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Biomedical subjects

Henry A Spiller

Publications and source records attributed to Henry A Spiller.

At least 19 recordsLinked to original sources
PubMed2006

Two fatal cases of selenium toxicity.

Two patients, a 36-year-old female and a 36-year-old male, separately experienced new onset nausea, vomiting, diarrhea, abdominal pain, muscle weakness and pallor. Over a period of 14-16 h these symptoms continue and progress to include hypotension refractory to therapy, pulmonary edema and cardiovascular collapse. Autopsies show hemorrhagic pulmonary edema, splenomegaly and lack of anatomical cause for sudden death. Postmortem analysis, in one case post-embalming and exhumation, revealed elevated selenium concentrations and a determination of the cause of death. These two cases present several important features associated with selenium toxicity, two of which are previously unreported: (1) selenium as a potential homicidal agent, (2) the toxidrome and time frame of selenium toxicity, (3) selenium determination in exhumed, embalmed tissues, (4) postmortem urinary selenium concentration, and (5) decrease in tissue concentrations over time.

Abdominal Pain↗
PubMed2006

Toxicology of oral antidiabetic medications.

PURPOSE: The toxicology of oral antidiabetic agents is reviewed. SUMMARY: Type 2 diabetes mellitus is increasing to near epidemic proportions, with a reported 190 million patients worldwide. Use of oral antidiabetic medications is increasing along with a proportional increase in adverse events. Oral antidiabetic medications can be separated by mechanism of action into two groups: hypoglycemics (sulfonylureas and meglitinides) and antihyperglycemics (biguanides and alpha-glucosidase inhibitors). The hypoglycemic agents pose a significant risk of morbidity, mortality, and permanent sequelae secondary to prolonged periods of hypoglycemia. However, outcomes are routinely good if intervention is initiated early, with the primary goal return of euglycemia using supplemental dextrose infusion and octreotide to reduce further insulin secretion. Metformin-associated lactic acidosis (MALA) can occur with both acute and chronic metformin exposure. While MALA is not common, its associated rates of morbidity and mortality can be high. Secondary to MALA, the patient may experience changes in the central nervous system, cardiovascular collapse, renal failure, and death. The primary goals of therapy are restoration of acid-base status and removal of metformin, using hemodialysis and bicarbonate therapy. There is no specific antidote for MALA. The alpha-glucosidase inhibitors and thiazolidinediones pose minimal risk of adverse events in acute overdose. However, acarbose and all thiazolidinediones have been reported to produce hepatic injury with chronic therapy. Cessation of therapy with the offending agent and supportive care are the mainstays of overdose management with these drugs. CONCLUSION: The toxicity of oral antidiabetic agents differs widely in clinical manifestations, severity, and treatment.

Diabetes Mellitus, Type 2↗
PubMed2006

Efficacy of activated charcoal administered more than four hours after acetaminophen overdose.

To evaluate whether administration of activated charcoal, in addition to standard N-acetylcysteine (NAC) therapy, after acetaminophen overdose provides additional patient benefit over NAC therapy alone, a 1-year non-randomized prospective, multi-center, observational case series was performed at three poison centers and one poison center system. Entrance criteria were all acute acetaminophen overdoses with: 1) an acetaminophen blood concentration determined to be in the toxic range by the Rumack-Matthew nomogram; and 2) all therapies, including NAC and activated charcoal, initiated between 4 and 16 h post-ingestion. There were 145 patients meeting entrance criteria, of whom 58 patients (40%) received NAC only and 87 patients (60%) received NAC and activated charcoal. Overall, 23 patients had elevations of AST or ALT greater than 1000 IU/L, of which 21 patients received NAC only (38% of total NAC only group) and 2 patients received NAC and activated charcoal (2% of total NAC+AC group). Administration of activated charcoal in this series of patients with toxic acetaminophen concentrations treated with NAC was associated with reduced incidence of liver injury, as measured by elevated serum transaminases and prothrombin times.

Acetaminophen↗
PubMed2005

Atomoxetine ingestions in children: a report from poison centers.

BACKGROUND: Atomoxetine uses a novel non-stimulant approach to the treatment of attention deficit hyperactivity disorder. There is limited information on overdose of atomoxetine in children or adults. OBJECTIVE: To provide information on atomoxetine in overdose. METHODS: Case series were conducted at 3 regional poison centers for atomoxetine ingestion in children (age < or = 17 y). Exclusion criteria were polypharmacy or lack of follow-up. RESULTS: Forty patients were included (25 boys; 63%) in the study. The mean +/- SD age was 6.1 +/- 4.9 years (range 9 mo-17 y). Twenty-five patients were managed at home, 14 in hospital emergency departments (3 children were admitted), and 1 patient was managed in a physician's office. Symptoms reported were tachycardia, drowsiness, nausea, hypertension, and vomiting. A seizure was reported in one child who had recently started atomoxetine therapy. No arrhythmias beyond sinus tachycardia were reported. Mean maximum heart rate in patients with tachycardia was 131 +/- 14 beats/min. The mean dose ingested, categorized by medical outcome, was: no effect (n = 22), 40 +/- 32 mg; minor effect (n = 14), 167 +/- 221 mg; and moderate effect (n = 4), 249 +/- 326 mg. There were no major outcomes or fatalities. The lowest dose ingested that resulted in hypertension was 480 mg, in a 14-year-old girl (BP 136/95 mm Hg). CONCLUSIONS: In this case series, clinically significant cardiovascular effects requiring direct intervention did not occur. Activated charcoal and/or observation appear to be sufficient for accidental ingestion. Further investigation may be needed to indicate whether seizures occur from atomoxetine ingestion.

Adolescent↗
PubMed2005

Toxic clonidine ingestion in children.

OBJECTIVES: We performed a prospective case series to seek dosage or clinical parameters to better identify patients who need direct medical evaluation. STUDY DESIGN: All clonidine ingestions in children younger than 12 years of age reported to 6 poison centers were followed for a minimum of 24 hours. Exclusion criterion was polydrug ingestion. RESULTS: The study included 113 patients, of whom 63 were male. Mean age was 3.8 years (+/-2.4 SD). Clinical effects were common, but severe adverse effects occurred in <10% of patients. The dose ingested was reported for 90 patients (80%); 61 (68%) children ingested <0.3 mg and none had coma, respiratory depression, or hypotension. The lowest dose ingested by history with coma and respiratory depression was 0.3 mg (0.015 mg/kg). Prior clonidine therapy did not affect outcome. Onset of full clinical effects in all cases was complete within 4 hours of ingestion. CONCLUSIONS: We recommend direct medical evaluation for (1) all children 4 years of age and younger with unintentional clonidine ingestion of >or=0.1 mg, (2) ingestion of >0.2 mg in children 5 to 8 years of age, and (3) ingestion of >or=0.4 mg in children older than 8 years of age. Observation for 4 hours may be sufficient to detect patients who will develop severe effects.

Analgesics↗
PubMed2005

Retrospective evaluation of tiagabine overdose.

BACKGROUND: Tiagabine is an anticonvulsant that blocks reuptake of the inhibitory neurotransmitter GABA. There are no published studies or case series of tiagabine overdoses. METHODS: The records of six poison centers and one statewide poison center network were searched for all exposures to tiagabine for the years 2000-2002. Inclusion criterion was a human tiagabine exposure with follow-up to a known outcome; exclusion criterion was multiple drug ingestion. RESULTS: 57 cases met the inclusion criterion. Thirty-seven patients were female (67%). Mean and median ages were 30.5 years (S.D. +/- 18.5) and 31 years, respectively, with a range of 2 to 80 years. Seven patients were < or = 6 years. Neurologic symptoms were common: lethargy, seizures (multiple), status epilepticus, seizure (single), coma, confusion, agitation, tremors, dizziness, dystonias/abnormal posturing, and hallucinations. Other symptoms included respiratory depression, tachycardia, hypertension, and hypotension. Therapies included benzodiazepines, mechanical ventilation, phenytoin, phenobarbital, diphenhydramine, and dopamine. The mean onset and duration of symptoms were 1.3 hours (+/- 0.5, range 1-2 hours) and 9.1 hours (+/- 3.8, range 4-24 hours), respectively. Dose ingested by history was known for 38 patients (67%). The lowest dose with the development of multiple seizures and coma was 96 mg. This occurred in a 36-year-old female with a history of epilepsy. The lowest dose with symptoms in a child was 8 mg, in a 6-year-old with drowsiness. Mean dose of those with and without symptoms was 102 mg and 10 mg, respectively. The mean dose for patients experiencing seizures was 224 mg (+/- 172, range 96 to 680 mg). The mean dose for patients experiencing coma and respiratory depression was 270 mg (+/- 204, range 96 to 680 mg). Fifty-two patients (91%) were evaluated in the ED of whom 43 were admitted for medical care. CONCLUSION: Seizures and altered mental status were common with tiagabine overdose, with rapid onset and resolution of symptoms. In this series, seizures did not occur until the ingestion was greater than three times the maximum recommended daily dose.

Anticonvulsants↗
PubMed2005

Fatal fluoxetine ingestion with postmortem blood concentrations.

A 37-year-old male ingested 12 gm of fluoxetine approximately 2 hours prior to arrival at an emergency department. The patient developed tonic-clonic seizures, which resolved with diazepam and midazolam therapy. The patient then developed profound bradycardia that progressed to ventricular fibrillation and asystole. A postmortem toxicology analysis reported a fluoxetine concentration of 4500 mcg/L and diazepam of 500 mcg/L. No other drugs were detected. We report an unusual case of massive fluoxetine ingestion resulting in neurological and cardiovascular toxicity resulting in death.

Adult↗
PubMed2005

Acute selenium poisoning: suicide by ingestion.

Selenium is a ubiquitous element in the environment essential to the human diet and widely utilized in industrial processes. Fatal human selenium intoxication is rare. The authors report a case in which investigators recovered a bottle of gun-bluing agent beside a 24-year-old man. He exhibited signs and symptoms typical of acute selenium intoxication presenting with nausea and vomiting, followed by pulmonary edema and rapid cardiovascular collapse approximately 3 to 4 h after ingestion. Classic electrocardiographic (EKG) changes, which have been reported to occur in acute selenium intoxication, included sinus tachycardia with ST wave alteration. Toxicological results confirmed elevated blood and tissue concentrations. The cause of death was ascribed to acute selenium intoxication, which ensued rapidly after oral consumption. The manner of death was suicide. This case report, which presents an overview of acute and chronic selenium poisoning, underscores the value of thorough toxicologic analyses of tissue and body fluids in humans.

Adult↗
PubMed2005

Lethal envenomation: medicolegal aspects of snakebites and religious snake handlers in Kentucky: a report of three cases with comment on medical, legal, and public policy ramifications.

Ritualistic serpent qua snake handling, which rests upon inveterate religious conviction arising out of literal interpretation of selected passages of the New Testament, is a rare ceremony practiced by a distinct minority of Christians predominantly in rural Appalachian regions of the United States commonly referred to as the Bible belt. The fervent, frenzied pursuit by anointed "sign-followers" of intimate contact with a variety of poisonous snakes, however, puts the handler together with sect members or bystanders at risk for lethal envenomation, particularly when prompt medical attention is held by the congregation of faith to contravene God's will. The authors report three separate cases of death due to envenomation by snakebite during a church service and the handler's faith-based refusal to seek treatment. Postmortem examination of each yielded similar physical findings attributable to various toxic sequelae of the complex venoms. A review of the injurious constituents of these chemical toxins also includes a discussion of complex pathophysiological mechanisms causing death. In addition, the authors review the history of representative legislative and judicial responses to the sensationally mortal phenomenon, all of which ineluctably grapple with fundamental Constitutional issues devolving from such controversial religious practices. We underscore the view that a thoroughly documented medicolegal investigation and autopsy are indispensable to both inform matters of public health and thereby contribute to the formulation of sound public policy.

Adult↗
PubMed2004

Toxic effects from metformin exposure.

BACKGROUND: The major risk associated with metformin is lactic acidosis. The incidence of lactic acidosis is not clear. Hypoglycemia is not expected to be a major concern after metformin exposure. OBJECTIVE: This study assessed the demographics, toxic effects, and clinical syndromes of metformin exposures reported to poison centers nationally. METHODS: The Toxic Exposure Surveillance System (TESS) of the American Association of Poison Control Centers was searched for all metformin-only exposures occurring from January 1, 1996, through December 31, 2000. RESULTS: There were 10,958,526 total poisoning exposures reported to TESS during the study period. Of those, 4072 cases met the study criteria. Exposures occurred in 2421 (59%) women and were categorized in all patients as acute (3074; 75%), acute-on-chronic (767; 19%), chronic (200; 5%), and chronicity unknown (31; 1%). Children < or =12 years old experienced few adverse outcomes and no deaths. There were 20 moderate-effect outcomes (1.8%) and 2 major-effect outcomes (0.2%) in children <6 years old and 4 moderate-effect outcomes (2.3%) and no major-effect outcomes in children 6-12 years old. In the adult population, the adverse outcomes were distributed evenly across the age span, with a trend toward more serious outcomes in the elderly. There were 9 deaths (0.2%), 32 major-effect cases (0.8%), and 187 moderate-effect cases (4.6%). In all age groups, acidosis was rare (n = 68; 1.6%). Hypoglycemia is more common than previously reported (n = 112; 2.8%). Clinical effects associated with a major outcome or death were hyperglycemia, acidosis, elevated anion gap, elevated creatinine, hypotension, and coma. CONCLUSIONS: Severe adverse events after exposure to metformin are not common, occurring in approximately 1% of cases; this is in agreement with previous reports. The presence of hypotension, acidosis, elevated anion gap, hyperglycemia, and coma may be prognostic of severe or fatal outcome.

Acidosis, Lactic↗
PubMed2004

Epidemiology of volatile substance abuse (VSA) cases reported to US poison centers.

Volatile substance abuse (VSA) is believed to be widespread. The Toxic Exposure Surveillance System (TESS) of the American Association of Poison Control Systems offers an opportunity to evaluate the epidemiology of volatile substance abuse using a data set that captures data from a large geographic area covering a wide-ranging group of socioeconomic strata, ethnic groups, and demographics. To utilize this potential we analyzed a data set of TESS for the 6-year period of 1996 through 2001 involving all cases of intentional inhalational abuse of nonpharmaceutical substances. Over the study period there was a mean annual decline of 9% of reported VSA with an overall decline of 37% from 1996 to 2001. Volatile substance abuse was reported primarily in children, with 6358 cases (54%) in children 13-19 yr and 1803 (15%) cases in children 6-12 yr. Fifty-two cases were reported in children < 5 or = 5 yr. A total of 2330 (20%) VSA cases had a serious outcome, defined as either moderate effect (n = 2000), major effect (n = 267), or death (n = 63). The top five categories of substances abused were gasoline (41%), paint (13%), propane/butane (6%), air fresheners (6%), and formalin (5%). Three categories were responsible for the majority of deaths: gasoline (45%), air fresheners (26%), and propane/butane (11%). While there was a decline in reported cases, there was no decline in major outcomes or fatalities. Volatile substance abuse was reported in all 50 states, with case distribution similar to population distribution. However, seven states had > 2 times the expected rate based on their population; three western states, two midwestern states, and two Appalachian states. The role of urban vs. rural population may possibly explain the difference in numbers, with a greater incidence of VSA cases reported in states with large rural populations. The mean monthly occurrence rate was 162 VSA cases/month (S.D. +/- 10.85). There were 4 months that were > 2 standard deviations from the mean, with two peak months (May, 192/month and March, 187/month) and two trough months (December, 126/month and January, 137/month). This report presents a broad picture of VSA in the United States. Volatile substance abuse, as reported to U.S. poison centers, appears to be on the decline, but continues to be an ongoing problem. Volatile substance abuse is reported throughout the U.S. in all areas of the country, with a higher incidence in states with large rural populations. A small group of substances appears responsible for the majority of deaths. It is imperative that we continue to educate the public and healthcare professionals regarding the risks of VSA and hopefully impact the incidence of VSA.

Administration, Inhalation↗
PubMed2004

Retrospective review of Tizanidine (Zanaflex) overdose.

BACKGROUND: Tizanidine is a centrally acting muscle relaxant with a novel mechanism of action and structurally related to clonidine. There are no large case series of tizanidine exposure. METHODS: Retrospective review of all ingestions involving tizanidine reported to a poison control center from January 2000 through February 2003. Exclusion criteria were polydrug ingestion, no follow-up or lost to follow-up. RESULTS: There were 121 cases of which 45 patients met entrance criteria. Mean age was 32 years (range 1 to 80). Thirty-seven patients were evaluated in a health care facility of which 27 were admitted for medical care. Clinical effects included lethargy (n = 38), bradycardia (n = 14), hypotension (n = 8), agitation (n = 7), confusion (n = 5), vomiting (n = 3), and coma (n = 2). Mean dose ingested by history was 72 mg (S.D. + 86). The lowest dose associated with hypotension was 28mg, which occurred in a 63-year-old female with a BP of 88/52 and a HR of 54. The lowest dose associated with coma was between 60 mg and 120 mg, which occurred in a 30-year-old female with a HR of 30 and BP of 81/48. There were 6 patients < 6 yrs. The lowest dose with bradycardia and drowsiness in a small child was 16 mg in a 2 YO (weight unknown). All other cases in children < 6 yrs involved ingestion of a single tablet (2 or 4 mg) with only mild drowsiness reported. Therapy in this series was primarily supportive and included pressors in 3 cases and intubation in 3 cases. Naloxone was administered to 7 patients. There was no response to naloxone in 5 patients, poor documentation of response in one, and arousal in one patient. All patients recovered without residual complications. CONCLUSION: Clinical manifestations of tizanidine overdose include alterations of mental status, bradycardia, and hypotension. In this series, outcome was good with supportive therapy.

Adolescent↗
PubMed2004

Evaluation of the effect of a public educator on calls and poisonings reported to a regional poison center.

There are few studies that use measurable outcomes to gauge the effect of a public educator on the mission of the poison center. Human exposures, penetrance and total call volume from 2 regional poison centers for 7y (1996-2002) were evaluated. In poison center 1 a dedicated educator was employed for the final 4y of data (1999-2002). Poison center 2 data acted as a control with no dedicated educator for the 7-y period. The 2 centers were comparable in a number of ways: similar demographic rural and urban populations; similar geographic and economic region; and served the entire state. Human exposures in poison center 1 increased 4.3 % after employment of a dedicated educator, while exposure continued to decline at center 2 (1.7%). A steep decline in penetrance in poison center 1 was reversed after employment of a dedicated educator. Human exposures and penetrance for poison center 2 continued to decline during the study years. Total calls to center 1 increased 13.8% while total calls to center 2 remained flat (0.2%). This is the first study to use measurable outcomes to evaluate the impact of a public educator on the mission of a poison center. The addition of a public educator was associated with a positive impact on human exposures and penetrance reported to a regional poison center.

Hotlines↗
PubMed2003

Use of dosage as a triage guideline for unintentional cyclic antidepressant (UCA) ingestions in children.

Triage guidelines for unintentional cyclic antidepressant (UCA) ingestions vary widely, with limited supportive evidence. All records of UCA ingestion reported to 4 certified regional poison centers were evaluated for the years 1998 through 2000. Inclusion criteria included age </=6 years patients with a known outcome and known ingested dose by history. Exclusion criterion was polydrug ingestion. Two hundred forty-six cases were evaluated. The mean age was 2.4 years (standard deviation, +/-1.2 y). One hundred thirty-six patients (55%) were managed in a hospital. One hundred ten patients were managed at home with observation and telephone follow up. Symptoms reported were drowsiness (n = 59), tachycardia (n = 4), agitation (n = 2), coma (n = 2), respiratory depression (n = 1), and ataxia (n = 1). Medical outcome was reported as no effect (n = 185; 75%), minor effect (n = 57; 23%), moderate effect (n = 2; 1%); and major effect (n = 2; 1%). Mean dosage of patients with and without symptoms was 6.3 mg/kg (+/- 9.3) and 2.9 mg/kg (+/- 3.1), respectively. Forty-three of 57 patients (75%) with minor symptoms reported a dosage of <5 mg/kg. All patients with a moderate or major outcome (n = 4) reported a dosage of >5 mg/kg. The majority of UCA ingestions produced limited or no symptomatology. In this series, all children with ingestions of <5 mg/kg developed no or minor effects. Home monitoring might be appropriate in such cases.

Antidepressive Agents, Tricyclic↗
PubMed2003

Intermediate syndrome after exposure to chlorpyrifos in a 16-month-old girl.

We describe a case of intermediate syndrome after chlorpyrifos ingestion in a toddler, despite a continuous pralidoxime infusion. A 16-month-old girl ingested a pesticide containing chlorpyrifos. She was brought to an Emergency Department where she became lethargic and tachycardic, and subsequently developed pulmonary edema requiring mechanical ventilation. Pralidoxime 150 mg i.v. was administered twice, and an infusion begun at 15 mg/kg/h. At 24.5 h post-ingestion the child had a normal neurologic examination, showed no signs of cholinergic excess, and was extubated successfully. At 27.5 h post-ingestion the child became flaccid, bradycardic and apneic. She was emergently re-intubated. The child's delayed onset of respiratory arrest and flaccid paralysis after an asymptomatic period is consistent with Intermediate Syndrome. This is an unusual case in that it occurred in a young child, was related to chlorpyrifos, and occurred despite continuous and adequate oxime therapy.

Chlorpyrifos↗