Nitrogen-Phosphorus-Potassium containing liquid fertilizer intoxication presenting with extreme hyperkalemia, metabolic acidosis and ECG changes.

Liquid fertilizers are widely used for fertilizing in- and outdoor vegetation. Despite the easy accessibility and widespread use, serious intoxications are rare. This case report describes a 61-year-old woman who was treated for life-threatening hyperkalemia, metabolic acidosis and ECG changes after intentional ingestion of liquid fertilizer. Our case shows that intake of liquid fertilizer, though infrequent, can cause serious, life threatening complications.

[Drug of abuse screening in urine in emergency situations; useful or not?] / Toxicologische screening van urine in acute situaties.

Drug of abuse (DOA) screening in urine is often performed in the clinical emergency setting. However, there is considerable evidence that questions the usefulness of this screening in the acute management of patients with suspected intoxications. The used method is an immunoassay, in which cross reactivity with false positive results may occur. A positive result does not always indicate current toxicity, a negative result does not exclude drug use or a current intoxication. Therefore, DOA screening has limited value in the acute clinical management of patients with intoxications.

Study of enteric pathogens among children in the tropics and effects of prolonged storage of stool samples.

The study was performed to compare real-time PCR after nucleic acid extraction directly from stool samples as well as from samples stored and transported on Whatman papers or flocked swabs at ambient temperature in the tropics. In addition, the possible suitability for a clear determination of likely aetiological relevance of PCR-based pathogen detections based on cycle threshold (Ct) values was assessed. From 632 Tanzanian children <5 years of age with and without gastrointestinal symptoms, 466 samples were subjected to nucleic acid extraction and real-time PCR for gastrointestinal viral, bacterial and protozoan pathogens. Equal or even higher frequencies of pathogen detections from Whatman papers or flocked swabs were achieved compared with nucleic acid extraction directly from stool samples. Comparison of the Ct values showed no significant difference according to the nucleic acid extraction strategy. Also, the Ct values did not allow a decision whether a detected pathogen was associated with gastrointestinal symptoms.

The Impact of a Standardized Pre-visit Laboratory Testing Panel in the Internal Medicine Outpatient Clinic: a Controlled "On-Off" Trial.

BACKGROUND: In several settings, a shorter time to diagnosis has been shown to lead to improved clinical outcomes. The implementation of a rapid laboratory testing allows for a pre-visit testing in the outpatient clinic, meaning that test results are available during the first outpatient visit. OBJECTIVE: To determine whether the pre-visit laboratory testing leads to a shorter time to diagnosis in the general internal medicine outpatient clinic. DESIGN: An "on-off" trial, allocating subjects to one of two treatment arms in consecutive alternating blocks. PARTICIPANTS: All new referrals to the internal medicine outpatient clinic of a university hospital were included, excluding second opinions. A total of 595 patients were eligible; one person declined to participate, leaving data from 594 patients for analysis. INTERVENTION: In the intervention group, patients had a standardized pre-visit laboratory testing before the first visit. MAIN MEASURES: The primary outcome was the time to diagnosis. Secondary outcomes were the correctness of the preliminary diagnosis on the first day, health care utilization, and patient and physician satisfaction. KEY RESULTS: There was no difference in time to diagnosis between the two groups (median 35 days vs 35 days; hazard ratio 1.03 [0.87-1.22]; p = .71). The pre-visit testing group had higher proportions of both correct preliminary diagnoses on day 1 (24% vs 14%; p = .003) and diagnostic workups being completed on day 1 (10% vs 3%; p < .001). The intervention group had more laboratory tests done (50.0 [interquartile range (IQR) 39.0-69.0] vs 43.0 [IQR 31.0-68.5]; p < .001). Otherwise, there were no differences between the groups. CONCLUSIONS: Pre-visit testing did not lead to a shorter overall time to diagnosis. However, a greater proportion of patients had a correct diagnosis on the first day. Further studies should focus on customizing pre-visit laboratory panels, to improve their efficacy. TRIAL REGISTRATION: NL5009.

Clinical value of serum lactate measurement in diagnosing acute mesenteric ischaemia.

Acute mesenteric ischaemia (AMI) is a life-threatening disease with a mortality rate around 60%. This high mortality rate is largely caused by diagnostic delay, which means there is a pressing need for a reliable biomarker. In clinical practice, serum lactate measurement is often used for the diagnosis of AMI. To assess the diagnostic value of serum lactate, we performed a literature search. Lactate has two different isomers. The well-known L-lactate, produced by anaerobic glycolysis, and the more unknown D-lactate which is only produced by intestinal bacteria. In this review, we present and evaluate the current literature on the diagnostic value of the measurement of both lactate isomers. Furthermore, we suggest another biomarker which might have the potential to serve as a useful diagnostic test in the future.

[Intoxication with new psychoactive substances: drug unknown, but complications are still treatable]. / Intoxicatie met nieuwe psychoactieve stoffen.

Abuse of new psychoactive substances (NPS) and the number of patients presenting to the ER with intoxication are increasing. Treatment may at first sight seem complicated because of limited knowledge of the substance involved, but should be based on a general supportive approach recognising the relatively predictable spectrum of symptoms caused by adrenergic, serotonergic and dopaminergic stimulation. In this article, we discuss the vital elements of this approach and possible complications of NPS intoxication. This is illustrated by two 20-year-old male patients with NPS intoxication who presented to our ER as participants in a group intoxication. Patient A suffered from mild symptoms and tested positive for 4-iodo-2,5-dimethoxy-N-(2-methoxybenzyl)phenethylamine (2C-I-NBOMe) only. Patient B presented with agitated delirium and tested positive for both 2C-I-NBOMe and cocaine. While patient A was treated with benzodiazepines and rehydration, patient B required sedation, intubation and short-term ventilation.

[It is all about the form - adrenaline in anaphylaxis: intravenous or intramuscular administration?] / Het gaat om de formulering, niet om de inhoud.

BACKGROUND: Medication errors are a frequent problem in the accident and emergency (A&E) department. CASE DESCRIPTION: A 17-year-old boy was referred to our A&E department with an anaphylactic reaction to peanuts. Because of various shortcomings in the care process in A&E, adrenaline was administered intravenously instead of intramuscularly, resulting in a broad complex tachycardia. We analysed these shortcomings using the 'Prevention and recovery information system for monitoring and analysis' (PRISMA) method. CONCLUSION: Medication errors are usually a result of shortcomings in non-technical skills, such as communication and situational awareness. Training these skills by applying the concept 'Crew resource management' may reduce medication errors and improve patient safety.

[Aggression and restlessness following baclofen overdose: the narrow line between intoxication and withdrawal symptoms]. / Agressie en onrust na overdosis baclofen.

BACKGROUND: Baclofen is increasingly prescribed for alcohol dependency. Subsequently, the risk of self-intoxication with this medicinal product is increasing. CASE DESCRIPTION: A 23-year-old man with a history of alcohol dependence was admitted to our hospital after self-intoxication with 2700 mg baclofen and 330 mg mirtazapine. Respiratory insufficiency as a result of the baclofen intoxication required intubation and admission to the ICU. During the first day, despite the use of sedatives, the patient became intermittently agitated and aggressive. In the following days, he developed severe delirium, probably due to baclofen withdrawal. The reintroduction of baclofen quickly resolved these symptoms. CONCLUSION: In the case of baclofen, in practice it is difficult to differentiate between intoxication and withdrawal. To prevent potentially severe withdrawal symptoms, we recommend reintroduction of baclofen when the first signs of restlessness and agitation arise following intoxication.

Group B Streptococci serotype distribution in pregnant women in Ghana: assessment of potential coverage through future vaccines.

OBJECTIVE: Group B streptococcal (GBS) colonization of pregnant women can lead to subsequent infection of the new-born and potentially fatal invasive disease. Data on GBS colonization prevalence and serotype distribution from Africa are scarce, although GBS-related infections are estimated to contribute substantially to infant mortality. In recent years, GBS vaccine candidates provided promising results in phase I and II clinical trials. We aimed to assess the prevalence and serotype distribution of GBS in Ghana since this knowledge is a prerequisite for future evaluation of vaccine trials. METHODS: This double-centre study was conducted in one rural and one urban hospital in central Ghana, West Africa. Women in late pregnancy (≥35 weeks of gestation) attending the antenatal care clinic (ANC) provided recto-vaginal swabs for GBS testing. GBS isolates were analysed for serotype and antibiotic susceptibility. GBS-positive women were treated with intrapartum antibiotic prophylaxis (IAP) according to current guidelines of the Center for Disease Control and Prevention (CDC). RESULTS: In total, 519 women were recruited at both study sites, recto-vaginal swabs were taken from 509. The overall prevalence of GBS was 19.1% (18.1% in rural Pramso and 23.1% in urban Kumasi, restrospectively). Capsular polysaccharide serotype (CPS) Ia accounted for the most frequent serotype beyond all isolates (28.1%), followed by serotype V (27.1%) and III (21.9%). No resistance to Penicillin was found, resistances to second line antibiotics clindamycin and erythromycin were 3.1% and 1%, respectively. DISCUSSION: Group B Streptococcus serotype distribution in Ghana is similar to that worldwide, but variations in prevalence of certain serotypes between the urban and rural study site were high. Antibiotic resistance of GBS strains was surprisingly low in this study.

Stimulus level effects on neural excitation and eCAP amplitude.

The common assumption that the electrically evoked compound action potential (eCAP) has a linear relationship with the number of excited nerve fibres is derived from the acoustical unitary response concept. This study tests the validity of this hypothesis for electrical stimulation. Five guinea pigs were implanted with the tip of a human HiFocus electrode. eCAPs were measured with the forward masking paradigm, using anodic- and cathodic-leading biphasic current pulses and the inter-pulse interval was varied. Masker and probe amplitudes were varied either individually or simultaneously. Surprisingly, at high levels decreasing eCAP amplitudes were measured with increasing stimulus current. In search for an explanation, the experimental conditions were implemented in our 3D computational model of the implanted guinea pig cochlea to perform a functional comparison. In the final experiment, with fixed inter-pulse interval (IPI) and anodic-leading pulses, increasing stimulus currents showed growing numbers of excited nerve fibres and decreasing eCAP amplitudes at high levels, again. While simulating the relative contribution of single fibres to the overall eCAP, an explanation for this could be found in a waveform change in the modelled single fibre action potentials at high levels. We conclude that highly stimulated nerve fibres have another contribution to the eCAP response than lower stimulated fibres, which leads to a reduction of the eCAP amplitude at high levels.

The role of reactive oxygen species in apoptosis of the diabetic kidney.

Increased levels of reactive oxygen species (ROS) by hyperglycemia can induce apoptosis of renal cells and diabetic nephropathy. The redox balance in the renal cell seems, therefore, of the utmost importance. ROS-mediated apoptosis may be further aggravated by an inadequate cytoprotective response against ROS. When there are insufficient cytoprotective and ROS scavenging molecules, ROS lead to considerable cellular damage and to a point of no return in apoptosis. Induction of cytoprotective proteins may prevent or attenuate apoptosis, renal cell injury, and finally diabetic nephropathy. Here, we discuss some mechanisms of apoptosis and several strategies that have been probed to ameliorate, or to prevent apoptosis in the diabetic kidney.

Locomotive engineers and their spouses: coffee consumption, mood, and sleep reports.

Locomotive engineers (train drivers) on irregular work schedules reported a general coffee consumption rate higher than that reported by a comparison sample of permanent shift factory workers. The present study examines the impact of this consumption on workday and non-workday sleep behaviour and mood ratings. Twenty-seven engineers and their spouses each completed daily logs for 30 consecutive days. Daily logs were then sorted into workday and non-workday categories. Workday sleep length was significantly shorter than non-workday sleep length for both engineers and spouses. For the engineers only, coffee consumption on workdays was higher than on non-workdays. This increased coffee consumption was correlated with longer sleep latency, increased negative mood, and decreased positive mood on both work and non-workdays. This was not true for spouses. These results may be related to a days-off carry-over effect of caffeine or a general consumption behaviour characteristic.

Development and application of a "real time" lead-in-air analyzer in controlling lead exposure at a primary lead smelter.

To assist in locating and quantifying fugitive emissions in a primary lead smelter, a "real time" lead-in-air analyzer has been developed. Dust is collected on paper tape filters and the lead analysed by X-ray fluorescence. The unit has been used successfully to assist in the implementation of an engineering control monitoring program.

EEG coherence and power in the discrimination of psychiatric disorders and medication effects.

Electroencephalogram (EEG) coherence (COH) and power measures were included in a series of stepwise discriminant analyses to determine which variables were most sensitive in the differentiation of four psychiatric inpatient groups and two major classes of psychotropic medication. Eight channels of eyes-closed, bipolar EEG activity were recorded from 74 inpatients (paranoid schizophrenics, dysthymics, major affectives receiving tricyclics, neuroleptics, or no medication, and geriatrics). Discriminant analyses were conducted for theta, alpha, and fast beta frequency bands for power variables, COH variables, and the resultant significant power and COH discriminating variables. Without exception, COH measures, usually in the alpha band, were more sensitive than power measures in differentiating the various groups. Results suggested that COH decreases with age, is greatest in paranoid schizophrenics, decreases with neuroleptic medication, and increases with tricyclic antidepressants. Group differences were interpreted in accordance with an arousal model for COH.

EEG coherence and power changes during a continuous movement task.

EEG coherence (COH) is a mathematically derived measure of the time- and frequency-related similarities between a pair of EEG channels. In this report, COH was measured during an externally verified motor task in which the areas of cortical involvement are known, with special consideration given to procedural and artifactual issues. Fourteen right-handed women (ages 18-39, means = 26.7 years) were instructed to alternate continuously between fist-clenching and finger extension of the right hand, left hand, both hands, or neither hand (rest condition) in a counter-balanced sequence (4 one-minute trials for each condition; 16 total minutes). One minute each of intentional eye-movement (EOG) and intentional facial muscle tension (EMG) was recorded for artifact assessment. Eight channels of eyes-closed EEG were recorded from Fp1, Fp2, F3, F4, C3, C4, P3 and P4, each referenced to the ipsilateral earlobe. FFT spectral power analyses were conducted on 8 EEG channels and COH analyses (percentage of seconds/minute in which COH greater than or equal to 0.80) were performed on 16 pairs of leads: 4 interhemispheric, 6 intrahemispheric (left) and 6 intrahemispheric (right). COH measures increased during hand movement conditions, especially in the 9-12 Hz range, and were most apparent from prefrontal, premotor and motor areas. Parietal sources were essentially unchanged. Power measures were unchanged for virtually all leads and conditions. Increases in COH were not due to EOG or EMG artifact contamination. Evidence for lateralized increases was equivocal; significant bilateral increases were observed more often regardless of the hand clenched. Implications and suggested areas for future research are discussed.

Complex stability of ferrous ascorbate in aqueous solution and its significance for iron absorption.

The greater absorption of iron in vivo from ferrous ascorbate [Fe(HL)2] as compared with ferrous sulfate has been ascribed both to retardation or prevention of Fe(II) oxidation by ascorbate and to the existence of Fe(II) as a chelate with ascorbate. The available literature and our own results demonstrate that Fe(HL)2 dissociates in aqueous solution into a monomeric cationic species Fe(HL)1+, Fe2+ and HL-. The HL anion acts as a monodentate. The low stability constant KFe(HL)1, about 20 l.mol-1 at mu = 0 and 25 degrees C, results in the conclusion that Fe(HL)2 is almost completely dissociated into Fe2+ and HL- at about pH = 5, so (chelate) complex formation does not contribute significantly to the increased iron absorption. Between pH = 6 and pH = 8 a solubility enhancing effect of ascorbate is observed which may be of relevance for the iron absorption from ferrous ascorbate.

Stability of corticosteroids under anaerobic conditions. VII. 17a-hydroxy-17a-hydroxymethyl-17-keto-D-homosteroid phosphate.

The major decomposition product of prednisolone phosphate formed under anaerobic decomposition conditions in aqueous solution at pH = 8.3 is identified as 17a-hydroxy-17a-hydroxymethyl-17-keto-D-homosteroid phosphate. The chromatographic properties, the isolation and the structure elucidation of both the D-homosteroid phosphate and its specific dephosphorylated analogue are given. Finally a mechanism leading to the D-homosteroid phosphate is postulated.