Biomedical subjects
Publications and source records attributed to Jerrold B Leikin.
This article presents two years of billing and collection data for a bedside toxicology consultation service. The collections rate was 34% or dollars 26.19 per hour of consultative time. There was an inverse correlation between collection rates and patient acuity.
OBJECTIVE: To describe the results of combined exchange transfusion and chelation therapy in a neonate with an elevated blood lead level (BLL). CASE SUMMARY: A 34-year-old Latina woman with a long history of pica (eating glazed pottery) gave birth to a healthy-appearing girl at 40 weeks of gestation. The mother's preconception BLL was 117 microg/dL and remained elevated throughout pregnancy. At parturition, the mother's BLL was 87 microg/dL and the infant's cord BLL was 100 microg/dL. The infant underwent single-volume exchange transfusion within 12 hours of birth. BLL was 28 microg/dL following the exchange, and a 5-day course of chelation with dimercaprol and CaNa2 ethylenediamine tetraacetic acid was initiated at 36 hours of life. The infant's BLL was 37 microg/dL at the end of inpatient chelation. DISCUSSION: Long-term neurologic disability from in utero lead exposure is well described, but the optimal treatment of elevated neonatal BLLs in healthy-appearing infants at the time of birth is not established. This strategy of combined chelation and exchange transfusion therapy was well tolerated and resulted in decreased lead levels, but the long-term neurologic efficacy of our combination strategy remains to be seen. CONCLUSIONS: Combined exchange transfusion and chelation therapy resulted in rapidly decreased lead levels in a neonate with chronic in utero lead exposure.
BACKGROUND: A significant number of patients seek medical evaluation for chronic subjective symptoms they presume to be associated with a single toxic trigger. This report describes our clinic experience with these patients. CASE SERIES: Twenty patients (of a total of 261 patients) with a mean age of 41 years (median age 42 years; range: 4 to 65 years) were evaluated over an 8 month period. All describe a single past toxic exposure triggering their nonspecific (usually vaguely neurologic) symptoms. Zero of 20 (0%) describe other chemical sensitivities; 2/20 (10%) report ongoing exposure, 18/20 (90%) had a limited exposure dating 1 month to 6 yrs prior to toxicology clinic evaluation; 9/20 (45%) are currently employed; 6/20 (30%) sought alternative medical therapy prior to toxicologist evaluation; 6/20/(30%) have attempted litigation. CONCLUSION: Despite repeatedly normal toxicologic and medical evaluations, all data refuting an underlying toxic cause are not accepted by this series of patients, and their search for a diagnostic linkage persists. Specific toxin identification or treatment for these patients is unlikely to occur.
Dieffenbachia is a common domestic plant. Oral contact with the plant usually is associated with minimal consequences. However, chewing on the stem or the leaf of the Dieffenbachia can result in painful oropharyngeal edema and the inability to speak or handle secretions. Airway compromise has been reported only in a pediatric ingestion. We report a case of an adult who bit into the stem of the plant thinking it was sugar cane. He instantly spit out the remaining stem and despite this brief exposure, oropharyngeal edema developed refractory to medicinal therapy, requiring surgical airway management. The exact mechanism of edema is not known; therefore, methods of treatment are variable. We recommend caution when presented with a patient exposed to Dieffenbachia. Even the patient who initially seems stable may have an airway that will quickly deteriorate.
Mass exposure to radiologic substances presents a unique challenge to the entire response effort, which includes health care professionals, law enforcement personnel, and other first responders. Recognition of signs and symptoms of exposure, and focus on removal and decontamination are priorities of management. Radiation injuries require specialized equipment and access to experts. Patients can have complex patterns of injury, ranging from trauma and the immediate results of an explosion or exposure, to progressive damage associated with radiation sickness. Both conventional injury and radiation illness may require critical care management. Remembering the essentials of first response, that is, treat the patient, not the poison, by addressing the ABCs of airway, breathing, and circulation, is critical to appropriate treatment of radiation exposure. Understanding the basic science of radiologic agents will aid the provider in managing affected patients and preventing further casualties.
The evaluation of postmortem laboratory assays of drugs needs to be performed in a systematic manner. The condition of the body, drug characteristics, matrix and site analysis are factors which need to be considered in the proper interpretation of an autopsy specimen result.
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We describe a patient who developed facial nerve injury following significant exposure to UV radiation. A 49-y-old construction worker developed erythema and edema on the left side of his face (exposed side) 12 h after working within 18 in of a compromised metal halide incandescent light bulb for a total of 2 h. One month later, the patient noted a painful burning sensation over the left side of his face associated with marked left facial weakness and inability to close his eye (peripheral VIIth nerve palsy). Two months later, synkinetic left facial movements were consistent with aberrant regeneration. Over the next several months, forceful episodic spasmodic activity developed in the muscles of facial expression on the left, identical to that seen in hemifacial spasm. Rarely has UV radiation been implicated in damage to subcutaneous nerves. This case demonstrates that significant neurologic morbidity may follow high exposure to UV radiation.
Nerve agents are discussed. The article discusses their properties, routes of exposure, toxicodynamics, targets of toxicity, and treatment. It is concluded that a focused organized approach to the treatment of nerve agents is key to its successful management.
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A 38-y-old male with occult inhalant abuse underwent an 18-mo evaluation for presumed seizure disorder. Although past medical history was significant for alcohol abuse, his wife confirmed a 6-y histoy of abstinence. His seizures were characterized as episodes of unconsciousness preceded by a feeling of "things slowing down". No muscular activity was witnessed during these episodes, and upon regaining consciousness the patient had slurred speech, disorientation, dissociative amnesia, and bizarre behavior that resolved spontaneously. Despite 4 emergency department visits, 4 hospital admissions, 5 neurologic and 7 psychiatric outpatient evaluations, extensive work-up was non-diagnostic. These episodes recurred until his wife found him huffing trichloroethylene. Questioning of the patient revealed that huffing always preceded these episodes and that he started huffing after discontinuing alcohol. The patient underwent addiction treatment. Toxic inhalants should be suspected as a substitute drug of abuse in patients attempting abstention. Disorientation clinically similar to dissociative amnesia can occur following loss of consciousness during an episode of trichloroethylene use.
A 33-y-old male developed severe acidosis, renal failure, and profound neutrophilia after ingesting ethylene glycol. Workup for his neutrophilia excluded infectious and malignant causes. An elevated leukocyte alkaline phosphatase (LAP) level confirmed a leukemoid response, and the neutrophila resolved. Although several leukemoid reactions have been published due to therapeutic agents these reports are often incomplete or inaccurate; this is the first case of leukemoid response to a toxin. Leukemoid response is distinguishable from leukemia by the absence of clonally derived cells, although this is not easily apparent in extreme neutrophilia. Elevated LAP is useful in identifying leukemoid reaction from leukemia in cases of extreme neutrophila. If a patient develops extreme neutrophila in association with drug or toxin exposure, a leukemoid reaction should be considered and an LAP obtained.
The objective of this article is to provide a concise overview of the most likely biological and chemical agents that could be used as biochemical weapons. The diagnosis, pathology, prevention, decontamination, treatment, and disposition of these biological and chemical agents are presented in a tabular format for quick reference purposes. The information provided outlines the bare essentials needed to deal with any emergency or catastrophic event involving these agents.
Emergency department (ED)-based observation units are becoming increasingly used for the assessment and treatment of patients who may not require inpatient management or monitoring. This is a retrospective study of 5,714 patients seen in an ED observation unit from October 16, 1996 through July 12, 2000. Of the 5,714 patients seen in the observation unit, 4,191 were discharged and 1,314 were admitted. The average length of stay was 14.92 hours. The largest group of patients seen in the observation unit was those with chest pain (almost 26%). Patients suffering abdominal pain/colic represented the second largest group (almost 16%). Pediatric patients had the shortest stay, averaging only 11.2 hours, although adult and geriatric patients averaged 15.1 hours and 15.4 hours, respectfully. The ED-based observation unit can be of great value to patient care. Although not a substitute for an inpatient unit, it is meant to be a convenient location from which to observe patients who exhibit questionable admitting criteria.
Fomepizole (Antizol) was recently approved by the US Food and Drug Administration for treatment of methanol poisoning. By inhibiting the hepatic enzyme alcohol dehydrogenase, it presents formation of toxic metabolites with far fewer consequences than traditional ethanol therapy. It appears that fomepizole will become standard therapy for methanol intoxication as it is for ethylene glycol poisoning.
Methylene blue finds its major utilization in toxicology in the treatment of methemoglobinemia at a dose of 1 to 2 mg/kg intravenously. By interacting with methemoglobin and the erythrocyte's enzyme systems to reduce back to hemoglobin, methylene blue is a generally safe drug with dose-related hemolytic effects. People with G-6-PD deficiency, along with patients exposed to aniline dyes and dapsone, may present with special risks in the treatment of methemoglobinemia.