Influence of a 100-km ultra-marathon on hepatitis B carrier runners.

This study compares the serological markers between runners who are hepatitis B virus carries (HBVc) and runners who are non-HBVc in a 100-km ultra-marathon race. Blood samples of 8 HBVc and 18 non-HBVc runners were drawn 1 week before, immediately following, and 24 h after the race. Samples were analyzed and compared between the 2 groups for liver function tests, muscle damage markers and oxidative stress cytokines. For HBVc runners, HBV-DNA (hepatitis B virus-deoxyribonucleic acid) levels were also evaluated for virus reactivation. The results demonstrate a statistically significant increase in both immediate and 24-h post-race values for alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), creatine kinase (CK), high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α), compared with pre-race values. No statistically significant difference was observed between the 2 groups for the values of AST, LDH, CK, hs-CRP, IL-6 and TNF-α either before or after the race. There was also no statistically significant change in the levels of HBV-DNA in HBVc runners. These findings suggest that HBVc runners do not have higher risks of liver function impairment, muscle breakdown and inflammatory response compared to non-HBVc runners in such endurance races.

Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.

OBJECTIVES: To investigate clinical features and outcomes in patients with acute cholecystitis with gall bladder perforation receiving open cholecystectomy or percutaneous transhepatic gall bladder drainage in the emergency department. METHODS: From 1996 through 2005, 33 patients with non-traumatic gall bladder perforation, among 585 patients with acute cholecystitis, were enrolled. Patients were divided into two groups: open cholecystectomy in 16 patients and percutaneous transhepatic gall bladder drainage in 17 patients. Medical records, including demographic data, past history of systemic diseases or gallbladder stones, initial clinical presentations, laboratory data, physical status, therapeutic interventions, and outcomes, were analysed. RESULTS: Mean patient age was 72.6 years (range 54-92 years). 28 patients (84.8%) were male. Median time of symptom onset before emergency department diagnosis was 5 days (range 0.5-30 days). Estimated incidence of gall bladder perforation was 5.6% (33/585). 27 patients (81.8%) had gallstones operatively or in image studies. All patients had either right upper quadrant pain/tenderness or epigastric pain/tenderness. Only 9 (27.3%) patients had positive Murphy's sign. Six patients in the percutaneous transhepatic gall bladder drainage group received further open cholecystectomy. Overall mortality was 24.2% (8/33). The direct cause of death was disease related sepsis in all patients. Patients receiving percutaneous transhepatic gall bladder drainage had a higher survival rate than those receiving open cholecystectomy (100% vs 50%, p<0.001). No differences in complications and length of hospital stay of survivors were observed between groups. CONCLUSIONS: In this study, we delineated clinical features of patients with gall bladder perforation. Better clinical outcome is observed for percutaneous transhepatic gall bladder drainage, and this is suggested as an initial therapeutic choice, especially in high risk patients who are likely to need surgery.

Acute toxicities of betel nut: rare but probably overlooked events.

BACKGROUND: Betel nut chewing has long been a social habit in Taiwan and other Asian and tropical countries. It produces various autonomic and psychoneurologic effects including tachycardia, flushing, warmth, cholinergic activation, alertness, and euphoria. Although the oral carcinogenic effects are well known, data concerning its acute toxicity are few. To better understand the toxicity of betel nut, cases reported to the Taiwan Poison Control Center as probable or possible betel nut-related toxicity (January 1988-June 1998) were reviewed. In the 17 cases suitable for review (14 males, 3 females, age 21 to 60 years), the most common manifestations were tachycardia/palpitations (7); tachypnea/dyspnea (6); hypotension and sweating (5); vomiting, dizziness, and chest discomfort (4); abdominal colic, nausea, numbness, and coma (3); and acute myocardial infarction and related manifestations (2). The reported quantity of betel nut used was low (1 to 6 nuts), except an extract of 100 betel nuts was used in 1 case and 66 chewed in another. Most cases recovered within 24 hours after the exposure. One patient developed probable acute myocardial infarction and ventricular fibrillation and died despite repeated cardiac defibrillation. Although betel nut chewing is widespread, significant toxicity as reported to a poison center is rare. Because most betel nut-related effects are transient and mild in nature, the incidence of such events is likely to be underreported. Nevertheless, betel nut chewing can produce significant cholinergic, neurological, cardiovascular, and gastrointestinal manifestations. It is possible that it may aggravate cardiac diseases in susceptible patients but this hypothesis must be further investigated. Treatment is symptomatic. With timely support, rapid and complete recovery is anticipated but a small risk of major complications cannot yet be discounted.

Hemodynamic response of modified fluid gelatin compared with lactated ringer's solution for volume expansion in emergency resuscitation of hypovolemic shock patients: preliminary report of a prospective, randomized trial.

The objective of this study was to compare the cardiac and hemodynamic responses to a rapid infusion of 1000 ml of modified fluid gelatin (group A) or 1000 ml of lactated Ringer's solution (group B) in emergency room patients suffering from shock. This prospective, randomized, open, noncrossover study was performed at a medical center university hospital in a surgical resuscitation room in the emergency department. The subjects were 34 patients with either hypovolemic or neurogenic shock who were admitted to the emergency room. A resuscitation protocol according to Advanced Trauma Life Support (ATLS) with an additional central venous line or Swan-Ganz catheters for hemodynamic monitoring was used. Physical parameters and hemodynamic variables were measured at baseline and 15 minutes, 30 minutes, and 1 hour after the infusion of each fluid. In both groups the mean arterial blood pressure (MAP), systolic and diastolic pressure, central venous pressure (CVP), and pulmonary artery occlusion pressure (PAOP) increased significantly. The CVP and PAOP increased significantly more in the modified fluid gelatin resuscitation group. In patients with traumatic or neurogenic shock due to acute volume deficiency, there was significantly better hemodynamic improvement, judged by CVP and PAOP measurements using the modified fluid gelatin for volume replacement than with lactated Ringer's solution during the first hour of resuscitation.

Characteristics of patients at a Taipei summer rock concert festival.

BACKGROUND: Rock concerts are popular mass gatherings in Taiwan. Millions of fans participate in rock concerts in Taiwan each year. However, there were no reports on the characteristics of the patients seen in rock concerts in Taiwan. METHODS: Medical care for a summer rock concert festival held in an outdoor stadium in Taipei was coordinated by emergency physicians of a medical center. About 50,000 attendees participated in the two-night concert. Three stations were set up to provide advanced medical care. A standardized form was used to collect information about patients. RESULTS: A total of 28 cases visited the medical stations, fourteen cases each day. They were aged from 13 to 40 years, with an average of 20.8 +/- 6.4. Twenty-one cases were female and seven were male. Twenty-two (79%) were spectators, five (18%) were on-duty staff, and one was a by-stander. Based on an estimation of totally 50,000 participants in the stadium for this two-night festival, the medical use rate was roughly 5.6 PPTT (patients per ten thousand attendees). The most common major problem was fainting which accounted for 13 cases (46%). Of these 13 cases, three cases (23%) lost consciousness and 12 cases (92%) were female. Sixteen cases (57%) were classified as requiring ALS (advanced life support) and 12 cases (43%) as requiring BLS (basic life support). Most cases improved and were discharged after onsite treatment. Only one case was transferred by ambulance due to persistent chest pain. However, she recovered several hours later. CONCLUSIONS: By this preliminary data, first reported in Taiwan, we found that the most common problem was fainting. More than half of the cases seen at the concert required advanced life support. A well-designed emergency medical service (EMS) system is mandatory to provide services for these events.

Ingestion of low-concentration hydrofluoric acid: an insidious and potentially fatal poisoning.

STUDY OBJECTIVE: The purpose of this study was to provide the first description of the effects of ingestion of low-concentration hydrofluoric acid in a population reported to a regional poison control center. METHODS: A retrospective analysis of data collected by trained personnel using a standardized data collection system was performed. All charts involving hydrofluoric acid exposures for a 2-year period from a certified regional poison control center were identified by a computerized search. Each chart was abstracted by trained and blinded personnel. RESULTS: There were 1,772 exposures to hydrofluoric acid; 135 involved ingestion. There were 99 cases of human hydrofluoric acid ingestion for analysis. All ingestions involved consumer products containing 6% to 8% hydrofluoric acid. Symptoms, most commonly mild gastrointestinal effects, were reported by 49 patients. Two patients with minimal effects during an observation period of 2 to 4 hours deteriorated suddenly and died. All other patients recovered completely. Of 29 cases in which calcium concentrations were recorded, 4 cases of hypocalcemia occurred. All patients who had major effects or died were adults who had ingested more than 3 ounces of hydrofluoric acid with suicidal intent. Death occurred precipitously in patients who had appeared well a few minutes earlier. CONCLUSION: Death occurred in 2 patients, both of whom were adults who had ingested more than 3 ounces with suicidal intent. Ingestion of a household product containing hydrofluoric acid is a potentially life-threatening condition that requires close monitoring and prompt therapy. The abrupt deterioration and lack of warning signs indicate the need for better diagnostic methods.

Renal abscess: early diagnosis and treatment.

The purpose of this study was to identify initial clinical characteristics that can lead to early diagnosis of renal abscess in the emergency department and predict poor prognosis. A retrospective review of 88 renal abscess patients, from April 1979 through January 1996, was conducted. Patients were categorized into two groups. In group 1, renal abscess was diagnosed by an emergency physician, whereas in group 2 renal abscess was not diagnosed by an emergency physician. Clinical characteristics included demographic data, predisposing medical problems, duration of illness before diagnosis, time spent in hospital diagnosis, initial signs and symptoms, laboratory tests, and radiology studies that may have been useful in the early diagnostic regimes. Clinical factors were also analyzed for their value in predicting poor prognosis. The mean age of 88 patients with renal abscess was 59.8 years. The most common predisposing disorder was diabetes mellitus, followed by renal calculi and ureteral obstruction. The duration of diagnosis by emergency physicians was shorter for group 1 patients (1.2 +/- .4 v group 2, 2.8 +/- 2.9 days; P < .01) and the blood urea nitrogen level was higher in group 1 (55.7 +/- 42.2 mg/dL, v group 2, 33.5 +/- 33.5 mg/dL; P = .02). In the early diagnosis of renal abscess, emergency physicians should focus on patients who have predisposing disorders, ie, diabetes mellitus, renal stones, immunosuppression, longer duration of symptoms of urinary tract infection, and renal failure, who should promptly be investigated with ultrasound in the emergency department. The cure rate after treatment with routine antibiotics plus percutaneous drainage was 64%. This therapy is recommended for initial treatment. Poor prognosis is associated with elderly patients with lethargy and with elevation of the serum blood urea nitrogen level.

Elderly use of the ED in an Asian metropolis.

To compare emergency department (ED) use by elderly patients (age 65 yrs or older) with that by younger adult patients (age 15-64 yrs), a prospective consecutive chart review study was conducted from August 1, 1995 through May 31, 1996 in eight designated hospitals in Taipei city (which has 2.6 million residents, 8.4% of whom are 65 yrs or older). Patient age, sex, mode of arrival, living status, triage category, advanced life support (ALS) eligibility, referral, confinement to bed, intensive care unit (ICU) admission, impression, trauma mechanism, and disposition were recorded and compared between the two groups. Of 27,765 adult emergency patients studied during the 10 months, 24% were elderly. The elderly were more likely to be ambulance cases, of high acuity and ALS eligibility, living alone, bed-ridden, and ICU cases (19.4% v 10.5%, 14.8% v 5.5%, 14.7% v 4.3%, 9.7% v 4.1%, 16% v 1.1%, and 4.0 v 1.1%, respectively). The three leading illnesses in the elderly were cerebral vascular accident (6.6%), cancer (5.6%), and cardiovascular disease (5.6%), and the two most common trauma mechanisms were trip (fall from the same level surface) (57.2%) and traffic accident (20.7%). Twenty-seven percent and 22.7% of elderly were disposed to admission and observation, respectively, compared with the 10.9% and 11.4% of the younger patients. Elderly patients have significantly different and more severe presentations to the ED compared with younger adults.

Emergency medical resource use in Taipei city.

BACKGROUND: It is a worldwide trend to serve emergency patients at emergency department (EDs) staffed by board-certified emergency physicians (EPs). The question arises as to how many EPs are cost effective? This cannot be answered until utilization of emergency resources in the community is explored, so that appropriate plans for efficient ED use, staffing and training of EPs can be made. METHODS: A prospective randomized chart-review study was conducted from August 1, 1995, until May 31, 1996, in the EDs of eight large hospitals in Taipei City. These included Chung-Hsin Municipal Hospital (CHH), Chung-Shiaw Municipal Hospital (CSH), Ho-Ping Municipal Hospital (HPH), Jen-Ai Municipal (JAH), Mackay Memorial Hospital (MMH), Tri-Service General Hospital (TSGH), Veterans General Hospital-Taipei (VGH-T) and the Yang-Ming Municipal Hospital (YMH). RESULTS: Of 37,889 cases reviewed, the average daily ED census at each hospital was: VGH-T 198; TSGH 148; MMH 224; HPH 62; YMH 84; CHH 41; JAH 102; and CSH 139. At MMH, pediatric patients comprised 38.8% of emergency patients and the elderly comprised 49% of patients of VGH-T. The average age of patients was 56 years in VGH-T and 40 years in other hospitals. There were 71 (11.1%) pediatric patients and 3,087 (1.8%) adult patients taken to hospital by an emergency medical services (EMS) ambulance. A total of 176 pediatric and 2,230 (8.1%) adult patients belonged to triage categories 1 and 2. VGH-T had a much higher percentage of triage 1 and 2 patients (769, 13%) than the other hospitals. A total of 30.7% of pediatric and 17.4% of adult patients were classified as triage 4 (pseudoemergency). Patients requiring advanced life support, referral cases and patients requiring an intensive care unit (ICU) bed accounted for 1.1%, 0.9% and 0.6% of pediatric patients, and 6.8%, 3.4% and 1.8% of adult patients, respectively. These figures increased to 11.1%, 7.7% and 3.5%, respectively, in VGH-T. Among patients requiring ICU admission, 30% of pediatric and 53% of adult patients were not admitted on presentation to the ED. Of 10,099 children and 27,555 adults who were evaluated for case disposition, 651 (6.5%) and 4,061 (14.7%), respectively, were considered for admission. Among these 542 (83.3%) and 2,894 (71.3%), respectively, were admitted. CONCLUSIONS: VGH-T is a favorable training ground for EPs due to its high volume of adult and elderly, advanced life support eligible, ICU and high acuity patients. MMH is an ideal place for training in pediatric emergency medicine. Utilization of the 119 emergency response system is low. The number of patients with high acuity triage in Taipei City is low. However, Taipei City faces a shortage of acute care beds, especially ICU beds.

Arterial oxygen desaturation during emergent nonsedated upper gastrointestinal endoscopy in the emergency department.

A prospective study was conducted to see whether emergent esophagogastroduodenoscopy (EGD) in patients with active upper gastrointestinal (GI) bleeding is associated with more oxygen desaturation than nonemergent EGD. Emergent EGD was performed in the study patients with active upper GI bleeding. Nonemergent EGD was performed in the control patients. Determination of oxygen saturation (Sao2) was measured by pulse oximeter. A decrease in Sao2 of > 4% was more frequent in the study patients (26%, 13 of 50) than in controls (6%, 3 of 50) (P < .01). During EGD, mean oxygen saturation decreased significantly in both groups of patients. After EGD, mean oxygen saturation did not recover toward the pre-endoscopy insertion level in the study group (P < .01). A linear association was found that oxygen desaturation = 5.46 + 0.15 (status) -0.06 (baseline oxygen saturation). Emergent EGD for active upper GI bleeding in the emergency department tends to be associated with more frequent significant oxygen desaturation than nonemergent EGD. Continuous oxygen supplementation and oxygen saturation monitoring may be used during emergent nonsedated EGD in the emergency department.

The difficulty in handling poisonings associated with Chinese traditional medicine: a poison control center experience for 1991-1993.

The purpose of this prospective case series was to outline the characteristics of Chinese traditional medicine poisonings and develop essential information for poison prevention and management. All phone inquiries made to the Poison Center related to Chinese traditional medicines from January 1, 1991 to December 31, 1993 were included. Standardized questionnaires were used to capture relevant information. Among the 318 phone inquiries about Chinese traditional medicines, 273 cases were classified as poisonings; and 22 mortalities occurred (6.9%). All of the poisonings occurred because of suicide attempts, accidents, or erroneous or improper use or processing. In our study, 47% of the potential toxic effects of Chinese traditional medicines were either unknown or could not be found in the literature. There existed undefinable uncertainty in attributing the clinical effects to the exposures to Chinese traditional medicines. We recommend that the strategy in handling Chinese traditional medicine poisonings to decrease mortality should be comprised of confirmation of the generic name of the substances and the specific part of the plant used, awareness of improper processing methods, maintenance of records on a broad review of systems and laboratory data, identification of active principles and potential interactions among the individual active agents; verification of histopathologic effects of the toxins; development of information on toxicodynamics and toxicokinetics; intensive supportive care for poisoned patients, and investigation of potential antidotes. There are several regulatory options available to health authorities to control the unrestricted use of these potentially toxic medicines and to help safeguard the public.

Psoas abscess: making an early diagnosis in the ED.

The variable and nonspecific presentations of psoas abscess, as well as its infrequent incidence in the emergency department (ED), can result in delayed diagnosis or misdiagnosis. Previous reports have not discussed the diagnostic difficulties of psoas abscess from the viewpoint of emergency physicians (EPs), especially in light of the widespread use of ED ultrasonography. This report describes a 1-year experience between November 1993 and October 1994, during which 10 ED patients were diagnosed to have psoas abscess; in 7 cases, diagnoses were established in the ED. Patients' mean age was 64.6 years (range, 46 to 76). Pain was the most frequently encountered symptom (80%), with 5 patients (50%) complaining of flank pain. The triad of fever, flank pain, and limitation of hip movement, which is specific for psoas abscess, was present only in 3 patients (30%). The mean duration of symptoms was 10.6 days (range, 1 to 30 days). The mean time spent to establish the diagnosis was 1.7 days (range, 0 to 7 days). The diagnosis of psoas abscess was established by ultrasound in 6 patients, by computed tomography (CT) in 3 patients, and by surgery in 1 patient. Four patients who presented with either sepsis and nonspecific abdominal/flank pain or sepsis and thigh swelling were diagnosed to have psoas abscess by ultrasound performed by EPs. Only 3 patients were admitted to the ED with an initial diagnosis of psoas abscess. The remaining 7 had the following initial ED diagnoses: 2, fever of unknown origin; 2, septic shock; 1, shock; 1, sepsis; and 1, peritonitis. All but one had manifestations of sepsis. Two patients died of septic shock; these two patients had failed to be drained well. This report also includes a discussion of the role of EPs and ultrasonography in the diagnosis of psoas abscess. With their alertness and their expertise in ultrasonographic techniques, EPs can make an immediate diagnosis and arrange an early drainage procedure. For patients with sepsis of unknown origin, prolonged fever of unknown origin, and some specific manifestations suggestive of psoas abscess, the screening ultrasound should scan not only abdominal solid organs but also peritoneal cavity and retroperitoneal space. In addition, a flow chart is presented for facilitating the diagnosis of psoas abscess in the ED.

Analysis of prehospital ALS cases in a rural community.

BACKGROUND: An Emergency Medical Services (EMS) system containing the advanced life support (ALS) and manned with paramedics, is developing in many countries in view of the importance of prehospital ALS skills on ALS eligible patients, although previous studies have only revealed that a meager need for ALS in urban community. The purpose of this study is to understand the real demand of ALS in a rural community, so that a well organized and cost-effective EMS system can be developed in this country. METHODS: An EMS system with a single tiered response configuration, using firefighters to give basic prehospital care, stored in computer with some necessary informations was established in Ilan County. Cases with ALS from January 1993 through December 1994 were retrieved from the computer. The ones truely eligible for ALS were reconfirmed and analized in terms of neurological outcome while discharging from hospital, sex, age, response time, time spent on scene, transportation time, as well as whether the cases were trauma or medically induced. RESULTS: Of 11352 cases collected during 731 study days, 594(5.28%) ALS eligible cases (including 211 DOA and 383 nonDOA) were studied. Of 211 DOA, 103(48%) were caused by trauma. The response time, time spent on scene and transportation time in ALS and DOA cases were 5.5min., 4.7min., 13.6min., and 5.6min., 5.6min., and 15.7min., respectively. Of 211 cases of trauma (55% of total ALS cases), traffic accident accounted for 46%. Altered mental status and chest pain or tightness made of 90% of medical induced ALS cases. Five percent of patients felt worsening of condition during transit. One third of patients seemed to experience a bad outcome. CONCLUSIONS: Based on the characteristics of low demand for ALS services, more than half trauma-induced ALS cases, acceptable response time, short transportation time, extremely few medically-induced DOA cases, and quite a poor outcome in the setting of limited prehospital care, a unique EMS system different from that in the United States or in the urban area is needed in the rural area.

Outcomes in severely ill patients transported without prehospital ALS.

Because of the debate regarding the impact of advanced life support (ALS) care on the outcome of prehospital patients, we monitored the influence of lack of sophisticated prehospital treatment in cases of severe illness arriving by ambulance to the emergency department (ED). A prospective cohort study to examine and compare the outcome of trauma- and nontrauma-induced "ALS-eligible" cases in the setting of no prehospital care was carried out from August 1, 1993 through May 31, 1994. On arriving at the ED, patients meeting the criteria for ALS cases and sent by EMS public prehospital personnel were assessed for subjective and objective status and change in severity by triage nurses as well as being followed up for neurological status until discharged from the hospital. Chi-Square method was used to compare the data between two groups and P < .05 was considered statistically significant. Of 667 studied ALS cases (155 trauma and 512 nontrauma), < 20% had their condition change subjectively and < 10% had their condition change objectively; 68% of medical patients and 60% of trauma cases were discharged from the hospital (neurologically intact). However, subgroup analysis showed that objective measures worsened in transit in nearly 18% of trauma victims, a rate nearly 3 times greater than that of medical cases. Moreover, neurological outcome was particularly poor in trauma cases. These results suggest that ALS care may be valuable for severely ill trauma victims.

[Three years' experience of emergency medical services in Ilan County].

The Emergency Medical Services (EMS) aims to improve the survival rate of patients who are dead on arrival (DOA) at hospital, particularly those whose coronary artery disease (CAD) has induced sudden death. Based on the low prevalence of CAD-induced sudden death in Taipei city, as well as the differences between urban and rural communities in Taiwan, an understanding of the characteristics of rural areas is necessary in order to establish a well-organized and cost-effective EMS policy in this country. The data were drawn from a computer database which stored prehospitalization information from Ilan County from 1992 through 1994, including age, sex, response time, time spent on the scene, transportation time, service unit, reasons for emergency call and trauma mechanism. In 1096 study days, 20058 cases (18/day) were collected, of which 16560 (15/day; 83.6%) were transported to hospital. Trauma was responsible for the majority (77%) of these cases, followed by chronic diseases (4.0%), trivial matters (2.6%), drunkenness (2.3%), altered mental status (2.3%), suicide attempt (2.2%), and cardiac arrest (1.8%). Among the trauma cases, traffic accidents were the most common cause (84%); motorcycle accidents comprised 65% of trauma cases. The average response time was 6.6 minutes, time spent on the scene was 3.6 minutes, and transportation time was 17.7 minutes. Trauma and non-trauma accounted for half of the DOA cases, with each making up 0.9% of the total cases transported. In conclusion, it is important that the EMS needs of each community are known for a proper system appropriate to that particular area to be developed.

The clinical experience of acute cyanide poisoning.

The authors reviewed the clinical manifestations, complications, and the prognosis affected by Lilly Cyanide Antidote in 21 victims of acute cyanide poisoning over a 10-year period. The clinical signs and symptoms in cyanide poisoning are variable. Among 21 cases, loss of consciousness (15), metabolic acidosis (14), and cardiopulmonary failure (9) were the three leading manifestations of cyanide intoxication. Anoxic encephalopathy (6) was not uncommon in the severely intoxicated victims. Diabetes insipidus (1) or clinical signs and symptoms mimicking diabetes insipidus (3) may be an ominous sign to encephalopathy victims. The major cause of fatal cyanide poisoning is the intentional ingestion of cyanide compounds as part of a suicide attempt. Decrease of arteriovenous difference of O2 partial pressure may be a clue for the suspicion of cyanide intoxication. Although the authors cannot show a statistically significant difference (P = .47) for the Lilly cyanide antidote kit in terms of improving the survival rate for victims of cyanide poisoning, the antidote kit was always mandatory in our study in the cases of severely intoxicated victims who survived. Early diagnosis, prompt, intensive therapy with antidote, and supportive care are still the golden rules for the treatment of acute cyanide poisoning, whether in the ED or on the scene.

Podophyllotoxin intoxication: toxic effect of Bajiaolian in herbal therapeutics.

Bajiaolian (Dysosma pleianthum), one species in the Mayapple family, has been widely used as a general remedy and for the treatment of snake bite, weakness, condyloma accuminata, lymphadenopathy and tumours in China for thousands of years. However, the textbooks of traditional Chinese medicine mention little about the toxicity of Bajiaolian. Within 1 year, the authors saw five people who manifested nausea, vomiting, diarrhoea, abdominal pain, thrombocytopenia, leucopenia, abnormal liver function tests, sensory ataxia, altered consciousness and persistant peripheral tingling or numbness after drinking infusions made with Bajiaolian. The herb was recommended by either traditional Chinese medical doctors or herbal pharmacies for postpartum recovery and treatment of a neck mass, hepatoma, lumbago and dysmenorrhoea. Podophyllotoxin is one of the main ingredients of the Bajiaolian root. The clinical manifestations observed in our patients were consistent with podophyllum intoxication. Podophyllotoxin intoxication usually results from the accidental ingestion or topical application of podophyllum resin. However, these cases of Bajiaolian intoxication were iatrogenic and results from 'therapeutic doses' of Bajiaolian cited in the textbooks of traditional Chinese medicine.