Toxin ophthalmia caused by nuchal gland secretion of the Taiwan tiger keelback (Rhabdophis tigrinus formosanus).

Rhabdophis tigrinus is a common colubrid snake that can be found in an extensive geographical region in East Asia. It consists of two subspecies: R.t. tigrinus (yamakagashi) and R.t. formosanus (Taiwan tiger keelback). R. tigrinus possesses two different sets of poisonous glands: the Duvernoy's glands in the maxilla, and the nuchal glands in the dorsal skin of the neck. We report the first case in current English literature of toxin ophthalmia caused by the nuchal gland secretion of R.t. formosanus. The patient was a 40-year-old man whose right eye was sprayed by the nuchal gland fluid of R.t. formosanus. He presented with symptoms of foreign body sensation, progressive burning pain, and blurred vision. Ophthalmologic examination revealed diffuse superficial punctate keratitis, corneal stromal edema with Descemet folds, and conjunctival congestion. The patient responded well to topical treatment with a corticosteroid, antihistamine, and antibiotic, and had a favorable clinical course and outcome.

Plasma corticotrophin response to desmopressin in patients with Cushing's disease correlates with the expression of vasopressin receptor 2, but not with that of vasopressin receptor 1 or 3, in their pituitary tumours.

OBJECTIVES: Most patients with Cushing's disease (CD) respond to corticotrophin-releasing hormone (CRH) or desmopressin with increased corticotrophin (ACTH) and cortisol levels. Although the vasopressin receptor subtype located on normal corticotrophs is the V3 receptor (V3R), desmopressin is a selective V2 receptor (V2R) agonist and it is unclear whether corticotrophinomas exhibit aberrant V2R expression. Furthermore, no studies have determined the relationship between the in vivo response of CD patients to desmopressin and vasopressin receptor expression, or between the response to CRH and CRH receptor (CRHR) expression. Therefore, the aim of this study was to investigate the expression of vasopressin receptors (V1R, V2R, and V3R) and CRHR on corticotroph tumours and its possible relation to the in vivo response. DESIGNS: A prospective study of 29 patients with CD. METHODS: Patients underwent desmopressin and CRH stimulation tests before surgery. The expression of vasopressin receptors and CRHR on corticotrophinomas was determined by immunocytochemistry. RESULTS: Most of the corticotrophinomas exhibited abundant expression of V1R, V3R, and CRHR, whereas the expression of V2R varied greatly and was lower in macroadenomas than in microadenomas. Both the percentage increment of ACTH and net area under the curve (AUC) of ACTH in the desmopressin stimulation test were found to be correlated with tumour volume. After adjustment for tumour volume, a positive correlation was found between the percentage increment of ACTH and the degree of V2R expression, but not between that of V1R or V3R. No relationship between the level of expression of CRHR on tumour tissues and the percentage increment or netAUC of ACTH to CRH was observed in CD patients. CONCLUSIONS: We concluded that V2R was expressed on corticotrophinomas and that the level of its expression correlated well with the ACTH response to desmopressin in CD patients, although abundant expression of V1R and V3R was also found in almost all corticotroph tumours. Further studies are needed to elucidate the role of these receptors in the pathogenesis of CD.

The effects of lazaroid U-74389G in a rat sepsis model.

OBJECTIVE AND DESIGN: To examine the protective effects of a lazaroid, 21-aminosteroid U-74389G, in a rat septic shock model. MATERIALS OR SUBJECTS: Male Sprague-Dawley rats (n = 60) aged 6-8 months. TREATMENT: Groups were exposed to 500 cGy radiation followed by E. coli inoculation, and either placebo or lazaroid injection (10 mg/kg intraperitoneal) 5 days after irradiation. METHODS: Hemodynamic measurements, arterial blood gases, serum lactate, total antioxidative capacity, and cytokine levels were measured at specific time intervals. RESULTS: Treatment with the lazaroid U-74389G maintained cardiac output and mean aortic pressure. Lazaroid treatment also prevented the increase in serum lactate seen in placebo-treated rats. Cytokine serum levels in lazaroid-treated rats were not significantly different from those in placebo-treated rats at any time point. CONCLUSIONS: Lazaroid treatment of E. coli-inoculated septic animals lessens the hemodynamic deterioration seen in sepsis.

Usefulness of triggering receptor expressed on myeloid cells-1 in differentiating between typical and atypical community-acquired pneumonia.

OBJECTIVES: The purpose of this study is to investigate the clinical use of inflammatory marker triggering receptor expressed on myeloid cells (TREM)-1 at admission for differentiating between typical and atypical bacterial community-acquired pneumonia (CAP). METHODS: A prospective, noninterventional study of patients with CAP hospitalized through the emergency department was performed. Surface expression of TREM-1 was analyzed using flow cytometry on peripheral blood cells, and soluble TREM-1 (sTREM-1) concentration was determined in plasma. RESULTS: Eighty-eight patients with clinical suspicion of CAP were eligible. The causative pathogen was identified in 39 patients (44.3%). After excluding 4 mixed pneumonia cases, 21 typical and 14 atypical bacterial infections were enrolled. Patients with typical bacterial CAP demonstrated increased TREM-1 surface expression on monocytes and neutrophils. Median plasma sTREM-1 levels at admission were 65.2 pg/mL (range, 17.6-138.1 pg/mL) in patients with typical CAP and 25.9 pg/mL (range, 11.5-54.8 pg/mL) in patients with atypical CAP (P < .001). Soluble TREM-1 had good discriminative value to differentiate typical from atypical pathogens with an area under the receiver operating characteristic curve of 0.87 (95% confidence interval, 0.75-0.98). At a cutoff level of 44.2 pg/mL, sTREM-1 yielded a sensitivity of 81%, a specificity of 79%, a positive likelihood ratio of 3.79, and a negative likelihood ratio of 0.24. CONCLUSIONS: In newly admitted patients with CAP, determination of the TREM-1 levels may provide useful additional diagnostic information on the bacterial etiology.

Atrioventricular conduction abnormality and hyperchloremic metabolic acidosis in toluene sniffing.

Toluene is an aromatic hydrocarbon with widespread industrial use as an organic solvent. As a result of the euphoric effect and availability of these substances, inhalation of toluene-based products is popular among young adults and children. Chronic or acute exposure is known to cause acid-base and electrolyte disorders, and to be toxic to the nervous and hematopoietic systems. We report a 38-year-old man who suffered from general muscular weakness of all extremities after toluene sniffing, which was complicated with hypokalemic paralysis, atrioventricular conduction abnormality, and normal anion gap hyperchloremic metabolic acidosis. Renal function, serum potassium and acid-base status normalized within 3 days after aggressive potassium chloride and intravenous fluid replacement. Electrocardiography showed regression of first-degree atrioventricular block. Exposure to toluene can lead to cardiac arrhythmias and sudden sniffing death syndrome. Tachyarrhythmia is the classical manifestation of toluene cardiotoxicity. Atrioventricular conduction abnormalities have been rarely mentioned in the literature. Knowledge of the toxicology and medical complications associated with toluene sniffing is essential for clinical management of these patients.

Spleen artery embolization aggravates endotoxin hyporesponse of peripheral blood mononuclear cells in patients with spleen injury.

BACKGROUND: : Spleen artery embolization (SAE) increases the success of nonoperative management of spleen injury; however, the immune alternation after SAE is unclear. This study searched the endotoxin responses of peripheral blood mononuclear cells (PBMCs) in injured patients who received SAE. METHODS: : Patients were subsequently enrolled when their spleen injuries were confirmed by computed tomographic scan. Peripheral blood samples were obtained within first, at third, fifth, and seventh postinjury days. PBMCs were isolated; nuclear factor (NF)-kB translocations, phosphorylated I-kB expressions, and in vitro tumor necrosis factor (TNF)-alpha levels were assayed after endotoxin stimulation (ES). RESULTS: : Sixteen patients who received nonoperative managements were enrolled. Five patients received SAE (embolized patients) and 11 patients did not (nonembolized patients). Compared with those in controls, NF-kB translocations, phosphorylated I-kB expressions, and TNF-alpha levels after ES decreased significantly early in injured patients. NF-kB translocation and TNF-alpha levels after ES were indifferent at seventh day between nonembolized patients and controls, whereas significantly lower NF-kB p65 translocation and TNF-alpha levels after ES were found at seventh postinjury day in embolized patients than in controls. Compared with nonembolized patients, embolized patients had significantly lower levels of NF-kBp50 translocations after ES from first to third postinjury days and lower levels of NF-kB p65 translocations, TNF-alpha, and phosphorylated I-kB expressions after ES from first to fifth postinjury days. CONCLUSIONS: : SAE dysregulates the NF-kB system and aggravates the cytokine hyporesponse upon ES of PBMCs in patients with spleen injury. These results implicate that SAE alters immune response and may increase susceptibility to infections in injured patients.

Diagnosis of unrecognized primary overt hypothyroidism in the ED.

OBJECTIVE: The aims of the study were to evaluate the incidence of newly diagnosed primary overt hypothyroidism among adults admitted through the emergency department (ED) and to assess how previously undiagnosed hypothyroidism presents. METHODS: From July 1, 2002 to June 30, 2006, 56 adult patients were enrolled for further analysis. RESULTS: The incidence of newly diagnosed primary overt hypothyroidism among adults admitted through the ED is 0.1%. The mean age of the patients was 75.8 ± 12.8 years (range, 27-98 years). Most of our patients presented in the winter. Individual symptoms and signs were not sensitive. Drugs (13 patients, 23%), nongoitrogenous autoimmune thyroiditis (12 patients, 21%), and previous surgery or irradiation related (11 patients, 20%) are frequent causes of unrecognized hypothyroidism in this iodine-replete region. Only 21% of patients were admitted with a correct initial impression. Half of myxedema coma patients were missed during the initial ED stay. Thirty-three patients (59%) had cardiomegaly on chest x-ray receiving further echocardiography examination. Pericardial effusion was found in 18 patients. Of these, 7 patients had moderate to large pericardial effusion, but none had cardiac tamponade. Only 6 patients have depressed left ventricular ejection fraction (<40%). CONCLUSIONS: The diagnosis of hypothyroidism is often missed during the ED evaluation of patients at risk for this uncommon disease. Hypothyroidism should always be considered in patients who present with nonspecific symptoms suggestive of the disease, including weakness, cold intolerance, and alterations in mental status, and receive drugs impairing thyroid function or treatment of advanced head and neck cancer. In addition, patients with stable chronic heart failure or unexplained pericardial effusion warrant serum thyroid testing.

Anticoagulant-induced intramural intestinal hemorrhage.

BACKGROUND: Long-term use of warfarin can provide benefits in the treatment of many diseases, but adverse bleeding events are unpreventable because of a narrow therapeutic range. OBJECTIVE: The aim of this retrospective chart review with data abstraction was to investigate the clinical presentations of intestinal intramural hemorrhage in emergency department (ED) patients. METHODS: We reviewed the cases of 17 patients with acute abdominal pain in our ED. Medical records including demographic data and results of abdominal computed tomography were retrospectively reviewed and analyzed. RESULTS: The mean ± SD age of the reviewed patients was 77.7 ± 8.5 years (range, 60-93 years). The mean ± SD duration from onset of symptoms to ED visit was 2.5 ± 1.3 days (range, 1-5 days). All patients had abdominal pain, and 64.7% had nausea/vomiting. A total of 64.7% of patients had peritoneal signs. The jejunum was most commonly involved (88.2% of all cases). The maximal mean ± SD wall thickening of the bowel was 14.1 ± 4.4 mm (range, 7.4-26.7 mm), and the estimated mean ± SD length was 35.6 ± 24.4 cm (range, 9-105 cm). The mean ± SD prothrombin time and activated partial thromboplastin time were prolonged to 86.5 ± 26.9 and 116.2 ± 43.1 seconds, respectively. All patients received medical treatment and survived. At the last follow-up (mean, 27.4 months), none of the patients had recurrence of intestinal intramural hemorrhage or intestinal obstruction. CONCLUSION: Prolonged prothrombin time and drug history can indicate the possibility of intramural intestinal hemorrhage, and abdominal computed tomography may help to exclude surgical diseases and prevent unnecessary surgery.

Bajiaolian poisoning-a poisoning with high misdiagnostic rate.

BACKGROUND: One of the oldest Chinese herbal medicine, bajiaolian is widely used in traditional therapy. In Taiwan, bajiaolian is the fifth highest cause of poisoning among herbal medicines. The diagnosis is difficult because physicians are unfamiliar with this medicine's multiple presentations in different stages of intoxication. PROCEDURES: The records of 4 major poison centers in Taiwan were searched for all bajiaolian intoxication from July 1985 (the opening of first poison center) to March 2003. Two emergency physicians with toxicologic training reviewed the admission charts and visited case patients for follow-up. FINDINGS: Seventeen patients were identified, of which 15 (88.2%) had been misdiagnosed initially. In the beginning of their medical care, 14 cases were diagnosed as acute gastroenteritis. CONCLUSION: Bajiaolian intoxication is probably misdiagnosed because of early gastrointestinal symptoms followed by neurologic symptoms. A detailed patient history should be taken, and symptoms should be reviewed systemically to improve diagnostic accuracy.

Alternations of heart rate variability at lower altitude in the predication of trekkers with acute mountain sickness at high altitude.

OBJECTIVE: To determine the change and relationship of spectral components of heart rate variability (HRV) measurements in subjects with or without acute mountain sickness (AMS) at both low and high altitude. DESIGN: A prospective study. SETTING: A 12-day itinerary by trekking to the Namche Bazaar, 3440 m in Nepal. PARTICIPANTS: A total of 32 subjects were recruited. INTERVENTIONS: The alternations were measured by heart rate (HR), arterial oxygen saturation (SpO(2)), and spectral analysis of HRV at sea level, 1317 m, 3440 m, 1317 m, and sea level, respectively. MAIN OUTCOME MEASURES: Spectral analysis of HRV. RESULTS: There were statistically significant increases in HR and decreases in SpO(2) in all subjects at high altitude. In HRV, the values of R-R interval, total variance, high frequency (HF), low frequency (LF), and HF% were significantly lower at 3440 m than at sea level, respectively (P < 0.05). The subjects with AMS had significantly lower total variance, HF, and HF%, respectively, but higher LF:HF ratio (P < 0.05) at 3440 m. Subjects with both HF% < 20% (nu) and LF:HF ratio > 1.3 measured at 1317 m had odds ratios of 7.00 (95% confidence interval, 1.11 to 44.06; P = 0.047) to get AMS at 3440 m. CONCLUSIONS: The HRV measurements in total variances, HF, and HF% in trekkers with AMS were statistically significantly lower at high altitude. HF% < 20% (nu) or LF:HF ratio > 1.3 at lower altitudes could be an important predication parameter of trekkers with AMS at higher altitudes.

Emergency femoral hemodialysis catheter placement complicated by prevesical hematoma.

The femoral vein is the most popular location for temporary catheterization during emergency hemodialysis. Common complications are infection, thrombosis, arterial puncture, and groin hematoma. We report herein a patient with femoral vein perforation and prevesical hematoma.

Reappraisal of radiographic signs of pneumoperitoneum at emergency department.

PURPOSE: This study aimed to evaluate the sensitivities of the reported free air signs on supine chest and abdominal radiographs of hollow organ perforation. We also verified the value of supine radiographic images as compared with erect chest and decubitus abdominal radiographs in detection of pneumoperitoneum. METHODS: Two hundred fifty cases with surgically proven hollow organ perforation were included. Five hundred twenty-seven radiographs were retrospectively reviewed on the picture archiving and communication system. Medical charts were reviewed for operative findings of upper gastrointestinal tract, small bowel, or colon perforations. The variable free air signs on both supine abdominal radiographs (KUB) and supine chest radiographs (CXR) were evaluated and determined by consensus without knowledge of initial radiographic reports or final diagnosis. Erect CXR and left decubitus abdominal radiographs were evaluated for subphrenic free air or air over nondependent part of the right abdomen. RESULT: Upper gastrointestinal tract perforation was proven in 91.2%; small bowel perforation, in 6.8%; and colon perforation, in 2.0%. The positive rate of free air was 80.4% on supine KUB, 78.7% on supine CXR, 85.1% on erect CXR, and 98.0% on left decubitus abdominal radiograph. Anterior superior oval sign was the most common radiographic sign on supine KUB (44.0%) and supine CXR (34.0%). Other free air signs ranged from 0% to 30.4%. CONCLUSIONS: Most free air signs on supine radiographs are located over the right upper abdomen. Familiarity with free air signs on supine radiographs is very important to emergency physicians and radiologists for detection of hollow organ perforation.

D-dimer in patients with suspected acute mesenteric ischemia.

OBJECTIVES: The aims of this study were to assess the diagnostic value of D-dimer in patients with suspected acute mesenteric ischemia (AMI) and to evaluate the correlation between D-dimer levels and the severity of bowel necrosis. METHODS: A prospective, noninterventional study of 67 patients with clinical suspicion of AMI was performed. Measurement of D-dimer levels was performed using a latex turbidimetric method. RESULTS: Acute mesenteric ischemia was diagnosed in 23 patients (34.3%) and non-AMI in 44 patients (65.7%). Median D-dimer levels on admission were 6.24 microg fibrinogen equivalent units (FEU)/mL (range, 0.96-53.48 microg FEU/mL) in patients with AMI and 3.45 microg FEU/mL (range, 0.50-44.69 microg FEU/mL) in non-AMI patients (P = .064). D-dimer had poor discriminative value to differentiate the presence from the absence of AMI with an area under the receiver operating characteristic curve of 0.64 (95% confidence interval, 0.50-0.78). A serum D-dimer cutoff value of 1.0 microg FEU/mL had a sensitivity of 96%, a specificity of 18%, a positive likelihood ratio of 1.17, and a negative likelihood ratio of 0.24. Among patients with AMI verified at operation, 8 had resectable bowl necrosis and 9 had unresectable bowel necrosis. There was no difference in serum D-dimer levels between resectable and unresectable bowel necrosis (P = .665). CONCLUSIONS: Detection of serum D-dimer could not help to differentiate patient with AMI from those with non-AMI. We did not find a correlation between serum D-dimer levels and the severity of AMI. However, measurement of D-dimer levels can be of value for a small decrease in the likelihood of AMI, when the result is low.

Urine output and performance of runners in a 12-hour ultramarathon.

OBJECTIVE: To understand the urination pattern and to determine the relationships between urine output and performance of ultramarathon runners. DESIGN: Prospective observational study. SETTING: The 2005 Soochow University international ultramarathon, in which each athlete ran for 12 hours. PARTICIPANTS: All entrants in the 12-hour race were invited to participate in the study. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Athletes were weighed immediately before and after the race. Urine samples were collected during the race and immediately after the race. RESULTS: There was a trend toward better performance of the group with less urination (LU), although the difference was not statistically significant. Further analysis of hourly running distances between groups showed better performance in the group with LU during the first 11 hours of the competition. Comparison of athletes in 3 levels of running distance (tertiles) showed statistically significant differences between groups in total urine output. The fastest tertile had lower prerace body weight and greater body weight change than the slowest and intermediate tertiles, but the differences were not statistically significant. Linear regression analysis using the stepwise method showed that total urine output and prerace body weight were negatively associated with performance. CONCLUSIONS: Runners with LU had better performance during the first 11 hours of the competition. Linear regression analysis showed that total urine output and prerace body weight were negatively associated with performance.

Use of screw-rod system in occipitocervical fixation.

BACKGROUND: This study retrospectively reviewed 9 patients who underwent occipitocervical fixation with a newly developed screw-rod fixation system between April 2004 and November 2005. The objective was to evaluate the clinical result of occipitocervical fixation with the screw-rod fixation system, including symptom relief, fusion rate and complications. METHODS: All 9 patients received occipitocervical fixation surgery with screw-rod fixation system and autologous bone grafts for fusion. Fusion was assessed by plain cervical X-ray films, and the myelopathy by Nurick scale. RESULTS: Four males and 5 females were enrolled into this study. Mean age was 58.8 years, and mean follow-up period was 15 months. One female patient experienced surgical site infection with instrument pullout 20 months after surgery; she received a second operation for instrument revision. The overall fusion rate was 100%. The mean Nurick scores were 3 preoperatively and 2.1 postoperatively, with advancement of 0.9 points on average. Seven of 9 patients experienced pain or myelopathy improvement. There were no complications except for the 1 infection mentioned above. CONCLUSION: The fusion rate, complication rate and improvement in neurological function of occipitocervical fixation surgery using the screw-rod system were comparable to those of the widely used wire-rod system and screw-plate system.

L-arginine causes amelioration of cerebrovascular dysfunction and brain inflammation during experimental heatstroke.

Cerebrovascular dysfunction ensuing from severe heatstroke includes intracranial hypertension, cerebral hypoperfusion, and brain inflammation. We attempted to assess whether L-arginine improves survival during experimental heatstroke by attenuating these reactions. Anesthetized rats, 70 min after the start of heat stress (43 degrees C), were divided into two major groups and given the following: vehicle solution (1 mL/kg body weight) or L-arginine (50-250 mg/kg body weight) intravenously. Another group of rats was exposed to room temperature (24 degrees C) and used as normothermic controls. Their physiological and biochemical parameters were continuously monitored. When the vehicle-treated rats underwent heat stress, their survival time values were found to be 20 to 26 min. Treatment with i.v. doses of L-arginine significantly improved the survival rate during heatstroke (54-245 min). As compared with those of normothermic controls, all vehicle-treated heatstroke animals displayed higher levels of core temperature, intracranial pressure, and NO metabolite, glutamate, glycerol, lactate-pyruvate ratio, and dihydroxybenzoic acid in hypothalamus. In addition, hypothalamic levels of IL-1beta and TNF-alpha were elevated after heatstroke onset. In contrast, all vehicle-treated heatstroke animals had lower levels of MAP, cerebral perfusion pressure, cerebral blood flow, and brain partial pressure of oxygen. Administration of L-arginine immediately after the onset of heatstroke significantly reduced the intracranial hypertension and the increased levels of NO metabolite, glutamate, glycerol, lactate-pyruvate ratio, and dihydroxybenzoic acid in the hypothalamus that occurred during heatstroke. The heatstroke-induced increased levels of IL-1beta and TNF-alpha in the hypothalamus were suppressed by L-arginine treatment. In contrast, the hypothalamic levels of IL-10 were significantly elevated by L-arginine during heatstroke. The results suggest that L-arginine may cause attenuation of heatstroke by reducing cerebrovascular dysfunction and brain inflammation.

Oxidative stress and erythropoietin response in altitude exposure.

PURPOSE: Oxidative stress and erythropoietin (EPO) levels are increased following high altitude exposure. We hypothesized that the altitude-oxidative stress and EPO response would be associated with the presence or absence of acute mountain sickness (AMS) in subjects exposed at high altitude. METHODS: The study enrolled 29 healthy volunteers exposed at altitudes without strenuous physical exercise. Oxidative stress was determined by the spectrophotometric measurement of the colour occurring during the reaction of malondialdehyde (MDA) with thiobarbituric acid (TBA) on blood samples. Ferritin and EPO were also measured simultaneously. RESULTS: During a rise in altitude at 2000 and 3000 m, there were no changes in plasma ferritin level in either of the 2 groups with or without AMS. In contrast, EPO increased at an altitude of 3000 m and after returning to sea level (28.2+/-2.7, 26.9+/-3.3 vs 12.2+/-1.4 and 17.1+/-1.6, P < 0.05, in group without AMS; 29.3+/-4.5, 22.8+/-2.7 vs 10.6+/-1.0 and 16.1+/-1.5, # P < 0.05, in group with AMS; compared with the baseline level and at the height of 2000 meters). At a height of 3000 m, plasma MDA level was elevated compared with that at the altitude of baseline and 2000 m in both groups of subjects with and without AMS (3.77+/-0.29 vs 1.14+/-0.17, and 1.64+/-0.22, P < 0.001, in subjects with AMS; 3.65+/-0.39 vs 1.71+/-0.21, and 1.73+/-0.21, P < 0.001, in subjects without AMS) . After returning to sea level, subjects without AMS had lower MDA oxidative stress compared with those with AMS (2.58+/-0.26 vs 3.51+/-0.24, P = 0.0223). Along with a rise in altitude, the oxidative stress in these both groups was not correlated with the changes in EPO (r2 = 0.0728, P = 0.1096). CONCLUSION: High altitude-induced oxidative stress, detected by MDA assay, is not different between the two groups of subjects with and without AMS. Upon return to sea level, subjects without AMS had lower MDA oxidative stress burden and higher EPO level than those with AMS. Whether the subjects with altitude illness had delayed recovery from oxidative stress merits further investigation.

A rare case of massive retroperitoneal hemorrhage after bone marrow aspiration alone.

The use of dapsone is increasing even though overdose is rarely reported and physicians must be aware of its toxicity and management. Mortality can occur due to methemoglobinemia and hemolytic anemia. Although activated charcoal and methylene blue are recommended, the use of hemodialysis is reported only in few studies. Literature on the kinetic profile indicates that 50% to 80% of dapsone is protein bound and indicates a possibility to dialyze the unbound form. This study describes a case of deliberate severe dapsone overdose with cyanosis, methemoglobinemia, and hemolytic anemia, which improved after repetitive hemodialysis.

Heart rate variability measures as predictors of in-hospital mortality in ED patients with sepsis.

OBJECTIVE: To determine the predictive capability of heart rate variability (HRV) measures of patients with sepsis in the ED for in-hospital death. METHODS: This was a prospective, observational study. A consecutive cohort of patients visiting the ED of a university teaching hospital who met the criteria of sepsis over a 6-month period were enrolled in this study. General demographics, vital signs, laboratory data, and Mortality in Emergency Department Sepsis score were obtained in the ED; the in-patient medical record was reviewed; and a series of continuous 10-minute electrocardiographic signals were recorded for off-line HRV analysis to assess the in-hospital mortality of the patients. RESULTS: One hundred thirty-two patients aged 27 to 86 years who met the inclusion criteria were enrolled. According to the in-hospital outcome, the patients were categorized into 2 groups: nonsurvivors (n = 10) and survivors (n = 122). The baseline HRV measures, including SDNN, TP, VLFP, LFP, and LFP/HFP ratio, of nonsurvivors were significantly lower, whereas the nHFP was significantly higher, than those of survivors. Multiple logistic regression model identified SDNN and nHFP as the significant independent variables in the prediction of in-hospital mortality for ED patients with sepsis. The receiver operating characteristic area for SDNN and nHFP in predicting the risk of death was 0.700 and 0.739, respectively. CONCLUSIONS: Heart rate variability measures, especially the SDNN and nHFP, may be used as valuable predictors of in-hospital mortality in patients with sepsis attending the ED.

Hemoperitoneum increases the incidence of bacterial translocation.

BACKGROUND/AIMS: Severe hemorrhage may induce bacterial translocation (BT) from the bowel. Presence of hemoperitoneum is supposed to further increase the incidence of BT. METHODOLOGY: Blood was drawn from the femoral artery of rats and hemoperitoneum was created by replacing the drawn blood. Rats were randomly segregated into 5 groups. Control group rats received a sham operation. Rats in groups 1 and 2 received mild hemorrhage (15mL blood/kg body weight withdrawn) with and without hemoperitoneum respectively. Rats in groups 3 and 4 received severe hemorrhage (25mL blood/kg body withdrawn) with and without hemoperitoneum respectively. Twenty-four hours after the above manipulation, mesentery lymph nodes, livers, spleens, and finally cecums were removed for bacterial cultures. RESULTS: Rats that received severe hemorrhage had a significantly higher incidence of BT, both in tissues and in individuals, than rats that received mild hemorrhage did. group 1 rats had a higher incidence of BT in tissues compared with group 2, although the difference in individuals was not significant. On the other hand, group 3 had a higher incidence of BT either in tissues or in individuals compared with group 4. Cecal populations of bacteria assessment showed that groups with hemoperitoneum had higher levels of bacteria in comparison with groups without hemoperitoneum. CONCLUSIONS: Severe hemorrhage in rats increases the incidence of BT and the incidence is even greater in the presence of hemoperitoneum.