Biomedical subjects
Publications and source records attributed to A Woolf.
Household bleach is a frequent nonpharmaceutical childhood ingestion in the US. It is regarded as a benign ingestion. A rare presentation is reported of poisoning by low-concentration hypochlorite household bleach in a toddler that led to severe respiratory sequelae. The literature on respiratory and nonrespiratory sequelae of liquid household bleach ingestion is reviewed.
BACKGROUND: Childhood poisonings continue to exact a notable toll in injury-related morbidity and economic cost. Because a substantial portion of this morbidity and economic cost is associated with hospitalization, an analysis of the cost of poisoning hospitalizations might help to identify areas in which medical care could be improved and costs could be reduced. OBJECTIVE: To assess the aggregate cost of poison-related hospitalizations and to analyze the trends in categorical poisoning costs during a 4-year period. DESIGN: Cost-benefit analysis of charge data and length of stay (LOS) for poison-related hospitalizations. SETTING: Admissions to one urban children's hospital. PATIENTS: Case mix data were reviewed to identify those children whose hospitalizations had a primary discharge diagnosis related to poisoning in fiscal years 1992 to 1995. MAIN OUTCOME MEASURES: Mean aggregate hospital charges and LOS for poisonings were compared for each of the 4 years of the study. Comparisons were also made with charges and LOS for hospitalizations for all other diagnoses during the same period. Trends in hospital charges and LOS for the most common specific types of poisoning were analyzed individually. Linear regression statistics were used to compare the costs and LOS of specific types of poisoning. RESULTS: There were 638 poison-related hospitalizations during the 4-year study (0.9% of all pediatric hospital admissions). Charges per case decreased from $7934 in fiscal year 1992 to $4968 in fiscal year 1995 (z = -2.74, P = .006); mean LOS decreased from 5.85 days in 1992 to 3.45 days in 1995 (z = 2.84, P = .005). These trends exceeded smaller trends toward decreasing charges and LOS seen also for non-poison-related hospitalizations. Acetaminophen, lead, and antidepressant medications were the most common and most costly specific agents implicated in poison-related hospitalizations during the study period. Linear regression analysis showed a significant decrease in charges (F = 6.35, R2 = 0.09, P = .014) and LOS for acetaminophen (F = 4.30, R2 = 0.063, P < .04) but not for lead or antidepressant poison-related hospitalizations. CONCLUSIONS: Despite an increasing number of children hospitalized for poisoning at one institution during a 4-year period, per case hospital charges decreased substantially. The cost savings were associated with a marked decrease in LOS. Still, poison-related admissions to a single pediatric facility accounted for almost $1 million in hospital charges in fiscal year 1995. A few agents are overrepresented; new poisoning prevention measures aimed at these toxic agents are warranted. We conclude that further outcomes studies are needed to delineate cost-effective improvements in patient care targeted toward poisonings owing to those agents.
OBJECTIVES: To describe the changes over time of the QRS interval and terminal 40-msec QRS frontal axis (T40-ms) in patients with acute tricyclic antidepressant poisoning, to identify clinical factors and treatment associated with these changes, and to determine if patients with tricyclic antidepressant-related complications (seizures and/or arrhythmias) had differences in such serial electrocardiogram (ECG) changes when compared with patients without complications. DESIGN: Prospective, observational, cohort study. SETTING: Emergency departments of community and university-based hospitals in Massachusetts that consulted a large regional poison center. PATIENTS: Thirty-six patients who presented with an acute ingestion (< 24 hrs) of a tricyclic antidepressant, who had at least three electrocardiograms in the first 8 hrs and serial ECGs until discharge, and who had a peak tricyclic antidepressant concentration of > 300 ng/mL. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The maximal limb-lead QRS interval and T40-ms axis were measured manually in all ECGs. The maximum recorded QRS interval occurred at the time of presentation for 24(80%) of 30 patients whose QRS was > or = 100 msecs and a median time of 3 hrs (range 1 to 9) for the other six patients. The maximum recorded T40-ms axis occurred at the time of presentation for 31(86%) of 36 patients and at a median time of 3 hrs (range 1 to 5) for the remaining five patients. The minimum QRS interval observed remained > or = 100 msecs in 15 patients (range 100 to 140 msecs) and decreased to < 100 msecs in 15 patients. The median time from presentation to the first ECG with a QRS < 100 msecs was 20 hrs (range 1 to 153) in those 15 patients. There were no significant differences in clinical characteristics and treatment (including sodium bicarbonate therapy) between the two groups. The minimum recorded T40-ms remained > or = 120 degrees in 30 patients and decreased to < 120 degrees in six patients. The median time from presentation until the first ECG with a T40-ms axis < 120 degrees was 13 hrs (range 2 to 30) for the six patients. All ECG measurements were greater and remained abnormal for a significantly longer duration in those patients who developed seizures and/or ventricular arrhythmias. These two ECG parameters demonstrated ongoing changes and persistent abnormalities despite clinical improvement in all patients except one. CONCLUSIONS: The conduction abnormalities seen in severe tricyclic antidepressant toxicity vary widely in the time observed for resolution of these abnormalities and sometimes remain persistently abnormal. All ECG parameters were significantly more abnormal in those patients who developed seizures and/or arrhythmias. Clinical improvement occurred both before and during these ECG changes.
OBJECTIVE: To describe the circumstances, medical complications, and outcomes of children exposed to a transdermal nicotine patch (TNP). DESIGN: Prospective case series; postmarketing surveillance study over a 24-month period. SETTING: Thirty-four United States poison centers. Patients. Children 0 to 15 years old exposed to a TNP. INTERVENTIONS: None. OUTCOME MEASURES: Exposure circumstances, symptoms and signs of toxicity, complications, disposition, and hospital length of stay. RESULTS: Reports were received concerning 36 exposures to TNP in children younger than 16 years old (mean: 3 years old). Eighteen of these TNP exposures were dermal; 18 additional children had bitten, chewed, or swallowed part of a patch. All four commercial brands of TNP were represented; no brand was associated with more symptoms or an increased severity of illness. Fourteen children (39%) developed symptoms, including gastrointestinal distress (nausea, vomiting, diarrhea, abdominal pain), weakness, dizziness, or localized rashes. Occurrence of symptoms after a dermal exposure to a TNP was associated with an estimated nicotine dose >/=.10 mg (>/=.01 mg/kg body weight). Ten children were seen in the emergency department; two were admitted overnight. All recovered fully. CONCLUSIONS: In this series, unintentional exposures to TNPs among young children usually involved used patches, were transient (<20 minutes duration), and required only skin decontamination and supportive care. Continued monitoring of inadvertent childhood exposures to TNPs is recommended to confirm these observations.
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Cottontail rabbits (Sylvilagus floridanus) usually are thought to succumb to infection with Francisella tularensis. Reports of a rabbit population from southern Illinois (USA) with a high prevalence of F. tularensis antibodies suggested that some cottontails survived infection with this typically fatal bacterium. Our goal was to examine the humoral response of cottontails from a study area in southern Illinois for which multiple serum samples existed. Multiple sera were collected from 79 cottontails from 1986 to 1990 and 63% gained, lost, or maintained ELISA titers of IgM and IgG isotype antibodies. The typical pattern of antibody response appeared to be IgM isotype antibodies first, followed by IgG isotype antibodies, with both generally increasing to high titers. Negative culture attempts of liver tissue from 51 cottontails with varying antibody responses suggested that chronic infection did not occur in rabbits that developed antibody. The significance of the cottontail antibody response in resolution or prevention of tularemia infection remains unclear.
OBJECTIVE: To investigate the characteristics and outcomes of poisoning cases involving the dermal application of multiple transdermal nicotine patches. DESIGN: Case series; prospective postmarketing surveillance over a 24 month period. SETTING: Telephone reports from 34 participating US poison centers. PATIENTS: Human poisonings involving more than one transdermal nicotine patch applied simultaneously. RESULTS: Nine cases of dermal exposure to 2-20 transdermal nicotine patches were reported. Cases resulted from either intentional misuse or suicide attempts and included concomitant exposure to other drugs in 7 of 9 cases. Mean age was 45 years; seven of nine patients were female. All suffered medical complications including seizures (3 subjects), other central nervous system changes (8 subjects), cardiovascular effects (6 subjects), and respiratory failure (4 subjects). Eight patients were hospitalized; all recovered. Plasma nicotine/cotinine concentrations did not correlate with the severity of illness. CONCLUSIONS: This case series demonstrated that simultaneous application of several transdermal nicotine patches can be implicated in adult suicide attempts. While signs of toxicity included gastrointestinal complaints, changes in level of consciousness, seizures and parasympathetic effects typical of nicotine poisoning, the frequent presence of co-intoxicants complicated the clinical course. As the accessibility of transdermal nicotine patches increases, increasing misuse of these products by suicidal adults is likely.
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Gizzards from 64 hunter-shot Canada geese (Branta canadensis) were collected in southern Illinois (USA) in December 1991 and January 1992 to determine the prevalence and intensity of gizzard nematodes. Three species of gizzard nematodes were recovered: Amidostomum anseris, Amidostomum spatulatum, and Epomidiostomum crami. The prevalence of infection was 98%. Mean intensity was 17.8 nematodes per host and was significantly greater for immature geese (40.3 nematodes/host) than for adult geese (10.9 nematodes/host). The intensity of both A. anseris and E. crami was greater in immature geese, but even the most heavily infected birds did not display serious lesions. Despite a dramatic increase in the population of geese, mean intensity in adult geese was similar to mean intensity reported from earlier studies at the same site. Mean intensity in immature geese in 1991 and 1992 was greater than in earlier studies.
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STUDY OBJECTIVE: To investigate the efficacy of magnesium citrate in reducing gastrointestinal transit time of activated charcoal in children. DESIGN: A prospective, randomized, clinical comparison of four magnesium doses. SETTING: Urban children's hospital emergency department. PARTICIPANTS: Children aged 1 month to 6 years who presented for management of an acute toxic ingestion. INTERVENTION: Each child received 1 g/kg activated charcoal combined with a randomly assigned dose of a 6% solution of magnesium citrate: 0 mL/kg, 4 mL/kg (standard recommended dose), 6 mL/kg, or 8 mL/kg. The primary outcome measure was the interval to first activated charcoal-containing stool, which was determined by follow-up telephone call or review of the medical record. RESULTS: Sixty-four children were enrolled. Median times to first charcoal stool were 19.5 hours (0 mL/kg), 13.0 hours (4 mL/kg), 14.0 hours (6 mL/kg), and 12.0 hours (8 mL/kg). Intergroup differences were significant by Kruskal-Wallis analysis of variance (P = .0035). CONCLUSION: Magnesium citrate reduces gastrointestinal transit times of activated charcoal stools when administered to children who receive activated charcoal for a toxic ingestion. Further study is needed to determine the clinical value of this reduction.
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Twenty-nine males with hemophilia completed the Medical Compliance Incomplete Stories Test (M-CIST), and their scores were correlated with health care professionals' ratings of four aspects of medical compliance, along with measures of possible moderating variables. The results indicated that significant associations were found between most of the M-CIST category scores, particularly the Compliance/coping subscale, and the health care specialists' ratings of how well the children exhibited compliant responses to bleeding episodes, and inverse associations with the incidence of monthly bleeding episodes. The findings suggested that the M-CIST continues to demonstrate promise as an instrument to be used in studies of compliance among pediatric chronic illness patients.
The woodchuck is a seasonally breeding sciurid rodent. Female woodchucks are monoestrous and, when isolated from males, remain in a prolonged period of estrus characterized by a clear predominance of cornified cells in the vaginal smear. This study was designed to characterize relationships between the degree of vaginal cornification and sexual receptivity, and to study ovulation and related phenomena of this species in captivity. Fourteen individually caged adult females, maintained under standard laboratory conditions for 9-23 mo, were used in this investigation. Females exhibiting predominantly (67-97%) cornified smears were always receptive, regardless of the time interval from the onset of estrus, and mated within 24 h of pairing. Mated females allowed to complete pregnancy gave birth to live pups 30-32 days later. Litter size ranged from 3-7 pups. Serum progesterone (P) levels increased to approximately 2 ng/ml during the first week of pregnancy and greater than 5 ng/ml during the second and third weeks of pregnancy. Serum estradiol (E2) levels were elevated during the first week of pregnancy and began to decline thereafter. Examination of ovarian serial sections revealed that ovulation took place between 20 and 32 h after copulation. Serum levels increased significantly (4-fold) after ovulation (1.2 +/- 0.3 vs. 0.3 +/- 0.01 ng/ml). However, the circulating levels of E2 remained unchanged between the periods before (53 +/- 1 pg/ml) and after ovulation (60 +/- 3 pg/ml). Ovulation was not simultaneous in all mature follicles.(ABSTRACT TRUNCATED AT 250 WORDS)
The medical literature contains few, if any, reports of severe iron (Fe) poisonings from ingestion of chewable multivitamins with iron. One possible explanation for this observation is that iron from multivitamins is more poorly absorbed than iron from iron tablets. To compare iron absorption from multivitamins with iron absorption from ferrous fumarate tablets, male adult volunteers were given 6 mg of elemental Fe/kg body weight as chewable multivitamins with iron or as crushed ferrous fumarate tablets in a crossover study. Serum Fe and total iron binding capacity (TIBC) were determined prior to administration of the tablets and one, two, four, and six hours after ingestion. Statistical analyses demonstrated increased and more rapid absorption of Fe from the multivitamin preparation. These results suggest that iron is well absorbed from chewable multivitamins with iron and should theoretically have the potential for producing serious toxicity when taken in overdose. The reasons that such toxicity is not commonly seen clinically are discussed, and a plan for further investigation of this issue is proposed.