Sensitivity of dose-estimations for acute acetaminophen overdose in predicting hepatotoxicity risk using the Rumack-Matthew Nomogram.

Timely assessment of acetaminophen concentration in overdose situations is not always available in resource-poor settings. The 150 mg/kg dose-estimate for acetaminophen is widely considered as criterion for acetaminophen overdose. Its sensitivity and specificity when compared to the 150 mg/L treatment line on the Rumack-Matthew Nomogram (150-treatment line) has rarely been evaluated. This is a retrospective chart review of acute acetaminophen overdose patients. We evaluated the sensitivity and specificity of the 150, 200 mg/kg and 8- and 10-g dose-estimates by plotting the serum acetaminophen levels and using 150-treatment line on the Nomogram as the treatment cut-off. A comparison of medical care costs was performed. We enrolled 784 cases for analysis. Median (IQR) age was 23 (20-28) years (81.9% female). There were 545 cases (69.5%) where the estimated ingested acetaminophen dose were ≥150 mg/kg and 406 cases (51.8%) with concentrations ≥150-treatment line. Hepatotoxicity and acute liver injury (ALI) occurred in 7.3% and 23.9%, respectively. The sensitivity and specificity of 150 mg/kg dose-estimate for the 150-treatment line were 92.6% (95% CI 89.6, 94.8) and 55.3% (95% CI 50.3, 60.2). Among patients with dose-estimate below150 mg/kg, none developed hepatotoxicity and 17 (7.1%) develop ALI. The administration of activated charcoal significantly decreased the risk of being above the 150-treatment line by half. In resource-poor setings, the use of 150 mg/kg dose-estimate as a stand-alone criteria for initiation of N-acetylcysteine therapy is satisfactory, especially when combined with decontamination with activated charcoal and follow up of aminotransferase at 24 h.

Prevalence and cluster effect of self-reported allergic reactions among insect consumers.

BACKGROUND: Entomophagy is a common practice in many parts of the world. Allergic symptoms after insect consumption have been reported in healthcare literature and in the news. OBJECTIVE: We evaluated prevalence and association of allergic history and self-reported allergic reactions after entomophagy. METHODS: We conducted a cross sectional internet-based survey. Participants were people who have consumed insects. Collected information included demographic data, the practice of entomophagy, allergic history and self-reported allergic symptoms. RESULTS: During May to October 2017, 140 people completed the survey. Median and range of age are 27 and 18-64 years. Ninety-two (65.7%) were female. Thirty-seven (26.4%) and 13 (9.3%) participants had history of allergy and seafood allergy, respectively. Eighteen (12.9%; 95% confidence intervals (CI) 7.3-18.4) participants reported allergic reactions after insect consumption. Nine symptomatic participants reported other people who partook insects to have allergic symptoms. Reported factors with significant association with allergic reactions were history of allergy and seafood allergy with prevalence ratios of 4.83 (CI 1.83-10.44) and 3.76 (CI 1.59-8.87), respectively. CONCLUSIONS: The prevalence of self-reported allergic reactions after entomophagy is 12.9%. Clusters of people with post-entomophagy allergic symptoms are found. History of allergy and seafood allergy are associated with post-entomophagy allergic reactions.

Effects of unconventional recreational drug use in pregnancy.

Recreational drug toxicity is a rapidly evolving aspect in clinical practice. The prevalence of recreational drug abuse in the past decade has achieved an epidemic scale due to invention of new agents and ease of accessibility to the abused drugs. "Unconventional recreational drugs" is the term that includes new psychoactive drugs and medications diverted for recreational goals. Misuse of unconventional recreational drugs during pregnancy can affect both the pregnant woman and the fetus. However, the problems are usually unrecognized and overlooked by healthcare professionals. In this articles, obstetric complications, teratogenicity and neonatal abstinence syndrome from exposure during pregnancy to synthetic cannabinoids, synthetic cathinones, tramadol, kratom, olanzapine, quetiapine, ketamine and ketamine are reviewed. The main purpose is to create awareness about maternal, fetal and neonatal effects of these unconventional recreational drugs, so healthcare professionals will have improved vigilance for these under-recognized issues.

Being overweight or obese as a risk factor for acute liver injury secondary to acute acetaminophen overdose.

PURPOSE: Increased incidences of hepatotoxicity have been observed in obese patients with acute acetaminophen overdose. We evaluate whether the status of being overweight or obese is associated with increase in the development of hepatotoxicity and acute liver injury (ALI) in patients with acute acetaminophen overdose. METHODS: This was a retrospective cohort study comparing the risk of hepatotoxicity and ALI between overweight or obese patients (body mass index [BMI] ≥ 25) and normal BMI patients (BMI ≤ 24.9) presenting with acute acetaminophen overdose at Siriraj Hospital during January 2004 to June 2012. All patients were treated with intravenous N-acetylcysteine. Psi parameters were calculated. High psi was defined as psi of ≥5.0 mM-hour. Data were analyzed using multinomial logistic regressions, odds ratio (OR), stratified OR, and 95% confidence interval (CI). RESULTS: There were 197 patients who fulfilled the criteria for analysis, 35 (17.8%) were obese, 24 (12.2%) were overweight, and 138 (70%) were normal BMI cases. Hepatotoxicity and ALI developed in 25 (12.7%) and 40 (20.3%) cases, respectively. Multinomial logistic regression revealed that the overweight-obesity status and log10 (psi value) were significant risk factors of ALI, with OR (95% CI) of 2.68 (1.21-5.95) and 1.74 (1.27-2.38), respectively, while only log10 (psi) was a significant risk factor of hepatotoxicity with OR (95% CI) 378.51 (39.49-3627.99). From stratification, overweight-obesity had significant odds ratios for ALI in strata with low acetaminophen concentration, early initiation of N-acetylcysteine and low psi. CONCLUSION: We conclude that being overweight or obese is an independent risk factor of ALI in acute acetaminophen overdoses.

Histamine poisoning from insect consumption: an outbreak investigation from Thailand.

BACKGROUND: Insect consumption is a common practice in the Asian culture and all over the world. We are reporting an outbreak investigation of histamine poisoning from ingestion of fried insects. METHODS: On 24 July 2014, a group of students at a seminar presented to Angthong Provincial Hospital, Thailand, with pruritic rash after ingesting snacks consisting of fried insects from a vendor. We initiated an outbreak investigation with retrospective cohort design and collected samples of remaining foods for analyses. Attack rates, relative risks and their confidence intervals (CI) were calculated. RESULTS: Out of 227 students, 28 developed illnesses that were consistent with our case definition which included, flushing, pruritus, urticarial rashes, headache, nausea, vomiting, diarrhea, dyspnea and bronchospasm. Two children were hospitalized for progressive bronchospasm overnight without serious complications. The types of food ingested included a lunch that was provided at the seminar for all students and snacks that 41 students bought from the only vendor in the vicinity. The snacks included fried grasshoppers, silkworm pupae, common green frogs, bamboo borers, crickets and meat balls. The attack rates were highest (82.6 and 85.0%) among students who ingested fried grasshoppers and silkworm pupae and lowest (4.4 and 5.3%) among those who did not ingest them, with relative risk of 18.7 (95% CI 9.6-36.4) for grasshoppers and 16.0 (95% CI 8.8-29.3) for silkworm pupae. Histamine concentrations in the fried grasshoppers and silkworm pupae were 9.73 and 7.66 mg/100g, respectively. DISCUSSION AND CONCLUSION: Through epidemiological analysis and laboratory confirmation, we have illustrated that histamine poisoning can occur from ingestion of fried insects. We postulate that histidine, which is present in high concentration in grasshoppers and silkworm pupae, is decarboxylated by bacteria to histamine, a heat stable toxin. The ingestion of histamine is responsible for the clinical pictures being reported.

Transfer of Methamphetamine (MA) into Breast Milk and Urine of Postpartum Women who Smoked MA Tablets during Pregnancy: Implications for Initiation of Breastfeeding.

BACKGROUND: Methamphetamine (MA) use by pregnant women remains a growing problem in South East Asia. After delivery, a negative maternal urine MA assay is assumed to reflect the absence of MA in breast milk and marks breastfeeding initiation. To date, no data exist that describe the relationship between the peripartum and postpartum transfer of MA into breast milk and its urinary excretion in women, following recreational use by smoking. OBJECTIVE: This study aimed to determine the pharmacokinetic of smoked MA in breast milk and its relationship to urinary MA excretion in postpartum women who tested positive for MA before delivery. METHODS: Timed urine and breast milk samples of 33 women who had positive urine drug screens for MA prior to delivery were analyzed for MA using Acquity Ultra Performance Liquid Chromatography (Waters, Milford, Massachusetts, USA) with the ACQUITY UPLC Photodiode Array Detector (Waters). Those participants with 4 or more timed breast milk samples were included for pharmacokinetic calculation using log-linear trapezoidal rule. RESULTS: Pharmacokinetic data from 2 women were analyzed. The half-life values for MA in the breast milk were 11.3 and 40.3 hours. The absolute infant doses were 21.3 and 51.7 µg/kg/day. Methamphetamine disappears from breast milk approximately 1 day before the maternal urine MA becomes negative. CONCLUSION: Smoked MA shows a similar breast milk pharmacokinetic pattern to previously reported intravenous MA. Breastfeeding can be safely initiated in mothers whose urine MA screen has turned negative for ≥ 24 hours. However, concurrent maternal substance use treatment and screening is necessary for continued promotion of lactation.

Global patterns of methamphetamine use.

PURPOSE OF REVIEW: As the most popular psychostimulant in the world, methamphetamine use has reached epidemic proportions. Its enormous popularity has created subcultures of methamphetamine users all over the globe. The purpose of this review is to describe the geographic availability of different types of methamphetamine, the characteristics of each user population, and the psychosocial impact the two have on society. RECENT FINDINGS: Methamphetamine has diversified immensely from the early days of its use. Different forms of methamphetamine - ICE, powder, and pills - have different pharmacokinetic characteristics that make them popular among certain types of users. New studies have shown that addiction to methamphetamine results in a very characteristic loss of inhibition that augments various risk-taking behaviors in its users. Also, recent seizure data suggest that its production and trafficking is spreading into new areas of the globe. SUMMARY: From recreational use to addiction, methamphetamine use represents a serious risk to health and wellbeing of the community. Recognizing the pattern of abuse in specific populations is the key to assessing the risk, implementing prevention, and harm reduction measures, as well as making public policies.

Acetaminophen Psi Nomogram: a sensitive and specific clinical tool to predict hepatotoxicity secondary to acute acetaminophen overdose.

BACKGROUND: Acetaminophen Psi Parameter (APP) is a composite of acetaminophen (paracetamol) level and lag time before N-acetylcysteine (NAC) therapy. The APP is a significant predictor of hepatotoxicity secondary to acute acetaminophen overdose. Acetaminophen Psi Nomogram (APN) was invented as a graphic analog of the APP for use in predicting individual patient's risk of hepatotoxicity. Clinical accuracy of the APN has never been validated OBJECTIVE: The authors are reporting the validity of APN in predicting hepatotoxicity secondary to acute acetaminophen overdose at Siriraj Hospital. MATERIAL AND METHOD: This present study is a retrospective review of medical records of patients with acute acetaminophen overdose at Siriraj Hospital between January 2004 and June 2009. Each case was classified by APN into an appropriate risk group. The outcome of interest was hepatotoxicity. The validity of the APN is reported as sensitivity and specificity. Secondary outcomes include serum acetaminophen concentrations, delay to NAC therapy, and APP for each APN's risk group. RESULTS: One hundred and sixty-one patients were enrolled Higher APN risk classifications are associated with a trend towards higher acetaminophen levels, longer delayed to NAC initiation, and larger APP. Twenty five patients (15.5%) developed hepatotoxicity. The number of patients who were above the APN's risk lines, 1% and 50% were 88 (54.7%) and 17 (10.6%), respectively, with corresponding sensitivities of 100.0% (95% CI 186.6, 100.0) and 40.0% (95% C121.2, 61.3). APN's risk lines 50% had specificity of 94.9% (95% CI 89.7, 97.9). CONCLUSION: Acetaminophen Psi Nomogram is a sensitive and specific tool for prediction of hepatotoxicity secondary to acute acetaminophen overdose. By application of the APN, a significant proportion of patients may not require either further follow-up after the completion of NAC therapy or prolongation of NAC therapy. Patients in high APN's risk ranges may be treated and monitored more intensively with confidence.

Patient expectations for health supervision advice in continuity clinic: experience from a teaching hospital in Thailand.

BACKGROUND AND OBJECTIVE: To evaluate the ability ofpediatric residents in a continuity clinic to meet patient expectations regarding health supervision advice. MATERIAL AND METHOD: This was a cross sectional prospective study conducted at the continuity clinic (COC) and outpatient well-child clinic (OPD-WCC) at the Department of Pediatrics Siriraj Hospital in 2008. The patients attending both clinics over a four-week period were asked to participate in a 2-part questionnaire. The first part, participants were asked to rank six health supervision topics in the order of their perceived importance. After the visit, the participants rated the advice quality given in each topic. The top three most-desired advices were termed 'Priority Topics 'and the researchers categorized the visit quality as Interactive, Informative, or Missed Opportunity (MO) according to the participants 'perceived level of interaction. The participants were not aware of the 'Priority Topic' grouping prior to their participation. Main outcome measures were the proportions of Interactive visits and MO visits in for each of the six focus topics in the COC vs. OPD-WCC setting. RESULTS: The COC setting reported more Interactive sessions when the topic is discipline (31.6%, 9.1%, p<0.05) than the OPD-WCC group, as well as more Informative sessions when the topics were behavior and dental care. There were also more MO in dental (50%, 0%, p< or =0.05) and discipline 50%, 15.8%, p<0.05) among the OPD-WCC than the COC group. CONCLUSION: Physicians are better able to meet their patient's expectation regarding health supervision in a continuity setting. They are also more likely to be interactive regarding their advice and are less likely to miss the opportunities to address issues desired by their patient.

Accuracy and precision of transcutaneous bilirubinometry in postdischarge Asian neonates.

UNLABELLED: A prospective cross-sectional study was conducted in a tertiary care center to determine the accuracy of transcutaneous bilirubin measurements (TcB) measured by the Konica Minolta JM-103™ meter compared to total serum bilirubin (TSB) in Asian infants aged 5-14 days. There were 405 late-preterm and term infants involved, and 455 paired samples were obtained by venepuncture and analyzed for bilirubin levels. TcB measurements were performed using the average of three measurements (TcB3) and a single measurement (TcB1) method. The overall correlation between TSB and the TcB was 0.80 (p ≤ 0.001) for TcB3 and 0.76 (p ≤ 0.001) for TcB1, respectively. The mean (SD) difference between TcB3 and TSB was -17.6 (29.5) µmol/L (median, -17.0; interquartile range (IQR), -39.1 to 1.7) and between TcB1 and TSB was -20.7 (32.3) µmol/L (median, -20.4; IQR, -42.5 to 1.7). The mean difference (SD) between the TcB3 and TSB in the low-risk (TSB < 170 µmol/L), intermediate-risk (TSB 170-254 µmol/L), and high-risk (TSB ≥ 255 µmol/L) groups was -2.8 (27.2), -13.4 (27.0), and -33.4 (29.1) µmol/L, respectively. To detect a TSB level of ≥255 µmol/L, using the TcB cutoff level of 204 µmol/L provides a sensitivity of 96 % with a specificity of 58 %. CONCLUSION: The TcB meter using a specific cutoff level can be reliably used as a screening tool for jaundice detection in older, postdischarge neonates, including the Asian population. Lower cutoff values can be set to capture all infants who merit closer surveillance, potential investigation, and treatment with higher accompanying screening costs.

Pediatric fatality from gun bluing solution: the need for a chemical equivalent of the one-pill-can-kill list.

Gun bluing solution is commonly used to polish guns and prevent rusting. The authors report a case of a 2-year-old boy who inadvertently ingested approximately 15 ml of his father's Fox Gun Blue solution. The patient subsequently developed acidosis, hypotension, and coma. He died within four hours after ingestion. His plasma selenium level was 857 ng/ml. A brief review of other reported ingestion of gun bluing liquid in both adults and children is also included.

Stimulant methamphetamine and dextromethorphan use among Thai adolescents: implications for health of women and children.

For over a decade, amphetamine-type stimulants have made their way into the adolescent culture of Thailand. Coupled with the more recent emergence of the legal, over-the-counter cough medicine dextromethorphan (DM), they represent the most commonly abused substances among Thai youths today. Methamphetamine is the second most popular drug of abuse in Thailand, the first being cannabis. It is available in the crystalline version, ICE, and the less pure methamphetamine tablets. The tablets are frequently crushed and smoked. Its use has gained enormous popularity among teenagers and young adults, including women of child-bearing age. As such, it has become the most common drug being detected in the urine of peripartum women, resulting in peripartum and postpartum complications for both mother and child. DM is a newer drug which has gained popularity among middle school and high school students due to its easy availability as a single product over the counter. It is usually taken with soft drinks at parties and gathering. It is metabolized by CYP4502D6 to dextrorphan, the substance responsible for the feeling of euphoria. Consequently, those who are poor metabolizers often experience the "negative" effects associated with the drug. The recreational use of methamphetamine and dextromethorphan in teenagers and young adults in Thailand is a serious problem. Recognizing not only the toxicological but also the emotional and psychosocial impacts of these drugs on Thai youth is an integral part of approaching the problem.

Toxicity from ingestion of Jatropha curcas ('saboo dum') seeds in Thai children.

Jatropha curcas is widely cultivated in Thailand, the seeds of which yield high quality oil used for biodiesel production. Toxicity due to ingestion of Jatropha curcas has become more common among children due to the close proximity between cultivation and residential areas. We report 10 calls made over a 40-month period to the Siriraj Poison Control Center involving 75 children ages 2-14 years who experienced toxicity after ingesting various amounts of Jatropha beans. The amounts ingested, presenting symptoms, pertinent laboratory findings and their collective dispositions are reported. A brief review of recent published literature on toxicity due to ingestion of Jatropha curcas was also done.

Accuracy of pediatric triage at Siriraj Hospital, Bangkok, Thailand.

BACKGROUND: Siriraj Hospital is a busy 2500-bed hospital located in Bangkok, Thailand It has over 1.7 million outpatients, including 120,000 emergency room visits a year, 20,000 of which are pediatric patients. The Pediatric Triage (Pedtriage) system has been in used since the year 2001, but the factors that affect the performance of triage nurse have not been evaluated. OBJECTIVE: To compare the performance non-pediatric nurses who are responsible for pediatric patients in the emergency room before and after pediatric triage training at Siriraj Hospital. MATERIAL AND METHOD: Pediatric Triage Training was set up for emergency room and outpatient department nurses between June and October 2006 The training consisted of 5 hours of didactic sessions on the concepts of pediatric triage and 4-5 hour sessions where the nurses were allowed to triage actual pediatric patients under the supervision ofa triage-training nurse. A pre-test and post-test examination was administered. The outcome of triage performance was categorized into under-triage if the patient had an urgent or emergent condition and was triaged as non-urgent, over-triage if a patient had a non-urgent condition and was triaged as urgent or emergent. Statistical description included percent, averages, and standard deviation where appropriate. A standard 4x4 contingency table was used to calculate the sensitivity and specificity. For comparison of performance, a post-hoc analysis was done where the nurses were divided into two groups, those with work experience ofless than or equal to 5 years (group 1) and more than 5 years (group 2). An independent samples t-test was used to determine the difference in performance between the two groups. RESULTS: Overall, performance on pre-test-post-test differedsignificantly before and after training. The nurses in Group 1 had higher pre-test scores (Group 1 mean = 62.35%, Group 2 mean = 52.41%, p-value = 0.001), were less likely to overtriage (Group 1 mean = 4.11%, Group 2 mean = 6.46%, p-value = 0.021) and had higher specificity oftriage than Group 2 (Group 1 mean = 95.61, Group 2 = 92.39, p-value = 0.019). However, the nurses in Group 2 had more improvement in their post-test scores (percent of improvement from pre-test: Group I mean = 8.56%, Group 2 = 34.69%, p-value = 0.005). CONCLUSION: Work experience is an important consideration in the triage knowledge and performance of non-pediatric nurses during triage training.

A comparison of body-image perception, health outlook and eating behavior in mildly obese versus moderately-to-severely obese adolescents.

BACKGROUND: Adolescent obesity is rapidly becoming a majorpubic health concern in Thailand. Factors that contribute to adolescent obesity are increasingly sedentary behaviors, changes in eating habits and physical activity Body-image perception and peer influence are substantial for adolescents. As a result, knowing the obesity-relatedpsychological impacts in adolescent will be the great benefit for health care providers in taking care of obese adolescents. OBJECTIVE: The purpose of this study was to investigate the impact ofobesity has on the behaviors and attitudes regarding self-perception, health outlook, and eating behavior in the mildly obese and the moderately-to-severely obese Thai adolescents. MATERIAL AND METHOD: Participants were obese students who were being followed at the school-based Teen Health Clinic on a regular basis. All participants were followed regularly at their respective school-based Teen Health Clinics. Each participant s percent weight for height was calculated by using Thai National Growth charts. Participants were categorized into 2 groups according to the percent weight for height (% WFH). Those with% WFH below 120% was considered not obese and excluded from the study. The two participating groups were% WFH of 120-140% who are mildly obese (M-O group) and % WFH of greater than 140% who are moderately-severely obese (M-S-O group). A 3-part questionnaire was used to assess the impact of obesity on emotional and psychosocial aspects of each participant, their eating and nutritional attitude and their level of physical activity. RESULTS: Of the 5366 students, grade 7-12 who attended 2 metropolitan Bangkok schools, 678 were diagnosed as overweight or obese. There were 175 obese students who attended the clinic regularly were asked to participate in this study and there were 167 adolescents who completed the questionnaires recruited for this study. Both the M-O and M-S-O groups reported dissatisfaction with their body weight (85.9% and 91.7% respectively) and perceived their need for weight reduction. The M-S-O groups expressed more concerns to lose their weight for medical reasons than the M-O group (52.1% vs. 35.2%, p-value < 0.03). Being obese was shown to have more significant impact to their confidence in M-S-O group than the M-O group (71.9% vs. 50.7%, p < 0.005). The students in M-O group eat lunch regularly otherwise M-S-O group, few of them, skips lunch meal (100% vs. 93.8%, p < 0.032). CONCLUSION: From our study, significant obese adolescents were shown to have poorer self-image with greater prevalence being shown in the significantly obese group.

Infantile lead poisoning from an Asian tongue powder: a case report & subsequent public health inquiry.

INTRODUCTION: Lead poisoning from novel environmental sources continues to present a challenge to clinicians who treat infants and children. CASE REPORT: A 12 month old infant of Thai parents was found during well child care to have a venous blood lead concentration of 61 mcg/dL. He was hospitalized for parenteral chelation with CaNa2EDTA and subsequently managed as an outpatient with oral succimer, with a reduction in blood lead concentration to 23 mcg/dL. Chronic lead poisoning was attributed to the use of a Thai tongue powder by the parents for the first seven months of the infant's life. This ethnic remedy was applied to the tongue to absorb toxins, reduce white patches present after milk feedings, and preserve the infant's health. INVESTIGATIONS: Lead contaminated the powder at 109,000 ppm as measured by x-ray fluorescence spectrometry. Two poison centers in Thailand were contacted and initiated a public health inquiry with the Thai Food & Drug Administration (Thai FDA) to remove contaminated products from the marketplace. Their investigation found six additional contaminated tongue powders (of 10 tested) in a Bangkok shop offering Chinese remedies, some with lead levels > 9000 ppm. These products, unregistered with the Thai FDA, were confiscated and the shop closed. Local media attention and case-finding activities of health officials identified one additional infant suffering from lead poisoning due to tongue powders. CONCLUSIONS: Asian tongue powders can be a source of lead poisoning. Medical toxicologists, poison centers, and public health agencies can work together internationally to accomplish effective post-marketing product surveillance.

Fetal poisoning after maternal paraquat ingestion during third trimester of pregnancy: case report and literature review.

INTRODUCTION: Paraquat remains one of the common substances involved in intentional ingestions in Thailand. However, data on outcomes of paraquat ingestion during pregnancy is rarely available and the management is controversial. CASE REPORT: A 17-year-old female in 36 weeks of gestation attempted suicide by ingesting 1/2 a glass of Gramozonetrade mark (paraquat 27.6 % w/v) 5 hours prior to arrival to the hospital. Gastric aspiration and lavage was performed and she was given 50 g of activated charcoal and 150 g of Fuller's Earth suspension. A male infant, weighing 2,390 g with an Apgar score of 71 1010, was delivered via emergency caesarean section 7 hours after ingestion. Due to presence of paraquat in the gastric lavage fluid, the mother was placed on dexamethasone/cyclophosphamide therapy. She developed mild renal insufficiency 63 hours after the ingestion. The infant developed tachypnea immediately after birth that self-resolved. The infant developed tachypnea again on day 6 of life. A chest x-ray revealed right lower lobe infiltration that progressed to diffuse interstitial pattern; subsequent chest x-rays showed evidence of fibrosis. Both mother and infant survived and the infant was discharged and sent home with oxygen 0.5 LPM. Upon follow up at 10 months of age, he still had evidence of chronic lung disease clinically and on chest x-ray. CONCLUSION: Paraquat ingestion during the third trimester of pregnancy usually carries a very poor prognosis. Review of reported literature suggests that this case report represents only the second survival of mother and child.

Predictors of elevated blood lead level in Thai children: a pilot study using risk assessment questionnaire.

INTRODUCTION: In the era post leaded-gasoline use, the risk of exposure to environmental lead in Thai children is not well described. This is a pilot study using a risk assessment questionnaire to identify children with elevated blood lead level. MATERIAL AND METHOD: Children from 4 communities, 2 in the Bangkok metropolitan area and 2 in Kanchanaburi province, were recruited during their well child visits. Blood lead levels were obtained in all children and parents are asked to fill out a 25-item risk assessment questionnaire. STATISTICAL ANALYSIS: The relationship between the blood lead level and dependent variables were tested using linear regression and one-way analysis of variance (ANOVA) as appropriate. RESULTS: There were 296 children included in the study; 33 from Klong Toey and 114 from Siriraj community in Bangkok while 149 were from two different communities in Kanchanaburi province. The average blood lead level was 5.65 +/- 3.05 mcg/dL. The overall prevalence of children with blood lead level > 10 mcg/dL was 8.1%, while that of the Klong Toey community was 12.5%. The questionnaire identified 3 independent predictors of elevated blood lead levels; the presence of peeling paint in or outside the house, eating paints chips, and the geographic location of children. CONCLUSION: Using a risk assessment questionnaire, together with obtaining blood lead level has proven effective in identifying key environmental features associated with elevated blood lead level in children from sampled Thai communities. The challenge now is to conduct a larger epidemiological study of a similar type in order to guide the screening and preventive efforts.

Dextromethorphan abuse in Thai adolescents: A report of two cases and review of literature.

INTRODUCTION: Dextromethorphan is an opiod-derived, easily available cough remedy that, when used in large quantities, can have stimulatory effects which mimic that of amphetamine and other psychedelic drugs. Due to its easy availability, dextromethorphan is gaining widespread popularity as a recreational drug among Thai youths. Symptoms of overdose are directly related to its pharmacodynamic and pharmacokinetic properties. Dextromethorphan is metabolized by cytochrome p450 2D6, an isoenzyme that exhibit polymorphism in Asians. The drug is also a serotonin-reuptake inhibitor and has significant interactions with other drugs that exert their effects through the serotonin pathway such as the amphetamines, cocaine, and Lysergic Acid (LSD). CASE REPORT: We report here two cases of dextromethorphan overdose that presented to the Pediatric Toxicology Service at Siriraj Hospital, Bangkok, Thailand. Both cases presented with hyper-agitation, confusion, with signs of sympathomimetic overdose. Both patients were treated with supportive care and fully recovered within 24 hours without sequalae. CONCLUSION: Although the acute toxicity of dextromethorphan is abated within 24 hours, its pharmacological properties still render it a dangerous drug to use alone or in combination with other drugs.