Acute cholinergic syndrome following ingestion of contaminated herbal extract.

Herbal preparations are becoming more and more popular and increasingly used in the USA. Herbs are from natural plants and therefore often considered to be harmless compared with western medicines. Nevertheless, as the use of herbal remedies has risen, so has the incidence of acute and chronic herbal intoxication. The case history is presented of a 68-year-old man who presented with an acute cholinergic syndrome soon after ingesting a herbal preparation containing Flemingia macrophylla and ginseng. His red blood cell acetylcholinesterase activity dropped to 50% of the normal reference range. He was treated successfully with atropine and supportive care. It was thought that contamination with pesticides, such as organophosphate residue, was the probable cause. This case highlights the need to be more aware of the possibility of acute pesticide intoxication in herbal users, even when only small amounts are consumed.

Preventable deaths in patients admitted from emergency department.

BACKGROUND: There is limited data about how appropriate medical care is in the emergency department (ED). OBJECTIVES: To investigate the rate and types of preventable deaths among patients with early mortality after emergency admission from the ED. METHODS: We retrospectively reviewed charts of early mortality (defined as mortality which occurred within 24 hours after admission from the ED) over a 3 year period. Those patients with terminal cancer or out of hospital cardiac arrest (OHCA) at presentation were excluded. Two independent assessors reviewed each eligible chart and determined whether early mortality was preventable. Any disagreements were resolved through discussion between the investigators. A mortality event was considered preventable if actions or missed actions were identified that would have prevented the death. The types of preventability were categorised as misdiagnosis, delayed diagnosis, and inappropriate medical management. Interrater reliability in the initial determination was assessed using Cohen kappa statistic. RESULTS: Over a 3 year period, 210 early mortality cases were identified. Excluding patients with terminal cancer or OHCA, the rate of preventable deaths was 25.8% (32/124). The types of preventability were inappropriate medical management (17 patients), delayed diagnosis (eight), and misdiagnosis (seven). There was good agreement between assessors with a Cohen kappa statistic of 0.81. CONCLUSIONS: Preventable deaths in emergency admitted patients with early mortality are not uncommon. Analysis and identification of preventability early mortality by using a chart based method may be used as a quality assurance index in emergency medical care.

Ultrasonography is superior to plain radiography in the diagnosis of pneumoperitoneum.

BACKGROUND: The aim of this study was to compare plain radiography with abdominal ultrasonography in the detection of pneumoperitoneum. METHODS: A total of 188 patients with suspected hollow organ perforation were studied. All patients had abdominal ultrasonography, upright chest radiography and left lateral decubitus abdominal radiography examinations. The sensitivity, specificity, positive and negative predictive value, and accuracy of chest and abdominal radiography were compared with that of abdominal ultrasonography. RESULTS: One hundred and seventy-eight patients underwent laparotomy; 170 patients had hollow organ perforation, five patients had perforated appendicitis and three had acute cholecystitis. In the diagnosis of pneumoperitoneum, ultrasonography had improved sensitivity (92 versus 78 per cent), negative predictive value (39 versus 20 per cent) and accuracy (88 versus 76 per cent), and similar specificity (both 53 per cent) and positive predictive value (95 versus 94 per cent) compared with plain radiography. CONCLUSION: Ultrasonography is more sensitive than plain radiography in the diagnosis of pneumoperitoneum.