Renal and liver transplantation for toxin-induced organ failure.

OBJECTIVE: Determine the number and outcome of renal (January 1987-June 2001, inclusive) and liver transplants (January 1993-June 2001) performed in Ireland for drug or toxin-induced organ failure and identify the toxins involved. METHODS: Retrospective review of national transplant coordinators' records and patient charts. RESULTS: Fourteen patients received renal transplants for nephropathy secondary to drugs or toxins. In 12 of these cases, renal failure was attributed to chronic toxicity, principally cyclosporin A therapy (seven cases). One-year patient and graft survival were 100%. Twenty-nine liver transplants were for toxin-induced organ failure, and 20 of these were for chronic ethanol induced liver disease. One-year patient and graft survival rates were 77% and 73%, respectively. CONCLUSIONS: Kidney and liver transplants were needed more often because of chronic toxicity than acute poisoning. Both groups had good outcomes at one year post-transplantation.

Bupropion (Zyban) toxicity.

Bupropion is a monocyclic antidepressant structurally related to amphetamine. Zyban, a sustained-release formulation of bupropion hydrochloride, was recently released in Ireland, as a smoking cessation aid. In the initial 6 months since it's introduction, 12 overdose cases have been reported to The National Poisons Information Centre. 8 patients developed symptoms of toxicity. Common features included tachycardia, drowsiness, hallucinations and convulsions. Two patients developed severe cardiac arrhythmias, including one patient who was resuscitated following a cardiac arrest. All patients recovered without sequelae. We report a case of a 31 year old female who required admission to the Intensive Care Unit for ventilation and full supportive therapy, following ingestion of 13.5g bupropion. Recurrent seizures were treated with diazepam and broad complex tachycardia was successfully treated with adenosine. Zyban caused significant neurological and cardiovascular toxicity in overdose. The potential toxic effects should be considered when prescribing it as a smoking cessation aid.

Sources of information for acute poisoning in accident and emergency departments in Dublin, Ireland.

BACKGROUND: Access by accident and emergency staff to up-to-date information on poisoning is essential for optimal management of acute poisoning. Apart from the National Poisons Information Centre, other information sources can be used. The objectives of the study were to identify sources of information on acute poisoning in accidents and emergencies and satisfaction with their use. METHODS: In a cross-sectional survey of medical staff of accidents and emergencies in Dublin in 1997, data were collected by interviewer-administered questionnaire. RESULTS: All 11 accidents and emergencies participated, with a staff response rate of 95%. One hundred and twenty-eight respondents were included. Ninety-seven percent had managed cases of poisoning (median 3 per week). The National Poisons Information Centre had been used by 93% of respondents, textbooks by 80%, paper database by 63%, and disc database (CD-ROM) by 10%. Of those managing cases, the National Poisons Information Centre would always be contacted by 23% and by 53% in most cases. The National Poisons Information Centre and CD-ROMs were rated the most useful sources of information. Information provided by the National Poisons Information Centre was considered sufficient by 98% of respondents. Thirty-three percent considered that advice should always be confirmed by fax. Limitations with the National Poisons Information Centre were described by 55% (e.g., manual transcription), with textbooks (e.g., limited content) by 83%, with paper databases (e.g., incompleteness) by 85%, and with CD-ROMs (e.g., time-consuming) by 54%. CONCLUSION: For the optimal management of acute poisoning, direct access to computerized information databases in accidents and emergencies combined with telephone access to the National Poisons Information Centre is required, with information available in hard copy.

The prospective value of the IPCS/EC/EAPCCT poisoning severity score in cases of poisoning.

INTRODUCTION: The poisoning severity score is a four-point severity-classification scale, developed by the International Programme on Chemical Safety, the Commission of the European Union, and the European Association of Poison Centres and Clinical Toxicologists (IPCS/EC/EAPCCT), for the retrospective assessment of cases of poisoning reported to poisons information centers. OBJECTIVES: The aims of this study were to test the validity of using the poisoning severity score obtained at initial referral to assess clinical severity and the likelihood of subsequent deterioration, to select cases for follow-up, and also to determine the need for referral to a clinical toxicologist. METHODS: The poisoning severity score was determined at the time of initial inquiry. Follow-up was then undertaken until either the patient was discharged from medical attention or died. A second poisoning severity score was then calculated taking note of the most severe features present after the initial inquiry. RESULTS: Of 718 consecutive telephone inquiries, 397 were given an initial poisoning severity score of 0 (no signs and symptoms), 225 a score of 1 (mild symptoms), 71 a score of 2 (moderate symptoms), and 25 a score of 3 (severe symptoms). Follow-up data are available only in 638 cases because the patient or referring doctor could not be traced in 80 instances. Of the 638 cases, 41 deteriorated; 31 of these were graded initially as poisoning severity score 0, four as 1, and six as 2. Five patients died (two with an initial score of 2 and three with an initial score of 3). CONCLUSIONS: This study demonstrates that it is useful to score telephone inquiries to a poisons information service at initial referral with the poisoning severity score. First, the poisoning severity score is helpful in assessing accurately the clinical severity and the likelihood of further deterioration. Second, the poisoning severity score is useful in determining the need for referral of the inquiry to a clinical toxicologist, thus ensuring that more serious and complicated cases of poisoning receive expert medical advice on management. Third, the poisoning severity score is helpful in selecting those cases which warrant follow-up for medical and epidemiological reasons.

Pesticide incidents reported to the Health and Safety Executive 1989/90- 1991/92.

1. Data concerning pesticide incidents investigated by the Field Operations Division (FOD) of the Health and Safety Executive (HSE) in Great Britain have been collated for the three year period April 1989 to March 1992. Over this period the HSE investigated 613 incidents concerning pesticides: 338 related to general or environmental complaints not involving human poisoning and 275 were suspected poisoning incidents. 2. The two hundred and seventy-five suspected poisoning incidents were assessed by the Pesticide Incidents Appraisal Panel (PIAP) as 'confirmed', 'likely', 'unlikely', 'not confirmed', or that there were 'insufficient data' to make an assessment. Assessed data are unavailable for eight incidents reported in 1989. 3. Four hundred and eighteen members of the public were involved in 202 assessed incidents and 79 workers were exposed in 65 assessed incidents. Overall, 129 (48%) incidents were assessed as 'confirmed' or 'likely', 121 (45%) as 'unlikely' or 'not confirmed' and in 17 (6%) there were 'insufficient data' to form a judgement. Incidents occurring in an occupational setting were assessed as 'confirmed' or 'likely' more frequently (62%) than those involving members of the public (44%). 5. Thirty-six per cent of those involved in a 'confirmed' poisoning incident were working with a pesticide or were in close proximity to the operator; 41% were on private property adjacent to a field being sprayed and a further 23% involved those walking, cycling or jogging past a sprayed field.(ABSTRACT TRUNCATED AT 250 WORDS)

Deaths from pesticide poisoning in England and Wales 1990-1991.

1. Data on deaths from pesticide poisoning occurring in England and Wales in 1990 and 1991 have been collated. Pesticides were responsible for 44 of 3978 deaths from poisoning (excluding carbon monoxide and other gases) over this period. 2. At least 66% of all pesticide fatalities were due to suicide and overall there was a predominance of males (male:female ratio 2.4:1). Eighty per cent of deaths occurred in those more than 44 years old and no child under 10 years old died, although almost 50% of suspected pesticide poisoning incidents involve this age group. 3. Herbicides were responsible for 35 of the 44 deaths; seven were caused by insecticides, one by a molluscicide and one by an unspecified agent. The herbicide, paraquat, was responsible for 33 of 44 deaths (75%) and, although fewer fatalities have occurred from this cause in recent years, paraquat remains the most common cause of fatal pesticide poisoning in England and Wales.

Suspected paediatric pesticide poisoning in the UK. I--Home Accident Surveillance System 1982-1988.

1. Between 1982 and 1988, 239,350 children under 10 years old attended 20 A & E Departments in England and Wales (22 departments throughout the UK in 1988) as a result of a home accident. 15,144 of 239,350 were suspected cases of poisoning and 514 attendances involved pesticides. 2. 501 of 514 children who attended hospital were under 6 years old and 41% were thought to have ingested a rodenticide, 37% an insecticide or other animal poison, 13% an herbicide or fungicide and 9% other pesticides. 3. Overall 189 of 514 children were admitted to hospital and of these 189 cases 35% were discharged home in less than one day; 94% left hospital within 2 days. 4. Using these data we estimate that over the period of study approximately 1,850 children annually attended an Accident and Emergency Department in the UK with suspected pesticide poisoning and that some 450 were admitted to hospital. However, the morbidity from this cause is low and no deaths from pesticide poisoning have been reported in children in England and Wales for more than two decades.

Suspected paediatric pesticide poisoning in the UK. II--Home Accident Surveillance System 1989-1991.

1. Between 1989 and 1991, 121,708 children less than 10 years old attended 22 Accident and Emergency (A & E) Departments in the UK as a result of an accident at home; 6,478 of these were cases of suspected poisoning. 2. Two hundred and fifty (124 boys and 126 girls) of 6,478 cases involved pesticides. Forty two per cent of these children were thought to have been poisoned by rodenticides, 33% by a different animal poison, 13% by an herbicide or fungicide, 7% by creosote and 5% by mothballs; a pattern similar to that observed in previous years. 3. Fifty-seven of 250 children (23%) were admitted to hospital. The proportion of children admitted to hospital between 1989 and 1991 is smaller than that observed between 1982-1988 (37%). Forty-six per cent of children were discharged home within one day and 95% within 2 days, whereas between 1982 and 1988 only 35% of children were discharged within one day. No child died during the study confirming the low morbidity. 4. Using these data we estimate that between 1989 and 1991 approximately 1,500 children annually attended an A & E Department in the UK with a diagnosis of suspected pesticide poisoning and that some 350 children were admitted each year.

Methemoglobinemia following ingestion of a monolinuron/paraquat herbicide (Gramonol)

A 59-year-old man ingested a mouthful of Gramonol with suicidal intent and was admitted to a local hospital six and a half hours later. It was noted that he looked "ashen grey" and was centrally cyanosed. The methemoglobin and plasma paraquat concentrations performed on arrival at the Regional Poisons Treatment Unit eight hours after paraquat ingestion were 52% and 1100 micrograms/L respectively; the administration of methylene blue reversed methemoglobinemia within two hours. The patient suffered extensive paraquat-induced oral, and probably esophageal, ulceration and developed multiple organ (particularly renal, respiratory and hepatic) failure and died some 10 days later. This is the most severe case of Gramonol poisoning reported both in terms of the amount of paraquat ingested and the concentration of methemoglobin formed. We believe that the methemoglobinemia in this patient was caused by monolinuron not paraquat.

Childhood poisoning in Dublin.

A prospective survey was carried out over a three month period to assess the incidence of accidental poisoning in children. The survey also examined the role of child resistant closures (CRC) and other form of packaging in the prevention of poisoning. Two hundred and six children with suspected poisoning attended the casualty departments of the three Dublin children's hospitals surveyed. Ninety three percent of the children were less than five years old. Medications were thought to have been ingested by 65%, household or gardening products by 34% and plants by 1%. Most children had no symptoms and received no treatment except emesis or oral fluid and demulcents. Twenty five percent required admission to hospital. There were no fatalities during the study period. Only 8.5% of the medications involved had been in containers with CRC's. Twenty percent were in blister packs or strips. A substantial number of poisonings occurred at a time when medicines were not in their normal place although in most cases they were still in the original container. We propose a two-phase approach to poisoning prevention--more widespread use of CRC's and public education on safe storage of medicines.

Propofol sedation for outpatient upper gastrointestinal endoscopy: comparison with midazolam.

The objectives of this study were to assess midazolam and propofol as sedative agents for outpatient gastrointestinal endoscopy, with particular reference to recovery profile, amnesic effects, and haemodynamic state and oxygenation during the procedure. Forty consecutive patients were allocated randomly to two groups. Patients in group I (n = 19) received midazolam 81 (SEM 32) micrograms kg-1; those in group II (n = 21) received propofol 950 (400) micrograms kg-1. Both agents were administered as single injections to similar end-points of sedation. Psychomotor function was assessed using the digit symbol substitution test (DSST). Amnesia was measured with a visual memory test and subjective questionnaire. Patients in group I had a lower DSST score than those in group II (P less than 0.01), indicating a hangover effect from midazolam. Amnesia was similar in the two groups up to the time of removal of the endoscope. More patients in group II remembered removal of the endoscope (P less than 0.001). Oxygen desaturation from baseline was similar in both groups (P less than 0.01). An increase in heart rate and decrease in mean arterial pressure were noted in both groups. Propofol provided more rapid recovery compared with midazolam, but was associated with pain on injection, a short amnesia span, and reduced patient acceptance.