The predictive value of self-report questions in a clinical decision rule for pediatric lead poisoning screening.

OBJECTIVE: We derived a clinical decision rule for determining which young children need testing for lead poisoning. We developed an equation that combines lead exposure self-report questions with the child's census-block housing and socioeconomic characteristics, personal demographic characteristics, and Medicaid status. This equation better predicts elevated blood lead level (EBLL) than one using ZIP code and Medicaid status. METHODS: A survey regarding potential lead exposure was administered from October 2001 to January 2003 to Michigan parents at pediatric clinics (n=3,396). These self-report survey data were linked to a statewide clinical registry of blood lead level (BLL) tests. Sensitivity and specificity were calculated and then used to estimate the cost-effectiveness of the equation. RESULTS: The census-block group prediction equation explained 18.1% of the variance in BLLs. Replacing block group characteristics with the self-report questions and dichotomized ZIP code risk explained only 12.6% of the variance. Adding three self-report questions to the census-block group model increased the variance explained to 19.9% and increased specificity with no loss in sensitivity in detecting EBLLs of ≥ 10 micrograms per deciliter. CONCLUSIONS: Relying solely on self-reports of lead exposure predicted BLL less effectively than the block group model. However, adding three of 13 self-report questions to our clinical decision rule significantly improved prediction of which children require a BLL test. Using the equation as the clinical decision rule would annually eliminate more than 7,200 unnecessary tests in Michigan and save more than $220,000.

Preserving the United States's poison control system.

The funding of United States's poison control centers is threatened. The following Commentary argues for support of the current outstanding poison control system by presenting the evidence for its cost-effectiveness.

Unrecognized hypoglycemia due to maltodextrin interference with bedside glucometry.

INTRODUCTION: Glucometry is widely used to confirm or exclude hypoglycemia in patients with suggestive clinical findings. Nonglucose sugars may be detected by certain types of glucometers, causing false elevation of the glucometer analysis of the blood sugar. Since these other sugars are not functionally glucose and may even induce excess insulin release, clinical hypoglycemia may be missed. CASE REPORT: We report a 79-year-old man on enteral feeds containing maltodextrin, a glucose polymer, who had persistently high glucometer-measured blood glucose despite normal blood glucose measured by formal laboratory analysis. DISCUSSION: Excess insulin administration, based on the erroneous glucometer reading, may have caused unrecognized fatal clinical hypoglycemia. This has been reported following intravenous administration of related nonglucose sugars but not with enteral maltodextrin. Further study is required to confirm the effects of maltodextrin on glucometry. CONCLUSION: False elevation of blood glucose measured on certain point-of-care glucometers can occur following the oral administration of maltodextrin.

Mental health and emergency medicine: a research agenda.

The burden of mental illness is profound and growing. Coupled with large gaps in extant psychiatric services, this mental health burden has often forced emergency departments (EDs) to become the de facto primary and acute care provider of mental health care in the United States. An expanded emergency medical and mental health research agenda is required to meet the need for improved education, screening, surveillance, and ED-initiated interventions for mental health problems. As an increasing fraction of undiagnosed and untreated psychiatric patients passes through the revolving doors of U.S. EDs, the opportunities for improving the art and science of acute mental health care have never been greater. These opportunities span macroepidemiologic surveillance research to intervention studies with individual patients. Feasible screening, intervention, and referral programs for mental health patients presenting to general EDs are needed. Additional research is needed to improve the quality of care, including the attitudes, abilities, interests, and virtues of ED providers. Research that optimizes provider education and training can help academic settings validate psychosocial issues as core components and responsibilities of emergency medicine. Transdisciplinary research with federal partners and investigators in neuropsychiatry and related fields can improve the mechanistic understanding of acute mental health problems. To have lasting impact, however, advances in ED mental health care must be translated into real-world policies and sustainable program enhancements to assure the uptake of best practices for ED screening, treatment, and management of mental disorders and psychosocial problems.

A novel neuromuscular syndrome associated with clenbuterol-tainted heroin.

BACKGROUND: Clenbuterol is a potent, long-acting beta-adrenergic agonist that has been reported as an adulterant of heroin. We describe an atypical syndrome in five users of clenbuterol-tainted heroin. METHODS: All cases were referred to a regional Poison Control Center. Urine and blood were analyzed using gas and liquid chromatography as well as mass spectrometry. CASE SERIES: Five heroin users presented with a syndrome characterized by muscular spasm, tremor, hyperreflexia, and elevated serum creatine phosphokinase concentrations. All patients lacked findings of acute clenbuterol toxicity but tested positive for clenbuterol and negative for strychnine and a battery of common potential adulterants. CONCLUSIONS: We report five cases of a novel neuromuscular syndrome in users of clenbuterol-adulterated heroin. It is unclear whether these reactions represent an atypical response to clenbuterol or another unidentified contaminant.

A descriptive study of an outbreak of clenbuterol-containing heroin.

STUDY OBJECTIVE: Illicit drugs may be adulterated with substances other than the sought-after substance of abuse. Although the true incidence and clinical effects of this practice are unknown, geographically disparate outbreaks of clinically significant adulteration continue to occur. We report on a recent outbreak of clenbuterol-adulterated heroin occurring along the East Coast of the United States. METHODS: After identification of index cases, 5 US poison centers collaborated with state and territorial health departments to alert the public of clenbuterol-tainted heroin. A case definition of clenbuterol-tainted heroin toxicity was promulgated, and emergency departments (EDs) were asked to contact poison centers when cases were identified. RESULTS: We identified 34 probable or confirmed ED presentations in 5 states during a 6-month period. Thirteen of the 34 patients met the criteria for "confirmed" exposures. Clenbuterol was identified in the blood and or urine of 12 of these 13 patients. Clenbuterol concentrations ranged from 2.4 to 26 ng/mL in the blood and 9.4 to 12,526 ng/mL in the urine. Symptoms included nausea, chest pain, palpitations, dyspnea, and tremor. Physical findings included significant tachycardia, hypotension, and laboratory evidence of hyperglycemia, hypokalemia, and increased lactate levels. Six patients demonstrated biochemical evidence of myocardial injury. Ten patients received beta-adrenergic antagonists without adverse effect. CONCLUSION: The adulteration of heroin by clenbuterol was associated with sympathomimetic effects, metabolic acidosis, and myocardial injury. The report also highlights how collaborative efforts among poison centers using the Centers for Disease Control and Prevention's Epi-X system rapidly identified a disease outbreak.

Massive strontium ferrite ingestion without acute toxicity.

Ingestion of strontium ferrite is previously unreported. We document absorption of strontium without acute toxicity. A 22 year-old schizophrenic man was brought to hospital after he was witnessed to pulverize and ingest flexible adhesive magnets, which later were identified as strontium ferrite. Other than auditory hallucinations his vital signs, physical examination, ECG and routine laboratories were unremarkable. Abdominal radiographs revealed diffuse radiopaque material. He was treated with whole bowel irrigation with polyethylene glycol electrolyte lavage solution (PEG-ELS) until radiographically cleared. His initial blood and urine strontium levels were 2900 microg/l and 15,000 microg/l, respectively (reference range for urine: <240 microg/l, occupational threshold 800 microg/l). A repeat urine level one week later was 370 microg/l. His hospital course was complicated by bacteraemia secondary to a thrombophlebitis at the site of the intravenous catheter, and the patient was treated with intravenous and oral antibiotics. He remained otherwise asymptomatic and was discharged to a psychiatric unit approximately 3 weeks later. Although clearly absorbed, strontium ferrite does not appear to produce acute toxicity. Delayed, and or chronic toxicity cannot be excluded based on this report.

The availability and use of charcoal hemoperfusion in the treatment of poisoned patients.

BACKGROUND: Charcoal hemoperfusion (CHP) has been one of the preferred methods to enhance the elimination of certain toxins in selected poisoned patients. However, the availability of CHP may be limited because of the expense of cartridges, their narrow indications, and their limited shelf life. Improvements in hemodialysis (HD) technology may contribute to making CHP obsolete. We investigated the availability of CHP in in-hospital HD units at hospitals receiving ambulances dispatched through New York City's emergency response system, hereafter referred to as 911-receiving hospitals, and their recent history of CHP use in poisoned patients. METHODS: The medical directors or managers of all in-hospital HD units in the 911-receiving hospitals of New York City were contacted by E-mail and/or telephone. Participants were administered a standard survey that included questions regarding the availability of CHP cartridges and the date and indication for last CHP use. Participants at institutions that did not stock CHP cartridges were questioned about their opinions on the utility of CHP. RESULTS: Forty-two in-hospital HD units were surveyed, of which 34 (81%) completed the survey. Ten units (29%) had CHP cartridges available for immediate use. Each of these 10 units stocked between 1 and 4 adult-size CHP cartridges, and 1 unit stocked 2 pediatric-size CHP cartridges. Nine units had in-date CHP cartridges, and 1 unit had only expired CHP cartridges. Only 3 units performed CHP in the past 5 years (2 units, theophylline poisonings; 1 unit, aluminum overload). In the 24 units without CHP cartridges, 21 directors believed that most common toxins could be removed effectively through HD and thus CHP rarely was indicated. Only 1 director cited expense as a factor in not stocking CHP cartridges. Two directors reported no specific reason for not stocking the cartridges. CONCLUSION: CHP cartridges are available in only approximately one third of 911-receiving hospitals in New York City. CHP is infrequently performed to enhance toxin elimination in poisoned patients.

Cardioactive steroid poisoning: a comparison of plant- and animal-derived compounds.

INTRODUCTION: Cardioactive steroids (CASs) are found in plants, animals, and insects. Their affinity for Na+-K+ ATPase is attenuated by the type of lactone at carbon 17 (C17) of the steroid backbone: those with 5-membered lactone rings, or cardenolides, are derived mostly from plants with 6-membered rings or from animals with bufadienolides. A systematic review of CAS poisoning was performed to compare the mortality rate of cardenolides and bufadienolides. METHODS: MEDLINE was searched for articles using commonly reported names of CASs, and keywords were limited to human cases only. We searched cases from 1982 to 2003, so that supportive care was similar and digoxin-specific Fab was available. Identified reports of CAS poisoning were read to exclude cases involving licensed pharmaceuticals. Inclusion criteria included hyperkalemia, gastrointestinal symptoms, electrocardiographic evidence of CAS toxicity, digoxin serum concentration, or history of exposure to a substance containing a CAS. Clinical data was collected, including information about treatment with digoxin-specific Fab and treatment outcome. RESULTS: Fifty-nine articles, describing 924 patients, were identified. Eight hundred ninety-seven patients (97%) ingested a CAS with a 5-membered lactone ring, and mortality was 6% (n = 54). Twenty-seven patients (2.9%) ingested a CAS with a 6-membered lactone ring, and mortality was 29.6% (n = 8). The difference in mortality rates was statistically significant (p < 0.001, [X2]). CASs with 6-member rings accounted for the highest percentage of nonsuicidal exposures. CONCLUSION: Although cardenolides accounted for the majority of exposures, bufadienolides were five times more lethal than cardenolides.