[Emergent drugs (II): the Pharming phenomenon]. / Drogas emergentes (II): el pharming.

The use of medicines, with or without medical prescription, for recreational ends by the young population has received little attention from doctors. In the USA, one in five adolescents has used medicines for recreational purposes, and consultations in Emergency Departments for medicine abuse have exceeded those for illegal drugs. Although few data are available in Spain, such consumption is situated between 3.1 and 8.6% according to surveys. The medicines most used are dextromethorphan and methylphenidate. The former, on sale without prescription, presents a varied symptomatology, dosage and dependent metabolic action, ranging from euphoria to hallucinations. Methylphenidate, taken orally, nasally or intravenously, is used as a stimulant in substitution for cocaine and is one of the medicines most diverted onto the illicit market at the world level. In principle, other substances like modafinil and propofol present a limited incidence of non-medical use, but they have a probable abuse potential that should be borne in mind, above all in the health context. Finally, opiates like fentanyl, oxycodone and buprenorphine, with new pharmaceutical presentations, have recently become generalized in the therapeutic arsenal of many medical specialities; they are giving rise to phenomena of abuse, dependence and diversion towards the illicit market. Demands for detoxification treatment, their mixture with illegal substances, and cases of death should alert us to the abuse of these medicines.

Fatal hydrogen sulphide poisoning in unconfined spaces.

Fatal hydrogen sulphide poisoning usually occurs in confined spaces. We report two fatal accidents in unconfined spaces. The first accident caused the death of three workers who entered an unconfined room in a silo of sludge at the same time that a truck dumped several tons of sludge from water purification stations. The hydrogen sulphide that had accumulated inside the silo spilled out into the interior of the room due to a 'splashing effect' caused by the impact of the dumped sludge. The second accident occurred when the foreman of a wastewater treatment plant entered one of the substations to perform routine checks and suddenly lost consciousness. Although he was rapidly transferred to an intensive care unit, death occurred a few hours later. Hydrogen sulphide production was, in this case, due to an 'embolism effect' produced by the displacement of wastewater when the substation pumps were activated. We suggest ways in which accidents such as these caused by sudden release of hydrogen sulphide can be prevented.

[Basis for the clinical management of fire smoke poisoning "Docohumo Madrid 2010"]. / Bases del manejo clínico de la intoxicación por humo de incendios «Docohumo Madrid 2010¼

Poisoning by smoke is the main cause of morbidity and mortality in fires. Smoke is a mixture of carbonaceous particles suspended in hot air and toxic gases. Of these, carbon monoxide (CO) and primarily hydrocyanic acid (CNH), are those that provoke tissue anoxia. The clinical manifestations of smoke poisoning are variables. Some of the potential manifestations could be: eye irritation, sore throat, laryngeal stridor, dysphagia, carbonaceous sputum, cough, dyspnea, laryngospasm, bronchospasm, coronary syndrome, coma, hypoxemia, lactic acidosis, cyanosis and death. In the assessment of these patients the presence of soot in the nose, mouth or sputum suggests serious poisoning. Lactate levels higher than 10mmol/L indicates levels of cyanide major than 40micromole/L. The pulse co-oximetry has assumed an important step forward for the diagnosis, appraisal and monitoring of these patients. In the treatment it will be essential to assess the need of an early intubation. The administration of oxygen to the 100% will be essential. As an antidote to the cyanide, the first-choice is the hydroxocobalamin. Its administration has to be early. Its administration criteria are: patient who has inhaled smoke (remnants of soot in the mouth, pharynx or sputum) and has neurological disorder (confusion, coma, agitation, seizures) and also presents one of the following circumstances: bradypnea, respiratory arrest, cardiorespiratory arrest, shock, hypotension, lactate ≥8mmol/L or lactic acidosis. Logically, the rest of the management will be conventional depending on symptoms or complications.

[Visits to the emergency department due to ecstasy (MDMA) and amphetamine derivative consumption: Epidemiological, clinical and evolutional profile]. / Consultas urgentes derivadas del consumo de éxtasis (3,4-metilenodioximetanfetamina) y derivados anfetamínicos: perfil epidemiológico, clínico y evolutivo.

OBJECTIVES: To describe clinical and epidemiologic characteristics of emergency department visits related with ecstasy usage, determine the rate of re-visits of the patients and their related factors. MATERIAL AND METHODS: The clinical histories of the patients coming to the Emergency Department for ecstasy-related problems were reviewed during 89 consecutive months in order to define the epidemiological and clinical profile. The computerized system of admission was used to study re-visits to the emergency department, reviewing the clinical history of the re-visits to see if they were related with drug consumption. RESULTS: The study included 498 cases (71% male, mean age 26.5 years). The majority of the patients were attended on the weekend (66.6%) and at night (57%). Main complaints were anxiety or altered thoughts (32.8%), agitation (17.2%), impaired awareness level (7.2%) and convulsions or abnormal movements (5.6%). A total of 81% of the patients had consumed other substances besides ecstasy, mainly ethanol (53%), cocaine (36%) and gammahydroxibutirate (liquid ecstasy, 25%). Twenty six patients (5%) required admission to hospital (6 in the intensive care unit) and 4 died (0.8%). Fifteen percent of the patients were re-attended in the same ED for drug-related problems after a mean follow-up of 3 years, the new visit being more frequent during the first months. The need for an urgent psychiatric visit (OR: 6.3; 95% CI: 2.9-12.8) and hospital admission (OR: 3.5; 95% CI: 1.5-8.4) during their first ED attendance were independently associated with a greater risk of re-attendance. CONCLUSIONS: Ecstasy consumption frequently leads to an ED visit, sometimes due to severe medical complications, and at least 15% of patients will need urgent care again for drug-related problems within the next 3 years. This likelihood increases along with increased severity of the index episode (need of psychiatric consultation or hospital admission).

[Follow-up of two patients with mesangial IgA glomerulonephritis exposed to cadmium and organic solvents]. / Seguimiento de dos pacientes con glomerulonefritis IgA mesangial con antecedentes de exposición a tóxicos (cadmio y disolventes orgánicos).

For several years we carried out a follow-up of two patients with IgA mesangial glomerulonephritis with antecedents of exposure to toxic substances (cadmium and organic solvents). The first case involved a 47 year old male who was diagnosed with mesangial IgA glomerulonephritis eight years ago; he had been working for twelve years as a solderer. He had used metal bars containing 25% cadmium as part of the soldering material. Very high levels of cadmium were detected in his blood and urine. The second case involved a 50 year male who was exposed to a wide number of organic dissolvents for 23 years. Three years ago he was diagnosed with a proliferative diffuse mesangial glomerulonephritis with IgA deposits; in spite of that, the patient continued working until one year ago, when was found to have a chronic stage 3 renal disease secondary to IgA nephropathy. Patients diagnosed with mesangial IgA glomerulonephritis should be kept apart from exposure to nephrotoxic substances.

[Sodium intoxication with fatal outcome caused by peritoneal lavage with hypertonic solution of NaCl].

We report a case of fatal sodium poisoning due to the unintentional use of 20% hypertonic saline serum during peritoneal lavage after intestinal resection. The patient presented with unconsciousness, metabolic acidosis, and plasma sodium concentration of 193 mE/l. After 3 hours, he developed paroxysmal supraventricular tachycardia, hyperthermia, generalized tonic-clonic convulsions, disseminated intravascular coagulation, and adult respiratory distress syndrome. The patient died 15 hours after the operation. Pathological examination revealed cerebral and lung oedema, pericentral hepatic necrosis, and fibrin thrombi in the lungs, stomach, and kidneys. We review, in addition, other reported cases of sodium poisoning.

Severe acute poisoning due to a glufosinate containing preparation without mitochondrial involvement.

Glufosinate is a non-selective herbicide widely used in domestic gardens and agriculture. Few cases of glufosinate poisoning have been reported although there has been an increase in recent years, particularly in Japan. Glufosinate toxicity is related to its capacity to inhibit glutamine synthetase and glutamate decarboxylase, which may lead to a potentially fatal multiorgan failure. We report the case of a 41-year-old woman who ingested between 30 and 50 mL of a herbicide (Finale) containing glufosinate (14%) in a suicide attempt. One hour after ingestion, the patient attended the Emergency Department of her own volition. Her overall status was good, and the physical examination was unremarkable. Gastric lavage was carried out, 25 g of activated charcoal was administered, and the patient was admitted for observation. Seventeen hours later, the patient presented drowsiness and a sinus bradycardia of 40 bpm. Thirty-two hours after ingestion, the Glasgow Coma Score was 8, and orotracheal intubation and mechanical ventilation were begun. At 3 days, the patient presented a self-limiting episode of ventricular tachycardia. She recovered consciousness progressively and was extubated without complications. The evolution was favorable, but the sinus bradycardia persisted up to 8 days after the ingestion. A study of lymphocyte mitochondrial function showed no alteration in mitochondrial oxidative capacity or the enzymatic activity of the complexes of the electron transport chain. A small ingestion of glufosinate can cause severe poisoning, whose manifestations predominantly involve the central nervous system and heart rhythm. Signs and symptoms may not appear for several hours and may persist for several days. In spite of these multi-organ manifestations, no alteration in lymphocyte mitochondrial function has been reported.

Progressive supranuclear palsy-like parkinsonism resulting from occupational exposure to lead sulphate batteries.

A 53-year-old man who had worked for 17 years manufacturing car batteries, with overt exposure to lead, developed a clinical picture initially characterized by signs of parkinsonism, followed by atypical signs such as loss of memory, reduction of eye movement, dysarthria, chorea-like dyskinesia and sexual impotence. The diagnosis of atypical parkinsonism was eventually changed to progressive supranuclear palsy-like parkinsonism. The patient was treated with various anti-Parkinson's disease drugs, including levodopa, with modest improvement. The symptoms deteriorated progressively, leading to permanent occupational disability with noticeable limitation of daily activities. Toxicological studies revealed abnormally high blood levels of lead. Discontinuation of lead exposure was followed first by clinical stabilization and then steady improvement. This case confirms recent reports that link exposure to lead and its compounds with degenerative diseases of the central nervous system, such as Parkinson's disease.

Life-threatening isopropyl alcohol intoxication: is hemodialysis really necessary?

Isopropyl alcohol (IPA) is widely used in industrial and home-cleaning products, easily available to general public and inexpensive: intoxications can occur unintentionally, in suicide attempts or by alcohol abusers as a substitute for ethanol. Symptoms involve the gastrointestinal tract, central nervous system and at high doses cardiovascular manifestations may appear. Ketonemia, ketonuria without hyperglicemia or acidosis and elevated osmol gap are common laboratory findings. Mortality and morbidity is low, but some fatal cases have been reported in patients in deep coma and especially those with hypotension. We present a life-threatening intoxication, with deep coma and hypotension, treated successfully with hemodialysis. Whether hemodialysis must always be performed is a controversial question. Our opinion is hemodialysis is not needed, even in life-threatening situations. Arguments about this opinion are presented.

Gamma hydroxybutirate use for sexual assault.

The use of gamma hydroxybutyrate (GHB) as a recreational drug has quickly spread among European young people during the past decade. Although it has been claimed that GHB can be potentially used to facilitate sexual assault, no case reports have been previously described. A case is described in which GHB was used with that criminal purpose and a review of previous literature is undertaken.

[Long-term functional results of unilateral congenital cataract treatment with early surgery: 20 case studies]. / Résultats fonctionnels à long terme du traitement des cataractes congénitales unilatérales opérées précocement. A propos de 20 cas.

PURPOSE: Evaluation of the long-term functional results of the treatment of unilateral congenital cataract (UCC) surgery before age 1. MATERIAL AND METHODS: Retrospective analysis of 20 consecutive cases of UCC operated on before age 1 and followed by the same medical team during the entire treatment period. Lens implantation adopted when surgically possible (15 cases) and medical treatment of amblyopia are described. Functional results are analyzed with a mean follow-up of 6 years (3.5-11 years) and compared with those of 31 similar cases operated on between 1 and 8 years of age. RESULTS: Four cases had less than 0.1 of final visual acuity, 8 cases remained between 0.1 and 0.4, and 8 cases obtained at least 0.5. Functional results with surgical, refractive, visual, oculomotor, and binocular data of all cases are described. Amblyograms are presented. DISCUSSION: Age at surgery, postoperative delay, type of cataract, and refractive progression were not found to be decisive in final results. We discuss the factors that seem important in the visual outcome and consequences on the sound eye of this heavy amblyopia treatment. In addition to early treatment, the absence of surgical complications and the continuity of patching, the quality of the initial organization of therapeutic strategy, and the continuity of the follow-up seem to be major factors for the success of long-term treatment. Treatment and follow-up should be centralized around a specialized team that will help the local team during the entire length of the treatment.

[Acute pharmacologic poisoning (I). Psychotropic and antiarrhythmic drugs]. / Intoxicaciones medicamentosas (I). Psicofármacos y antiarrítmicos.

In the evaluation of Acute Drug Poisoning (ADP) in patients seriously ill with a potentially non-toxic dose of the drug that is theoretically responsible, it is important to insist on anamnesis in the coingestion of other drugs or toxics. Initially attention is given to life support measures, oxygenation, protection of the airway and expanding the volemia. The ECG is a diagnostic tool of the first order in ADPs, above all for tricyclic antidepressants (TAD) and cardio-vascular drugs. In the majority of cases continuous monitoring is usually necessary during the first 12-24 hours. The benzodiazepines do not usually give rise to serious poisoning. The use of flumazenil will be reserved for cases of respiratory depression, deep coma or where the cause is undetermined. They can give rise to convulsions, above all in the case of mixed poisonings with anti-depressants and abstinence syndrome. The TADs have an enormous potential seriousness, as they can cause mortal arrhythmias. The therapeutic range of lithium is very narrow; it can produce signs of basically digestive and neurological toxicity. In the case of poisoning by digoxin, the use of anti-digital anti-bodies will be considered in cases of serious bradyarrhythmias, AV blocks or PCR. Glucagon is the antidote for serious poisoning by beta-blockers and for refractory hypotension in cases of calcioantagonists.