Bottle Gourd (Lagenaria siceraria) Toxicity Diagnosed in the Emergency Department.

BACKGROUND: Bottle gourd (Lagenaria siceraria) is sometimes used in complementary medicine practice for the treatment of chronic ailments. However, there have been reports of toxicity due to consumption of bottle gourd juice, leading to severe abdominal upset and upper gastrointestinal bleeding. CASE REPORT: We present a case of a 41-year-old gentleman who presented to the Emergency Department with multiple episodes of vomiting, hematemesis, and diarrhea after consuming bottle gourd juice. The patient was resuscitated and stabilized with fluids, proton pump inhibitors, and antiemetics. He was subsequently admitted to the General Medicine ward for further management. He continued to receive symptomatic treatment in the ward and underwent esophagogastroduodenoscopy during his hospitalization stay. His symptoms improved and he was discharged stable 5 days later. Why Should an Emergency Physician Be Aware of This? Early recognition of this rare presentation of bottle gourd toxicity is important in our local context, especially where traditional medicine is widely prevalent nowadays. Treatment is supportive. Public awareness of dangerous effects from the consumption of bitter bottle gourd juice and complementary medicine without proper consultation with a practitioner plays a crucial role to prevent further cases. Physicians need to advise patients on the use of traditional medicine and their potential side effects.

The use of a formative OSCE to prepare emergency medicine residents for summative OSCEs: a mixed-methods cohort study.

BACKGROUND: The objective structured clinical examination (OSCE) is a part of emergency medicine (EM) examinations such as the Masters of Medicine in Emergency Medicine (MMed) examination and the equivalent Member of the Royal College of Emergency Medicine (MRCEM) examination. The use of formative OSCEs to prepare EM residents for summative OSCEs has not been investigated. This study aimed to evaluate the role of formative OSCEs in preparing EM residents for the MMed and MRCEM OSCE. METHODS: This was an observational, retrospective, mixed-methods cohort study. We analysed data from formative OSCEs conducted by the National Healthcare Group EM residency programme from 2013 to 2019, and from a questionnaire distributed to all residents during the study period. Residents' formative OSCE participation and scores were compared with first-attempt summative OSCE success. Qualitative analysis of residents' opinions on the usefulness of the formative OSCE was performed. RESULTS: Forty-three of the 50 (86.0%) residents attended at least one formative OSCE. Of the 46 who responded to the questionnaire, 40 (87.0%) had attempted and succeeded in the MMed or MRCEM OSCE, of whom 35 (87.5%) had succeeded on the first attempt. Residents who succeeded in the summative OSCE on the first attempt tended to have higher proximate (mean = 70.6, SD = 8.9 vs mean = 64.3, SD = 10.8) and mean (mean = 67.4, SD = 7.1 vs mean = 62.8, SD = 7.3) formative OSCE scores. All 8/40 (20.0%) residents who attended more than three formative OSCEs succeeded in the summative OSCE on their first attempt. Residents' formative OSCE scores tended to improve with successive formative OSCEs, demonstrating a positive training effect. All residents felt that the formative OSCE was useful in preparing them for the summative OSCE. CONCLUSIONS: Participation in multiple formative OSCEs was beneficial in preparing residents for the summative OSCE. The formative OSCE was useful in familiarising residents with the examination, giving them an opportunity to perform in near-examination conditions, and providing feedback to residents and faculty about their progress. Our findings may support the implementation of formative OSCEs in other training programmes to prepare learners for high-stake summative OSCEs.

Datura and Brugmansia plants related antimuscarinic toxicity: an analysis of poisoning cases reported to the Taiwan poison control center.

INTRODUCTION: Datura and Brugmansia plants, especially Datura species, have been used for their hallucinogenic effects in the United States and Europe; whereas Datura plants have been used as a traditional medicine in many Asian countries. This study was conducted to better understand the pattern and outcome of Datura/Brugmansia plant related poisoning in Taiwan. METHODS: This is a retrospective case series study of all cases with Datura/Brugmansia exposure reported to the Taiwan Poison Control Center between 1986 and 2015. Data for patients with relevant poisoning were reviewed and abstracted. Logistic regression analysis was used to identify potential predictors of the severity of poisoning; bivariate analysis was employed to assess the effectiveness of physostigmine in the treatment of Datura/Brugmansia poisoning. RESULTS: A total of 203 cases involving 114 Datura exposures and 89 Brugmansia suaveolens exposures were eligible for analysis. Using Datura/Brugmansia for a medicinal purpose by the patients without consulting Chinese medicine practitioners was the most common reason of poisoning (81.2%); whereas only 2% of the patients were poisoned after medicinal use associated with the prescription from Chinese medicine practitioners. None of the 203 patients had used Datura/Brugmansia plant for recreational purpose. Most frequently observed clinical effect was mydriasis (53.2%), followed by confusion (40%), tachycardia (35.5%), dry mouth (35.5%), dizziness (34%), dry skin (32.5%), and delirium (31%). Seventy-three cases (36%) had severe effects; none of them died. Misidentification of the plants and ingestion of plant parts other than flowers were positively associated with the severity of poisoning. Forty patients (19.7%) received physostigmine therapy and patients receiving physostigmine had an earlier resolution of central nervous system toxicity than those who did not. CONCLUSIONS: Medicinal use without consulting Chinese medicine practitioners is the main reason for Datura/Brugmansia poisoning in Taiwan. Consumption of parts other than flowers and misidentification of the plants predicted the severity of poisoning in this study. Patients who received physostigmine appear to have earlier improvement in the central nervous system effects. No adverse events were reported from physostigmine administration.

Performance of an emergency department observation unit protocol in reducing length of stay for acetaminophen overdose: a retrospective study.

INTRODUCTION: Acetaminophen is one of the most common causes of poisoning among developed countries. The emergency department observation unit (EDOU) has been increasingly used in the management of various conditions to reduce hospitalisation but its efficacy in not well studied in management of poisoned patients. In this study, we aim to study the effectiveness of our EDOU in the management of acetaminophen overdosed patients. RESULTS: Medical records of patients admitted from the emergency department from 2012 to 2016 for acetaminophen overdose were reviewed. One hundred ninety-five patients presenting with acetaminophen overdose were admitted to the EDOU while 184 were admitted to the general ward. Of these, 27 patients admitted to EDOU did not meet the admission criteria for it while 71 patients who met EDOU criteria were admitted to the ward instead. For patients who fulfilled EDOU admission criteria, median length of stay for EDOU patients was 23 h (IQR 19-24) while that for those admitted to the ward was 66 h (IQR 62.5-88.3). CONCLUSION: The EDOU is a safe alternative to hospitalisation for patients presenting with acetaminophen poisoning. It is also associated with a shorter length of stay for such patients. Further studies need to be done to assess the cost-effectiveness of EDOU for management of patients presenting with acetaminophen overdose.

The Little India riot: experience of an emergency department in Singapore.

INTRODUCTION: Singapore experienced its second riot in 40 years on 8 December 2013, in the area known as Little India. A retrospective review of 36 casualties treated at the emergency department was conducted to evaluate injury patterns. METHODS: Characteristics including the rate of arrival, injury severity, type and location, and disposition of the casualties were analysed. RESULTS: The injuries were predominantly mild (97.2%), with the most common injuries involving the head (50.0%) and limbs (38.9%). 97.2% of the casualties were managed as outpatient cases. CONCLUSION: The majority of the injuries in this incident were mild and could be managed as outpatient cases. Important lessons were learnt from the incident about the utilisation of manpower and safety of staff in the emergency department.

Cognitive aspect of diagnostic errors.

Diagnostic errors can result in tangible harm to patients. Despite our advances in medicine, the mental processes required to make a diagnosis exhibits shortcomings, causing diagnostic errors. Cognitive factors are found to be an important cause of diagnostic errors. With new understanding from psychology and social sciences, clinical medicine is now beginning to appreciate that our clinical reasoning can take the form of analytical reasoning or heuristics. Different factors like cognitive biases and affective influences can also impel unwary clinicians to make diagnostic errors. Various strategies have been proposed to reduce the effect of cognitive biases and affective influences when clinicians make diagnoses; however evidence for the efficacy of these methods is still sparse. This paper aims to introduce the reader to the cognitive aspect of diagnostic errors, in the hope that clinicians can use this knowledge to improve diagnostic accuracy and patient outcomes.

Severe chlorate poisoning successfully treated with methylene blue.

BACKGROUND: Chlorate poisoning as a cause of methemoglobinemia is regarded in current literature to be resistant to treatment by methylene blue due to the oxidizing and denaturing properties of the chlorate anion, and often leads to severe renal and hematological complications with a high mortality rate. Recent case studies suggest practitioners have eschewed the use of methylene blue in such situations. OBJECTIVES: This report describes a case of chlorate poisoning presenting as severe methemoglobinemia successfully treated with methylene blue alone, believed to be a first in reported literature. CASE REPORT: A 34-year-old male construction worker presented 4 h after accidental ingestion of an industrial chemical, with giddiness and breathlessness. Physical examination did not reveal any abnormal cardiorespiratory findings, although arterial blood gas analysis and pulse oximetry revealed an "oxygen saturation gap." Methemoglobin levels were found to be severely elevated at 66.8% 6 h after ingestion, and the patient was promptly treated with methylene blue. Clinical examination and laboratory tests suggested the absence of hemolysis at the time of treatment. The patient was discharged after a brief and uneventful hospital stay. Subsequent tests revealed the chemical ingested to be sodium chlorate. CONCLUSION: The successful outcome in our case suggests that a window of opportunity as long as 6 h may exist during which treatment of chlorate poisoning with methylene blue may be of clinical value. We postulate that the absence of significant hemolysis and hematological alterations at the time of antidote administration may be a necessary prerequisite for treatment success.

Aconitine intoxication mimicking acute myocardial infarction.

INTRODUCTION: Cardiotoxicity in acute aconitine intoxication is well known; however, elevation of troponin I level and abnormal scintigraphy findings had not previously been reported. CASE REPORT: A 60-year-old man developed chest tightness, syncope and convulsion after ingesting processed Aconitum carmichaeli (Chuanwu) extract for treatment of headache. Electrocardiogram showed first degree atrioventricular (AV) block. Troponin I level was elevated at 14.8 ng/mL 13 hours post-ingestion. Creatine kinase was also increased to 414 U/L. However, echocardiography did not show any abnormal cardiac wall motion. Tc-99m-PYP scintigraphy revealed diffusely increased uptake in the myocardium, suggesting the presence of myocardial necrosis or myocarditis. DISCUSSION: Aconitine poisoning can mimic acute myocardial infarction with chest tightness and elevated cardiac enzymes. Increased cardiac markers and myocardial insult seen in this patient were likely to be related to the toxicity of aconitine. Care should be taken in making the diagnosis in such instances. Management is primarily supportive.

An outbreak of foxglove leaf poisoning.

Comfrey (Symphytum officinale) leaves resemble those of foxglove (Digitalis purpurea) when the plant is not in bloom and, therefore, cardiac glycoside poisoning may occur when people confuse foxglove with comfrey. We report an outbreak of foxglove leaf poisoning following the use of alleged "comfrey" herbal tea. Nine patients were involved and initially presented with nausea, vomiting, diarrhea and dizziness. Significant cardiotoxicity developed later among the 3 patients who also had mild hyperkalemia. Peak serum digoxin concentration measured by immunoassay was elevated in all patients and ranged from 4.4 ng/mL to 139.5 ng/mL. Patients with severe cardiotoxicity were treated with temporary cardiac pacing. Moreover, 40-80 mg of digoxin-specific antibody therapy was given without any effect. All patients recovered uneventfully. Our report highlights the potential risk of misidentification of herbs; in this case, D. purpurea was mistaken for S. officinale. Physicians should be aware that cardiac glycoside poisoning could arise from such misidentification. Public education about the toxicity of D. purpurea poisoning may reduce the risk of misidentification and subsequent poisoning.

Neonicotinoid insecticides: an emerging cause of acute pesticide poisoning.

INTRODUCTION: Neonicotinoids are a relatively new class of insecticides. They exhibit agonistic effects at postsynaptic nicotinic receptors in insects and are believed to have low toxicity in humans. METHODS: We conducted a retrospective analysis of all neonicotinoid exposures reported to the Taiwan National Poison Center to better understand the toxicity profile of neonicotinoid insecticides. RESULTS: A total of 70 patients were analyzed. Most exposures involved suicidal ingestions of imidacloprid alone. Clinical manifestations of neonicotinoid insecticide toxicity bear some resemblance to those of acute nicotine poisoning. Although most exposures were of mild-to-moderate severity, eight patients developed major effects and two died. Aspiration pneumonia and respiratory failure were the main cause of severe toxicity. CONCLUSION: Significant toxicity of neonicotinoids can occur following large amount of oral ingestion. Poisoned patients may present with cholinergic syndrome, and judicious use of atropine seems justified. Symptomatic treatment, especially ventilator support, remains most important in clinical management.

Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care.

STUDY OBJECTIVE: We developed recommendations for antidote stocking at hospitals that provide emergency care. METHODS: An expert panel representing diverse perspectives (clinical pharmacology, clinical toxicology, critical care medicine, clinical pharmacy, emergency medicine, internal medicine, pediatrics, poison centers, pulmonary medicine, and hospital accreditation) was formed to create recommendations for antidote stocking. Using a standardized summary of the medical literature, the primary reviewer for each antidote proposed guidelines for antidote stocking to the full panel. The panel used a formal iterative process to reach their recommendation for the quantity of an antidote that should be stocked and the acceptable period for delivery of each antidote. RESULTS: The panel recommended consideration of 24 antidotes for stocking. The panel recommended that 12 of the antidotes be available for immediate administration on patient arrival. In most hospitals, this period requires that the antidote be stocked in the emergency department. Another 9 antidotes were recommended for availability within 1 hour of the decision to administer, allowing the antidote to be stocked in the hospital pharmacy if the hospital has a mechanism for prompt delivery of antidotes. The panel identified additional antidotes that should be stocked by the hospital but are not usually needed within the first hour of treatment. The panel recommended that each hospital perform a formal antidote hazard vulnerability assessment to determine the need for antidote stocking in that hospital. CONCLUSION: The antidote expert recommendations provide a tool to be used in creating practices for appropriate and adequate antidote stocking in hospitals that provide emergency care.

Human Melia azedarach poisoning.

INTRODUCTION: In traditional Chinese medicine, Melia azedarach (Ku-lian) is used orally and topically as an antiparasitic and antifungal agent. Although toxicity of this plant has been widely described in veterinary literature, human poisoning is rarely reported. We describe five patients with M. azedarach poisoning who recovered with supportive care. CASE SERIES: Five patients were identified retrospectively from the database of the Taiwan National Poison Center at the Taipei Veterans General Hospital. Three cases were on-site patients, and two were telephone consultations from outside hospitals. Neurological symptoms were the major manifestation in four cases: weakness, myalgia, numbness, and ptosis. Treatment was symptomatic and supportive; all patients recovered without sequelae. DISCUSSION: It is not known which limonoids are responsible for human toxicity. In the Chinese medical literature, human M. azedarach poisoning is said to occur if six to nine fruits, 30 to 40 seeds, or 400 g of the bark is consumed. Onset of symptoms typically occurs within 4-6 h, but as short as 0.5 h had been documented. In our patients, the onset of M. azedarach poisoning was variable, ranging from a few hours to up to 3 weeks after consumption of the herb. CONCLUSIONS: M. azedarach poisoning may result in gastrointestinal, cardiovascular, respiratory, or neurological effects, and death in severe cases.