. Removal of contact lenses and immediate irrigation with room temperature tap water is recommended for ocular exposures. All patients with symptoms of eye injury should be referred for an ophthalmologic exam (Grade D). (4) Patients with symptoms of ethylene glycol poisoning should be referred immediately for evaluation regardless of the reported dose (Grade C). (5) The absence of symptoms shortly after ingestion does not exclude a potentially toxic dose and should not be used as a triage criterion (Grade C). (6) Adults who ingest a "swallow" (10-30 mL), children who ingest more than a witnessed taste or lick, or if the amount is unknown of most ethylene glycol products should be referred immediately for evaluation. The potential toxic volume of dilute solutions (e.g., concentration <20%) is larger and can be estimated by a formula in the text (Grade C). (7) A witnessed taste or lick only by a child, or an adult who unintentionally drinks and then expectorates the product without swallowing, does not need referral (Grade C). (8) Referral is not needed if it has been >24 hours since a potentially toxic unintentional exposure, the patient has been asymptomatic, and no alcohol was co-ingested (Grade D). (9) Gastrointestinal decontamination with ipecac syrup, gastric lavage or activated charcoal is not recommended. Transportation to an emergency department should not be delayed for any decontamination procedures (Grade D). (10) Patients meeting referral criteria should be evaluated at a hospital emergency department rather than a clinic. A facility that can quickly obtain an ethylene glycol serum concentration and has alcohol or fomepizole therapy available is preferred. This referral should be guided by local poison center procedures and community resources (Grade D). (11) The administration of alcohol, fomepizole, thiamine, or pyridoxine is not recommended in the out-of-hospital setting (Grade D).     

Methylphenidate poisoning: an evidence-based consensus guideline for out-of-hospital management

A review of US poison center data for 2004 showed over 8,000 ingestions of methylphenidate. A guideline that determines the conditions for emergency department referral and prehospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce health care costs, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial out-of-hospital management of patients with suspected ingestions of methylphenidate by 1) describing the process by which a specialist in poison information should evaluate an exposure to methylphenidate, 2) identifying the key decision elements in managing cases of methylphenidate ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This review focuses on the ingestion of more than a single therapeutic dose of methylphenidate and the effects of an overdose and is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) All patients with suicidal intent, intentional abuse, or in cases in which a malicious intent is suspected (e.g., child abuse or neglect) should be referred to an emergency department (Grade D). 2) In patients without evidence of self-harm, abuse, or malicious intent, poison center personnel should elicit additional information including the time of the ingestion, the precise dose ingested, and the presence of coingestants (Grade D). 3) Patients who are chronically taking a monoamine oxidase inhibitor and who have ingested any amount of methylphenidate require referral to an emergency department (Grade D). 4) Patients experiencing any changes in behavior other than mild stimulation or agitation should be referred to an emergency department. Examples of moderate to severe symptoms that warrant referral include moderate-to-severe agitation, hallucinations, abnormal muscle movements, headache, chest pain, loss of consciousness, or convulsions (Grade D). 5) For patients referred to an emergency department, transportation via ambulance should be considered based on several factors including the condition of the patient and the length of time it will take for the patient to arrive at the emergency department (Grade D). 6) If the patient has no symptoms, and more than 3 hours have elapsed between the time of ingestion and the call to the poison center, referral to an emergency department is not recommended (Grade D). 7) Patients with acute or acute-on-chronic ingestions of less than a toxic dose (see recommendations 8, 9, and 10) or chronic exposures to methylphenidate with no or mild symptoms can be observed at home with instructions to call the poison center back if symptoms develop or worsen. For acute-on-chronic ingestions, the caller should be instructed not to administer methylphenidate to the patient for the next 24 hours. The poison center should consider making a follow-up call at approximately 3 hours after ingestion (Grade D). 8) Patients who ingest more than 2 mg/kg or 60 mg, whichever is less, of an immediate-release formulation (or the equivalent amount of a modified-release formulation that has been chewed) should be referred to an emergency department (Grade C). 9) If a patch has been swallowed, consider the entire contents of the patch (not just the labeled dose of the patch) to have been ingested. Patients who ingest more than 2 mg/kg or 60 mg, whichever is less should be referred to an emergency department. If it is known that the patch has been chewed only briefly, and the patch remains intact, significant toxicity is unlikely and emergency department referral is not necessary (Grade D). 10) Patients who ingest more than 4 mg/kg or 120 mg, whichever is less, of an intact modified-release formulation should be referred to an emergency department (Grade D). 11) For oral exposures, do not induce emesis (Grade D). 12) Pre-hospital activated charcoal administration, if available, should only be carried out by health professionals and only if no contraindications are present. Do not delay transportation in order to administer activate charcoal (Grade D). 13) Benzodiazepines can be administered by EMS personnel if agitation, dystonia, or convulsions are present and if authorized by EMS medical direction expressed by written treatment protocol or policy or direct medical oversight (Grade C). 14) Standard advanced cardiac life support (ACLS) measures should be administered by EMS personnel if respiratory arrest, cardiac dysrhythmias, or cardiac arrest are present and if authorized by EMS medical direction expressed by written treatment protocol or policy or direct medical oversight (Grade C).     

Ethylene Glycol Exposure: an Evidence-Based Consensus Guideline for Out-of-Hospital Management

In 2002, poison centers in the US reported 5816 human exposures to ethylene glycol. A guideline that effectively determines the threshold dose for emergency department referral and need for pre-hospital decontamination could potentially avoid unnecessary emergency department visits, reduce health care costs, optimize patient outcome, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with a suspected exposure to ethylene glycol by 1) describing the process by which the exposure might be evaluated, 2) identifying the key decision elements in managing the case, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care, considering all of the circumstances involved. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) A patient with exposure due to suspected self-harm, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the dose reported (Grade D). 2) Patients with inhalation exposures will not develop systemic toxicity and can be managed out-of-hospital if asymptomatic (Grade B). Patients with clinically significant mucous membrane irritation should be referred for evaluation (Grade D). 3) Decontamination of dermal exposures should include routine cleansing with mild soap and water. Removal of contact lenses and immediate irrigation with room temperature tap water is recommended for ocular exposures. All patients with symptoms of eye injury should be referred for an ophthalmologic exam (Grade D). 4) Patients with symptoms of ethylene glycol poisoning should be referred immediately for evaluation regardless of the reported dose (Grade C). 5) The absence of symptoms shortly after ingestion does not exclude a potentially toxic dose and should not be used as a triage criterion (Grade C). 6) Adults who ingest a “swallow” (10–30 mL), children who ingest more than a witnessed taste or lick, or if the amount is unknown of most ethylene glycol products should be referred immediately for evaluation. The potential toxic volume of dilute solutions (e.g., concentration < 20%) is larger and can be estimated by a formula in the text (Grade C). 7) A witnessed taste or lick only by a child, or an adult who unintentionally drinks and then expectorates the product without swallowing, does not need referral (Grade C). 8) Referral is not needed if it has been > 24 hours since a potentially toxic unintentional exposure, the patient has been asymptomatic, and no alcohol was co-ingested (Grade D). 9) Gastrointestinal decontamination with ipecac syrup, gastric lavage or activated charcoal is not recommended. Transportation to an emergency department should not be delayed for any decontamination procedures (Grade D). 10) Patients meeting referral criteria should be evaluated at a hospital emergency department rather than a clinic. A facility that can quickly obtain an ethylene glycol serum concentration and has alcohol or fomepizole therapy available is preferred. This referral should be guided by local poison center procedures and community resources (Grade D). 11) The administration of alcohol, fomepizole, thiamine, or pyridoxine is not recommended in the out-of-hospital setting (Grade D).     

Long-acting anticoagulant rodenticide poisoning: an evidence-based consensus guideline for out-of-hospital management

The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with suspected exposure to long-acting anticoagulant rodenticides (LAAR). An evidence-based expert consensus process was used to create this guideline. It is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care. The grade of recommendation is in parentheses. 1) Patients with exposure due to suspected self-harm, abuse, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the doses reported (Grade D). 2) Patients with symptoms of LAAR poisoning (e.g., bleeding, bruising) should be referred immediately to an emergency department for evaluation regardless of the doses reported (Grade C). 3) Patients with chronic ingestion of LAAR should be referred immediately to an emergency department for evaluation of intent and potential coagulopathy (Grade B). 4) Patients taking anticoagulants therapeutically and who ingest any dose of a LAAR should have a baseline prothrombin time measured and then again at 48-72 hours after ingestion (Grade D). 5) Patients with unintentional ingestion of less than 1 mg of LAAR active ingredient can be safely observed at home without laboratory monitoring. This includes practically all unintentional ingestions in children less than 6 years of age (Grade C). 6) Pregnant patients with unintentional exposure to less than 1 mg of LAAR active ingredient should be evaluated by their obstetrician or primary care provider as an outpatient. Immediate referral to an ED or clinic is not required (Grade D). 7) Patients with unintentional ingestion of 1 mg or more of active ingredient and are asymptomatic should be evaluated for coagulopathy at 48-72 hours after exposure (Grade B). 8) Physicians' offices or outpatient clinics must be able to obtain coagulation study results in a timely manner, preferably in less than 24 hours, for patients who require outpatient monitoring (Grade D). 9) Gastrointestinal decontamination with ipecac syrup or gastric lavage is not recommended (Grade D). 10) Transportation to an emergency department should not be delayed for administration of activated charcoal (Grade D). 11) Patients with dermal exposures should be decontaminated by washing the skin with mild soap and water (Grade D). 12) The administration of vitamin K is not recommended prior to evaluation for coagulopathy (Grade D).     

Antiglobulin test using an immunoenzyme method

An enzyme-linked antiglobulin test (ELAT) is described. All reagents are commercially available. The antiglobulin reagent is a monoclonal anti-IgG conjugated with alkaline phosphatase. The substrate (p-nitrophenylphosphate) is stable and innocuous. The procedure requires long incubations, particularly between red cells and the enzyme-conjugated antibody. However most of the time actively spent by the technician is consumed by washing procedures (LAV). These may be avoided by using density gradient centrifugation (CSG). ELAT is significantly more sensitive than agglutination, using either washing or gradient centrifugation (P = 0.002 and P = 0.0005, respectively). Moreover ELAT-CSG is significantly more sensitive than ELAT-LAV (P = 0.03). CSG yields better reproducibility and probably avoids some of the spontaneous elution of the primary and/or secondary antibody which may occur during washing.     

The management of allergic reaction to venomous insect stings

Insects that sting play a vital role in our ecosystem by consuming crop pests and by pollinating plants (Earth-Life Web Productions, 2004). Some of these insects, particularly bees and wasps (hymenoptera), can also deliver a painful and venomous sting. Their bodies contain a sac of venom attached to a stinger which is forced through the skin. The painful sting occurs when the sac contracts and venom is deposited in the tissues (Prodigy, 2004). The venom contains allergens that typically produce an intense, burning pain followed by erythema (redness) and a small area of oedema (up to 1 cm) which usually subsides within a few hours (Ewan, 1998a). Some people suffer more serious localised or systemic reactions including anaphylaxis. Every year in the UK between two and nine people die as a consequence of a severe allergic reaction to a bee or wasp sting (The Anaphylaxis Campaign, 2004).     

Elemental mercury exposure: an evidence-based consensus guideline for out-of-hospital management

The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with suspected exposures to elemental mercury. An evidence-based expert consensus process was used to create this guideline. It is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care. The grade of recommendation is in parentheses. Recommendations: 1) Patients with exposure due to suspected self-harm, abuse, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the exposure reported (Grade D). 2) Patients with symptoms of acute elemental mercury poisoning (e.g., cough, dyspnea, chest pain) should be referred immediately to an emergency department for evaluation regardless of the reported dose. Patients with symptoms of chronic toxicity (rash, tremor, weight loss, etc.) should be referred for healthcare evaluation, the timing and location of which is guided by the severity of illness and circumstances of the exposure (Grade C). 3) If the elemental mercury was recently heated (e.g., from stove top, oven, furnace) in an enclosed area, all people within the exposure area should be evaluated at a healthcare facility due to the high risk of toxicity (Grade C). 4) If the elemental mercury was vacuumed or swept with a broom, the health department should be contacted to perform an environmental assessment for mercury contamination. Consider healthcare referral for those exposed to documented high air mercury concentrations (Grade C). 5) Patients ingesting more mercury than in a household fever thermometer or those with abdominal pain after ingestion should be referred to an emergency department for evaluation (Grade C). Do not induce emesis or administer activated charcoal. 6) Asymptomatic patients with brief, unintentional, low-dose vapor exposures can be observed at home. Asymptomatic patients can be evaluated as non-urgent outpatients if there is concern for exposures to high doses (e.g., more than contained in a thermometer) or for chronic duration (Grade D). 7) Pregnant patients unintentionally exposed to elemental mercury and who are asymptomatic should be evaluated by their obstetrician or primary care provider as an outpatient. Immediate referral to an ED is not required (Grade D). 8) Patients with elemental mercury deposited or injected into soft tissue should be referred for evaluation of surgical removal (Grade C). 9) All elemental mercury spills should be properly cleaned up, including the small amount of mercury from a broken thermometer. Brooms and vacuum cleaners should not be used to clean up elemental mercury. The clean-up of any spill larger than a broken thermometer should be performed by a professional company, state health department, or the EPA. Detailed instructions are provided on the EPA website: www.epa.gov/epaoswer/hazwaste/mercury/faq/spills.htm (Grade D). 10) Patients with dermal exposures should remove all jewelry and wash the affected area with mild soap and water. Remove all contaminated clothing and place these items in a sealed plastic double-bag for proper disposal (Grade D). 11) Do not discard elemental mercury in household trash, plumbing drains, or sewer systems. Consult local authorities for the proper disposal of low-level elemental mercury-contaminated household items and thermometers (Grade D).     

糖尿病血清同型半胱氨酸测定的临床意义

目的 :探讨 2型糖尿病患者高同型半胱氨酸 (Hcy)与心脑血管病及肾病的关系。方法 :比较 132例糖尿病 (单纯 2型糖尿病、糖尿病合并心脑血管病及肾病 )患者与正常人群血清 Hcy的水平 ,并观察叶酸对其治疗的效果。结果 :单纯 2型糖尿病组、糖尿病合并冠心病组、糖尿病合并脑梗死组及糖尿病合并肾病组的血清Hcy水平均明显高于对照组 (P均 <0 .0 0 1) ;糖尿病合并冠心病组、糖尿病合并脑梗死组及糖尿病合并肾病组的血清 Hcy水平也均明显高于单纯 2型糖尿病组 (P均 <0 .0 0 1) ;单纯冠心病或单纯脑梗死组血清 Hcy水平均高于单纯 2型糖尿病组 (P均 <0 .0 0 1)。糖尿病合并冠心病及糖尿病合并脑梗死组与单纯冠心病及脑梗死组比较均有显著性差异 (P均 <0 .0 0 1)。应用叶酸治疗 ,高 Hcy水平明显下降 (P<0 .0 0 1)。结论 :高 Hcy是 2型糖尿病合并心脑血管病及肾病的危险因素 ,小剂量叶酸对治疗高 Hcy血症有效。     

Management of postoperative pain in children

TREATMENT OF PAIN: Undertreatment of postoperative pain in children is a problem in clinical practice. This is due to a lack of both knowledge about age-specific aspects of physiology and pharmacology, and routine pain assessment. For example, the fear of side-effects prevents the adequate usage of opioids. It is of major importance to select a route of drug administration where the child feels comfortable with (avoid intramuscular injections). NON-OPIOID ANALGESICS: Non-opioid analgesics are recommended for basic pain treatment after minor surgical procedures. Instead of using the whole multitude of drugs available, the doctor should stick to those drugs he is familiar with (acetaminophen, ibuprofen, diclofenac, dipyrone). OPIOIDS: Opioid usage requires individual dose titration and careful monitoring of side-effects (respiratory monitoring, sedation score). The strong opioids piritramide and morphine may advantageously be administered as either continuous, or patient-controlled iv- infusion (PCA). FORMS OF THERAPY: In addition to infiltration anesthesia, intraoperatively applied nerve blocks provide excellent pain relief. Epidural analgesia with local anesthetics and/or opioids via a thoracic or lumbar epidural catheter is a therapeutic option after thoracic or abdominal surgery, or after extensive orthopedic or urological interventions. Adjuvant analgesics and nonpharmacologic interventions, i. e. transcutaneous electrical nerve stimulation (TENS), are primarily indicated in patients suffering from neuropathic pain. CONCLUSION: The establishment of pain services and the comprehensive education of both the nursing and the medical staff should help to improve postoperative pediatric pain therapy.     

Linezolid versus vancomycin in treatment of complicated skin and soft tissue infections

Skin and soft tissue infections (SSTIs) are a common cause of morbidity in both the community and the hospital. An SSTI is classified as complicated if the infection has spread to the deeper soft tissues, if surgical intervention is necessary, or if the patient has a comorbid condition hindering treatment response (e.g., diabetes mellitus or human immunodeficiency virus). The purpose of this study was to compare linezolid to vancomycin in the treatment of suspected or proven methicillin-resistant gram-positive complicated SSTIs (CSSTIs) requiring hospitalization. This was a randomized, open-label, comparator-controlled, multicenter, multinational study that included patients with suspected or proven methicillin-resistant Staphylococcus aureus (MRSA) infections that involved substantial areas of skin or deeper soft tissues, such as cellulitis, abscesses, infected ulcers, or burns (<10% of total body surface area). Patients were randomized (1:1) to receive linezolid (600 mg) every 12 h either intravenously (i.v.) or orally or vancomycin (1 g) every 12 h i.v. In the intent-to-treat population, 92.2% and 88.5% of patients treated with linezolid and vancomycin, respectively, were clinically cured at the test-of-cure (TOC) visit (P=0.057). Linezolid outcomes (124/140 patients or 88.6%) were superior to vancomycin outcomes (97/145 patients or 66.9%) at the TOC visit for patients with MRSA infections (P<0.001). Drug-related adverse events were reported in similar numbers in both the linezolid and the vancomycin arms of the trial. The results of this study demonstrate that linezolid therapy is well tolerated, equivalent to vancomycin in treating CSSTIs, and superior to vancomycin in the treatment of CSSTIs due to MRSA.     

Thrombocytosis accompanying urinary tract infection suggests obstruction or abscess

OBJECTIVE: Reactive thrombocytosis can be found in patients with different types of infections, including upper urinary tract infection (UTI). In this study, we determined whether thrombocytosis in patients with upper UTI is a random phenomenon or is related to complications associated with the UTI. METHODS: We reviewed the charts of patients admitted to the urology department with a diagnosis of upper UTI and thrombocytosis (platelet count >500 x 10(9)/L) in the years 1991 to 2003 (study group). Patients admitted to the urology department in the year 2003 with a diagnosis of upper UTI without thrombocytosis served as the control group. RESULTS: The study group consisted of 83 patients admitted to the urology department with a diagnosis of upper UTI and thrombocytosis (mean platelet count, 593 x 10(9)/L; SD, 88; range, 501-949). The control group consisted of 99 patients. An obstructed kidney was found in 54 patients (65%) of the study group and in 18 patients (18%) of the control group (P < .00001). Perinephric abscess was found in 7 patients (8%) in the study group compared with none in the control group (P < .003). The positive predictive value of thrombocytosis for kidney obstruction or abscess in patients with upper UTI was 71%. Nephrectomy of a nonfunctioning infected kidney was required in 6 patients of the study group (7%) and 2 of the control group (P = .14). In 26 patients (31%) of the study group, the finding of thrombocytosis preceded the diagnosis of the complication (by a median period of 3 days). In these patients, thrombocytosis was essentially an early marker for the complication. CONCLUSIONS: Thrombocytosis in a patient with upper UTI is not a random phenomenon. It is a marker of kidney obstruction or perinephric abscess. The finding of thrombocytosis in a patient with upper UTI should alert the attending physician to actively search for these complications. Cross-sectional imaging study (abdominal ultrasonography or computed tomography) should be performed.     

Asian guidelines for urinary tract infection in children

The followings are the level of evidence (LE) and grade of recommendation (GR) on pediatric UTI in Asia. Classification according to the sites of infection (lower versus upper tract), the number of episode (first versus recurrent), the severity (simple versus severe), or the existence of complicating factor (uncomplicated versus complicated) is useful to differentiate children with UTI whether they are at risk of renal damage or not (LE: 2, GR: B). Diagnosis of UTI requires both urinalysis that suggests infection and positive urine culture (LE:3, GR B). For pre-toilet trained children, urine specimen for culture should be collected by urethral catheterization or suprapubic aspiration. For toilet trained children, midstream clean catch urine is reliable (LE: 3, GR: A). Urine culture is considered positive if it demonstrates growth of a single bacterium with the following colony counts: (1) any growth by suprapubic aspiration, (2) >5 × 104 CFU/ml by urethral catheterization, or (3) >100,000 CFU/ml by midstream clean catch (LE:3, GR: B). For children with febrile UTI, renal and bladder ultrasonography (RBUS) should be routinely performed as soon as possible (LE: 3, GR: C). RBUS should be followed up 6 months later in children with acute pyelonephritis and/or VUR (LE: 3, GR: C). Acute DMSA scan can be performed when severe acute pyelonephritis or congenital hypodysplasia is noted on RBUS or when the diagnosis of UTI is in doubt by the clinical presentation (LE: 3, GR: C). Late DMSA scan (>6 months after the febrile UTI) can be performed in children with severe acute pyelonephritis, high-grade VUR, recurrent febrile UTIs, or abnormal renal parenchyma on the follow-up RBUS (LE: 3, GR: C). Top-down or bottom-up approach for febrile UTI is suggested for the diagnosis of VUR. For top-down approach, VCUG should not be performed routinely for children after the first febrile UTI. VCUG is indicated when abnormalities are apparent on either RBUS or DMSA scan or both (LE: 2, GR: B). VCUG is also suggested after a repeat febrile UTI (LE:2, GR: B).Appropriate antibiotic should be given immediately after urine specimen for culture has been obtained (LE:2, GR: A). Initiating therapy with oral or parenteral antibiotics is equally efficacious for children (>3 months) with uncomplicated UTI (LE: 2: GR: A). The choice of empirical antibiotic agents is guided by the expected pathogen and the local resistance patterns (LE: 2, GR: A). For children with febrile UTI, the total course of antibiotic therapy should be 7–14 days (LE: 2, GR: B). Circumcision may, but not definitively, reduce the risk of febrile UTI in males and breakthrough febrile UTI in males with VUR. Circumcision should be offered to uncircumcised boys with febrile UTI and VUR in countries where circumcision is accepted by the general population (LE: 3, GR: B), while in countries where childhood circumcision is rarely performed, other measures for febrile UTI/VUR should be the preferred choice (LE: 4, GR: C). Bladder bowel dysfunction (BBD) is one of the key factors of progression of renal scarring (LE: 2). Early recognition and management of BBD are important in prevention of UTI recurrence (LE:2, GR: A). Antibiotic prophylaxis to prevent recurrent febrile UTI is indicated in children with moderate to high grade (III–V) VUR (LE: 1b, GR: A). Surgical intervention may be used to treat VUR in the setting of recurrent febrile UTI because it has been shown to decrease the incidence of recurrent pyelonephritis (LE: 2, GR: B).     

Multiple sparse priors for the M/EEG inverse problem

This paper describes an application of hierarchical or empirical Bayes to the distributed source reconstruction problem in electro- and magnetoencephalography (EEG and MEG). The key contribution is the automatic selection of multiple cortical sources with compact spatial support that are specified in terms of empirical priors. This obviates the need to use priors with a specific form (e.g., smoothness or minimum norm) or with spatial structure (e.g., priors based on depth constraints or functional magnetic resonance imaging results). Furthermore, the inversion scheme allows for a sparse solution for distributed sources, of the sort enforced by equivalent current dipole (ECD) models. This means the approach automatically selects either a sparse or a distributed model, depending on the data. The scheme is compared with conventional applications of Bayesian solutions to quantify the improvement in performance.     

盐酸美沙酮片治疗晚期癌症疼痛的临床观察

目的:比较美沙酮与硫酸吗啡控释片治疗中、重度癌痛的止痛效果和不良反应。方法:60例中、重度癌痛患者(应用第二阶梯止痛药不能缓解者),随机分为两组,治疗药物分别为美沙酮组和美施康定组,在用药后15天评价疼痛缓解率及不良反应。结果:疼痛缓解率美沙酮组为83.3％(25/30),美施康定组86.7％(26/30),差异无显著性(P>0.05)。美施康定组便秘、恶心及呕吐发生率显著高于美沙酮组,差异有显著性(P<0.05)。结论:美沙酮由于对中、重度癌痛的止痛效果好,副作用低,为治疗中、重度癌痛较好的药物。     

Chromogranin A in children with neuroblastoma. Serum concentration parallels disease stage and predicts survival.

Chromogranin A is an acidic protein costored and coreleased with catecholamines from storage vesicles. Its serum concentration is elevated in patients with peptide-producing endocrine neoplasia. We measured serum chromogranin A at the time of diagnosis in 34 children with all stages of neuroblastoma. With a sensitivity of 91% and specificity of 100%, serum chromogranin A emerged as a useful diagnostic tool for neuroblastoma, comparable to or better than other measurements such as neuron-specific enolase, ferritin, or dopamine-beta-hydroxylase. Mean serum chromogranin A correlated with disease stage (r = 0.76, P less than 0.01). The relationship of prognosis (progression-free survival) to baseline serum chromogranin A, age, and disease stage was determined in 34 patients at risk for relapse, with a median followup period of 18 mo (range, 1-48 mo). The survival rate for patients with lower serum chromogranin A levels (less than 190 ng/ml at the time of diagnosis) was 69%, whereas it was 30% for those with higher chromogranin A levels (P less than 0.05). Furthermore, when subjects were additionally stratified by either age or stage, chromogranin A was an effective prognostic tool in patients who either were older than 1 yr (P less than 0.005) or had more advanced disease (stage III or IV; P less than 0.05). We conclude that serum chromogranin A in neuroblastoma is (a) a valuable (sensitive and specific) diagnostic tool, (b) a correlate of tumor burden, and (c) a useful predictor of survival.