Increased risk of chronic osteomyelitis after hip replacement: a retrospective population-based cohort study in an Asian population.

The correlation between hip replacement (Hip-Repl) and chronic osteomyelitis (COM) has not been studied in Asian populations. Thus, we assessed Hip-Repl-related risk of developing COM via a population-based, nationwide, retrospective cohort study. The Hip-Repl cohort was obtained from Taiwan's Longitudinal Health Insurance Database 2000, and included patients who underwent Hip-Repl between 2000 and 2010; the control cohort was also selected from this database. Patients with a history of COM were excluded in both cohorts. We used univariate and multivariate Cox proportional hazards regression models to calculate the adjusted hazard ratios (aHRs) by age, sex, and comorbidities for developing COM. A total of 5349 patients who received a Hip-Repl and 10,372 matched controls were enrolled. In the Hip-Repl group, the risk for COM was 4.18-fold [95 % confidence interval (CI) = 2.24-7.80] higher than that in the control group after adjustment. For patients aged ≤65 years, the risk was 10.0-fold higher (95 % CI = 2.89-34.6). Furthermore, the risk was higher in the Hip-Repl cohort than in the non-Hip-Repl cohort, for both patients without comorbidity (aHR = 16.5, 95 % CI = 2.07-132.3) and those with comorbidity (aHR = 3.49, 95 % CI = 1.78-6.83). The impact of Hip-Repl on the risk for COM was greater among patients not using immunosuppressive drugs, and occurred during the first postoperative year. Patients who received Hip-Repl have an increased risk of developing COM. This risk was higher among males and patients aged 65 years or younger, and during the first postoperative year.

Anti-tuberculosis treatments and risk of hepatocellular carcinoma in tuberculosis patients with liver cirrhosis: a population-based case-control study.

The objective of this study was to evaluate the association between the use of anti-tuberculosis (anti-TB) agents, isoniazid (INH), rifampicin (RIF), and their combination (INH + RIF), and the risk of hepatocellular carcinoma (HCC) in cirrhotic patients. This population-based case-control study was conducted using a research database of Taiwan's National Health Insurance program. Cirrhotic patients first diagnosed with HCC between 1996 and 2011 (n = 50,351), among whom 4,738 were anti-TB medication users, were evaluated. Cirrhotic patients who did not develop HCC within the same period, frequency-matched according to age, sex, and index year, were evaluated as the control group (n = 47,488). The adjusted odds ratio (OR) of HCC was 1.34 [95 % confidence interval (CI), 1.20-1.50] in INH + RIF users compared with non-INH + RIF users. Long-term (>12 months) use of INH, RIF, and INH + RIF was significantly associated with increased risk of HCC, with an adjusted OR of 3.51 (95 % CI, 2.11-5.84), 4.17 (95 % CI, 2.76-4.31), and 7.17 (95 % CI, 4.08-12.6), respectively, after adjusting for age, sex, and comorbidities. An average dose of INH + RIF >16,050 mg/year was associated with increased risk of HCC in cirrhotic patients, with an adjusted OR of 1.48 (95 % CI, 1.27-1.73). Our results indicate that cirrhotic patients with long-term or high-dose INH and RIF treatment, particularly their combination, are associated with increased risk of HCC development.

Bromism caused by mix-formulated analgesic injectables.

Bromism, chronic bromide intoxication, can be caused by a variety of medicines, but bromism due to pain-relieving injectable medications has not been reported. In this study, the methods used were internet searching on bromide-containing injectables available in Taiwan and the first case report of bromism due to mixed-formulated injectable medication. Many analgesic/antipyretic and antihistamine injections containing bromides are still being used in Taiwan. They contain sodium bromide up to 1000 mg/ampoule or calcium bromide up to 800 mg/amp. A 25-year-old female suffered from forgetfulness and unstable gait after long-term frequent injections of a preparation to relieve head and neck pain. Blood tests showed hyperchloremia (171 mEq/L) and a negative anion gap (-48.7 mEq/L). Serum bromide measured 2150 mg/L. She recovered completely in 3 days with saline treatment. Many bromide-containing injections are still being used in Taiwan. Clinicians should keep alert on this issue to avoid iatrogenic bromism or making misdiagnoses.

HMPAO brain SPECT in acute carbon monoxide poisoning.

UNLABELLED: Technetium-99m-hexamethylpropylene amine oxime (HMPAO) brain images with fanbeam SPECT, in combination with surface three-dimensional display, were used to detect basal ganglion and cerebral cortex anomalies in the acute phase of carbon monoxide (CO) poisoning. METHODS: Ten patients, aged 16-29 yr, with acute CO poisoning and no past history of neurologic disorders were enrolled in this study. After oxygen treatment, all 10 patients were investigated using 99mTc-HMPAO brain images with fanbeam SPECT and surface three-dimensional display. Meanwhile, 6 of 10 patients also received a brain CT scan. RESULTS: CT scan findings were negative in all 6 patients. Fanbeam SPECT demonstrated unilateral or bilateral hypoactivity of basal ganglia in 6 patients. Local hypoactivity anomalies were found in the brain cortex of 7 patients, using surface three-dimensional display of the brain. Only 2 of 10 patients had normal 99mTc-HMPAO brain images. CONCLUSION: This study suggests that, in comparison with traditional brain imaging techniques, 99mTc-HMPAO brain imaging with fanbeam SPECT in combination with surface three-dimensional display is a better tool for early detection of regional cerebral anomalies in acute CO poisoning.

Acute paraquat intoxication: using nuclear pulmonary studies to predict patient outcome.

STUDY OBJECTIVES: Paraquat, a widely used herbicide, has been shown to cause severe and often fatal pulmonary fibrosis in humans and laboratory animals. Although paraquat is known to be directly cytotoxic to lung parenchyma, changes in routine lung scintigraphy results after acute paraquat intoxication have not been reported. The objective of this project was to investigate changes in lung ventilation (LV) and alveolar permeability (AP) in patients with paraquat intoxication, using 99mTc diethylenetriamine pentaacetate (DTPA) radioaerosol lung scintigraphy. DESIGN: Prospective, blinded study. SETTING: Nuclear medicine and toxicology departments in two university-affiliated teaching hospitals. PATIENTS OR PARTICIPANTS: Thirteen patients with acute paraquat intoxication were included in this study. Ten volunteers without acute paraquat intoxication were studied for comparison. MEASUREMENTS AND RESULTS: 99mTc DTPA aerosol inhalation and 99mTc macroaggregated albumin (MAA) perfusion lung scintigraphies were performed to determine LV, AP, and lung perfusion (LP). Five of the 13 patients (38%) had significant LV abnormalities; 3 of these 5 patients also showed abnormal LP. Of the 13 patients, 4 patients (31%) showed normal AP and survived. The remaining 9 patients (69%) showed abnormal AP and died. The mean values for AP were statistically different (p < 0.01) between survivor (0.72 +/- 0.16%) and nonsurvivor (1.52 +/- 0.40%) groups. Data from the normal volunteers and survival patients showed a 99mTc clearance slope < 1.00%. Data from patients who died showed a clearance slope > 1.00%. CONCLUSION: These results indicate that AP, measured by 99mTc DTPA aerosol inhalation lung scintigraphy, may help predict outcome in patients with paraquat intoxication.

The present and future of poison control center in Taiwan.

The PCC-Taiwan was founded in July 1985 under the auspices of the Department of Health, Executive Yuan, and the Veterans General Hospital-Taipei, Republic of China. It has served a population of 21 million inhabitants on a 24-hours basis. It has also served as a referral center for treating poisoning cases nationwide, a training center for physicians and consultants, and a center for Analytical Toxicology. The average annual volume of telephone inquires to PCC is more than four thousand in recent few years and continue to increase annually. The present and future prospective of the PCC-Taiwan which have to be accomplished are: 1. to propagate public education of poisoning prevention and increase the utility of PCC before events of intoxication, 2. to establish, computerize and improve the database and network of domestic poisonous products or natural toxins, including herbs, 3. to establish an nationwide referral network for severely poisoned patients or cluster poisoning events, 4. to build up a global collaborative work with other poison centers.

Anterograde amnesia in triazolam overdose despite flumazenil treatment: a case report.

Anterograde amnesia, possibly accompanied by acute brain syndrome, is a potential side-effect of certain benzodiazepines, particularly triazolam. Flumazenil is a benzodiazepine antagonist that is highly effective in reversing the central nervous system effects of benzodiazepine overdose. We report a case of triazolam overdose resulting in anterograde amnesia after flumazenil administration had restored clear consciousness. The defect in memory may have been due to too little flumazenil being given or failure of memory consolidation affected by the character of triazolam during the induced lucent period. We feel that physicians should be aware of the potential occurrence of acute brain syndrome in patients with benzodiazepine overdose despite treatment with flumazenil.

Laryngeal survey in glyphosate intoxication: a pathophysiological investigation.

Respiratory aspiration is a serious potential complication of glyphosate-surfactant herbicide intoxication. From October 1, 1992 to June 30, 1996, we performed laryngeal evaluations in 53 cases to investigate the possible pathophysiological mechanism of glyphosate intoxication. There were 36 cases with significant laryngeal injury. The blood WBC count were significantly higher and the hospital stays were significantly longer in patients with laryngeal injury, when compared with patients with no laryngeal injury (Student t-test, P < 0.005). Laryngeal injury was strongly correlated with aspiration pneumonitis (mean 2 = 4.449, P < 0.05). We concluded that laryngeal injury may be the major cause of aspiration that leads to some degree of morbidity and mortality, following concentrated glyphosate-surfactant herbicide intoxication. Laryngeal survey may be indicated in cases of glyphosate-surfactant intoxication, to evaluate the severity of mucosal injury, and to apply adequate supportive management as early as possible to prevent from aspiration complications and even mortality.

Podophyllotoxin intoxication: toxic effect of Bajiaolian in herbal therapeutics.

Bajiaolian (Dysosma pleianthum), one species in the Mayapple family, has been widely used as a general remedy and for the treatment of snake bite, weakness, condyloma accuminata, lymphadenopathy and tumours in China for thousands of years. However, the textbooks of traditional Chinese medicine mention little about the toxicity of Bajiaolian. Within 1 year, the authors saw five people who manifested nausea, vomiting, diarrhoea, abdominal pain, thrombocytopenia, leucopenia, abnormal liver function tests, sensory ataxia, altered consciousness and persistant peripheral tingling or numbness after drinking infusions made with Bajiaolian. The herb was recommended by either traditional Chinese medical doctors or herbal pharmacies for postpartum recovery and treatment of a neck mass, hepatoma, lumbago and dysmenorrhoea. Podophyllotoxin is one of the main ingredients of the Bajiaolian root. The clinical manifestations observed in our patients were consistent with podophyllum intoxication. Podophyllotoxin intoxication usually results from the accidental ingestion or topical application of podophyllum resin. However, these cases of Bajiaolian intoxication were iatrogenic and results from 'therapeutic doses' of Bajiaolian cited in the textbooks of traditional Chinese medicine.

The climate and the occurrence of carbon monoxide poisoning in Taiwan.

Taiwan is an island situated in the subtropics. The lowest average temperature is around 15 degrees C (59 degrees F) during winter). Despite the mild climate, carbon monoxide intoxication still occurs frequently, especially during the winter. We studied which meteorological factor(s) affected the occurrence of carbon monoxide poisoning in Taiwan. Retrospective data over a period from December 1, 1986, to December 31, 1991, from patients who reported with carbon monoxide poisoning to the Poison Control Center, together with meteorological data were analysed. We found that a lower daily average temperature, especially while a special regional circulation pattern, called a 'cold front' or 'cold surge' (during winter) covers the Taiwan area, is strongly related to the occurrence of CO poisoning.

Acute basagran poisoning mimicking neuroleptic malignant syndrome.

A 27-year-old robust man, without any medical and surgical history, attempted to commit suicide by consumption of 300 cc (44.1%, 132.3 g) basagran, a readily available herbicide. This poisoning resulted in vomiting, fever, sweating, pipe-like muscle rigidity, sinus tachycardia, drowsiness, leukocytosis, rhabdomyolysis and hepatorenal damage. Emperical treatment with bromocriptine was temporally associated with resolution of above signs and symptoms. His clinical presentations and the effect of bromocriptine may be indicative that basagran poisoning mimicks neuroleptic malignant syndrome.

Prognostic implications of hyperkalemia in toad toxin intoxication.

The toad possesses several toxic substances. Toad toxin poisoning manifests itself primarily with digitalis-like, cardioactive effects which results in bradycardia, varying degrees of atrio-ventricular block, ventricular tachycardia, ventricular fibrillation and sudden death. We report a cluster poisoning in a family who became intoxicated after ingestion of cooked toad soup for a skin problem. The youngest one (15 months old) died of refractory bradydyarrhythmias soon after arriving at our hospital. A second child (20 months old), who survived, arrived in shock with hyperkalemia (potassium 7.3 mEq/ L) and varying degrees of atrio-ventricular block. She was successfully treated with atropine, lidocaine, and cardioversion, and had a transvenous temporary pacemaker implanted for 1 day. The third boy (16 years old) had hyperkalemia (potassium 6.3 mEq/L) and bradycardia. The remaining three adults had only mild symptoms of nausea, vomiting, watery diarrhea and a sensation of numbness over their oral mucosa. We found that the level of serum potassium had prognostic implications in toad intoxication. Determination of serum potassium level is readily available in almost every hospital and is therefore more convenient to measure than serum digoxin level. We conclude that if hyperkalemia develops, the treatment of toad intoxication must be more aggressive to prevent mortality.

Unique cerebral dysfunction following triphenyltin acetate poisoning.

1. In animal studies, TPTA was found to be neurotoxic. In humans, variable CNS pictures have been described with or without significant EEG findings. Brain CT does not usually reveal any abnormalities. 2. Our patient presented with intermittent unique spontaneous involuntary movement of hands, facial twitching, silly smile and crying. Diplopia, drowsiness, giddiness, vertigo, bidirectional nystagmus, impairment of calculation ability, as well as disorientation to time, people and place also developed. EEG showed mild cortical dysfunction without seizures. MRI and Tc-99m HMPAO brain SPECT revealed no significant findings. TPTA may cause cellular dysfunction of brain without structural damage, which results in variable CNS clinical presentations. 3. Nadir of leucopenia was noted on the sixth day after consumption of TPTA. Liver impairment occurred on the ninth day. Borderline demyelinated neuropathy developed on the fifty-third day. CNS abnormalities, delayed peripheral neuropathy, hepatitis and leucopenia deserve monitoring for a prolonged period, even when the victim initially presents with GI upset only after consumption of TPTA.

Clinical impact of upper gastrointestinal tract injuries in glyphosate-surfactant oral intoxication.

Fifty patients with glyphosate-surfactant oral ingestion were studied with upper gastrointestinal (UGI) endoscopic grading using Zargar's modified grading system for mucosal corrosive injury. Esophageal injury was seen in 68% of the patients, gastric injury in 72%, and duodenal injury in 16%. There were no grade 3 injuries. The upper gastrointestinal tract injuries caused by glyphosate-surfactant were minor in comparison with those by other strong acids. The WBC count, amount of glyphosate-surfactant ingested, length of hospital stay and the occurrence of serious complications increased markedly in the group which had grade 2 esophageal injuries. Thus, the severity of the esophageal injuries may be a prognostic factor for the patient with glyphosate-surfactant ingestion. The UGI endoscopy may be indicated for grading esophageal injury in patients who have ingested glyphosate-surfactant in amounts greater than 100 ml. Physicians should pay more attention to the patients with grade 2 or 3 esophageal injuries to prevent serious complications and to provide aggressive supportive care.

Dose estimation for repeated phosphorus-32 ingestion in human subjects.

Dose estimation was conducted for internal phosphorus-32 exposure in one young male subject from repeated oral mis-ingestion for > 1 year. Since disclosure for previous continuous contamination, a series of urine samples were collected from this individual weekly for a period of >2 months. P-32 radioactivity in urine samples were measured by the acid precipitation method. Estimation for retrospective total effective dose equivalent received by this subject was conducted for cumulative internal dose estimation. A minimum of 9.4 mSv was estimated for an assumed single ingestion. As this was a rare case in radiation protection and internal radiation dosimetry, its implications were of considerable significance.

Rapid diagnosis of Naja atra snakebites.

BACKGROUND: The clinical diagnosis of snakebites is critical and necessary in many parts of the world, especially in Southeastern Asia, where venomous snakebites are a burden on public health. It is difficult to define or recognize the species of venomous snake because of the overlapping clinical manifestations of envenomations. A quick and reliable method for identifying the snake species is necessary. We designed and tested a strip of lateral flow system for the diagnosis of cobra snake bites in Taiwan. METHODS: We developed a kit based on an immunochromatographic method for rapid detection of cobra (Naja atra) venom in human serum. The test and control lines composed of 1 mg/ml polyclonal duck antivenom and 0.5 mg/ml goat anti-rabbit immunoglobulin antibody solutions, respectively, were coated on nitrocellulose strips. Colloidal gold was conjugated with rabbit polyclonal anti-cobra venom antibodies. From July 2007 to December 2012, we used the kit to test serum from snakebite patients and to examine the agreement between our rapid test and the currently used sandwich enzyme-linked immunosorbent assay (ELISA). RESULTS: Our kit was able to detect cobra venom in serum samples in 20 minutes with a detection limit of 5 ng/ml. An absence of cross-reactivity with other non-cobra venoms from Taiwan was noted in vitro. A total of 88 snakebite patients (34 cobra and 54 other non-cobra) were tested. The sensitivity of the strips based on the ELISA results was 83.3% and the specificity was 100%. There was a strong agreement between the results of the ELISA and immunochromatographic strips (κ = 0.868). DISCUSSION AND CONCLUSIONS: This data indicates that an immunochromatographic strip might be suitable for cobra venom detection and could be used as a quick diagnostic tool in cases of N. atra snakebite.

Acute myocardial infarction temporally related to betel nut chewing.

A patient with coronary artery disease suffered an acute myocardial infarction temporally related to chewing a betel nut. Alkaloids in betel nut, such as arecoline, may play a contributing role in coronary artery spasm due to parasympathomimetic effects on vessels with abnormal endothelium. Chewing betel nuts may instantly induce a high concentration of arecoline in the circulation and do harm to a chewer with a history of coronary artery disease.

Dermatitis caused by dimethyl cyanocarbonimidodithioate.

Dimethyl cyanocarbonimidodithioate (CAS No. 10191-60-3) a raw material for cimetidine synthesis, is labelled as an irritant on its storage tank. There is no information available regarding the toxic effects of human exposure. We report a case of severe dermatitis clinically resembling erythema multiforme following an accidental exposure to dimethyl cyanocarbonimidodithioate in an occupational setting. A clerk sifted a handful of dimethyl cyanocarbonimidodithioate from an unlabelled bucket through his bare hands during an inspection prior to customs clearance. Five hours later, while he was washing his hands, pruritus, erythema and vesicles developed over the exposed area. The skin condition worsened within two weeks, extending to his whole body with generalized erythema and vesicles of various sizes. Some vesicles became confluent with ruptured bullae, resembling a second degree burn over 40% of the body. Elevation of the serum IgE (705 mu/mL, normal less than 300 mu/mL) and lymphocyte activation with an increased 3H-thymidine uptake by the patient's mononuclear cells suggested that this episode resulted from a cell-mediated allergic skin reaction. The skin lesions improved progressively after systemic steroid therapy for about two weeks. Dimethyl cyanocarbonimidodithioate is used as a raw material for cimetidine synthesis by some pharmaceutical manufacturers. Our experience suggests that a severe reaction similar to that caused by another H2-blocker, ranitidine and its intermediate may be caused by dimethyl cyanocarbonimidodithioate in occupational exposures. Systemic steroid administration is beneficial in treatment.

[Clinical experience in benzodiazepine antagonist].

Flumazenil, a potent benzodiazepine antagonist, is a newly synthetic imidazo-benzodiazepine, which blocks the neurological effects of benzodiazepines. The purpose of this study was to evaluate the effects of this agent in reversal of benzodiazepine overdose and differentiation of comatous patients with drug overdose. Fifteen comatous patients with suspected sedatives/hypnotics overdose were included in this study and flumazenil 0.25 mg per dose was administrated intravenously. The average score of Glasgow Coma Scale increased from 7.13 +/- 2.92 to 10.93 +/- 3.67 after one dose of flumazenil. Clear consciousness was restored after multiple doses of flumazenil administration. Three cases with different drug history and variant response after flumazenil treatment were also illustrated and discussed. The dosage of flumazenil used in this study ranged from 0.25 mg to 3 mg (average 0.87 +/- 0.74 mg). We concluded that flumazenil is an excellent antidote for benzodiazepine overdose and valuable for differentiating the patients in comatose.

The painful experience of inappropriate therapy of snake bites: a report of two cases.

Recognizing the exact species of snake and specific antivenin administration are the most important modality of treatment for poisonous snake bites. In Taiwan, there are six kinds of medically important snakes--two species of Elapidae and four species of Viperidae. Two kinds of polyvalent antivenins and one monovalent antivenin are available. But for snake bites, questions about the prescription of antivenins are still the major problems addressed to the Poison Control Center. Improper use of antivenin may delay a patient's recovery from snake poisoning and even lead to mortality. Here, two cases of snake bites are presented. Each had severe complications and mortality as a result of inappropriate therapy, and the most rational management of snake bite in Taiwan is discussed, too.