Review of Eastern coral snake (Micrurus fulvius fulvius) exposures managed by the Florida Poison Information Center Network: 1998-2010

CONTEXT

Envenomation by the Eastern coral snake is rare but may be associated with significant morbidity. While effective, acquisition of North American Coral Snake Antivenin (NACSAV) is difficult because production was discontinued for many years.

OBJECTIVE

The purpose of this study is to characterize coral snake exposures in Florida and determine the effects of varying treatment paradigms on patient outcomes.

METHODS

This study is an observational case series of cases received at Florida poison centers. Included cases were Eastern coral snake exposures occurring between January 1, 1998 and October 31, 2010. Excluded cases included those found to be unrelated or those not followed for at least 24 h post envenomation. Case comments were reviewed to obtain data. Comparisons were made between asymptomatic patients receiving empiric antivenom therapy (empiric group) and those asymptomatic patients who received antivenom upon developing signs of systemic envenomation (withhold group).

RESULTS

Of the 553 cases identified, 387 were included in the final analysis. According to case comments, 56.3% of patients had no reported systemic symptoms. Most commonly, patients were reported to have pain (40.6%), paresthesias (28.4%), nausea (12.7%), and emesis (11.4%). NACSAV was administered to 252 patients (65%). Of those patients receiving NACSAV, 18.25% were reported to have had an adverse reaction. Patients in the withhold group (n = 106) had significantly fewer minor, moderate, and major outcomes than patients in the empiric group (n = 134, p < 0.01).

DISCUSSION

While patients in the withhold group had favorable outcomes compared with those in the empiric group, this strategy cannot be applied to all patients presenting asymptomatic to healthcare facilities due to study limitations.

CONCLUSION

Further studies are needed to determine what treatment strategy is most appropriate for asymptomatic patients presenting to healthcare facilities.

[Immunohistochemistry study of EGFR expression in head and neck squamous cell carcinoma]

EGFR is an important transmembrane receptor member of the family of tyrosine kinases, that translates signals from both outside and inside the cell and plays a key role in numerous proceses that affect tumour development, growth, progresion, differentiation, inhibition of apoptosis and metastasis. Immunohistochemistry studies have shown that 40-80% of head and neck squamous cell carcinomas express EGFR and it has been suggested as a potential independent prognostic parameter. The objective of this study is to evaluate by immunohistochemistry the expresi6n of EGFR in a series of Head and Neck Squamous Cell Carcinoma and correlate it to clinico-pathological features and prognostic significance. We investigated expression of EGFR in 44 samples. There was a high expression in 41% of the cases. Even if we have not found that the expression of EGFR correlated with the prognosis of these patients the presence of EGFR is very important because there are chemical agents or drugs that can inhibit its activity.

The fission yeast TOR proteins and the rapamycin response: an unexpected tale

The TOR proteins are known as key regulators of cell growth in response to nutritional and mitogenic signals and as targets for the immunosuppressive and anti-cancerous drug rapamycin. The fission yeast Schizosaccharomyces pombe has two TOR homologues, tor1+ and tor2+. Despite their structural similarity, these genes have distinct functions: tor1+ is required under starvation, extreme temperatures, and osmotic or oxidative stress conditions, whereas tor2+ is required under normal growth conditions. Surprisingly, rapamycin does not seem to inhibit the S. pombe TOR-related functions. Rapamycin specifically inhibits sexual development in S. pombe, and this seems to stem from direct inhibition of the S. pombe FKBP12 homologue. Why S. pombe cells are resistant to rapamycin during the growth phase is as yet unclear and awaits further analysis of the TOR-dependent signaling pathways.

Rapamycin blocks sexual development in fission yeast through inhibition of the cellular function of an FKBP12 homolog

FKBP12 is a ubiquitous and a highly conserved prolyl isomerase that binds the immunosuppressive drugs FK506 and rapamycin. Members of the FKBP12 family have been implicated in many processes that include intracellular protein folding, transport, and assembly. In the budding yeast Saccharomyces cerevisiae and in human T cells, rapamycin forms a complex with FKBP12 that inhibits cell cycle progression by inhibition of the TOR kinases. We reported previously that rapamycin does not inhibit the vegetative growth of the fission yeast Schizosaccharomyces pombe; however, it specifically inhibits its sexual development. Here we show that disruption of the S. pombe FKBP12 homolog, fkh1(+), at its chromosomal locus results in a mating-deficient phenotype that is highly similar to that obtained by treatment of wild type cells with rapamycin. A screen for fkh1 mutants that can confer rapamycin resistance identified five amino acids in Fkh1 that are critical for the effect of rapamycin in S. pombe. All five amino acids are located in the putative rapamycin binding pocket. Together, our findings indicate that Fkh1 has an important role in sexual development and serves as the target for rapamycin action in S. pombe.

The fission yeast TOR homolog, tor1+, is required for the response to starvation and other stresses via a conserved serine

Targets of rapamycin (TORs) are conserved phosphatidylinositol kinase-related kinases that are involved in the coordination between nutritional or mitogenic signals and cell growth. Here we report the initial characterization of two Schizosaccharomyces pombe TOR homologs, tor1(+) and tor2(+). tor2(+) is an essential gene, whereas tor1(+) is required only under starvation and other stress conditions. Specifically, Deltator1 cells fail to enter stationary phase or undergo sexual development and are sensitive to cold, osmotic stress, and oxidative stress. In complex with the prolyl isomerase FKBP12, the drug rapamycin binds a conserved domain in TORs, FRB, thus inhibiting some of the functions of TORs. Mutations at a conserved serine within the FRB domain of Saccharomyces cerevisiae TOR proteins led to rapamycin resistance but did not otherwise affect the functions of the proteins. The S. pombe tor1(+) exhibits different features; substitution of the conserved serine residue, Ser(1834), with arginine compromises its functions and has no effect on the inhibition that rapamycin exerts on sexual development in S. pombe.

Quantitation of the change in GADD153 messenger RNA level as a molecular marker of tumor response in head and neck cancer

Cells injured by exposure to cisplatin (cDDP) undergo a cellular injury response that shares characteristics with responses produced by many other injurious agents. We sought to determine whether the increase of the message of the "growth arrest and DNA damage-inducible" gene, GADD153, could be used to assess the extent of the cellular injury response in model systems and in patients with head and neck cancer after treatment with cDDP. The mRNA levels of GADD153, a gene highly transcriptionally activated by cDDP damage, were increased in a transient, concentration-dependent manner by cDDP when human UMSCC10b head and neck carcinoma cells were treated with cDDP both in vitro and when grown as tumor xenografts in nude mice. There was a good correlation between the change in level of GADD153 mRNA and UMSCC10b cell kill by cDDP in vitro (r = 0.98). The magnitude of the increase was proportionally reduced in UMSCC10b sublines that were 3- or 6-fold resistant to cDDP. GADD153 mRNA levels were measured in biopsies obtained before and 24 h after treatment with cDDP from 32 patients with stage III/IV head and neck cancer. There was a relationship between the increase in GADD153 mRNA levels and the response rate. Seven of the 32 patients had no response and no increase in GADD153 mRNA level. Among the eight patients who attained a partial response, the increase in GADD153 message ranged from 0.7-2.5-fold. In contrast, 17 of 32 patients had a complete response, and this was accompanied by a 2-9-fold induction of GADD153. The mean increase in the complete responders (3.8+/-2.2-fold) differed significantly from that for the partial responders (1.6+/-0.9) and nonresponders (0.8+/-0.5; P <0.05); the difference between the partial responders and nonresponders was also significant (P <0.05). An increase of GADD153 mRNA of 1.75-fold or higher predicted a complete response, with a sensitivity of 94% and a specificity of 87%. We conclude that the magnitude of the increase in GADD153 mRNA is a promising candidate for service as an intermediate marker of head and neck tumor response to cDDP. The fact that the change in GADD153 mRNA reflects the actual extent of injury sustained by the tumor makes it particularly attractive as a potential marker. One strength of this approach is that it can provide a measure of the effectiveness of therapy as early as 24-48 h after the first dose of treatment.

Timing and classifying brief acoustic stimuli by songbirds and humans

The durations of animals' brief vocalizations provide conspecifics with important recognition cues. In the present experiments, zebra finches and humans (trained musicians) were rewarded for responding after S+ (standard) auditory signals from 56 to 663 ms and not for responding after shorter or longer S- (comparison) durations from 10 to 3684 ms. With either a single standard (Experiment 1) or multiple standards (Experiment 2), both zebra finches and humans timed brief signals to about the same level of accuracy. The results were in qualitative agreement with predictions from scalar timing theory and its connectionist implementation in both experiments. The connectionist model provides a good quantitative account of temporal gradients with a single standard (Experiment 1) but not with multiple standards (Experiment 2).

Frequency-range discriminations: special and general abilities in zebra finches (Taeniopygia guttata) and humans (Homo sapiens)

The acoustic frequency ranges in birdsongs and human speech can provide important pitch cues for recognition. Zebra finches and humans were trained to sort contiguous frequencies into 3 or 8 ranges, based on associations between the ranges and reward. The 3-range task was conducted separately in 3 spectral regions. Zebra finches discriminated 3 ranges in the medium and high spectral regions faster than in the low region and discriminated 8 ranges with precision. Humans discriminated 3 ranges in all 3 spectral regions to the same modest standard and acquired only a crude discrimination of the lowest and highest of 8 ranges. The results indicate that songbirds have a special sensitivity to the pitches in conspecific songs and, relative to humans, have a remarkable general ability to sort pitches into ranges.

The fission yeast mitotic regulator win1+ encodes an MAP kinase kinase kinase that phosphorylates and activates Wis1 MAP kinase kinase in response to high osmolarity

The Schizosaccharomyces pombe win1-1 mutant has a defect in the G2-M transition of the cell cycle. Although the defect is suppressed by wis1+ and wis4+, which are components of a stress-activated MAP kinase pathway that links stress response and cell cycle control, the molecular identity of Win1 has not been known. We show here that win1+ encodes a polypeptide of 1436 residues with an apparent molecular size of 180 kDa and demonstrate that Win1 is a MAP kinase kinase kinase that phosphorylates and activates Wis1. Despite extensive similarities between Win1 and Wis4, the two MAP kinase kinase kinases have distinct functions. Wis4 is able to compensate for loss of Win1 only under unstressed conditions to maintain basal Wis1 activity, but it fails to suppress the osmosignaling defect conferred by win1 mutations. The win1-1 mutation is a spontaneous duplication of 16 nucleotides, which leads to a frameshift and production of a truncated protein lacking the kinase domain. We discuss the cell cycle phenotype of the win1-1 cdc25-22 wee1-50 mutant and its suppression by wis genes.

Isoniazid poisonings in New York City

We identified 41 New York City residents who had been hospitalized at least overnight between January 1992 and September 1993 because of a toxic isoniazid (INH) exposure. Review of the available medical charts of 33 patients revealed that median age was 19 years, 27 (82%) were females, and 24 (83%) were taking INH chemoprophylaxis for tuberculosis infection. Twenty-two patients had seizures. Twenty-seven (82%) patients had attempted suicide using INH, and another three patients had intentionally misused INH by making up missed doses at one time. All patients survived. Physicians should be aware of the potential for INH toxicity and should assess their patients' current mental and psychosocial status when prescribing it. INH toxicity should be considered when young patients, particularly females, present with unexplained intractable seizures, and treatment with pyridoxine should be given.

all-trans retinoic acid enhances cisplatin-induced apoptosis in human ovarian adenocarcinoma and in squamous head and neck cancer cells

Cisplatin exerts its cytotoxicity by inducing apoptosis. Similarly, all-trans retinoic acid (ATRA) causes apoptosis in certain cells. We studied the interaction of cisplatin and ATRA in human ovarian adenocarcinoma cells 2008, in human head and neck squamous carcinoma cells UMSCC10b, and in their respective cisplatin-resistant sub-lines. ATRA enhanced the cytotoxicity of cisplatin. The interaction of the drugs was synergistic in combination index-isobologram analyses (combination index >0.5 at 50% cell survival) in all of the cell lines tested. ATRA inhibited the cellular accumulation of the cisplatin analogue [3H] cis-dichloroethylenediamineplatinum(II) by 22-33% in three of four cell lines tested but did not alter the cellular content of reduced glutathione. The expression of Bcl-2 relative to Bax decreased more after combined treatment with cisplatin and ATRA than after either drug alone. The apoptotic mechanism of cell death was confirmed by demonstrating cleavage of poly(ADP-ribose)polymerase and by morphological analysis. The combined treatment with ATRA and cisplatin induced apoptosis in significantly more cells than either drug alone. We conclude that ATRA enhances the cytotoxicity of cisplatin by facilitating apoptosis in ovarian and head and neck carcinoma cells.

Rapamycin specifically interferes with the developmental response of fission yeast to starvation

Rapamycin is a microbial macrolide which belongs to a family of immunosuppressive drugs that suppress the immune system by blocking stages of signal transduction in T lymphocytes. In Saccharomyces cerevisiae cells, as in T lymphocytes, rapamycin inhibits growth and cells become arrested at the G1 stage of the cell cycle. Rapamycin is also an effective antifungal agent, affecting the growth of yeast and filamentous fungi. Unexpectedly, we observed that rapamycin has no apparent effect on the vegetative growth of Schizosaccharomyces pombe. Instead, the drug becomes effective only when cells experience starvation. Under such conditions, homothallic wild-type cells will normally mate and undergo sporulation. In the presence of rapamycin, this sexual development process is strongly inhibited and cells adopt an alternative physiological option and enter stationary phase. Rapamycin strongly inhibits sexual development of haploid cells prior to the stage of sexual conjugation. In contrast, the drug has only a slight inhibitory effect on the sporulation of diploid cells. A genetic approach was applied to identify the signal transduction pathway that is inhibited by rapamycin. The results indicate that either rapamycin did not suppress the derepression of sexual development of strains in which adenylate cyclase was deleted or the cyclic AMP-dependent protein kinase encoded by pka1 was mutated. Nor did rapamycin inhibit the unscheduled meiosis observed in pat1-114 mutants. Overexpression of ras1+, an essential gene for sexual development, did not rescue the sterility of rapamycin-treated cells. However, expression of the activated allele, ras1Val17, antagonized the effect of rapamycin and restored the ability of the cells to respond to mating signals in the presence of the drug. We discuss possible mechanisms for the inhibitory effect of rapamycin on sexual development in S. pombe.

A novel organ preservation protocol for advanced carcinoma of the larynx and pharynx

OBJECTIVE

To pilot a targeted chemoradiation protocol for patients with advanced carcinoma of the larynx and pharynx that would circumvent upper aerodigestive tract dysfunction related to major oncologic surgery.

DESIGN

Weekly intra-arterial infusions of supradose cisplatin (150 mg/m2 per week x 4) rapidly delivered to the tumor bulk, simultaneous intravenous sodium thiosulfate for systemic drug neutralization, and conventional external-beam irradiation (1.80-2.00 Gy per fraction x 35) were used. Between February 1991 and April 1994, 42 patients were treated who would otherwise have required a major resection of the tongue base, pharyngeal wall, or larynx.

MAIN OUTCOME MEASURES

Tumor response, toxic effects, disease control above the clavicle, preservation of the larynx, maintenance of oral nutrition, and overall and disease-related 2-year survival.

RESULTS

Three complications were related to the weekly transfemoral superselective intra-arterial procedures performed 160 times. Grade 3 to 4 chemotoxic effects were infrequent, occurring in 9 (5.5%) of 160 cycles, and only 1 patient required a radiotherapy break because of severe mucositis. A complete response in the primary site was obtained in 36 (86%) of 42 patients, 2 of whom had residual disease in the neck. Median follow-up was 13 months (range, 3-46 months). To date, there have been 5 recurrences: 2 regional and 3 distant. The 2-year overall and disease-related survival was 64% and 76%, respectively. The rate of disease control above the clavicle at 2 years was 86%.

CONCLUSIONS

We believe this chemoradiation protocol represents an effective management scheme for patients with advanced head and neck cancer while minimizing dysfunction and possibly improving survival.

A multicopy suppressor of a cell cycle defect in S. pombe encodes a heat shock-inducible 40 kDa cyclophilin-like protein

Cyclophilins are peptidyl-prolyl cis-trans isomerases (PPIases) which have been implicated in intracellular protein folding, transport and assembly. Cyclophilins are also known as the intracellular receptors for the immunosuppressive drug cyclosporin A (CsA). The most common type of cyclophilins are the 18 kDa cytosolic proteins containing only the highly conserved core domain for PPIase and CsA binding activities. The wis2+ gene of the fission yeast Schizosaccharomyces pombe was isolated as a multicopy suppressor of wee1-50 cdc25-22 win1-1, a triple mutant strain which exhibits a cell cycle defect phenotype. Sequence analysis of wis2+ reveals that it encodes a 40 kDa cyclophilin-like protein, homologous to the mammalian cyclophilin 40. The 18 kDa cyclophilin domain (CyP-18) of wis2 is followed by a C-terminal region of 188 amino acids. The C-terminal region of wis2 is essential for suppression of the triple mutant defect. Furthermore this region of the protein is able to confer suppression activity on the 18 kDa S.pombe cyclophilin, cyp1, since a hybrid protein consisting of an 18 kDa S.pombe cyclophilin (cyp1) fused to the C-terminus of wis2 shows suppression activity. We also demonstrate that the level of wis2+ mRNA increases 10- to 20-fold upon heat shock of S.pombe cells suggesting a role for wis2+ in the heat-shock response.

Lateral rhinotomy and medial maxillectomy

Lateral rhinotomy and medial maxillectomy have evolved in the last 25 years as the treatment of choice for most neoplastic lesions involving the lateral nasal wall. Technical refinements have allowed this procedure to be performed with acceptable and minimal morbidity. This approach has had its widest application in the treatment of inverted papilloma, with a concomitant marked reduction in the recurrence rate of this tumor compared with more limited procedures. Its advantages are the excellent exposure provided, the opportunity to extend the approach to adjacent areas of tumor extension (orbit, cranial vault, frontal and contralateral ethmoid sinus), and en bloc removal of neoplasms. This approach remains the standard of treatment for lateral nasal wall tumors.

Anticholinergic poisoning associated with herbal tea

An outbreak of cholinergic poisoning occurred in New York City during a 3-day period. Seven individuals from three families of South American origin were affected. Signs and symptoms of illness included dry skin, hyperthermia, tachycardia, dilated pupils, agitation, and hallucinations. Onset of illness in all cases was temporally associated with consumption of a tea that was labeled "Paraguay Tea" and was purchased from a grocery store specializing in South American foods. Paraguay tea, made from the leaves of the holly, Ilex paraguariensis, contains caffeine and theophylline and is a popular beverage in South America. Samples of the tea analyzed with gas chromatography contained belladonna alkaloids but neither caffeine nor theophylline. An investigation by the New York City Department of Health personnel determined that the tea was from a single lot, imported by one distributor, and sold at one grocery store. Unsold inventories of the tea were quarantined, and no further cases of anticholinergic poisoning were reported.

Classification of frequencies into ranges by songbirds and humans

We trained songbirds and humans in go/no-go discriminations among 27 tones. In the compact discrimination, S + s formed a contiguous middle range (3080-4040 Hz), and S-s formed contiguous lower (2000-2960 Hz) and upper (4160-5120 Hz) ranges. In the distributed discrimination, S + s were spread across all 3 ranges. Songbirds acquired the compact discrimination more quickly and with higher accuracy than humans. Songbirds acquired the distributed discrimination only after much extended training; humans did not acquire the distributed discrimination. Compact groups (birds and humans) accurately classified test tones spaced 60 Hz from the training tones, but the distributed groups did not. A single reversal in discrimination between tones on the boundary between the lower S- and middle S + ranges did not propagate to all the tones in either range. A neural network model provided an account of the classification of tones in songbirds and humans.

Selective intra-arterial infusion of high-dose cisplatin in patients with advanced head and neck cancer results in high tumor platinum concentrations and cisplatin-DNA adduct formation

A group of 23 patients with advanced head and neck cancer were treated with highly selective intra-arterial (IA) cisplatin 150 mg/m2 delivered rapidly through microcatheters. The systemic effects of cisplatin were neutralized by concurrent administration of sodium thiosulfate. Two-to-threefold higher tumor platinum contents were detected in tumor biopsies after selective IA cisplatin administration compared to historical controls (treated with 100 mg/m2 IA). Cisplatin-induced DNA modification in human tumor biopsies was quantitated using the antiserum NKI-A59. High levels of cisplatin DNA adducts were detected which correlated linearly with the tumor platinum content (r2 = 0.62). The addition of radiotherapy to this high dose intensity cisplatin treatment resulted in a 92% complete response (CR) rate (12 of 13 patients achieved a CR). Since no difference in tumor platinum content was detected between patients receiving or not receiving radiotherapy (13 and 10 patients, respectively), but the response rate was substantially different (12 CR and 1 partial response with radiotherapy versus 6 partial and 4 non-responders without radiotherapy), these data suggest that the high platinum levels achieved by selective IA infusion were sufficient to produce enough interaction with radiotherapy to cause a 92% CR rate. Whether this interaction is additive or synergistic is as yet unclear.

Slight renal effect of mercury from amalgam fillings

The current study was to answer the question: Is enough mercury absorbed from dental amalgam fillings to produce renal damage? One hundred healthy adults (18-44 years old) filled out health questionnaires and voided urine samples. Urine mercury concentration and N-acetyl-beta-glucosaminidase (NAG) were measured. Subjects were grouped into those having amalgam fillings (N = 66) and those without (N = 34). Median (95% Confidence Interval) urine mercury was 1 (1-2) and 0 (0-0.6) ng/ml (P < 0.01) and median urine NAG was 23 (18-27) and 16 (11-18) units (P < 0.05) in the two groups respectively. People with mercury amalgam fillings excreted slightly more mercury than people without them, and have a very small increase in urinary NAG excretion that is probably of no clinical significance. This dose of mercury absorbed from amalgam appears to be too little to be a public health hazard for renal injury.

A targeted supradose cisplatin chemoradiation protocol for advanced head and neck cancer

BACKGROUND

Hypothesizing that cisplatin (DDP) drug resistance is dose dependent and the radiosensitizing effect of DDP is clinically beneficial, we conducted a chemoradiation protocol using extremely high doses of DDP delivered intra-arterially (IA) to locally advanced head and neck tumors.

PATIENTS AND METHODS

Twenty-nine patients with untreated stage IV disease received 4 weekly infusions of 150 mg/m2, simultaneous systemic DDP neutralization with intravenous (IV) bolus sodium thiosulfate, and concomitant radiotherapy (180 to 200 cGy/day x 35 fractions).

RESULTS

The complete response rate of the 24 evaluable patients as determined with repeat biopsies was 23/24 (96%). Of the 29 patients evaluable for toxicity, central nervous system complications related to the infusion technique occurred with 2/110 infusions, both of which were reversible. The rate of grade III to IV chemotoxicity was 13%. The median length of follow-up was 22 months. There have been 6 recurrences: 1 local; 3 regional; and 2 at distant sites. The projected overall and disease-free 3-year survival was 88% and 53%, respectively.

CONCLUSION

We conclude that the combination of rapid selective delivery of supradose DDP/IV thiosulfate neutralization and concomitant radiotherapy can be safely and effectively applied to patients with advanced head and neck cancer. Preliminary survival analysis indicates that this approach may improve the prognosis for patients with an otherwise devastating disease.

Mononeuritis multiplex. A harbinger of acute leukemia in relapse

OBJECTIVE

To report the findings in a patient who developed severe mononeuritis multiplex in the setting of hematologic remission from acute myeloid leukemia.

DESIGN

Single case report of the patient, hospital course, and autopsy findings.

PATIENT

A 63-year-old woman with a history of acute myeloid leukemia in hematologic remission experienced a succession of acute clinical neuropathies (left median, right radial, and left sciatica) several months before hematologic relapse of leukemia. Electrophysiologic tests localized the abnormalities of the left median and right radial nerves to the arms, and a magnetic resonance imaging scan of the right arm revealed focal swelling of the radial nerve proximal to the elbow. The patient refused treatment for leukemic relapse and died about 6 months after the onset of the neuropathies. An autopsy revealed leukemic infiltrates in multiple nerves without appreciable involvement of the cauda equina or many of the proximal nerves.

CONCLUSION

Mononeuritis multiplex, without polyradiculopathy or diffuse peripheral neuropathy, can be a presenting feature of leukemia.

Sexual Preferences of Female Zebra Finches: Imprinting On Beak Colour

Abstract

Sexual preferences of adult zebra finches are influenced by early learning of parental characteristics. We studied how imprinting affects the preference of female zebra finches for male beak colour. The beaks of male and female parents were painted, 2-3 days before hatch and thereafter until the young were fledged, as follows: male red, female orange (R-O group); male orange, female red (O-R group); both male and female red (R-R group); or both male and female orange (O-O group). Females were raised by painted parents until 35 days, then visually isolated from other birds until test at 100 days. In 4-way choice tests using red- and orange-painted stimulus males, females from Groups O-R and R-O chose males with beaks painted the same colour as their father's beak, whereas females from Groups R-R and O-O did not. We conclude that preference for male beak colour was acquired only by females reared by parents with unlike, discriminative, beak colours. The results suggest an associative learning basis for sexual imprinting.

Cerebral venous thrombosis in paroxysmal nocturnal hemoglobinuria: report of two cases

We report the clinical, radiologic, and postmortem findings in two patients with paroxysmal nocturnal hemoglobinuria (PNH) who developed cerebral venous thromboses (CVTs). In contrast with those in most published cases, our patients did not have focal neurologic signs. Antemortem diagnosis of CVT had been made by MR cerebral venograms. We conclude that (1) PNH should be considered in any patient with stroke associated with iron deficiency anemia, hemolysis, hemoglobinuria, or hemosiderinuria; (2) PNH should be in the differential diagnosis of CVT; (3) the latter could present without focal neurologic signs; and (4) MR cerebral venography may be a reliable diagnostic alternative to cerebral angiography when CVT is suspected.

Paperless Poison Center: an alternative to bubbling

The Paperless Poison Center (PPC) is a computer software program which allows for direct entering of data collection, data submission to the American Association of Poison Control Centers (AAPCC) and on-site analysis of data using RBASE. A comparison of the computer collection system vs bubbling of AAPCC sheets is discussed as to speed and ease of use, accuracy and cost. A summary of our comparison concludes that the computerized system is cost effective, more efficient, and more accurate than the paper method. Poison Information Specialist (PIS) acceptance of the program has been overwhelmingly positive.

Psychologic aspects of childhood reflex neurovascular dystrophy

Psychosocial factors in 21 families with children affected by reflex neurovascular dystrophy were studied. Each family was interviewed and given a battery of standardized psychologic tests. Two distinct types of families were identified. Fifteen families showed high internal cohesion, expressiveness, and organization and low levels of conflict. Six families showed high overt conflict with low levels of family cohesion, expressiveness, and organization. In all families parental enmeshment with the patient was present. Marital discord was present in 12 families. Thirteen patients had significant school problems (ten had learning disabilities). Although most of the children were described as especially bright, only four had above average intelligence test scores. Four had a history of sexual abuse. The patients and their mothers perceived the health problem as significantly worse than did children with arthritis from whom similar scores had been obtained. Possible role models with similar symptoms were reported by ten patients. These data support the concept that childhood reflex neurovascular dystrophy is frequently a stress-related disease; the therapeutic approach to treating these children and their families must take these psychosocial factors into account.

Treatment of myelodysplastic syndromes with low-dose oral 6-thioguanine

Several cytotoxic agents when used in vitro in very low concentrations have been shown to induce differentiation of leukemic cells. We treated 18 patients with myelodysplastic syndromes with low-dose oral 6-thioguanine (6-TG; 20 to 60 mg daily). Four patients demonstrated significant improvement in peripheral blood counts. An additional three patients had significant reductions in the percentage of leukemic myeloblasts in the marrow without a corresponding improvement in peripheral counts. With the exception of a fall in the peripheral neutrophil count in four patients requiring dose reductions, no toxicity was observed. Low-dose oral 6-TG gives a response rate in myelodysplastic syndromes similar to that of parenteral agents such as cytosine arabinoside. Given the ease of administration and lack of toxicity, oral 6-TG may be a useful treatment modality for these syndromes either alone or in combination with other differentiation-enhancing agents.

Clearance of ethylene glycol by kidneys and hemodialysis

A patient with acute ethylene glycol poisoning was treated with ethanol administration and hemodialysis, and his renal function remained consistently normal. Serial measurements of serum and urine levels of urea, creatinine, ethylene glycol, and ethanol were performed to compare the relative contributions of the hemodialyzer and the patient's kidneys in clearing ethylene glycol from the blood. Simultaneous measurements of the serum-osmolal gap (corrected for ethanol) and anion gap were correlated with these data. Mean renal clearance of ethylene glycol was 27.5 +/- 4.1 ml/min, with a fractional ethylene glycol excretion of 19.8 +/- 1.5%. This was lower than the mean urea clearance of 89.4 +/- 11.0 ml/min and fractional urea excretion of 66.0 +/- 7.8%. Hemodialyzer clearance of ethylene glycol was 156 ml/min. There was a nearly exact correlation between the serum ethylene glycol level and the corrected osmolal gap (r = 0.998, p less than 0.01). The calculated renal elimination half-life of ethylene glycol was 18 hr. We conclude that with a moderate diuresis, the normal human kidney contributes significantly to the removal of ethylene glycol from the blood. Corrected serum osmolal gap provides a nearly exact approximation of the serum ethylene glycol level and is a useful therapeutic guide.

Serum lidocaine concentrations following subcutaneous administration

Serum lidocaine concentrations were determined following subcutaneous administration for local anesthesia in the management of lacerations in the emergency room setting. Thirty patients received doses of lidocaine hydrochloride 1% solution ranging from 10 to 300 mg. Venous blood samples were drawn 15, 30, 45, and 60 minutes after lidocaine administration. Serum lidocaine determinations were made using an immunoassay system and verified by gas chromatography. There was no evidence of lidocaine absorption from the subcutaneous injection sites. There were no detectable concentrations of lidocaine in any of the patient blood samples. The absorption characteristics of subcutaneously administered lidocaine appear to be altered in traumatized tissue.

Management of overdose with psychoactive medications

General management of the patient who has ingested an overdose of psychoactive medication is emphasized, since the suicidal patient has almost invariably taken multiple substances and often alcohol as well. The drug groups considered in detail include the sedative hypnotics, tricyclic antidepressants, phenothiazines, and lithium.

New York City's Poison Control Center: a systematic approach to a complex problem

A pooling of public and private resources has created a regional poison control system which provides information and education to the medical and lay communities of metropolitan New York City. An overview of the poisoning problem on a national scale is followed by a description of the operations by the Center, and a special volunteer effort.

Teaching the recognition of odors

Odor recognition is a valuable skill for the emergency services provider, particularly when dealing with the poisoned patient. A simple "ten-tube sniffing bar" emphasizing sensory recognition of common toxins in association with representative case histories in an effective emergency services teaching tool. The odor, toxin, case history, and appropriate references are described for each component of the sniffing bar.

Bacterial food poisoning: what to do if prevention fails

The numerous etiologies of food poisoning make assessment of this disease a cultural, bacteriologic, chemical, gastronomic, and epidemiologic research project. Cautious investigation and study of etiologic possibilities are most stimulating intellectual exercises and obviously benefit the patient. Often, a case of food poisoning necessitates interaction with the local health department in search of the causative agent before other people are afflicted. A thorough knowledge of this field is essential to provide reasonable care to the millions "poisoned" by food annually.

Anticholinergic poisoning

Since the fall of 1979 numerous patients have been brought to emergency departments in New York City after being poisoned with an alcoholic beverage. On admission to the emergency services, they were noted to manifest significant anticholinergic toxicity. An analysis of the case histories, clinical presentations and laboratory data suggests that scopolamine eyedrops were deliberately used to poison these patients.