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Combined Exchange Transfusion and Chelation Therapy for Neonatal Lead Poisoning (May).
Mycyk MB, Leikin JB.
Division of Emergency Medicine, Northwestern University School of Medicine; Section of Toxicology, Cook County Hospital; Toxikon Consortium, Chicago, IL.
OBJECTIVE: To describe the results of combined exchange transfusion and chelation therapy in a neonate with an elevated blood lead level (BLL). CASE SUMMARY: A 34-year-old Latina woman with a long history of pica (eating glazed pottery) gave birth to a healthy-appearing girl at 40 weeks of gestation. The mother's preconception BLL was 117 micro g/dL and remained elevated throughout pregnancy. At parturition, the mother's BLL was 87 micro g/dL and the infant's cord BLL was 100 micro g/dL. The infant underwent single-volume exchange transfusion within 12 hours of birth. BLL was 28 micro g/dL following the exchange, and a 5-day course of chelation with dimercaprol and CaNa2 ethylenediamine tetraacetic acid was initiated at 36 hours of life. The infant's BLL was 37 micro g/dL at the end of inpatient chelation. DISCUSSION: Long-term neurologic disability from in utero lead exposure is well described, but the optimal treatment of elevated neonatal BLLs in healthy-appearing infants at the time of birth is not established. This strategy of combined chelation and exchange transfusion therapy was well tolerated and resulted in decreased lead levels, but the long-term neurologic efficacy of our combination strategy remains to be seen. CONCLUSIONS: Combined exchange transfusion and chelation therapy resulted in rapidly decreased lead levels in a neonate with chronic in utero lead exposure.
PMID: 15026564 [PubMed - as supplied by publisher]
Psoriasiform eruption induced by infliximab.
Verea MM, Del Pozo J, Yebra-Pimentel MT, Porta A, Fonseca E.
Department of Dermatology, Hospital Juan Canalejo, La Coruna, Spain. der@canalejo.org
OBJECTIVE: To report a case of psoriasiform eruption induced by infliximab. CASE SUMMARY: A 46-year-old woman with enterocutaneous fistula secondary to Crohn's disease developed pruriginous, erythematous, desquamative plaques on her elbows, knees, hands, and buttocks after receiving the second and third doses of intravenous infliximab. Histologic examination showed a lichenoid pattern. No new cutaneous lesions appeared after cessation of infliximab therapy. DISCUSSION: Several cutaneous reactions secondary to infliximab, a monoclonal antibody against tumor necrosis factor-alfa, have been described. Psoriasiform dermatitis has not been reported as a cutaneous reaction to infliximab, but there have been several previous reports of psoriasiform dermatitis secondary to other drugs. An objective causality assessment revealed that the adverse event was probable. CONCLUSIONS: This is the first report of a clinico-pathologic dissociated pattern of cutaneous reaction showing a histopathologic picture of lichenoid dermatitis resulting from infliximab treatment.
Publication Types:
PMID: 14742794 [PubMed - indexed for MEDLINE]
Clinicians' roles in management of arsenicosis in Bangladesh: interview study.
Murshed R, Douglas RM, Ranmuthugala G, Caldwell B.
Australian National University, National Centre for Epidemiology and Population Health, Canberra, ACT 0200, Australia.
PMID: 14988183 [PubMed - indexed for MEDLINE]
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Practice based education to improve delivery systems for prevention in primary care: randomised trial.
Margolis PA, Lannon CM, Stuart JM, Fried BJ, Keyes-Elstein L, Moore DE Jr.
University of North Carolina at Chapel Hill, North Carolina Center for Children's Healthcare Improvement, 730 Airport Rd, Ste 104, CB#7226, Chapel Hill, NC 27599, USA. Peter_Margolis@med.unc.edu
OBJECTIVE: To examine the effectiveness of an intervention that combined continuing medical education with process improvement methods to implement "office systems" to improve the delivery of preventive care to children. DESIGN: Randomised trial in primary care practices. SETTING: Private paediatric and family practices in two areas of North Carolina. PARTICIPANTS: Random sample of 44 practices allocated to intervention and control groups. INTERVENTION: Practice based continuing medical education in which project staff coached practice staff in reviewing performance and identifying, testing, and implementing new care processes (such as chart screening) to improve delivery of preventive care. MAIN OUTCOME MEASURE: Change over time in the proportion of children aged 24-30 months who received age appropriate care for four preventive services (immunisations, and screening for tuberculosis, anaemia, and lead). RESULTS: The proportion of children per practice with age appropriate delivery of all four preventive services changed, after a one year period of implementation, from 7% to 34% in intervention practices and from 9% to 10% in control practices. After adjustment for baseline differences in the groups, the change in the prevalence of all four services between the beginning and the end of the study was 4.6-fold greater (95% confidence interval 1.6 to 13.2) in intervention practices. Thirty months after baseline, the proportion of children who were up to date with preventive services was higher in intervention than in control practices; results for screening for tuberculosis (54% v 32%), lead (68% v 30%), and anaemia (79% v 71%) were statistically significant (P < 0.05). CONCLUSION: Continuing education combined with process improvement methods is effective in increasing rates of delivery of preventive care to children.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 14766718 [PubMed - indexed for MEDLINE]
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Toxic epidermal necrolysis-like reaction secondary to colchicine overdose.
Arroyo MP, Sanders S, Yee H, Schwartz D, Kamino H, Strober BE.
The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 560 First Avenue, New York, NY 10016, U.S.A.
Summary Colchicine is a microtubule-inhibiting drug used to treat gout, familial Mediterranean fever and many other skin diseases. Intoxication with colchicine affects multiple organs, often fatally. Cutaneous sequelae of colchicine toxicity are rare. We describe the clinical and histological features of a toxic epidermal necrolysis-like exanthem in a patient who lethally overdosed on colchicine.
PMID: 15030347 [PubMed - in process]
Transient verrucous hyperplasia after toxic epidermal necrolysis.
Garcia-Doval I, Florez A, De La Torre C, Conde A, Cruces MJ.
Publication Types:
PMID: 14632826 [PubMed - indexed for MEDLINE]
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A 6-month prospective survey of cutaneous drug reactions in a hospital setting.
Fiszenson-Albala F, Auzerie V, Mahe E, Farinotti R, Durand-Stocco C, Crickx B, Descamps V.
Department of Dermatology, Hopital Bichat-Claude Bernard, AP-HP, 46 rue Henri Huchard, 75018 Paris, France.
BACKGROUND: Few prospective studies are available on the incidence and analysis of the characteristics of adverse cutaneous drug reactions in hospital settings. OBJECTIVES: A 6-month prospective study was managed in our hospital among hospitalized patients to: (i) evaluate the incidence of cutaneous allergic reactions from systemic drugs; (ii) study characteristics of patients with cutaneous drug reactions; (iii) describe the adverse cutaneous reactions; and (iv) evaluate drug reaction imputability and preventability. METHODS: All suspected allergic cutaneous reactions to systemic drugs were collected during a 6-month period (November 2000 to May 2001). Exhaustivity of recording was ensured by regular dissemination of information about this study to the practitioners; a simple method for inclusion by fax was established. Inclusion criteria were suspected cutaneous allergic reactions induced by systemic drugs responsible for hospitalization or developed during hospitalization. A physical examination was done by a dermatologist who completed a standardized questionnaire. Requested information included patient characteristics (associated disorders, severity score), drug intake (list and chronology of the drug intake during the 3 weeks preceding the adverse reaction) and characteristics of the skin reaction (type, course). A group comprising dermatologists and pharmacologists evaluated the drug imputability and preventability. RESULTS: Forty-eight cases were collected. A prevalence of 3.6/1000 among hospitalized patients was estimated. The prevalence rate was higher in patients hospitalized in medical departments (0.5%) than in surgical departments (0.01%) (P < 0.001). The cases were mostly recruited in departments of infectious diseases and dermatology. The most frequent associated disorders were: human immunodeficiency virus (HIV) infection (19%), connective tissue disease (10%) and viral or autoimmune hepatitis (12%). Of these patients, 31% had had a previous immunological drug reaction. Adverse cutaneous drug reactions were principally exanthematous (56%). Reactions were considered severe in 34% of cases because they were responsible for hospitalization (18%), increased the duration of hospitalization (14%) or were life threatening (2%). Principal imputable drugs were antibiotics, mainly penicillins. An imputability score was likely in 56% of cases, but it was only possible to conclude definitively in 44% of patients. In 15% of the cases, the side-effect was considered to be preventable. CONCLUSIONS: This study finds a lower incidence than other studies that reported an incidence of 2% of cutaneous drug reactions in hospitalized patients, but only allergic adverse cutaneous reactions induced by systemic drugs were collected in this study. The previous studies were principally done in selected patients hospitalized only in general internal medicine or medical divisions. Our results confirm some data already known about skin drug reactions: HIV infection as a risk factor (P < 0.0001), high prevalence of adverse cutaneous reactions due to antibiotics, and difficulty in ascertaining the imputability of a drug. A high proportion (34%) of these reactions was severe and 15% were avoidable; these two facts justify the development of an intensive programme of clinical pharmacology.
PMID: 14632808 [PubMed - indexed for MEDLINE]
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The role of cytochrome-P450 inhibitors in the prevention of hepatotoxicity after paracetamol overdose in rats.
Walubo A, Barr S, Abraham AM, Coetsee C.
Department of Pharmacology, University of the Free State, Bloemfontein, South Africa. waluboa.md@mail.uovs.ac.za
Despite the understanding that some cytochrome P450 isoforms are responsible for activation of paracetamol to the hepatotoxic metabolite, N-acetyl-p-benzoquinineimine (NAPQI), the use of enzyme inhibitors for prevention and/or treatment of paracetamol hepatotoxicity is still not well researched. Here, a mixture of ketoconazole, isoniazid and caffeine (inhibitor solution), known inhibitors of CYP3A, CYP2E1 and CYP1A2, was investigated for prevention of hepatotoxicity after paracetamol over-dose in rats. The appropriate doses of paracetamol (1000 mg/kg/day) and the 'inhibitor solution' (ketoconazole 5 mg/kg, isoniazid 5 mg/kg and caffeine 10 mg/kg; =KIC-5-50), were selected in preliminary experiments. Thereafter, two groups of 15 male Sprague-Dawley rats each were treated with the toxic dose of paracetamol intraperitoneally to induce severe hepatotoxicity. But one of the two groups was treated with the KIC-5-50 intraperitoneally 5 min after administration of paracetamol. Five rats were killed at 24, 48 and 72 hours after paracetamol administration. Plasma concentrations of paracetamol were determined by the polarization fluorescent immunoassay and a piece of liver was sent for histopathology examination. Liver function tests at 48 hours were higher in the 'paracetamol only' treated group than in the 'KIC-5-50 + paracetamol' treated group' (P < 0.05), i.e., median (range) AST 2025 (530-4329) i.u./L, ALT 1174 (662-2395) i.u./L versus AST 194 (81-494) i.u./L, ALT 311 (201-945) i.u./L, respectively. The corresponding plasma concentrations of paracetamol were 0.26 (0.13-1.02) microg/mL for the 'paracetamol only' treated group versus 0.17 (0.07-0.33) microg/ml for the 'KIC-5-50 + paracetamol' treated group. Centrilobular necrosis, the pathogmonomic feature of paracetamol hepatotoxicity, was demonstrated only in the 'paracetamol only' treated group. In conclusion, coadministration of paracetamol with inhibitors of cytochrome P450 prevented the development of paracetamol-induced hepatotoxicity in rats, and this calls for research for enzyme inhibitors that may be of therapeutic value.
PMID: 15027815 [PubMed - in process]
Comment in:
Actual causes of death in the United States, 2000.
Mokdad AH, Marks JS, Stroup DF, Gerberding JL.
Division of Adult and Community Health, Centers for Disease Control and Prevention, Atlanta, Ga, USA. amokdad@cdc.gov
CONTEXT: Modifiable behavioral risk factors are leading causes of mortality in the United States. Quantifying these will provide insight into the effects of recent trends and the implications of missed prevention opportunities. OBJECTIVES: To identify and quantify the leading causes of mortality in the United States. DESIGN: Comprehensive MEDLINE search of English-language articles that identified epidemiological, clinical, and laboratory studies linking risk behaviors and mortality. The search was initially restricted to articles published during or after 1990, but we later included relevant articles published in 1980 to December 31, 2002. Prevalence and relative risk were identified during the literature search. We used 2000 mortality data reported to the Centers for Disease Control and Prevention to identify the causes and number of deaths. The estimates of cause of death were computed by multiplying estimates of the cause-attributable fraction of preventable deaths with the total mortality data. MAIN OUTCOME MEASURES: Actual causes of death. RESULTS: The leading causes of death in 2000 were tobacco (435 000 deaths; 18.1% of total US deaths), poor diet and physical inactivity (400 000 deaths; 16.6%), and alcohol consumption (85 000 deaths; 3.5%). Other actual causes of death were microbial agents (75 000), toxic agents (55 000), motor vehicle crashes (43 000), incidents involving firearms (29 000), sexual behaviors (20 000), and illicit use of drugs (17 000). CONCLUSIONS: These analyses show that smoking remains the leading cause of mortality. However, poor diet and physical inactivity may soon overtake tobacco as the leading cause of death. These findings, along with escalating health care costs and aging population, argue persuasively that the need to establish a more preventive orientation in the US health care and public health systems has become more urgent.
Publication Types:
PMID: 15010446 [PubMed - indexed for MEDLINE]
Use of carbon monoxide alarms to prevent poisonings during a power outage--North Carolina, December 2002.
Centers for Disease Control and Prevention (CDC).
Each year in the United States, approximately 500 persons die from unintentional carbon monoxide (CO) poisoning, often during electric power outages caused by severe storms. Use of residential CO alarms has been recommended to reduce the incidence of CO poisoning. In September 2000, Mecklenburg County, North Carolina (2002 population: 722,367), adopted a public health ordinance requiring a CO alarm in the majority of residences; all-electric residences without attached garages (35.4% of all homes) were exempt. The ordinance also permitted use of alarms without battery back-up. On December 4, 2002, an ice storm caused 78.9% of county households to lose power. During the next 9 days, 124 cases of symptomatic CO poisoning were reported. To characterize these poisonings and the effectiveness of the CO alarm ordinance, local emergency physicians, fire department authorities, and CDC conducted an investigation. This report summarizes the results of that investigation, which determined that 96.2% of the severe poisonings occurred in homes with no reported functioning CO alarm. As a result of these findings, on October 8, 2003, Mecklenburg County officials amended the ordinance to require alarms with battery back-ups in all residences. Officials in other communities should consider enacting such alarm ordinances to prevent CO poisonings.
PMID: 15017373 [PubMed - indexed for MEDLINE]
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