The flow pattern effects of hydrodynamic cavitation on waste activated sludge digestibility

The disintegration of raw sludge is of importance for enhancing biogas production and facilitates the degradation of substrates for microorganisms so that the efficiency of digestion can be increased. In this study, the effect of hydrodynamic cavitation (HC) as a pretreatment approach for waste activated sludge (WAS) was investigated at two upstream pressures (0.83 and 1.72 MPa) by using a milli-scale apparatus which makes sludge pass through an orifice with a restriction at the cross section of the flow. The HC probe made of polyether ether ketone (PEEK) material was tested using potassium iodide solution and it was made sure that cavitation occurred at the selected pressures. The analysis on chemical effects of HC bubbles collapse suggested that not only cavitation occurred at low upstream pressure, i.e., 0.83 MPa, but it also had high intensity at this pressure. The pretreatment results of HC implementation on WAS were also in agreement with the chemical characterization of HC collapse. Release of soluble organics and ammonium was observed in the treated samples, which proved the efficiency of the HC pretreatment. The methane production was improved during the digestion of the treated samples compared to the control one. The digestion of treated WAS sample at lower upstream pressure (0.83 MPa) resulted in higher methane production (128.4 mL CH4/g VS) compared to the treated sample at higher upstream pressure (119.1 mL CH4/g VS) and control sample (98.3 mL CH4/g VS). Thus, these results showed that the HC pretreatment for WAS led to a significant increase in methane production (up to 30.6%), which reveals the potential of HC in full-scale applications.

Impact of food waste addition in energy efficient municipal wastewater treatment by aerobic granular sludge process

Recently, one of the main purposes of wastewater treatment plants is to achieve a neutral or positive energy balance while meeting the discharge criteria. Aerobic granular sludge (AGS) technology is a promising technology that has low energy and footprint requirements as well as high treatment performance. The effect of co-treatment of municipal wastewater and food waste (FW) on the treatment performance, granule morphology, and settling behavior of the granules was investigated in the study. A biochemical methane potential (BMP) test was also performed to assess the methane potential of mono- and co-digestion of the excess sludge from the AGS process. The addition of FW into wastewater enhanced the nutrient treatment efficiency in the AGS process. BMP of the excess sludge from the AGS process fed with the mixture of wastewater and FW (195 ± 17 mL CH4/g VS) was slightly higher than BMP of excess sludge from the AGS process fed with solely wastewater (173 ± 16 mL CH4/g VS). The highest methane yield was observed for co-digestion of excess sludge from the AGS process and FW, which was 312 ± 8 mL CH4/g VS. Integration of FW as a co-substrate in the AGS process would potentially enhance energy recovery and the quality of effluent in municipal wastewater treatment.

Modelling of high-rate activated sludge process: Assessment of model parameters by sensitivity and uncertainty analyses

The objective of this study is to develop a mechanistic model to predict the long-term dynamic performance of High-Rate Activated Sludge (HRAS) process, including the removal of carbon (COD), nitrogen (N), and phosphorus (P). The model was formulated with inspiration from Activated Sludge Models No. 1 and 3 (ASM1 and ASM3) to incorporate essential mechanisms, such as adsorption and storage substrate, specific to HRAS systems. A stepwise protocol was followed for calibration with dynamic data from a pilot-scale HRAS plant. Sensitivity analysis identified influential model parameters, including maximum specific growth rate (μ), growth yield (YH), storage yield (YSTO), storage rate (kSTO), decay rate (b), and half saturation of the readily biodegradable substrate for growth (KS1). The calibrated model achieved prediction efficiencies above the normalized Mean Absolute Error (MAE) of 70 % for mixed liquor suspended solids (MLSS), total chemical oxygen demand (TCOD), soluble COD (SCOD), particulate COD (XCOD), total nitrogen (TN), ammonia nitrogen (SNH), total phosphorus (TP), soluble TP (STP), and particulate TP (XTP). Uncertainty analysis revealed that SCOD was underestimated. Based on the dynamic profiles of uncertainty bands and observed data, there is potential for improving the estimation of dynamic behavior in STP. The observed discrepancies may be attributed to variations in wastewater characteristics during the monitoring period, particularly concerning the phosphorus (P) fractions of the readily biodegradable substrate (SS) and soluble inerts (SI), which were not considered as dynamically changing parameters in the model.

Environmental impact of sewage sludge co-digestion with food waste and fat-oil-grease: Integrating plant-wide modeling with life cycle assessment approach

Anaerobic co-digestion of fat-oil-grease (FOG) and food waste (FW) with sewage sludge (SS) in wastewater treatment plants is a method used to increase biogas production. In this study, digestion scenarios were compared using plant-wide modeling and life cycle assessment: Scenario-0 (mono-digestion of waste-activated sludge (WAS)), Scenario-1 (co-digestion of WAS with FOG), and Scenario-2 (co-digestion of WAS with FW). Scenario-0, with the highest energy use and landfilling of FOG/FW, has the worst environmental impact. Scenario-1 and Scenario-2 minimize the environmental load by energy recovery and avoiding landfilling of organic waste. Scenario-wise, the change in greenhouse gas (GHG) emissions from treatment was negligible. However, due to the impact of landfilling, GHG emissions in Scenario-0 were 21% and 30% higher than in Scenario-1 and 2, respectively. The environmental benefit of anaerobic co-digestion of FOG/FW with SS is not only in the contribution to energy production but also in the recycling of organic waste.

Use of water treatment plant sludge in high-rate activated sludge systems: A techno-economic investigation

Coagulants such as aluminum sulfate (Al2(SO4)3 (alum)) and ferric chloride (FeCl3) used in water treatment plants (WTPs) led to the generation of sludge that is usually disposed to landfills. However, the utilization of WTP sludge is being encouraged by authorities to achieve sustainable development. This study aims to investigate WTP sludge utilization in a pilot-scale high-rate activated sludge (HRAS) system as a substitute for conventional coagulants. Based on jar tests, the iron sludge was selected for pilot-scale testing due to its superior ability to enhance the treatment efficiency of the HRAS process compared to alum sludge. Iron sludge addition (20.1 ± 1.6 mg dry sludge/L wastewater) slightly improved the removal efficiency of particulate chemical oxygen demand (pCOD) from 74 % to 81 % (p-value: 0.014). Iron sludge addition had a distinct effect on the sludge characteristics of the HRAS process. The average median particle size (d50) increased from 96 ± 3 to 163 ± 14 μm (p-value<0.00) with the addition of iron sludge, which improved the settleability of the HRAS process sludge. However, the biochemical methane potential (BMP) of the HRAS process sludge decreased by 8.9 % (p-value<0.00) after iron sludge addition. In a scenario analysis of WTP sludge use in a hypothetical HRAS plant, the effluent quality index (EQI), an indicator of environmental impact, was calculated and the cost related to the operation (the transfer and landfill disposal of WTP and HRAS process sludge, energy and chemical consumption of the HRAS plant) was estimated. As a result, using WTP sludge in the HRAS plant did not significantly affect the EQI of the plant but decreased overall cost by 11 %. The results showed that the use of WTP sludge as a coagulant in wastewater treatment could achieve mutual benefits for WTPs and WWTPs and have the potential to realize the circular economy model.

Impact of primary treatment methods on sludge characteristics and digestibility, and wastewater treatment plant-wide economics

Biogas production from anaerobic sludge digestion plays a central role for wastewater treatment plants to become more energy-efficient or even energy-neutral. Dedicated configurations have been developed to maximize the diversion of soluble and suspended organic matter to sludge streams for energy production through anaerobic digestion, such as A-stage treatment or chemically enhanced primary treatment (CEPT) instead of primary clarifiers. Still, it remains to be investigated to what extent these different treatment steps affect the sludge characteristics and digestibility, which may also impact the economic feasibility of the integrated systems. In this study, a detailed characterization has been performed for sludge obtained from primary clarification (primary sludge), A-stage treatment (A-sludge) and CEPT. The characteristics of all sludges differed significantly from each other. The organic compounds in primary sludge consisted mainly of 40% of carbohydrates, 23% of lipids, and 21% of proteins. A-sludge was characterized by a high amount of proteins (40%) and a moderate amount of carbohydrates (23%), and lipids (16%), while in CEPT sludge, organic compounds were mainly 26% of proteins, 18% of carbohydrates, 18% of lignin, and 12% of lipids. The highest methane yield was obtained from anaerobic digestion of primary sludge (347 ± 16 mL CH₄/g VS) and A-sludge (333 ± 6 mL CH₄/g VS), while it was lower for CEPT sludge (245 ± 5 mL CH₄/g VS). Furthermore, an economic evaluation has been carried out for the three systems, considering energy consumption and recovery, as well as effluent quality and chemical costs. Energy consumption of A-stage was the highest among the three configurations due to aeration energy demand, while CEPT had the highest operational costs due to chemical use. Energy surplus was the highest by the use of CEPT, resulting from the highest fraction of recovered organic matter. By considering the effluent quality of the three systems, CEPT had the highest benefits, followed by A-stage. Integration of CEPT or A-stage, instead of primary clarification in existing wastewater treatment plants, would potentially improve the effluent quality and energy recovery.

Energy and material refineries of future: Wastewater treatment plants

There have been many important milestones on humanity's long journey towards achieving environmental sanitation. In particular, the development of the activated sludge system can be claimed to be one of the most groundbreaking advances in the protection of both public health and the wider ecosystem. The first wastewater treatment plants (WWTPs) were developed over a century ago and were soon configured for use with activated sludge. However, despite their long history and service, conventional activated sludge (CAS) plants have become an unsustainable method of wastewater treatment. In addition, conventional WWTPs are intensive energy-consumers and at best allow only very limited material recovery. A paradigm shift to convert existing WWTPs into more sustainable facilities must therefore be considered necessary and to this end the wastewater biorefinery (WWBR) concept may be considered a solution that maximizes both energy and material recovery, in line with the circular economy approach.

Primary and A-sludge treatment by anaerobic membrane bioreactors in view of energy-positive wastewater treatment plants

Energy-rich sludge can be obtained from primary clarifiers preceding biological reactors. Alternatively, the incoming wastewater can be sent to a very-high-loaded activated sludge system, i.e., a so-called A-stage. However, the effects of applying an A-stage instead of a primary clarifier, on the subsequent sludge digestion for long-term operation is still unknown. In this study, biogas production and permeate quality, and filterability characteristics were investigated in a lab-scale anaerobic membrane bioreactor for primary sludge and A-stage sludge (A-sludge) treatment. A higher specific methane yield was obtained from digestion of A-sludge compared to primary sludge. Similarly, specific methanogenic activity was higher when the anaerobic membrane bioreactor was fed with A-sludge compared to primary sludge. Plant-wide mass balance analysis indicated that about 35% of the organic matter in wastewater was recovered as methane by including an A-stage, compared to about 20% with a primary clarifier.

High-rate activated sludge processes for municipal wastewater treatment: the effect of food waste addition and hydraulic limits of the system

Conventional activated sludge (CAS) process is one of the most commonly applied processes for municipal wastewater treatment. However, it requires a high energy input and does not promote energy recovery. Currently, high-rate activated sludge (HRAS) process is gaining importance as a good option to reduce the energy demand of wastewater treatment and to capture organic matter for valorizing through anaerobic digestion (AD). Besides, food waste addition to wastewater can help to increase the organic matter content of wastewater and thus, energy recovery in AD. The objective of this study is to evaluate the applicability of co-treatment of municipal wastewater and food waste in a pilot-scale HRAS system as well as to test the minimal hydraulic retention times (HRTs) such as 60 and 30 min. Food waste addition to the wastewater resulted in a 10% increase in chemical oxygen demand (COD) concentration of influent. In the following stages of the study, the pilot-scale system was operated with wastewater solely under the HRTs of 60 and 30 min. With the decrease of HRT, particulate COD removal increased; however, soluble COD removal decreased. The results demonstrated that if the settling process is optimized, more particulate matter can be diverted to sludge stream.

Life cycle assessment of upgrading options of a preliminary wastewater treatment plant including food waste addition

Life cycle assessment (LCA) is a beneficial tool to evaluate the performance of wastewater treatment plants (WWTPs) and to compare different upgrading options. The main objective of this study is to investigate the environmental impact of upgrading options of a preliminary WWTP in Istanbul, Turkey. The preliminary plant currently consists of mechanical treatment units and various upgrading options including primary treatment and high-rate activated sludge system (HRAS) process as well as the addition of food waste to wastewater were compared. Results showed that the baseline scenario (S0) had worse performance than all future scenarios (S1-3) except for climate change. The scenario of adding food waste to wastewater (S3) has the best performance in climate change, terrestrial acidification, terrestrial ecotoxicity and fossil depletion. Increased addition of food waste was also tested in the sensitivity analysis, and major improvements were obtained especially in climate change and terrestrial ecotoxicity.

Co-digestion performance of organic fraction of municipal solid waste with leachate: Preliminary studies

The main aim of the study was to evaluate the co-digestion performance of OFMSW with different wastes. Leachate, reverse osmosis (RO) concentrate collected from a leachate treatment facility and dewatered sewage sludge taken from a wastewater treatment plant (WWTP) were used for co-digestion in this paper. An extra effort was made to observe the effect of leachate inclusion in the co-digestion. In the study, the mono-digestion of OFMSW, leachate, RO concentrate and sewage sludge as well as digestion of 7 different waste mixtures were carried out for this objective. The experiments were carried out for approximately 50days under mesophilic conditions. The highest methane yield was 785L CH₄/kg VS_added in the reactor, which had only OFMSW. While the methane yield derived from OFMSW was found higher than previous studies, methane yield of leachate was found to be 110L CH₄/kg VS_added, which was lower than findings in the literature. The mono-substrate of OFMSW was followed by the reactor of having waste mixture of leachate+sewage sludge+OFMSW+water (C7) with 391L CH₄/kg VS_added, which was the only combination included water. In order to understand the effect of leachate and water inclusions on co-digestion, two separate waste combinations; leachate+sewage sludge+OFMSW+water (C7) and leachate+sewage sludge+OFMSW (C1) were prepared that had different amounts of leachate but same amounts of other wastes. The methane yield of leachate+sewage sludge+OFMSW+water (C7) indicated that addition of some water instead of leachate could stimulate biogas production. Methane yield of this reactor was found to be 71% higher than the waste combination of leachate+sewage sludge+OFMSW (C1). It could be thought that the high amount of non-biodegradable matters in leachate could be responsible for lower methane yield in leachate+sewage sludge+OFMSW (C1) reactor. Methane yields of the reactors showed that co-digestion of OFMSW and leachate could be a solution not only for treatment of leachate and but also increasing the biogas potential of leachate. Leachate addition could also adjust optimum total solids (TS) content in anaerobic digestion. It was also understood that RO concentrate did not affect the methane yield in a negative way. The similar characterization of leachate and RO concentrate in this study could offer the utilization of RO concentrate instead of leachate. The findings showed that volatile solids (VS) removals were changed from 32% to 61% in the reactors. While the reactor of leachate+RO concentrate+OFMSW (C6) had the highest VS removal, the reactor of the sole substrate leachate had the lowest VS removal.

Evaluation of vascular smooth muscle and corpus cavernosum on hypercholesterolemia. Is resveratrol promising on erectile dysfunction?

The aim of this study is to evaluate the effects of hypercholesterolemia in thoracic aorta (TA), mesenteric artery (MA), renal artery (RA), and corpus cavernosum (CC) isolated from cholesterol-fed rabbits. For determination of the maximum detrimental effect, vasorelaxation and vasoconstriction results of arteries and CC have been compared. Animals were fed with a diet that contained 2% w/w cholesterol and 2% w/w high cholesterol plus resveratrol (4 mg kg(-1) per day) for 6-week duration. Total cholesterol levels in the plasma were measured. Vascular and endothelial functions in RA, TA, MA, and CC were assessed by isolated tissue bath with cumulative doses of acetylcholine and sodium nitroprusside. The statistical significance of differences of groups was analyzed by means of one-way ANOVA or Student's t-test. P-values <0.05 were considered significant. There have been no significant changes on plasma total cholesterol levels between cholesterol and cholesterol + resveratrol-treated groups. Vasorelaxation responses to acetylcholine in resveratrol-treated group showed significant changes when compared with hypercholesterolemic group. No statistically significant differences were seen between non-receptor-mediated vasorelaxation responses between the three groups. Resveratrol might be an effective treatment in the prevention of atherosclerotic changes in arteries and CC. The initial effects of hypercholesterolemia on erectile dysfunction and endothelial dysfunction may be precluded with resveratrol. This protective effect may also ensure the prevention of coronary arterial diseases and renovascular diseases in hypercholesterolemic patients.

B-type natriuretic peptide as an indicator of right ventricular dysfunction in acute pulmonary embolism

OBJECTIVE

B-type natriuretic peptide (BNP) is a neurohormone secreted from cardiac ventricles in response to ventricular strain. The aim of present study was to evaluate the role of BNP in the diagnosis of the right ventricular (RV) dysfunction in acute pulmonary embolism (PE).

METHODS

BNP levels were measured in patients with acute PE as diagnosed by high probability lung scan or positive spiral computed tomography. All patients underwent standard echocardiography and blood tests during the second hour of the diagnosis.

RESULTS

Forty patients diagnosed as acute PE (mean age, 60.4 +/- 13.2 years; 62.5% women) were enrolled in this study. Patients with RV dysfunction had significantly higher BNP levels than patients without RV dysfunction (426 +/- 299.42 pg/ml vs. 39.09 +/- 25.22 pg/ml, p < 0.001). BNP-discriminated patients with or without RV dysfunction (area under the receiver operating characteristic curve, 0.943; 95% CI, 0.863-1.022). BNP > 90 pg/ml was associated with a risk ratio of 165 (95% CI, 13.7-1987.2) for the diagnosis of RV dysfunction. There was a significant correlation between RV end-diastolic diameter and BNP (r = 0.89, p < 0.001). Sixteen patients (40%) were diagnosed as having low-risk PE, 19 patients (47.5%) with submassive PE and five patients (12.5%) with massive PE. The mean BNP was 39.09 +/- 25.2, 378.4 +/- 288.4 and 609.2 +/- 279.2 pg/ml in each group respectively.

CONCLUSION

Measurement of BNP levels may be a useful approach in diagnosis of RV dysfunction in patients with acute PE. The possibility of RV dysfunction in patients with plasma BNP levels > 90 pg/ml should be strongly considered.

Vasorelaxant effect of iloprost on isolated human internal mammary artery

In this study, vasodilator effect of iloprost on KCl-induced contraction in human internal mammary artery (IMA) was studied and compared with other vasodilators papaverin and diltiazem. Ring segments of IMA were studied in organ baths for measurement of isometric tension. After the tissues has reached their baseline tension, precontraction was induced by 100 mm KCl and cumulative concentration-relaxation was measured by the application of iloprost (10(-9)-10(-6) m), papaverine (10(-5)-10(-4) m), diltiazem (10(-9)-10(-4) m) or ethanol; a solvent for iloprost; alone. The maximal relaxation of IMA segments to iloprost was 13.5 +/- 2.2%. Iloprost caused significantly limited relaxation when compared with papaverin (106.0 +/- 2.9%) and diltiazem (93.6 +/- 2.5%) (P < 0.001). Papaverin produced the greatest maximal relaxation to KCl-induced contraction of IMA. The potency of iloprost (-log EC(50) = 6.59 +/- 0.19) was significantly higher than those of papaverine (-log EC(50) = 4.21 +/- 0.11) and diltiazem (-log EC(50) = 5.63 +/- 0.06) (P < 0.001). In addition, -log EC(50) of diltiazem was significantly greater than papaverin (P < 0.001). Iloprost appears to be more potent than those of papaverine and diltiazem but it was inefficient in maximal inhibition on KCl-induced contraction. Iloprost may have little benefit in KCl-related vasoconstriction on human IMA segments.

Evaluation of ex vivo expanded human NK cells on antileukemia activity in SCID-beige mice

The possibility of using natural killer (NK) cells in treatment of human hematological malignancies has increased in recent years. One factor contributing to this is the introduction of new methods for ex vivo generation of enriched populations of clinical grade NK cells. The objective of the present study was to evaluate the safety and efficacy of human ex vivo expanded clinical grade NK cells against K562 leukemia cells in severe combined immunodeficiency disease (SCID)-beige mice. Irradiated SCID-beige mice were injected intravenously (i.v.) with K562 leukemia cells. Following leukemia cell injection, mice were injected with ex vivo expanded human NK cells. NK cells were followed in vivo and mice monitored for survival from leukemia. Administration of these ex vivo expanded clinical grade NK cells was safe and prevented leukemia development. In conclusion, these results imply possibilities for the use of this NK cell preparation in treatment trials of human hematological malignancies and possibly other forms of cancer.

Preperitoneal mesh repair of spigelian hernias under local anesthesia: description and clinical evaluation of a new technique

We report on a new method for the repair of spigelian hernia, in which we combined the step-by-step local anesthesia and open preperitoneal mesh repair techniques. After initial infiltration of local anesthetics, we incised the attenuated fascia and slightly enlarged the fascial defect to facilitate easy return of hernial content into the abdominal cavity. We injected preperitoneally, in a radial fashion around the peritoneal sac, more saline solution, consisting of 1:200,000 epinephrine (g:g) and 1/3 bupivacain (v:v). We dissected the peritoneum away from the anterior abdominal wall to create a preperitoneal pocket of sufficient size. We spread open a 9 x 9-cm polypropylene mesh in the area, as if we were doing a GPRVS of Stoppa. We followed up our four patients for an average of 32 months. All four cases had an uneventful recovery and were discharged in an average of 3.5 days. They returned to normal daily activity on the 9th day after surgery. We suggest that the preperitoneal mesh repair of a spigelian hernia under local anesthesia is a simple and feasible technique with favorable early and late postoperative results and deserves further investigation in larger series.

Expansion of natural killer (NK) and natural killer-like T (NKT)-cell populations derived from patients with B-chronic lymphocytic leukemia (B-CLL): a potential source for cellular immunotherapy

B-cell chronic lymphocytic leukemia (B-CLL) is the most common leukemia in the Western world. It is currently an incurable disease, making new treatment options such as immunotherapy desirable. Monoclonal antibodies (Mabs) to surface antigens of the tumor cell is one option. Administration of cytotoxic cells such as natural killer (NK) and natural killer-like T (NKT) cells expanded in vitro might be a useful treatment modality alone or in combination with MAbs. A limiting step in the development of successful cellular immunotherapy has been the availability of appropriate cytotoxic cells. Here, we report the feasibility of expanding populations of the human killer cells, CD3-CD56+ NK and CD3+CD56+ NKT cells, from peripheral blood mononuclear cells (PBMCs) of B-CLL patients. The influence of tumor B cells on the in vitro expansion of killer cells was assessed by depleting B cells from PBMCs by microbead separation before culture. The 21-day cultures from both B-cell- and non-B-cell-depleted PBMC showed a marked expansion of NK cells, and also of T cells, among which almost half had the NKT phenotype. Depletion of B cells before culture did not change the expansion rates of NK and NKT cells significantly. In patients with progressive B-CLL, NK cell expansion capacity was improved after fludarabine treatment when compared to samples obtained before treatment. Repeated samples of PBMCs from individual untreated patients with both indolent and progressive disease cultured under identical conditions gave similar NK cell expansion rates. Expanded killer cell populations had cytotoxic function against the NK-sensitive target K562 cell line and expressed high levels of Granzyme B. From our studies, we conclude that NK cells as well as NKT cells from the peripheral blood of B-CLL patients can be expanded, and that these cells have cytotoxic capacity.

Electrocardiographic changes during migraine attacks

OBJECTIVES

To clarify whether electrocardiographic (ECG) changes can be identified during a migraine attack and to determine whether there are ECG differences between periods with and without headache.

BACKGROUND

The clinical signs and symptoms of migraine point to involvement of the autonomic nervous system, and especially to disrupted regulation of the circulatory system and autonomic balance. This disruption may be more marked during a migraine attack. During a migraine attack, autonomic imbalance within the heart and its vessels conceivably may result in ECG abnormalities.

METHODS

In 30 patients with migraine, the ECG variables of heart rate, abnormalities of rhythm, PR interval, QRS duration, corrected QT interval, T inversion, and ST-segment changes were recorded during migraine attacks and pain-free periods.

RESULTS

Of the 30 patients studied during a migraine attack, 9 (30%) had one or more abnormalities of rhythm (including sinus arrhythmia, atrial premature contraction, and ventricular premature contraction), 20% had PR intervals greater than 0.20 seconds, 40% had corrected QT intervals greater than 0.44 seconds, 66% had T inversion, and 40% had ST-segment abnormalities. No patient had arrhythmia, PR intervals greater than 0.20 seconds, or corrected QT intervals greater than 0.44 seconds during a pain-free period. No differences were noted for ST-segment changes, T inversion, and total ECG changes between periods with and without headache, but both PR and corrected QT intervals were significantly longer during migraine attacks than during pain-free periods.

CONCLUSIONS

We conclude that ECG abnormalities often are present during a migraine attack, and for most of these, particularly PR and corrected QT interval lengthening, these abnormalities will be absent or less prominent during pain-free intervals.

Morgagni hernia: rare presentations in elderly patients

Morgagni hernia, which is both infrequent and generally asymptomatic, is often diagnosed when complications occur. Herein we present two elderly patients with Morgagni hernia, which were complicated with bowel perforation and upper gastro-intestinal bleeding. The recognition and management of these cases are discussed.

Basic toxicological approach has been effective in two poisoned patients with amitraz ingestion: case reports

Amitraz, a formamidine insecticide and acaricide used in veterinary practice, presents side effects in humans related to its pharmacological activity on alpha 2-adrenergic receptors. There is little information available in the literature about the toxicology of the product in man and the treatment of this poisoning. In this report, the clinical and laboratory features of amitraz poisoning in two patients by a veterinary formulation also containing xylene are presented. The major clinical findings were unconsciousness, drowsiness, respiratory failure requiring mechanical ventilation, miosis, hypothermia and bradycardia. The laboratory findings were hyperglycemia, hypertransaminasemia and increased urinary output. Supportive management of this poisoning in humans is suggested in only a few articles and there is no specific antidote for the subsequent possible pharmacological effects of amitraz. In our two cases, we performed supportive treatment such as mechanical ventilation, atropine, gastric lavage, active carbon, oxygen and fluid administration. We concluded that the basic approach to the patient with amitraz poisoning, including initial stabilization to correct immediate life-threatening problems, treatment to reduce absorption and measures to improve elimination of the toxin, is effective.

A new method for in vitro expansion of cytotoxic human CD3-CD56+ natural killer cells

Adoptive transfer of immunocompetent cells may induce anti-tumor effects in vivo. However, a significant obstacle to the development of successful cellular immunotherapy has been the availability of appropriate cytotoxic cells. Among the immunologic effector cells that are considered mediators of anti-tumor effects, those with the highest per-cell cytotoxic capacity express a natural killer (NK) cell phenotype, i.e., CD56(+)CD3(-). However, such cells are normally present only in low numbers in peripheral blood mononuclear cells (PBMCs), lymphokine activated killer (LAK), and cytokine induced killer (CIK) cell preparations. To optimize the expansion of human NK cells, PBMCs were cultured in different serum free medium supplemented with monoclonal anti-CD3 antibodies and interleukin (IL)-2 at varying concentrations. By using Cellgro stem cell growth medium supplemented with 5% human serum and IL-2 (500 U/ml) cells expanded 193-fold (median, range 21-277) after 21 days, and contained 55% (median, range 7-92) CD3(-)CD56(+) cells. The remaining cells were CD3(+) T cells, 22% (median, range 2-68) of which co-expressed CD56. The expanded cell population lysed 26 to 45% of K562 targets in a 1:1 effector to target ratio, signifying substantial cytotoxic efficacy. The described method is a simple and efficient way of expanding and enriching human NK cells. We have termed these high-yield CD3(-)CD56(+) cells cytokine-induced natural killer (CINK) cells.

The effects of captopril on serum digoxin levels in patients with severe congestive heart failure

The effects of captopril on serum digoxin concentrations were studied in 8 patients with severe (NYHA Class IV) congestive heart failure. Serum digoxin concentrations were determined before and after the administration of captopril for 1 week in patients on chronic digoxin therapy. Each patient who was taking 0.25 mg of digoxin PO q.d., was administered 12.5 mg of captopril PO t.i.d. for 7 days. The peak serum concentration of digoxin (Cmax) before and after (on Days 0 and 7) captopril administration was 1.7+/-0.2 ng/ml and 2.7+/-0.2 ng/ml, the time to peak (tmax) was 2.4+/-0.5 h and 1.3+/-0.2 h, and the area under the 24-hour digoxin concentration-time curve (AUC0-24h) was 30.0+/-1.5 ng x h/ml and 41.7+/-3.4 ng x h/ml, respectively. While captopril caused a significant increase in peak serum concentration and the area under the digoxin concentration-time curve, it decreased the time to digoxin peak (p = 0.01, p = 0.04, p = 0.01, respectively). No patient developed evidence of digoxin toxicity. Concomitant administration of captopril with digoxin increases serum digoxin concentration in patients with severe congestive heart failure.

Effects of subchronic parathion exposure on cyclosporine pharmacokinetics in rats

Parathion undergoes enzymatic oxidation by hepatic cytochrome P-450 (CYP450) enzymes to the active metabolite paraoxon. Consequently, alterations in CYP450-dependent oxidation may affect the pharmacokinetics and pharmacodynamics of drugs that are metabolized in the liver. The CYP3A family is known to be responsible for the majority of cyclosporine metabolism. The aim of the present study was to assess the disposition kinetics of cyclosporine during subchronic parathion exposure. Male Wistar rats were administered either water or two different doses of parathion (1/100 LD50, 1/25 LD50; LD50 = 14 mg/kg) by gavage for 6 wk. Subsequently, rats in each experimental group received a single oral dose of cyclosporine (10 mg/kg), and serial blood samples were drawn from the carotid artery over a period of 48 h. Pharmacokinetic analysis showed that parathion increased the blood cyclosporine concentration twofold as evidenced by AUC (area under the curve), half life (t 1/2) and peak plasma concentration (Cmax). This may be due to inhibition of cyclosporine metabolism, an interaction that may be of clinical relevance in immunosuppression therapy.

The effects of propofol on normal and hypercholesterolemic isolated rabbit heart

The aim of the present study was to compare the effects of propofol on cardiac contractile force in normal and hypercholesterolemic isolated rabbit hearts. While one group was fed with standard chow pellets (150 g/day), the other group received cholesterol (1% w/w) in addition to the same amount of rabbit chow pellets during 1 month. Hearts from standard-fed rabbits were given intralipid solvent or 25, 50 and 100 microM propofol by infusion. Hypercholesterolemic rabbit hearts were administered 25, 50 and 100 microM propofol by infusion. All concentrations of propofol did not result in any significant change of the heart rates (HR) in two groups. Propofol (25, 50 and 100 microM) infusion induced a concentration- and time-dependent inhibition in left ventricular pressure (LVP) in standard chow diet group (P<.05,.05 and.05, respectively). In hypercholesterolemic rabbit hearts, 25 and 50 microM propofol infusion developed a significant inhibition in LVP when compared with the standard chow diet group (P<.05 and.05, respectively). Propofol (100 microM) infusion developed a significant increase in LVP after 20 min in hypercholesterolemic rabbit hearts when compared with normal rabbit hearts (P<.05). Supratherapeutic concentration of propofol might have cardioprotective effect on hypercholesterolemic rabbit hearts.

Severe uvular angioedema caused by intranasal administration of Ecbalium elaterium

A 54-y-o woman presented to the Emergency Department with shortness of breath and sore throat after intranasal administration of Ecbalium elaterium as a folk remedy for her sinusitis. The patient's history included nasal aspiration of the juice of the squirting cucumber (Ecbalium elaterium) for acute maxillary sinusitis. An airway obstruction due to severe uvular angioedema was detected and confirmed by airway X-ray. The patient was treated with 100% oxygen with mask, 0.3 mg epinephrine s.c., and 80 mg prednisolone i.v. Renal and hepatic function tests were normal. After a 24-h observation, the patient was discharged in her previous state of health.

Midazolams cardiac depressant effects and their lack of reversal by flumazenil in isolated rabbit hearts

Midazolam is known to cause a dose-dependent increase and decrease in the contractile force of the myocardium. Whether flumazenil can reverse these effects of midazolam remains unclear. In this study, we determined the cardiac effects of midazolam and the counter effect of flumazenil on midazolam-induced myocardial depression in isolated rabbit hearts. Rabbit hearts were isolated and perfused using the Langendorff technique, and left ventricle pressure and heart rate were measured by a pressure transducer in the left ventricle. One set of hearts were perfused with increasing concentrations of midazolam for 10 min, another set were perfused with concomitant midazolam and flumazenil. Concentrations of 5, 10, 20 and 50 microM midazolam decreased left ventricle pressure significantly (P < 0.01, P < 0.05, P < 0.01, P < 0.01, respectively). Heart rates decreased with concentrations of 10, 20 and 50 microM midazolam (P < 0.01, P < 0.01, P < 0.05, respectively). Flumazenil had no effect on the midazolam-induced decrease in left ventricle pressure and heart rate. Midazolam decreased the cardiac contractile force and heart rate of isolated rabbit hearts in a concentration-dependent manner. The failure of flumazenil to reverse these effects suggest that this cardiac depressant effect of midazolam is not mediated through peripheral benzodiazepine receptors.

The probable role of nitric oxide on the relaxations obtained by caffeine and aminophylline in rat uterus

The aim of the present study was to investigate the effect of nitric oxide (NO) on the relaxant activity of caffeine and aminophylline on rat myometrial strips. Uteri of pregnant Wistar rats were removed and suspended in 10-ml organ baths containing 37 degreesC Krebs bicarbonate solution gassed with 95% O2 and 5% CO2. The significance of the results was assessed by Student's t-test and P<0.05 was considered significant. A relaxant effect was observed with 10(-5)-10(-2) M caffeine (n=8) and aminophylline (n=6) on pregnant rat myometrial strips precontracted with 64 mM K+ (IC50=4.21+/-0.35 and 4.25+/-0.26, respectively). Incubation with 10(-5) M methylene blue, 10(-5) M haemoglobin, 10(-6) M Nomega-nitro-L-arginine methyl ester (L-NAME), 2x10(-7) M forskolin and 10(-6) M zaprinast exerted no effect on the relaxations (P>0.05). When the concentration of external Ca2+ was decreased to 0.5 mM or increased to 4.5 mM from the control level of 1.5 mM, the concentration-inhibition curves for caffeine and aminophylline shifted to the left or to the right, respectively. Our results suggest that: (1) the L-arginine-NO-cGMP system has no effect on the inhibition induced by caffeine and aminophylline on K+ induced contractions of pregnant rat myometrium; (2) this inhibitory effect is not mediated by cAMP; (3) cGMP does not play a role on the relaxant effect of these drugs; and (4) that Ca2+ plays the major role on the relaxations obtained with methylxanthine derivatives on pregnant rat uterus. (c) 1998 The Italian Pharmacological Society.

The effects of 4-aminopyridine and Bay K 8644 on verapamil-induced cardiovascular toxicity in anesthetized rats

OBJECTIVE

To determine the effects of 4-aminopyridine and Bay K 8644 on mean arterial pressure and heart rate in an anesthetized rat model of verapamil toxicity.

METHODS

The study was a randomized, controlled animal study. Rats were anesthetized and the carotid artery was cannulated for mean arterial pressure and heart rate measurements while both jugular veins were cannulated for drug administration. All animals were infused with verapamil (15 mg/kg/h i.v.) until 45-60% reduction of mean arterial pressure and 30% reduction of heart rate were observed. After verapamil, control animals were given normal saline solution and the other groups received 4-aminopyridine (1 and 2 mg/kg/h) or Bay K 8644 (0.3 and 0.6 mg/kg/h) for 60 minutes.

RESULTS

While 4-aminopyridine (1 mg/kg/h i.v.) did not significantly increase mean arterial pressure (75.9 +/- 5.5%) when compared with the control group (64.3 +/- 5.1%, p > 0.05), 2 mg/kg/h i.v. of 4-aminopyridine improved mean arterial pressure within 40 minutes (87.4 +/- 6.6%, p < 0.05, 95% CI 66.4-108.6%). Because the 2 mg/kg/h 4-aminopyridine produced side effects including seizures, secretions, and fasciculations at 35 +/- 5 minutes, the infusion was stopped at that time. Only the 2 mg/kg/h 4-aminopyridine infusion increased the heart rate at 10 and 20 minutes compared with the control group (p < 0.05, 95% CI 283.2-364.4). Bay K 8644 (0.3 and 0.6 mg/kg/h i.v.) significantly enhanced mean arterial pressure within 5 minutes (68.0 +/- 4.1% and 73.0 +/- 2.9%, respectively, p < 0.05), (95% CI 56.8-78.0% and 95% CI 64.9-81.1%, respectively) but no significant changes in mean arterial pressure were observed after 5 minutes. The 4-aminopyridine (2 mg/kg/h) increased the heart rate at 10 and 20 minutes compared with the control group (p < 0.05, 95% CI 311.3-358.7). Bay K 8644 did not produce a significant effect on heart rate (p > 0.05).

CONCLUSIONS

4-Aminopyridine improved mean arterial pressure and heart rate in a dose-dependent fashion; however, the higher infusion rate (2 mg/kg/h) necessary to improve mean arterial pressure and heart rate resulted in convulsions and excessive secretions. The reversal effects of Bay K 8644 on mean arterial pressure were transient and did not affect heart rate.

Circadian rhythmicity in serotonin-induced acute gastric mucosal injury in rats

Time-dependent patterns in the susceptibility of the rat gastric mucosa to ulcerogenic stimuli involving stress or chemical injury have been described. The purpose of this study was to evaluate whether serotonin (5-HT)-induced gastric mucosal injury is produced in a circadian fashion in the rat model. In fasted Wistar rats (adapted for 3 weeks to a standard 12-h light-dark cycle), 5-HT administered subcutaneously (20 mg/kg, 4 h before autopsy) produced gastric mucosal injury. The stomachs were removed and the ulcers were scored for intensity, using a scale of 0-4. In studies performed at 4-h intervals, beginning 1 h after lights-on, most of the mucosal injury occurred at 2000 h, i.e. early in the dark phase. Likewise, serum corticosterone levels were also found to be high at the same time period. The time of 2000 h is approximately determined to be the beginning of the rats' active period. These results suggest that the extent of acute 5-HT-induced gastric mucosal injury varies with the time of day and that elevations in corticosterone concentrations might be responsible for the 5-HT-induced gastric mucosal injury.

Characterization of 5-HT receptors in rat proximal colon

1. In view of its multiple sites of action, we investigated the activity of 5-hydroxytryptamine (5-HT, serotonin) on various potential receptors in the isolated proximal colon of rats. 2. 5-HT induced concentration-dependent contractions of colonic strips (pEC50=7.54+/-0.12). 3. The 5-HT1 receptor agonist, 5-carboxamidotryptamine, induced concentration-dependent contractions (pEC50=5.93+/-0.27); however, neither the 5-HT3 receptor-agonist, phenylbiguanide, nor the 5-HT4 receptor-agonist, renzapride, caused contractions at concentrations as high as 10(-4) M. 4. The 5-HT 1/2 receptor antagonist, methiothepin, caused concentration-dependent nonsurmountable antagonism. The 5-HT3 receptor antagonist, tropisetron, inhibited the contractions to a concentration of 5-HT> or =10(-6) M. Ketanserin had no effect on responses to 5-HT. 5. Tetrodotoxin and atropine had no effect on responses to 5-HT. 6. We conclude that contractions to 5-HT are mediated by 5-HT1-like and probably 5-HT3 receptors that activate tetrodotoxin insensitive mechanisms.

Relationship between high serum digoxin levels and toxicity

A retrospective study of 1,269 patients on digoxin was done to determine the relationship between serum digoxin levels of 3.0 ng/ml or higher and clinical toxicity. Of 1,269 patients, 58 (4.6%) had digoxin serum levels of 3.0 ng/ml or higher. Clinical evidence of digoxin toxicity was present in only 11 of these patients and premature blood sampling accounted for the high levels in 10 other nontoxic patients. None of the patients with clinical toxicity died. The other 37 patients tolerated the high digoxin levels without exhibiting toxic effect. Low cardiac output, concomitant use of other drugs, and impaired renal function increased the serum digoxin levels in patients with and without clinical toxicity. Appropriate therapeutic digoxin level monitoring and confirmatory laboratory-clinical relationship may have important influences on these results. Additional work on further definition of "toxic" digoxin levels needs to be performed.

The effects of amrinone and glucagon on verapamil-induced myocardial depression in a rat isolated heart model

1. We measured the ability of glucagon and amrinone, used alone and in combination, to improve the myocardial function in a rat isolated heart model of calcium channel blocker (CCB) cardiotoxicity. 2. Verapamil 10(-4) mol consistently decreased heart rate and cardiac contractile force in our Langendorff rat isolated heart preparations. Glucagon increased the heart rate in a dose-dependent fashion. Amrinone increased the heart rate only at the 1 x 10(-1) mol concentration, and had no significant effect on cardiac contractility. 3. A positive linear correlation was found between the glucagon concentration and the percent recovery of baseline contractile force. 4. Although complete reversal of verapamil-induced myocardial depression occurred at glucagon concentrations of > 3 x 10(-6) mol, amrinone produced only 23.8 +/- 3.6% recovery from baseline at its highest concentration (4 x 10(-3) mol). 5. When glucagon and amrinone were administered together, there was no additional increase over glucagon alone in the increase in contractile force. 6. Glucagon, and not amrinone, is an appropriate agent, capable of reversing verapamil-induced myocardial toxicity in this rat isolated heart model. In vivo studies should be performed to assess whether this may be a reliable therapy in clinical cases.

The effects of amrinone and glucagon on verapamil-induced cardiovascular toxicity in anaesthetized rats

The goal of this study was to compare the effects of glucagon and amrinone on mean arterial pressure (MAP) and heart rate, when used alone and in combination, in an anaesthetized rat model of verapamil toxicity. Rats were anaesthetized and the carotid artery was cannulated for MAP and heart rate measurements. Jugular and femoral veins were cannulated for drug administration. After verapamil infusion (15 mg/kg/h), control animals were given normal saline solution and the other groups received amrinone (0.1 or 0.2 mg/kg/min), glucagon (0.3 mg/kg bolus followed by 0.1 or 0.2 mg/ kg/min infusion), glucagon plus amrinone (0.1 mg/kg/min and 0.1 mg/kg/min respectively) or glucagon plus amrinone (0.2 mg/kg/min and 0.1 mg/kg/min respectively). Glucagon (0.2 mg/kg/min) significantly increased MAP when compared to the control group (P < 0.01). The combination of glucagon and amrinone did not produce a synergistic effect for the recovery of MAP. Furthermore, this combination masked the positive effects of glucagon (0.2 mg/kg/min) on MAP. Glucagon (0.2 mg/kg/min) increased the heart rates compared with those of the control group (P < 0.05). Additionally, amrinone (0.1 mg/kg/min) plus glucagon (0.1 mg/kg/min) increased the heart rates (P < 0.05). Finally, glucagon dose dependently recovered MAP. While amrinone depressed MAP in combination with glucagon, it did not alter the positive chronotropic effect of high dose glucagon.

The prokinetic effect of domperidone in gallbladder--not upon dopaminergic receptors

The mechanism of the contractile effect of domperidone on gallbladder smooth muscle has been investigated by using an in-vivo and an in-vitro model. In the in-vivo part of the study 14 healthy males were administered 20 mg domperidone or two placebo tablets orally and gallbladder emptying was measured by ultrasonography. The reduction in the gallbladder volume was significant compared to the placebo at 45 and 55 min. In the in-vitro part of the study, the gallbladder strips isolated from guinea pigs were field stimulated and 10(-6)-10(-4) M concentrations of dopamine were administered before electrical field stimulation (EFS) was repeated. Dopamine exerted no significant effect upon the contractions obtained by EFS. The effect of dopamine and domperidone under basal conditions were also explored. Under basal conditions, dopamine neither contracted nor relaxed the gallbladder muscle between 10(-6) and 10(-4) M concentrations when added directly to the organ bath. Besides, a significant contraction was observed with 10(-4) M concentration of domperidone whereas 10(-7), 10(-6) and 10(-5) M concentrations exerted no effect. This effect of domperidone was thought to be nonspecific but inhibited by 10(-6) M atropine, 10(-5) M pirenzepine and abolished by 10(-6) M tetrodotoxin. In summary, domperidone produces a modest contraction in human gallbladder. This effect does not seem to occur upon dopaminergic receptors in guinea pig models.

Multiple-dose activated charcoal in an accidental vancomycin overdose

BACKGROUND

Multiple-dose activated charcoal may enhance the enterocapillary clearance of vancomycin.

CASE REPORT

A 17-day-old female neonate born with congenital meningomyelocele and Arnold-Chiari malformation was iatrogenically overdosed with a 500 mg intravenous bolus of vancomycin during a shunt operation. The Red Man's Syndrome developed within minutes, characterized by sudden hypotension, skin rash and cyanosis. Serum vancomycin level at one hour after the injection was 165.7 micrograms/mL, as measured by an enzyme immunoassay method (EMIT). Multiple dose activated charcoal, 1 g/kg, was first given five hours after injection, and continued every four hours for 12 doses. The half-life of vancomycin during charcoal administration was calculated to be 9.4 h or less than the reported 13.4-33.7 h half-life in normal neonates. The neonate's renal function tests and brainstem auditory responses remained normal.

CONCLUSIONS

Gastrointestinal dialysis with multiple-dose activated charcoal without cathartics appeared to shorten the elimination half-life of vancomycin.

Adsorption of botulinum toxin to activated charcoal with a mouse bioassay

STUDY OBJECTIVE

We evaluated the effectiveness of activated charcoal (AC) in adsorbing Clostridium botulinum type A toxin using a mouse bioassay.

DESIGN

Prospective, blinded, randomized, controlled animal study.

SETTING

Animal care facility.

PARTICIPANTS

One hundred forty Swiss/Webster ND-4 strain mice.

INTERVENTION

Food contaminated with type A botulinum toxin was homogenized in a phosphate/gel buffer (pH 6.2). The concentrate was diluted by factors of 1:10, 1:50, and 1:100. AC was added to aliquots of the dilutions to a 20% final concentration. The samples were centrifuged, supernatant was removed, and separate groups of mice were injected intraperitoneally with .5 mL of each dilution (those treated with AC and controls untreated with AC). The animals were then observed over 5 days for signs of botulism.

RESULTS

None of the 60 animals injected intraperitoneally with dilutions treated with AC was observed to have any signs of botulism. In contrast, deaths were observed in 10 of 20, 9 of 20 and 4 of 20 mice injected with untreated dilutions of 1:100, 1:50, and 1:10, respectively (P < .004).

CONCLUSION

In this model, treatment of botulinum toxin with AC before administration resulted in greatly reduced morbidity and mortality.

Elevation of breath ethanol measurements by metered-dose inhalers

STUDY OBJECTIVE

Metered-dose inhalers (MDIs) may contain as much as 38% ethanol. We evaluated the effects of ethanol-containing MDIs on breath alcohol testing.

DESIGN

Prospective, single-blind, crossover, controlled study.

PARTICIPANTS

Three healthy male volunteers 29 to 36 years old.

INTERVENTION

We studied three brands: Tornalate, (38% ethanol), Bronkometer, (30% ethanol), and Alupent, (0% ethanol). The effects of each MDI on breath and blood ethanol measurements were evaluated separately. Two puffs of each brand of MDI were administered. Breath ethanol measurements were obtained at baseline and .25, .5, 1, 2, 3, 5, and 10 minutes after MDI use. Blood ethanol measurements were obtained at baseline and 1 and 10 minutes after MDI use.

RESULTS

Overall, Tornalate had the highest breath ethanol readings, with a mean ethanol level of 189 mg/dL recorded just after MDI use. Breath ethanol levels subsequently decreased rapidly over time. Mean breath ethanol concentrations were lower after the use of Bronkometer and undetectable after the use of Alupent. Blood ethanol levels were undetectable at all times tested.

CONCLUSION

MDIs may cause elevations of breath alcohol above the legal criteria for intoxication. These effects are transient and may be prevented by a 10-minute interval between the use of an MDI and breath alcohol testing.

Prevention of oral dichlorvos toxicity by different activated charcoal products in mice

STUDY OBJECTIVE

To determine whether immediate treatment with oral activated charcoal (AC) products of differing surface areas prevents clinical toxicity of a lethal oral dose of dichlorvos in mice.

DESIGN

An in vivo, prospective, randomized, placebo-controlled study using 75 male albino mice.

INTERVENTIONS

Fasting mice were administered 57.5 mg/kg of a 0.55% dichlorvos solution via feeding tube. One minute later, groups of 15 mice each received 1 or 2 g/kg of Actidose-Aqua AC or 1 or 2 g/kg of Sigma AC or sterile water by feeding tube. In this way, all mice received 15 mL/kg of an AC suspension or sterile water. The animals were observed for 24 hours for seizures or death.

RESULTS

In all treatment groups, mice were found to have significantly fewer seizures and deaths (P < .05) than the control group when compared by chi 2 and Fisher's exact tests. No statistical difference was found between the death and seizure rates when treatment groups were compared with each other. The group sizes were too small, however, to rule out significant type II error (beta > .2).

CONCLUSION

In this in vivo mouse model, all AC products tested decreased the incidence of seizures and death. Further studies should be done to investigate the clinical effects of AC products with different surface areas.

Urginea maritima (squill) toxicity

A 55 year-old female ingested two bulbs of Urginea maritime (squill) plant as a folk remedy for her arthritic pains. Her past history was significant for Hashimoto thyroiditis and she was hypothyroid upon presentation. Subsequent effects resembling those seen with cardiac glycoside intoxication included nausea, vomiting, seizures, hyperkalemia, atrioventricular block and ventricular arrhythmias resembling digitalis toxicity. A serum digoxin level by an enzyme immunoassay method was 1.59 ng/mL. Despite supportive treatment and pacing, the patient expired from ventricular arrhythmias 30 h after ingestion. Squill has been recognized since antiquity for the clinical toxicity of its cardiac glycosides, but this appears to be the first report of a fatality since 1966.