Blood lead of intravenous drug users.

OBJECTIVE: A common method of illegal methamphetamine production uses lead acetate as a reagent. Production errors may result in methamphetamine grossly contaminated with lead. Three reports have documented outbreaks of acute lead poisoning in intravenous methamphetamine users. METHODS: This study measured blood lead concentrations in intravenous drug users of methamphetamine, cocaine or heroin presenting to the emergency department to determine the prevalence of subclinical lead poisoning in intravenous methamphetamine users. RESULTS: Mean blood leads for methamphetamine users (n = 92) were 6.22 micrograms/dL or 0.30 mumol/L (range 0.10-1.15, SD 0.20) and 7.25 micrograms/dL or 0.35 mumol/L (0.10-0.80, SD 0.15) for the nonmethamphetamine users (n = 53) with no significant difference between groups. CONCLUSIONS: The data suggest that previous outbreaks of acute intravenous lead poisoning among methamphetamine users were probably related to episodic contamination of methamphetamine. Subclinical lead poisoning was not found among the methamphetamine users presenting to the emergency department.

Report writing and testimony.

Guidelines for providing competent and fair medicolegal reports and testimony are provided. Among them are (1) remaining within one's area of clinical competence when performing medicolegal work, (2) obtaining board certification from a legitimate specialty board, (3) considering the patients' claims and diagnoses from the opposing medicolegal viewpoint, and (4) Performing differential diagnosis in each case. Experts are asked to strive for honesty, fairness, thoroughness, and accuracy while avoiding the attempts at persuasion which sometimes are made by legal referral sources.

Airway compromise and delayed death following attempted central vein injection of propylhexedrine.

Propylhexedrine is a potent alpha-adrenergic drug available as a nasal decongestant, which drug abusers sometimes extract and inject into a central vein. A 25-year-old white male presented to a local emergency department 32 h after attempting to inject his right internal jugular vein with "home-made crank." Following injection, he noted right neck pain, followed by fever and chills. On emergency department admission, he had inspiratory stridor and respiratory distress. Massive edema of his right neck extended from his anterior chest to the right parotid. Neck radiographs showed extensive paracervical swelling with displacement of the trachea. The patient was taken to surgery for nasotracheal intubation with fiberoptic guidance and surgical exploration. The neck contained extensive necrotic tissue that was surgically debrided. In spite of treatment with antibiotics, he developed progressive renal failure and hypotension unresponsive to fluid therapy, followed by cardiopulmonary arrest and death.

Freon injection injury to the hand. A report of four cases.

During a 6-month period, the poison center was consulted on three occasions for advice regarding accidental injection of hexafluorethane (Freon) used in the manufacturing process of athletic shoes. A fourth case was later identified after consulting physicians near the manufacturing facility. Little information exists in the medical literature concerning injection of freon or other volatile substances. In each of these cases, workers inadvertently injected concentrated hexafluorethane into a finger while holding the shoe component and attempting to inject hexafluorethane. Each case presented with edema, limitation of motion, and crepitation. Hand roentgenogram revealed subcutaneous gas. Treatment was nonsurgical, consisting of splinting, tetanus immunization, and antibiotics. Rapid resolution of symptoms occurred in all four cases. Hexafluorethane is relatively inert when injected and has low toxicity. However, potential rapid expansion warrants observation for pressure injury.

Massive levothyroxine ingestion. Conservative management.

The clinical course of a 29-month-old girl who was referred for evaluation after ingesting ninety 0.2-mg tablets of levothyroxine is reported. Despite an initial thyroxine (T4) level of 282 micrograms/dl and a triiodothyronine (T3) level of 1,837 ng/dl at 48 hours postingestion, her symptoms were mild and included irritability, vomiting, tremor, and tachycardia. Treatment was limited to activated charcoal and propranolol. Thyroid hormone levels fell to normal by 13 days postingestion. The child's clinical course was benign. Even after massive acute ingestions of levothyroxine, children's symptoms are usually mild and may be controlled with propranolol. This conservative approach should be considered before expensive and potentially dangerous therapies are undertaken.

Technology assessment applied to liver transplantation in adults.

This article is a review of liver transplantation in adults, in the context of ongoing technology assessments of the National Institutes of Health (NIH). Liver transplantation in adults has become an accepted therapeutic procedure for end-stage liver disease, as it is practiced in established programs of a number of experienced institutions. The number of medical centers instituting programs of liver transplantation has greatly increased since the 1983 NIH Consensus Conference on this subject, and this article traces the clear relationship between the experience level of the institution and the end result of adult transplantation. Five determinants of the survival rate, safety, and efficacy of liver transplantation are discussed: the supply of donor organs, the selection criteria for transplantation candidates, surgical technique, the support system and support staff available, and adequate suppression of the immunological response. Medical diagnoses most likely to produce successful results are enumerated.

Recurrent seizures following mucosal application of TAC.

A 5-year-old 20-kg boy developed grand mal seizures following application of 2 mL of tetracaine-adrenalin-cocaine to an oral mucosa laceration. Diazepam 6 mg IV followed by 195 mg phenobarbital was required to terminate the seizures. The patient was transferred to a pediatric intensive care unit for further evaluation and treatment. A toxicology screen obtained after transfer was positive only for diazepam and phenobarbital. The child remained lethargic for several hours but otherwise had a normal neurological examination. Brain computed tomography was normal. Anticonvulsant medication was discontinued prior to discharge and the child had no subsequent seizures.

9-1-1 implementation: implications for poison center access.

House Bill 3178, passed by the 1981 Oregon Legislature, requires state-wide participation in a 9-1-1 emergency telephone system by 1991. It further requires deletion of all emergency telephone numbers other than 9-1-1 from the front cover of all telephone directories. The gradual implementation of 9-1-1 provided a unique opportunity to study telephone access to the poison center. The impact of 9-1-1 implementation was assessed, in a two-month survey of calls from the general public, to determine awareness of 9-1-1 availability and the source used to gain access to the poison center. Results showed that most callers (72%) had access to and were aware of 9-1-1. Callers obtained the poison center number from the telephone directories (28%), health care providers (19%), poison symbols supplied by the poison center (15%), directory assistance (9%), or other sources. Only 3% of the callers were referred from 9-1-1. State-wide implementation of 9-1-1 will have a major impact on the public's access to the poison center. The results of this study will be used to develop strategies for cooperation with 9-1-1 agencies.

Health implications of obesity: an NIH Consensus Development Conference.

In February 1985, in Bethesda, MD, the National Institutes of Health held a Consensus Development Conference on the Health Implications of Obesity. Nineteen experts in pertinent subject areas presented the current state of the art to a panel of 15 senior-level professionals. On the basis of the scientific evidence presented and its discussion by the audience, the panel formulated a "consensus statement" of findings and recommendations in the form of a narrative reply to six key questions focused on the health implications of obesity. This article summarizes the results of the consensus conference and discusses the conclusions and recommendations of the panel and their implications for the dietetic profession. Also provided, as a practical tool for the dietitian, are two nomograms indicating body mass index and desirable weight and 20% and 40% overweight levels for men and women of different heights and weights.

Atrioventricular block following overdose of decongestant cold medication.

A 24-year-old man developed high-degree atrioventricular (A-V) block with a pulse rate of 40 beats per minute and hypertension following an overdose of a combination decongestant cold medication that contained phenylpropanolamine, phenylephrine, chlorpheniramine, and phenyltoloxamine. The patient was treated with ipecac, activated charcoal, and cathartics in the emergency department (ED). After his admission to the coronary care unit, the A-V block gradually resolved to sinus rhythm with periods of second-degree block, Mobitz types I and II. No treatment was required. The patient had a normal sinus rhythm and normal blood pressure prior to discharge.

Health implications of obesity: an NIH Consensus Development Conference.

A Consensus Development Conference on the Health Implications of Obesity was held in February 1985 at the National Institutes of Health in Bethesda, Maryland, USA. After presentations by 19 experts in relevant subject areas, a panel of 15 impartial senior level professionals presented their consensus of findings and recommendations. This paper summarizes the results of the conference and provides reference tables of body mass index (BMI) values and weight goals, along with nomograms of the BMI determined from height and weight scales, to show comparisons with weight goals. The goals are taken from two widely available tables of mortality data by weight. These reference aids are included to illustrate the potential clinical value of wider use of the BMI, as recommended in the conference.

Droperidol vs. haloperidol in the initial management of acutely agitated patients.

In a double-blind clinical study, 27 acutely agitated patients were treated with an intramuscular injection of 5 mg of droperidol or 5 mg of haloperidol from identical appearing vials. At 30 minutes following treatment, 81% of the patients treated with haloperidol but only 36% treated with droperidol required a second injection (p less than .05). Thus, droperidol, a safe butyrophenone neuroleptic, appears to be a drug of choice for rapid and reliable control of acute agitation.

Comparison of activated charcoal and gastric lavage in the prevention of aspirin absorption.

Effectiveness of initial treatment of aspirin (ASA) overdosage was evaluated by comparing treatment with activated charcoal (AC) to treatment with gastric lavage in combination with AC. Dogs were used as subjects in four experimental groups. All subjects were administered an overdose of 500 mg/kg of ASA. Treatment was performed 30 minutes later on all groups except controls. Treatment with AC alone resulted in a 17% reduction (P greater than .05) of peak plasma salicylate levels compared with controls. When lavage preceded administration of AC, a 37% reduction (P less than .05) occurred. There was a 48% reduction (P less than .025) in plasma salicylate levels when lavage was preceded and followed by administration of AC. This study demonstrates that gastric lavage in combination with AC is more effective in reducing ASA absorption than AC given alone.

Current concepts of nutritional therapy in chronic renal failure: an update.

The natural course of chronic renal disease with the passage of time is reviewed, parallel with rational nutritional management to counterbalance the ill effects of the progressive renal pathology. Progressive protein restriction, supplementation with essential amino acids and their keto-acid and hydroxy analogues, phosphate restriction, sodium and potassium regulation, and other measures are discussed, together with an elaboration on optimal nutritional management of adult maintenance dialysis patients and of children on dialysis.