Delayed presentation of transdermal cyanide poisoning.

A 45-year-old man attended to a warehouse fire involving burning plastic, without wearing full protective equipment. He subsequently presented to hospital with shortness of breath and his trachea was intubated for airway protection due to initial concerns of inhalational injury. However, a post-intubation bronchoscopy was normal. The patient's serum lactate level was normal on admission but was increased when measured 14 h after the initial event and accompanied by a metabolic acidosis. Transdermal cyanide poisoning was suspected given this delayed biochemical presentation and the absence of another apparent cause. A handheld chemical detector detected a high level of toxins on the patient's skin. Clinical improvement was not observed after the first dose of intravenous hydroxocobalamin, which was administered before full body decontamination. After decontamination and the administration of a second dose of hydroxocobalamin, the patient's acid-base status rapidly improved and serum lactate level returned to normal. Clinicians should have a high index of suspicion for transdermal cyanide poisoning in patients presenting after exposure to a fire.

Correlation of microalbuminuria and outcome in patients with extensive burns.

BACKGROUND: Microalbuminuria, often referred to as the urinary albumin-creatinine ratio (ACR), is thought to be a reflection of increased capillary permeability associated with the systemic inflammatory response syndrome, and has been found to be predictive of outcome in several studies. Therefore, we explored the usefulness of ACR as a predictor of mortality, and whether there was a correlation between ACR and PaO2/ FIO2 ratios in patients with extensive burns. METHODS: A retrospective observational study was carried out on all patients with extensive burns admitted to the burns intensive care unit. All adult patients with burns of at least 40%, or those with significant inhalational injury, were included. Exclusion criteria were paediatric patients or those with non-thermal processes such as Stevens-Johnson's syndrome. ACR was measured daily, and data including PaO2/ FIO2 ratios were collected. The outcome studied was mortality. RESULTS: A total of 21 patients were studied, of which there were 7 mortalities. Data were analysed using SPSS Ver11. Patient characteristic data between survivors and mortalities were similar. We did not find any correlation between trends of ACR with PaO2/ FIO2 ratios. However, in non-survivors, there were two peaks in ACR, an early peak at days 8-9, and a later peak at day 32, whereas concentrations remained stable in survivors. CONCLUSION: We conclude that while ACR is useful as a predictor of mortality and that mean ACR of more than 20 mg mmol(-1)is associated with poorer outcome, changes in ACR do not reflect changes in the patients' immediate clinical conditions.

Outbreak of suspected trichinosis among travelers returning from a neighboring island.

BACKGROUND: An outbreak of trichinosis involving a cohort of 33 returning travelers from a resort island in a neighboring country was suspected, beginning with 2 initial cases who were hospitalized with a syndrome of fever, myalgia and eosinophilia. METHOD: At the initial visit, a full history was obtained and a physical examination was performed for each individual. Also, blood was drawn for full blood count, blood film for malaria parasites and Trichinella serology. Extensive epidemiological investigations identified a total of 84 returning travelers from 6 separate groups, of which 58 (69%) were subjected to a detailed interview, including the kinds of meat consumed on the island. RESULTS: Twenty-five of these 33 persons (75.7 %) fulfilled clinical or serological case definition criteria for trichinosis. IgG antibody for Trichinella spiralis was detected in 8 out of 32 persons who had the test done (25%). Symptoms were generally mild, with only one patient (3%) requiring steroids for prolonged myositis. CONCLUSION: We suspect this outbreak to be due to trichinosis although the source could not be identified. Extensive epidemiological investigations identified a total of 84 returning travelers from 6 separate groups, of which 58 (69%) were subjected to a detailed interview, including the kinds of meat consumed on the island, but the source of the outbreak could not be identified.

The role of tryptophan residues in the hemolytic activity of stonustoxin,a lethal factor from stonefish (Synanceja horrida) venom.

Stonustoxin (SNTX) is a pore-forming cytolytic lethal factor, isolated from the venom of the stonefish Synanceja horrida, that has potent hemolytic activity. The role of tryptophan residues in the hemolytic activity of SNTX was investigated. Oxidation of tryptophan residues of SNTX with N-bromosuccinimide (NBS) resulted in loss of hemolytic activity. Binding of 8-anilino-1-naphthalenesulphonate (ANS) to SNTX resulted in occlusion of tryptophan residues that resulted in loss of hemolytic activity. Circular dichroism and fluorescence studies indicated that ANS binding resulted in a conformational change of SNTX, in particular, a relocation of surface tryptophan residues to the hydrophobic interior. NBS-modification resulted in oxidised surface tryptophan residues that did not relocate to the hydrophobic interior. These results suggest that native surface tryptophan residues play a pivotal role in the hemolytic activity of STNX, possibly by being an essential component of a hydrophobic surface necessary for pore-formation. This study is the first report on the essentiality of tryptophan residues in the activity of a lytic and lethal factor from a fish venom.

Crystallization and preliminary crystallographic study of stonustoxin, a protein lethal factor isolated from the stonefish (Synanceja horrida) venom.

Crystals of stonustoxin have been obtained and diffract to 3.4 A resolution. Stonustoxin is a protein lethal factor isolated from the venom of the stonefish, Synanceja horrida. The crystals belong to the tetragonal space group P422, with unit cell constants a = b = 109.0 A, c = 245.7 A. A native stonustoxin molecule has two subunits, designated alpha and beta, respectively, and there is one stonustoxin molecule per asymmetric unit.

Management of adenocarcinoma in situ (ACIS) of the uteri cervix--a clinical dilemma.

OBJECTIVE: We retrospectively reviewed 24 cases of adenocarcinoma in-situ (ACIS) of the cervix, managed at KK Hospital, with the objective of determining our local approach to its treatment, the consequent clinical outcome and problems encountered. METHODS: Except for one case, all patients were treated between 1991-1996. Nineteen cone biopsies (17 laser and 2 cold knife) and eleven hysterectomies were performed. The mean follow-up duration was 20.5 months (range: 1-75 months). RESULTS: The mean age was 44.2 years (range: 32-68) with 80% of the cohort being more than 35 years old and the mean parity was 2.2. Six (25%) patients were symptomatic. Majority (21/23) had an abnormal initial Pap smear. Glandular lesions were found in 39% (9/23) of Pap smear, 28% (6/21) of colposcopy, 58% (8/14) of cervical biopsies and in 3 of 4 endocervical curettage. Of the 17 laser cone biopsy specimens, lesion involved the surgical margin in 6 patients (35%). ACIS was found in conjunction with CIN in 14 patients (58%). Five hysterectomies were performed for involved surgical margin and one for dubious surgical margin of the prior cone biopsy, of which 3 had residual ACIS. At the time of the study, there was no case of recurrent ACIS or overt adenocarcinoma developing following cone biopsy. CONCLUSION: Preconisation diagnosis of ACIS using Pap smear, colposcopy and cervical biopsy was found to be difficult in our series. Concurrent CIN occurred in a sizeable portion of patients. Laser cone biopsy was the preferred method employed. Total hysterectomy was frequently employed following cone biopsy for treating possible residual disease. We recommend greater vigilance for this condition especially in patients with CIN and the need for regular endocervical sampling in the follow-up of patients treated by cone biopsy.