Late Metabolic Acidosis Caused by Renal Tubular Acidosis in Acute Salicylate Poisoning.

A 16-year-old man was transferred to our emergency department seven hours after ingesting 486 aspirin tablets. His blood salicylate level was 83.7 mg/dL. He was treated with fluid resuscitation and sodium bicarbonate infusion, and his condition gradually improved, with a decline in the blood salicylate level. However, eight days after admission, he again reported nausea, a venous blood gas revealed metabolic acidosis with a normal anion gap. The blood salicylate level was undetectable, and a urinalysis showed glycosuria, proteinuria and elevated beta-2 microglobulin and n-acetyl glucosamine levels, with a normal urinary pH despite the acidosis. We diagnosed him with relapse of metabolic acidosis caused by renal tubular acidosis.

[Survey of analytical works for drugs at emergency and critical care centers with high-performance instruments provided by the Ministry of Health and Welfare (at present: Ministry of Health, Labour, and Welfare) in fiscal 1998--continuation of survey with 2008 survey results as point of reference].

In a 2008 survey of the 73 emergency and critical care centers around the nation that were equipped with the drug and chemical analytical instrument provided by the Ministry of Welfare (currently the Ministry of Health, Labour, and Welfare) in 1998, 36 of those facilities were using the analytical instruments. Of these 36 facilities, a follow-up survey of the 17 facilities that recorded 50 or analyses per year. Responses were gained from 16 of the facilities and we learned that of those, 14 facilities (87.5%) were conducting analyses using the instrument. There was a positive mutual correlation between the annual number of cases of the 14 facilities conducting analyses with the instrument and the number of work hours. Depending on the instrument in use, average analytical instrument parts and maintenance expenses were roughly three million yen and consumables required a maximum three million yen for analysis of 51-200 cases per year. From this, we calculate that such expenses can be covered under the allowed budget for advanced emergency and critical care centers of 5,000 NHI points (1 point = 10 yen). We found there were few facilities using the instrument for all 15 of the toxic substances recommended for testing by the Japanese Society for Clinical Toxicology. There tended to be no use of the analytical instrument for compounds with no toxicology cases. However, flexible responses were noted at each facility in relation to frequently analyzed compounds. It is thought that a reevaluation of compounds subject to analysis is required.

[Tricyclic antidepressant overdose rescued by percutanenous cardiopulmonary support: report of two cases].

We report the case of two patients tricyclic antidepressant (TCA) overdoses complicated with severe circulatory failure, successfully resuscitated using percutaneous cardiopulmonary support (PCPS). In case 1, a woman transferred to our emergency department, presented with severe circulatory failure and developed cardiopulmonary arrest. She received prolonged cardiopulmonary resuscitation, and initiated with PCPS. In case 2, a woman presented our emergency department on foot. 3 hours after admission, she falled into severe circulatory failure with polymorphic ventricular tachycardia, and PCPS was started. TCA remains widely used despite its dangerous cardiovascular and neurological effects in overdosed patients. The most common cause of death after TCA overdose is cardiovascular toxicities. In current guidelines, cardiopulmonary resuscitation with extracorporeal cardiopulmonary bypass may be particularly effective for these patients to have a reversible etiology without preceding multisystem organ failure. Cardiotoxicities in TCA overdose are reversible and extracorporeal cardiopulmonary support should be promptly considered in refractory arrhythmia and hypotension despite conventional advanced life support.

[Two cases of methanol poisoning with chronological measurements of blood concentrations of methanol, ethanol and formate].

We report two cases of methanol poisoning and evaluate the kinetics of methanol, ethanol, and formate. The first case was a 48-year-old man (case 1). His initial methanol level was 56.4 mg/dL and serum ethanol level was 2.4 mg/dL. Serum formate was not detected, and ethanol administration was initiated. However, methanol was eliminated slowly, and serum formate increased. His methanol and formate levels decreased rapidly following hemodialysis. He was discharged without any sequelae. The second case was a 35-year-old man (case 2). His serum methanol level was 400 mg/dL, and serum ethanol was not detected. His serum formate level was 13.4 mg/dL, and ethanol and activated folate were administered. He underwent hemodialysis immediately after diagnosis. Methanol and formate decreased rapidly, and he was discharged without any sequelae. Methanol and formate are eliminated slowly if ethanol is administered alone. We suggest that hemodialysis should be considered immediately after ethanol administration.

[Survey of analytical work done for drugs at the emergency and critical care centers equipped with high-performance instruments provided by the Ministry of Health and Welfare (at present: Ministry of Health, Labour and Welfare) in fiscal 1998].

A questionnaire was sent to 73 emergency and critical care centers where high-performance instruments for analyzing drugs and chemicals were provided by the Ministry of Health and Welfare (currently Ministry of Health, Labour and Welfare) in fiscal 1998. 52 centers (71.2%) responded to the questionnaire. Among these, the instruments have been in operation at 36 centers. This means that analytical work has been performed in at least 49.3% (36/73) of facilities with the instruments. A positive correlation was observed between the annual number of patients tested for drugs and chemicals and analytical work hours at the 36 facilities. The results indicated that 150 cases may be tested for drugs and chemicals in a year on the condition that 100 hours a month of analytical work are secured, and 200 or more cases may be tested if 200 hours a month are secured. As for the running costs required for the operation of the instruments, the instrument maintenance and repair cost was estimated at 2 million yen a year, and it was calculated that 100 cases could be handled with a maximum annual supply expense of 1 million yen and 150 cases could be handled with a maximum annual supply expense of 2 million yen. These results suggest that the instrument running cost would be fully covered at nationwide emergency and critical care centers if the additional 5,000 NHI points (1 point = 10 yen) for hospital admission, which is approved for advanced emergency and critical care centers, were applicable to all facilities. Among the 36 facilities, the implementation of analysis varied for each of the 15 toxic substances recommended for analysis by the Japanese Society for Clinical Toxicology. Further research will be necessary to investigate and assess the frequency of analysis requests and combination of simple qualitative and instrumental analyses for each of the 15 substances, in order to evaluate the approach to the 15 substances in analytical work.

[Analysis of bialaphos and its active metabolite L-glufosinate in biological specimens by HPLC].

The symptoms of acute poisoning caused by ingestion of bialaphos (BIAL), an ingredient of herbicide, are supposed to be due to the L-glufosinate (L-GLUF), which is formed by the degradation of bialaphos. To elucidate the pharmacokinetics of BIAL and L-GLUF, we attempted a simultaneous analysis of BIAL and L-GLUF in biological samples by exploiting a reversed phase HPLC method. The derivatization reaction of BIAL and L-GLUF using (+) -1- (9-fluorenyl) ethyl chloroformate was completed in 30 min at 40 degrees C and both derivatives were stable for 48 hr at 25 degrees C. A fluorescence detector were used for HPLC; the exicitation wavelength was set at 265 nm and the emission wavelength at 315 nm. Respective calibration curves prepared by adding BIAL and L-GLUF to serum were linear within ranges of 0.01-10.0 and 0.005-10.0 microg/mL in derivatived liquid samples for introducing into HPLC. The lower limits of detection for BIAL and L-GLUF were 0.005 and 0.001 microg/mL, respectively. An 83-year old male who ingested approximately 350 mL of Herby Liquid, a herbicide containing 18% BIAL and 82% surfactant, in an attempt to commit suicide developed delayed respiratory depression and seizures. L-GLUF was detected in the serum of the patient 2.7 hr after ingestion, but BIAL was not. The change in serum L-GLUF concentration measured over time was consistent with a 2-compartment model, with a distribution half-life of 1.70 hr and an elimination half-life of 6.03 hr.

Effect of dietary intake on the levels of biliary unsaturated free Fatty acids having inhibitory activity on mutagens.

Unsaturated free fatty acids (FFAs), such as palmitoleic, oleic, linoleic, linolenic and arachidonic acids, have inhibitory actions on mutagenesis. These FFAs in bile may play a role in preventing cholecystopathy and their levels may be influenced by diet. However, the effects of dietary intake on biliary FFAs levels are not known. In order to examine possible associations between dietary habits and biliary FFAs levels, bile samples were collected from resected gallbladders of 114 Chilean female patients with gallstones, and FFAs were measured with an HPLC system. The long-term dietary intake of the patients was investigated through a semi-quantitative food frequency questionnaire. A high intake of vegetables was negatively correlated with the total FFA level (r = -0.264, P = 0.010). Positive correlations were found between fruit consumption and the lauric acid level (r = 0.200, P = 0.041), fish consumption and the levels of oleic (r = 0.370, P <0.0001), linolenic (r = 0.197, P = 0.038) and arachidonic (r = 0.200, P =0.035) acids, and consumption of foods fried in vegetable oil and the linoleic acid level (r = 0.269, P =0.004). Linoleic, linolenic, and arachidonic acids which may have an inhibitory effect on actions of unknown mutagens in bile appear to be increased by consumption of high levels of fish and fried foods.

[Clinical usefulness of the acetaminophen detection kit in treating acute poisoning--data from a survey of 28 cases treated at Niigata City general hospital].

In acute poisoning caused by acetaminophen (N-acetyl-p-aminophenol, APAP), it is critical to predict the onset of delayed liver injury based on the prompt measurement of serum APAP level and to administer the antidote N-acetylcysteine (NAC) without delay as needed. However, all emergency medical facilities are not necessarily equipped with an expensive analytical instrument that allows prompt determination of APAP. Here, we tested the clinical usefulness of the Acetaminophen Detection Kit (Kanto Chemical Co., Ltd.), which claims to rapidly detect APAP in serum using a simple procedure, by spectrophotometrically measuring the APAP concentration in 34 serum samples collected from 28 patients with acute APAP poisoning. The results showed that the correlation coefficient between the APAP value measured by the Acetaminophen Detection Kit and that determined by the HPLC method was, at 0.888, not very high, but that the decision on whether to administer NAC based on the measured APAP level was consistent between the two analytical methods in 23 out of 25 patients. Also, the value obtained by the Acetaminophen Detection Kit was equal to, or larger than, that obtained by the HPLC method, suggesting that it is unlikely that patients requiring NAC would be left untreated. These results indicate that the Acetaminophen Detection Kit, with its ease and simplicity of use, is clinically useful in emergency medical facilities for which an expensive analytical instrument is not affordable.

[Diphenhydramine poisoning presented with psychotic-like symptoms and choreic involuntary movement: report of two cases].

We encountered two cases of diphenhydramine-containing hypnotics overdose, exhibiting delirium and involuntary choreic movement. In case 1, a 32-year-old man ingested 24 tablets of Drewell, each containing 25 mg diphenhydramine, in a suicidal attempt. About four hours after ingestion, he showed generalized convulsion, delirium, and involuntary choreic movements. Intravenous diazepam was ineffective and he was sedated with continuous infusion of propofol. About 15 hours after ingestion and on discontinuing the sedation, he became alert and did not show any neurological abnormality. The blood concentration of diphenhydramine, measured by liquid chromatography/electrospray mass spectrometry (LC/MS), was 1.26 microg/ mL. In case 2, a 24-year-old woman ingested 114 tablets of Drewell and was admitted to our hospital. Her consciousness was impaired and she was treated with intravenous fluids. About four hours after ingestion, she became restless and showed confusion, agitation, and involuntary choreic movements. Sedation with continuous propofol infusion was required. She awoke the next day on discontinuing the sedation, and she did not show any neurological abnormalities. The blood concentration of diphenhydramine was 2.37 microg/mL. It is suggested that physicians should be aware of psychotic-like symptoms and choreic involuntary movement in patients with diphenhydramine-containing hypnotics overdose.

Ginkgo nut intoxication in a 2-year-old male.

This report describes a case of ginkgo nut intoxication in a 2-year-old male. The patient presented with vomiting and afebrile convulsion 4 hours after eating a large number of roasted gingko nuts. There was a large volume of ginkgo nuts in his vomited matter, and on admission the concentrations of 4-O-methoxypyridoxine in his serum and urine were elevated. The patient was diagnosed as having ginkgo nut intoxication, and diazepam and pyridoxal phosphate were administered intravenously. After the treatment, his symptoms were resolved. The neurotoxicity of ginkgo nuts should be recognized by pediatricians and parents who have infants.