Fatalities caused by the MDMA-related drug paramethoxyamphetamine (PMA).

The past several years have seen a marked increase in the recreational use of 3,4-methylenedioxymethamphetamine (MDMA) or "Ecstasy". MDMA use is especially common among young people participating in dance parties called "raves". Paramethoxyamphetamine (PMA) exhibits both structural and pharmacological similarity to MDMA. It may, however, be a more potent central stimulant, particularly in its effects on serotonergic transmission. Several fatalities from PMA have been reported in Australia, and here we report three recent fatalities that occurred in the midwestern United States in which each of the decedents believed that they were ingesting MDMA. Symptoms observed included agitation and bruxism, progressing to severe hyperthermia, convulsions, and hemorrhage. Blood was screened for drugs of abuse by enzyme immunoassay with the presence of amphetamines indicated in each case. Confirmation and quantitation for amphetamines was performed by gas chromatography-mass spectrometry. The deceased, two males ages 19 and 24 and a female age 18, had postmortem blood PMA concentrations of 1.07, 0.60, and 1.90 mg/L, respectively. PMA is not a contaminant of MDMA, and no MDMA was found in any of these cases. The primary metabolite of PMA is produced by O-demethylation to 4-hydroxyamphetamine, a reaction catalyzed by cytochrome P450 2D6. This enzyme is noted to be genetically polymorphic. Those with the "slow metabolizer" phenotype may be likely to have higher peak blood concentrations of PMA. Whether any of the decedents described herein were of the slow metabolizer phenotype is not known. Several groups have advocated the onsite use of the Marquis Test for the purpose of pill screening in efforts to distinguish PMA from MDMA. A dark purple is consistent with MDMA, whereas PMA imparts no color change in this test. PMA is often in the form of a white pill with a Mitsubishi symbol on one side. This design has been identified in at least one of these fatalities.

Acetaminophen ingestion in childhood--cost and relative risk of alternative referral strategies.

Acetaminophen is the pharmaceutical most frequently ingested by small children. Although past research has allowed the safe management of 90% of these ingestions at home, several thousand are still referred to emergency departments annually. With the goal of further reducing the number of unnecessary referrals, the risk/benefit considerations of alternate referral strategies were analyzed. In a retrospective poison center chart review study from 11 centers, the records of children between the ages 1 and 6 years who acutely ingested acetaminophen and were referred to a hospital for determination of serum acetaminophen concentration in 1986 and 1987 were identified using the database of the American Association of Poison Control Centers. Risk of hepatic injury was assigned on the basis of the Rumack-Matthew acetaminophen toxicity nomogram. The cohort was stratified in terms of the amount ingested and whether a pediatric or adult preparation was ingested. The direct cost of an evaluation was estimated from four centers. Sensitivity, specificity and direct cost of each risk identification strategy were calculated. Eight hundred sixty six of 2091 patients had a timed serum acetaminophen concentration recorded. Of these, three patients had results in the "probable risk" area of the nomogram. A referral reduction strategy which would refer only children who ingest 200 mg/kg or more of an adult preparation could eliminate 82% of referrals without missing any of these "probable risk" patients. Six other children were determined to have serum acetaminophen concentrations in an area of the nomogram labeled "possible risk". No referral reduction strategy explored identified all of these patients. The average charge for an emergency department evaluation in 1992 was $272.00. These data suggest that children less than six years of age who ingest pediatric acetaminophen products other than those from packages containing greater than 30 tablets or who ingest less than 200 mg/kg of an adult preparation may be safely managed at home without referral to a hospital. This strategy would result in significant cost savings and prevent unnecessary inconvenience to many patients and families.

Influence of time until emesis on the efficacy of decontamination using acetaminophen as a marker in a pediatric population.

STUDY OBJECTIVE: To determine the extent of drug removal by emesis at different times after the ingestion of a toxic substance. DESIGN: Multicenter retrospective chart review. METHODS: Using the American Association of Poison Control Centers' aggregate data base, children who had ingested acetaminophen and who were referred to a health care facility by one of 11 poison centers during a two-year period were identified. Charts of these patients were reviewed to determine the quantity ingested per kilogram of body weight, method of decontamination used, the timing of decontamination, and the serum acetaminophen concentration obtained four hours after ingestion. RESULT: Charts of 455 patients met all requirements for inclusion. When emesis occurred within one-half hour after ingestion, mean serum acetaminophen concentration drawn four hours after ingestion was approximately half that in a control group that received no decontamination. Emesis had less impact when it was delayed further and had no demonstrable impact when it occurred more than 90 minutes after ingestion. CONCLUSION: Many factors must be considered when deciding if and by what method a given patient should receive decontamination. When delayed gastric emptying is not expected, emesis can at best decrease a toxic burden by half if it occurs early. Medical care givers must continue to scrutinize management practice to ensure that syrup of ipecac is given only in situations in which it is likely to make a difference in outcome and in which it is the most effective agent to achieve this goal.

Hypovolemia, hyperosmolality, and acidosis associated with intraperitoneal infusion of nitrofurazone solution in healthy horses.

Nitrofurazone solution containing 0.2% nitrofurazone and 99.8% polyethylene glycol was given to 4 healthy horses (2 L in 2 L of lactated Ringer solution, intraperitoneally). Horses developed hypovolemia, hyperosmolality, and mixed respiratory and metabolic acidosis. These changes were largely attributable to polyethylene glycol, but a contribution of nitrofurazone cannot be excluded. Intraperitoneal infusion of nitrofurazone solution in horses is contraindicated.

Findings of ten years of clinical drug screening.

During the years from 1977 to 1986, 21,410 specimens were collected for clinical drug screening from 13,589 patients. The specimens included 9,530 blood samples, 9,184 urine samples and 2,717 samples of gastric contents. One or more drugs/drug metabolites were detected in 74% of the specimens. Gastric contents were positive most often (85%) followed by urine (79%) and blood (66%). Although the 5 most frequently detected drugs did not change (caffeine, ethanol, nicotine, salicylates and acetaminophen), the presence of cocaine, phenylpropanolamine, diphenhydramine and the group of cyclic antidepressants steadily increased over the time period. Over 200 different drugs/drug metabolites were detected in the drug screens, contributing a significant amount of information for the appropriate diagnosis and treatment of the patients for which the testing was requested.

A review of chemical eye burns referred to the Blodgett Regional Poison Center.

We reviewed a random sampling of 500 cases of chemical eye exposures referred to the Blodgett Regional Poison Center from July 1, 1986 to December 31, 1986. While some injuries were encountered in laboratories and industrial plants, the great majority originated in the home (84.4%) and involved commonly used household products. Most exposures were acute and reported within minutes to 1 hr. Cases predominantly involved children suffering accidental exposure. The most common symptoms were eye discomfort (56.2%) and redness (26.4%), but many patients were completely asymptomatic (11.4%). The reported injuries included corneal burns or abrasions (23 cases), and conjunctivitis (7 cases). Only 8 cases (1.6%) were initially seen by an ophthalmologist. In virtually all cases, the recommended emergency treatment was immediate prolonged rinsing of the eye.

An analysis of arsenic exposures referred to the Blodgett Regional Poison Center.

Fifty-seven cases of acute arsenic exposure were referred to Blodgett Regional Poison Center from January 1985 through December 1985. We will summarize epidemiologic aspects, laboratory values and the types of arsenicals involved. Cases predominantly involved children ingesting sodium arsenate in the form of ant poison. A great majority were accidental exposures related to the home use of ant killers in contrast to previous reports of homicidal or industrial poisoning. Initial urine arsenic levels, symptoms and therapy will be included. Most cases were reported within hours with patients being asymptomatic or with relatively few complaints. The current Blodgett Regional Poison Center Arsenic Protocol and instructions for the preparation of D-penicillamine suspension adapted from the Blodgett Pharmacy Department will be included. Conclusions, outcomes and recommendations are discussed.

Contribution of whole blood L-lactate, pyruvate, D-lactate, acetoacetate, and 3-hydroxybutyrate concentrations to the plasma anion gap in horses with intestinal disorders.

Increased anion gap (AG) was due, in part, to L-lactic acidosis in 14 of 14 horses with intestinal disorders. In a few horses, increased whole blood concentrations of D-lactate made a minor contribution to the AG. However, the increase in AG was often greater than the sum of the increases in these 2 acid anions. This unexplained increase was not a result of increases in whole blood pyruvate, 3-hydroxybutyrate, or acetoacetate concentrations or serum albumin or phosphate concentrations. Identification of other anions causing increased AG could lead to better understanding, diagnosis, and treatment of metabolic imbalances in critically ill horses.

Hypercalcemia associated with malignancy in a horse.

Hypercalcemia associated with malignancy was diagnosed in a 2-year-old Thoroughbred filly admitted because of weight loss and reduced exercise tolerance of approximately 2 months' duration. Laboratory findings included hypercalcemia, hypophosphatemia, anemia, marked neutrophilia with lymphopenia and eosinopenia, and normal immunoreactive parathyroid hormone concentration. At necropsy, a 53.6-kg tumor was located in the cranioventral aspect of the abdominal cavity. Gross renal lesions were not noticed. Bone tissue appeared to be normal on gross and histologic examinations. The parathyroid glands were not grossly identified at necropsy. A specific test does not exist for detection of hypercalcemia associated with malignancy. The diagnosis of hypercalcemia associated with malignancy was made on the basis of clinical history, physical examination, radiographic interpretation, laboratory findings, histologic examination, and ruling out other causes of hypercalcemia. Hypercalcemia, increased renal phosphate excretion in the presence of hypophosphatemia, absence of bone metastases, and identifying an abdominal mesenchymal tumor that may have originated from the left ovary satisfied the basic criteria for hypercalcemia associated with malignancy from a solid tumor.

Stabilization of atlantoaxial subluxation secondary to atlantooccipital malformation in a Devon calf.

Atlantoaxial subluxation secondary to atlantooccipital malformation in a 14-day-old female Devon calf was corrected by alignment and stabilization of the atlantoaxial joint. Stabilization was achieved by the ventral placement of pins and screws, and the dorsal placement of a figure 8 tension band wire. At 2 and 14 days post operatively, adequate alignment of the atlantoaxial joint was confirmed radiographically. Following surgery the calf improved clinically, but was terminated 14 days following the surgery due to a pneumonia. At necropsy the fixation was stable and spinal cord decompression had been achieved. It was concluded that this technique could be utilized to allow decompression, anatomical alignment, and stabilization of an atlantoaxial subluxation secondary to atlantooccipital malformation in a calf. At necropsy, there was gross and histologic evidence of congenital fusion of the basioccipital bone to the malformed atlas.

Diabetes mellitus associated with bilateral granulosa cell tumors in a mare.

Both ovaries in a 10-year-old American Saddle Horse mare were determined to be larger than normal. The mare had problems with infertility during the preceding 3 years. Clinical evaluation revealed that the mare was polyuric, polydypsic, hyperinsulinemic, and hyperglycemic, and had reduced tolerance to exogenous glucose. Bilateral granulosa cell tumors were identified on histologic examination of the ovaries. The precise mechanism for the secondary diabetes mellitus was not determined; however, the cause was suspected to be a result of the synthesis and release of a hormonal substance by the tumor that affected carbohydrate metabolism and resulted in decreased peripheral sensitivity to insulin.

Direct mail solicitation of contributions from poison center users--success or failure?

Funding problems seem to be an ever present obstacle for Regional Centers. To date, there has not been an effective solution for many, if not all, the centers. An often raised suggestion is the direct solicitation of the users of the services of the Poison Center. On March 1, 1985, the Blodgett Regional Poison Center (BRPC) initiated a direct solicitation project. For most BRPC calls involving a "patient", a packet containing informational and educational materials was mailed to the caller. This packet also included a letter requesting a donation to BRPC to help defray operational expenses. The letter suggested a $10.00 donation, or any amount the individual could afford. Results through the first 5 months of this project are presented with copies of all materials used in the solicitation.

Uterine rupture as a postpartum complication in two mares.

Uterine rupture was diagnosed in 2 postpartum mares with hemorrhagic vaginal discharge. Both mares had abdominal pain, as evidenced by pawing, kicking at the abdomen, or attempting to roll. Peritoneal fluid analysis was useful in establishing a diagnosis. One mare had many RBC in the peritoneal fluid and was anemic; this mare was managed medically with oxytocin, antibiotics, and blood transfusion. The mare was able to raise her foal to weaning age. The second mare had many RBC, degenerate neutrophils, and intracellular and extracellular bacteria in peritoneal fluid. Surgical repair of the uterus was performed, and the mare was treated for peritonitis. The mare later became pregnant.

Micronema granuloma in the gingiva of a horse.

A well-circumscribed proliferative mass was protruding from the body of the mandible of a 4-year-old Appaloosa gelding. The mass was uniformly firm and was ulcerated on the dorsal surface. The horse was euthanatized due to extensive involvement of the jaw and difficulty in eating. Microscopically, the mass consisted of numerous discrete microgranulomas separated by bands of abundant fibrous connective tissue containing lymphocytes, plasma cells, and histiocytic macrophages. Numerous rhabditiform nematodes were in the microgranulomas as well as in the surrounding connective tissue. The nematodes were identified as Micronema species.

Ventral approach for stabilization of atlantoaxial subluxation secondary to odontoid fracture in a foal.

Atlantoaxial subluxation secondary to odontoid fracture in a 30-day-old foal was corrected by alignment of the atlantoaxial joint and stabilization with 2 ventrally placed dynamic compression plates. At 90 days after surgery, healing of the fracture, with adequate alignment of the atlantoaxial joint, was confirmed radiographically. The foal was only slightly tetraparetic at that time. At 1 year after surgery, the gait was normal. It was concluded that the technique has advantages over the use of Steinmann's pins or external coaptation for stabilization. The ventral approach allows decompression, anatomic alignment, and immediate stabilization of the subluxation. Potential complications of the ventral approach include laryngeal paralysis.

Complications associated with immunotherapy of equine phycomycosis.

Five horses with pythiosis of the limbs were treated unsuccessfully by surgery or topical application of amphotericin B, or both. Follow-up immunotherapy resulted in 1 horse responding favorably. Three horses were cured of the fungal infection but developed osteitis or deep-seated laminitis, which necessitated their destruction. The remaining horse, which had severe anemia, died before the course of vaccination was completed.