Mushroom poisoning: A proposed new clinical classification.

Mushroom poisoning is a significant and increasing form of toxin-induced-disease. Existing classifications of mushroom poisoning do not include more recently described new syndromes of mushroom poisoning and this can impede the diagnostic process. We reviewed the literature on mushroom poisoning, concentrating on the period since the current major classification published in 1994, to identify all new syndromes of poisoning and organise them into a new integrated classification, supported by a new diagnostic algorithm. New syndromes were eligible for inclusion if there was sufficient detail about both causation and clinical descriptions. Criteria included: identity of mushrooms, clinical profile, epidemiology, and the distinctive features of poisoning in comparison with previously documented syndromes. We propose 6 major groups based on key clinical features relevant in distinguishing between poisoning syndromes. Some clinical features, notably gastrointestinal symptoms, are common to many mushroom poisoning syndromes. Group 1 - Cytotoxic mushroom poisoning. Syndromes with specific major internal organ pathology: (Subgroup 1.1; Primary hepatotoxicity); 1A, primary hepatotoxicity (amatoxins); (Subgroup 1.2; Primary nephrotoxicity); 1B, early primary nephrotoxicity (amino hexadienoic acid; AHDA); 1C, delayed primary nephrotoxicity (orellanines). Group 2 - Neurotoxic mushroom poisoning. Syndromes with primary neurotoxicity: 2A, hallucinogenic mushrooms (psilocybins and related toxins); 2B, autonomic-toxicity mushrooms (muscarines); 2C, CNS-toxicity mushrooms (ibotenic acid/muscimol); 2D, morel neurologic syndrome (Morchella spp.). Group 3 - Myotoxic mushroom poisoning. Syndromes with rhabdomyolysis as the primary feature: 3A, rapid onset (Russula spp.); 3B, delayed onset (Tricholoma spp.). Group 4 - Metabolic, endocrine and related toxicity mushroom poisoning. Syndromes with a variety of clinical presentations affecting metabolic and/or endocrine processes: 4A, GABA-blocking mushroom poisoning (gyromitrins); 4B, disulfiram-like (coprines); 4C, polyporic mushroom poisoning (polyporic acid); 4D, trichothecene mushroom poisoning (Podostroma spp.); 4E, hypoglycaemic mushroom poisoning (Trogia venenata); 4F, hyperprocalcitoninemia mushroom poisoning (Boletus satanas); 4G, pancytopenic mushroom poisoning (Ganoderma neojaponicum). Group 5 - Gastrointestinal irritant mushroom poisoning. This group includes a wide variety of mushrooms that cause gastrointestinal effects without causing other clinically significant effects. Group 6 - Miscellaneous adverse reactions to mushrooms. Syndromes which do not fit within the previous 5 groups: 6A, Shiitake mushroom dermatitis; 6B, erythromelagic mushrooms (Clitocybe acromelagia); 6C, Paxillus syndrome (Paxillus involutus); 6D, encephalopathy syndrome (Pleurocybella porrigens).

The scapular free flap: when versatility is needed in head and neck reconstruction.

OBJECTIVE: To review the experience with scapular free tissue transfer at the University of Western Ontario and to describe the various applications of both the fasciocutaneous and osteocutaneous versions. DESIGN: Retrospective review. SETTING: Tertiary care centre. METHODS: A retrospective review was conducted of patients who underwent a scapular free flap reconstruction between 1997 and 2007. Osteocutaneous and fasciocutaneous flaps were included. Demographic data including gender and age were collected. Defect analysis and complications were also reviewed. MAIN OUTCOME MEASURES: Defect analysis, flap-related complications, and non-flap-related complications. RESULTS: Sixty procedures, including 31 osteocutaneous and 29 fasciocutaneous flaps, were performed. Most fasciocutaneous flaps were used for large lateral skull base and facial defects (70%). The skin paddle dimensions ranged from 4 × 3 to 15 × 10 cm. All osteocutaneous flaps were used for mandibular reconstruction. The length of the bony defect ranged between 4 and 12 cm. Eleven patients required osteotomies. In most cases, the facial or external carotid arteries and internal jugular or facial veins were selected as recipient vessels. A vein graft was required in four cases. The total flap failure rate was 5%. Seven patients who had osteocutaneous flaps suffered medical complications, including one mortality. CONCLUSIONS: Scapular free flaps are reliable options. Fasciocutaneous applications are suitable for defects requiring facial contouring or complex skull base defects. Osteocutaneous flaps are acceptable options for patients with comorbidities requiring bony reconstructions. The flap complication rates were acceptable even in medically higher-risk patients.

Day stay pediatric tonsillectomy--a safe procedure.

OBJECTIVE: There is a controversy about day stay pediatric tonsillectomy in the UK and Australia. New Zealand has a similar health structure and we wished to compare day stay tonsillectomy from our hospital with those reported from other centers. METHODS: We performed a prospective audit of day stay tonsillectomy to determine conversion to hospital admission rate and the incidence of postoperative hemorrhage. RESULTS: There were 4850 paediatric tonsillectomies performed with 80% of them as day stay procedures over a 9-year study period (1993-2002) in a university-affiliated tertiary children's hospital. The primary postoperative hemorrhage rate (within 24h of surgery) was 0.9% (CI 0.68-1.22%) and 83% occurred within the mandatory 4h postoperative observation period. Primary hemorrhage requiring re-operation to achieve hemostasis occurred in 18 children (0.37%, CI 0.2-0.54%). No child with a primary hemorrhage who presented after discharge following day stay surgery required re-operation or blood transfusion. Day stay surgery was planned in 4041 children and 4.7% (CI 4.1-5.4%) required conversion to hospital admission. Postoperative vomiting was the most common indication for conversion (2.65%, CI 2.2-3.1%), while hemorrhage contributed only 0.95% (CI 0.64-1.24%). CONCLUSIONS: This study was performed in a health system similar to that of Australia and the UK. Complication and conversion rates are similar to those reported in North American centers. Pediatric day stay tonsillectomy is a safe procedure when performed with strict preoperative criteria, trained day stay unit (DSU) staff, and with in-patient facilities on site.

Estimation of radiation-induced interphase cell death in cultures of human tumor material and in cell lines.

A short-term assay method able to estimate the radiation response of human cancer tissue samples would be of great advantage to the individualization of radiotherapy in cancer patients. However, the effect of radiation on [3H]thymidine incorporation by proliferating cells reflects a composite of cell cycle arrest and induced cell death pathways. Here we consider whether it is feasible to correct for cell cycle effects based on comparison of the effects of radiation and the mitotic inhibitor paclitaxel on [3H]thymidine incorporation. Sixty-two short-term (7-day) cultures of human tumor tissue from 61 patients with melanoma, gynecological cancer, brain cancer, and head and neck cancer, as well as 18 5-day cultures of low passage human tumor cell lines, were irradiated at doses from 2 to 9 Gy, or exposed to paclitaxel (200 nM). [3H]Thymidine incorporation was measured at the end of the incubation. Cell cycle times could be estimated from the paclitaxel data and were 2.7 to 18.6 days for melanomas, 2.5 to >40 days for carcinomas, 3.9 to 39 days for brain tumors, and 1.1 to 3.8 days for cell lines. The effects of radiation on [3H]thymidine incorporation varied widely (0-97% and 0-99% inhibition for 2 and 9 Gy, respectively), and in 23 of the clinical samples, but in none of the cell lines, radiation caused significantly greater inhibition of [3H]thymidine incorporation than paclitaxel (p < 0.05). We argue that that these differences reflect radiation-induced cell loss from G1 phase and/or S phase. Responses of short-term cultures of clinical tumor material to radiation, with appropriate correction for cell cycle effects, might have the potential to provide information on radiation-induced cell death in individual patients.