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1.  Be Careful with an IV Line 
Obtaining an intravenous (IV) access is a simple procedure which can be done in almost any hospital setting. One of the most dreaded complications of this procedure is an inadvertent intra-arterial cannulation. This can result in an accidental injection of medications intra-arterially, which can potentially lead to life altering consequences. In the hope that these types of events can be prevented, we are presenting a case of a 57-year-old male who underwent bougie dilatation for an oesophageal stricture and was accidentally given medication for pain management intra-arterially through an improperly placed IV line, which resulted in ischaemia, gangrene and subsequent loss of the hand. Those who try to obtain an IV access should always be on the lookout for possible clues that can prevent an inadvertent IA injection, especially if cannulation is in an area where an artery is in close proximity to a vein; these clues include but are not limited to the following: a bright-red flash of blood in the cannula, pulsatile movement of blood in the IV line, and intense pain or burning at the site of injection. These signs, as well as educating the patient on early symptoms of ischaemia, may allow early action to be taken, to prevent irreparable damage. We always have to be careful when we insert an I.V line.
doi:10.7860/JCDR/2014/7937.4150
PMCID: PMC4003627  PMID: 24783122
Intravenous access; Intra-arterial cannulation; Intra-arterial injection; Gangrene
2.  Persistent left superior vena cava: diagnosed by bedside echocardiography in a liver transplant patient: a case report 
Korean Journal of Anesthesiology  2014;67(6):429-432.
In most cases, persistent left superior vena cava (PLSVC) is asymptomatic and discovered accidentally. This case involves a 43-year-old male who underwent an emergency cadaveric liver transplantation. Postoperatively, the left internal jugular vein was cannulated using a sono-guided Seldinger technique in the intensive care unit. But the chest X-ray showed that the catheter followed the left paramediastinal course instead of crossing midline to the right to enter the superior vena cava. In consideration of the patient's status, an intra-arterial or extra-vascular placement could be excluded. For a diagnosis, we performed a bed-side transthoracic echocardiography with an agitated saline micro-bubble test. When agitated saline was injected through the catheter, the coronary sinus was initially opacified, and then the right atrium followed. In conclusion, we were able to make a diagnosis of PLSVC by a bedside test without radiation exposure.
doi:10.4097/kjae.2014.67.6.429
PMCID: PMC4280483  PMID: 25558346
Congenital heart defects; Contrast media; Diagnostic use; Echocardiography
3.  Revalidation of a modified and safe approach of stellate ganglion block 
Indian Journal of Anaesthesia  2011;55(1):52-56.
Stellate ganglion block (SGB) is very effective in management of chronic regional pain syndrome (CRPS-1). However, serious complication may occur due to accidental intravascular (intra-arterial) injection of local anaesthetic agents. Abdi and others, has suggested a modified technique in which fluoroscopy-guided block is given at the junction of uncinate process and body of vertebra at C7 level. In this approach vascular structures remain away from the trajectory of needle and thus avoid accidental vascular injection. We have used this technique of SGB in nine patients who were treated for CRPS-I. The blocks were effective in all the patients all the time without any vascular or other serious complication.
doi:10.4103/0019-5049.76601
PMCID: PMC3057247  PMID: 21431054
CRPS-I; modified technique; stellate ganglion block
4.  Accidental intra-arterial injection. 
Archives of Disease in Childhood  1978;53(5):396-400.
Accidental intra-arterial injection of intramuscular antibiotic preparations is described in 3 cases in infants. In 2 benzathine penicillin was injected, and in 1 rolitetracycline. The clinical features are dominated by arteriolar obstruction which produces gangrene of the most severely affected limb. In addition, neuroloigcal involvement occurs when vessels to nerves or spinal cord are involved. The arteriolateral aspect of the thigh is preferable to the buttock as a site for intramuscular injection, and a short (2.5 cm) needle should be used to minimise the risk of intra-arterial injection.
Images
PMCID: PMC1544903  PMID: 666353
5.  Intravascular Lidocaine Toxicity: Influence of Epinephrine and Route of Administration 
Anesthesia Progress  1985;32(2):57-61.
The intravenous (tail vein) and intra-arterial (internal carotid artery) toxicities of 2% lidocaine, 1:100,000 epinephrine, and the combination of drugs were tested in unanesthetized rats. At least 3 doses (normally 10 animals/dose) were used per drug and route of administration; the drugs were given by bolus injection. Probit analysis of lethal dose-response curve data revealed that lidocaine, with or without epinephrine, was significantly more toxic intravenously than by internal carotid artery injection and that epinephrine potentiated the intravascular toxicity of lidocaine. These results modify proposals suggesting that local anesthetics injected accidentally into a branch of the external carotid artery may cause serious adverse reactions by flowing in retrograde fashion down to the internal carotid artery and then directly to the brain.
PMCID: PMC2148526  PMID: 3859230
6.  Unrecognized hand ischemia after intraarterial drug injection: successful management of a "near miss" event 
Background
Complications arising from accidental intraarterial drug injections have been described in the past. However, given the multitude of injected substances and complex pathophysiology, guidelines regarding diagnosis and management of patients with intraarterial injections remain vague. As such it remains unclear, when to expect limb ischemia and whether and for how long to monitor patients after intraarterial injections.
Case report
We present the case of a "near miss event" in an i.v. drug abuser presenting to the emergency department 3 hours after injection of water dissolved zolpidem (Ambien™) tablets into the right ulnar artery. Chief complaint was forearm pain. Clinical examination at the time revealed no concern for limb ischemia and patient was discharged. The patient returned unplanned 18 hours after injection with an ischemic right hand. Angiography revealed no flow in the distal ulnar artery and minimal flow in the palmar arch. Emergent intraarterial thrombolysis with Urokinase was performed and restored hand perfusion. Clinical follow-up 3 months after injury showed full recovery with regular recapillarisation and normal Allen test.
Conclusion
This case report highlights the need to rigorously monitor patients with suspected intraarterial injections for potential delayed onset of limb ischemia. This is to our knowledge the first described case report of a successful revascularization after prolonged ischemia with delayed onset after zolpidem injection. We recommend close monitoring of these patients for at least 24 hours in addition to starting prophylactic anticoagulation.
doi:10.1186/1754-9493-2-32
PMCID: PMC2614960  PMID: 19068131
7.  Femoral artery necrosis due to parenteral intravascular drug misuse: A case report and literature review 
The Ulster Medical Journal  2008;77(3):203-204.
Accidental intra-arterial injection as a consequence of drug misuse has been described in both the upper and lower limbs. We present a case in which a drug abuser injected heroin into his femoral artery. This resulted in necrosis of the femoral artery requiring an autologous graft. A life threatening haemorrhage necessitated ligation of the common femoral artery. His limb survived.
PMCID: PMC2604479  PMID: 18956804
Femoral artery necrosis; Intravenous drug abuse; Intra-arterial injection
8.  Cardiac arrest associated with carbon dioxide gas embolism during laparoscopic surgery for colorectal cancer and liver metastasis -A case report- 
Korean Journal of Anesthesiology  2012;63(5):469-472.
Clinically apparent carbon dioxide (CO2) gas embolism is uncommon, but it may be a potentially lethal complication if it occurs. We describe a 40-year-old woman who suffered a CO2 gas embolism with cardiac arrest during laparoscopic surgery for colorectal cancer and liver metastasis. Intra-abdominal pressure was controlled to less than 15 mmHg during CO2 gas pneumoperitoneum. The right hepatic vein was accidentally disrupted during liver dissection, and an emergent laparotomy was performed. A few minutes later, the end-tidal CO2 decreased, followed by bradycardia and pulseless electrical activity. External cardiac massage, epinephrine, and atropine were given promptly. Ventilation with 100% oxygen was started and the patient was moved to the Trendelenburg position. Two minutes after resuscitation was begun, a cardiac rhythm reappeared and a pulsatile arterial waveform was displayed. A transesophageal echocardiogram showed air bubbles in the right pulmonary artery. The patient recovered completely, with no cardiopulmonary or neurological sequelae.
doi:10.4097/kjae.2012.63.5.469
PMCID: PMC3506861  PMID: 23198045
Carbon dioxide gas embolism; Laparoscopic surgery; Transesophageal echocardiography
9.  Impact of a newly opened prison on an accident and emergency department 
Objective: To determine the impact of a newly opened prison on an accident and emergency (A&E) department.
Method: A new category B prison opened in April 1999, the first privately run prison in Scotland and the third largest in population. All prisoners referred to the A&E department for treatment were identified prospectively during the first year after the opening of the prison.
Results: 99 prisoners and four members of staff attended during the one year period. Ages ranged from 18–64 years with a mean age of 29.8 years. Presentations were as a result of deliberate self harm (22%), injury after violence (18%), sports injury (15%), surgical condition (15%), medical illness (13%), accidental injury (9%), ENT problem (2%), and miscellaneous (6%). Thirty seven prisoners (35.6%) were admitted to the hospital. Further review at outpatient clinics was arranged for 15 prisoners. One prisoner died, the result of suicide by hanging. The remaining prisoners were returned to the prison for further management by the prison medical and nursing team. Twelve prisoners re-attended a total of 37 times, ranging from twice to a maximum of eight visits. Some 42.3% of attendances were during "working hours" (09.00–17.00) and 57.7% attended "out of hours" (17.00–09.00). Twenty four referrals (23.1%) were deemed inappropriate by the prison medical team on retrospective review. Sixteen of these occurred "out of hours". Forty one prisoners (39.4%) were known to have a history of injecting drug misuse. Including re-attenders, 59 presentations (56.7%) to the A&E department had a history of injecting drug misuse. Of these 41 prisoners, 11 (26.8%) were hepatitis C positive, with eight of these having a positive polymerase chain reaction test. No prisoners had HIV and only one prisoner was hepatitis B positive.
Conclusion: The opening of the prison resulted in only a slight increase in the workload of the A&E department. A significant proportion of prisoners were admitted to the hospital highlighting the practical and logistical problems of managing people restrained and in custody. Most cases can be safely referred back to the prison. Increased input is required from the prison medical team when dealing with deliberate self harm, frequent attenders, and "out of hours" referrals. All A&E staff must be aware of the increased risk of hepatitis C infection when dealing with a confined prison population.
doi:10.1136/emj.20.1.48
PMCID: PMC1726011  PMID: 12533368
10.  Identification of neonatal near miss by systematic screening for metabolic acidosis at birth 
Facts, Views & Vision in ObGyn  2011;3(4):281-285.
Aims: To evaluate the relevance of systematic screening for neonatal metabolic acidosis at birth as part of perinatal audit.
Methods: For every baby, born in Ziekenhuis Oost Limburg, Genk Belgium between 1/1/2010 and 31/12/2010, cord blood was analysed to diagnose metabolic acidosis, defined as arterial or venous pH ≤ 7.05 or 7.17 respectively, in association with base excess of ≤ -10 mmol/L. Three observers identified indicators for suboptimal peripartal care with likely contribution to metabolic acidosis. In a multidisciplinary consensus meeting, these indicators were classified into 5 categories : (a) fetal monitoring error (b) labour management error, (c) instrumental vaginal delivery for fetal distress within 2 h of second stage, (d) non-obstetric medical complications, (e) preterm births or accidental cases at term.
Results: In a total of 2117 neonates, there were 11 intra-uterine, 1 intrapartum and 3 early neonatal deaths, bringing early perinatal mortality rate at 7.1‰. Metabolic acidosis was identified in 23 (1.1%) babies, of which 21 (91.3%) left hospital in good clinical condition. Two babies (0.9‰), born in category c, had chronic neurologic symptoms.
Discussion: Systematic screening for neonatal metabolic acidosis caused a 2.5-fold increase of case identifications eligible for perinatal audit and opened perspectives towards rationalised improvement of perinatal care, in addition to the information obtained from cases of perinatal mortality. Next to indicators of perinatal mortality, perinatal audit programs should include neonatal metabolic acidosis as an extra parameter for quality assessment of perinatal care.
Conclusion: Adding cases of near-miss neonatal morbidity to perinatal mortalities in perinatal audit programs increases opportunities for improvement of perinatal care.
PMCID: PMC3987470  PMID: 24753878
Birth asphyxia; metabolic acidosis; neonatal care; perinatal outcome; perinatal audit
11.  Radiation-induced chromosome damage in human lymphocytes 
ABSTRACT Analysis for chromosome aberrations in human peripheral blood lymphocytes has been developed as an indicator of dose from ionising radiation. This paper outlines the mechanism of production of aberrations, the technique for their analysis and the dose-effect relationships for various types of radiation. During the past ten years the National Radiological Protection Board has developed a service for the UK in which estimates of dose from chromosome aberration analysis are made on people known or suspected of being accidentally over-exposed. This service can provide estimates where no physical dosemeter was worn and is frequently able to resolve anomalous or disputed data from routine film badges. Several problems in the interpretation of chromosome aberration yields are reviewed. These include the effects of partial body irradiation and the response to variations in dose rate and the intermittent nature of some exposures. The dosimetry service is supported by a research programme which includes surveys of groups of patients irradiated for medical purposes. Two surveys are described. In the first, lymphocyte aberrations were examined in rheumatiod arthritis patients receiving intra-articular injections of colloidal radiogold or radioyttrium. A proportion of the nuclide leaked from the joint into the regional lymphatic system. In the second survey a comparison was made between the cytogenetic and physical estimates of whole body dose in patients receiving iodine 131 for thyroid carcinoma.
Images
PMCID: PMC1008276  PMID: 338021
12.  Accident and emergency attendances by children under the age of 1 year as a result of injury 
Objectives: To examine all accident and emergency (A&E) department attendances by children under the age of 1 year over a period of 12 months. Also to try to identify the prevalence and severity of accident types in small children and to suggest ways to reduce such accidents.
Methods: The A&E department of the Royal Aberdeen Children's Hospital (RACH) serves a population of over half a million. All children under 1 year of age attending this department in the year 2000 had their case notes reviewed by the author and the cause, type, and severity of the illness or injury noted.
Results: During the 12 month audit period 1416 new cases under the age of 1 year presented to RACH, 790 of which presented directly to A&E. Six hundred and eighteen (78%) were self referred and 116 children attended A&E on more than one occasion during the year. Four hundred and thirty four (55%) of the A&E attendances were classed as "accidents", the remainder were mainly for medical conditions such as respiratory distress. Two hundred and sixty four (61%) were caused by falls and 38% were admitted for inpatient management. Two hundred and twenty nine (29%) required radiographs, which revealed 30 fractures. Thirty seven children sustained scalds/burns and there were 33 accidental ingestions. Six cases were judged to be non-accidental.
Conclusions: There is a surprisingly high rate of "accidental" injury in this age group, bringing into question the effectiveness of current accident prevention strategies. Perhaps specific prevention advice should be targeted at parents and carers of young children. There should always be a high index of suspicion for non-accidental injury.
doi:10.1136/emj.20.1.21
PMCID: PMC1726023  PMID: 12533361
13.  A retrospective analysis of acute poisoning during pregnancy 
Objective
The aim of this study is to investigate and analyse pregnant women who were admitted to our emergency service due to acute poisoning.
Material and Methods
All cases were retrospectively collected from our computer records and emergency record book between 01.01.2006 and 01.01.2010; the registration data on age, gravidity, gestational week, whether the poisoning was deliberate or accidental, causative agent, admission time, treatment results and mortality outcome were collected and analyzed.
Results
Eighty eight women admitted with acute poisoning were known to be pregnant and the poisoning was accidental in 23% of the cases, while 77% were suicidal intoxications. 74% of patients were in the 21–34 age group. Accidental intoxications were due to carbon monoxide, foods and cleaning products. 75.4% of the suicidal poisonings were caused by medical drugs, with analgesics, multiple drugs and psychiatric drugs being the top culprits and accounted for 53%, 31% and 16% of drug poisonings respectively. In terms of gestational week, 47.4% of suicidal poisonings were within the first trimester and the relationship between suicidal attempt and gestational week was found to be statistically significant (p<0.015). However, the relationship between gravidity and the rate of suicidal attempts was not statistically significant (p=0.214). All patients were followed up and treated in the emergency service and no mortality was observed in the study.
Conclusion
Most cases of acute poisonings during pregnancy were suicidal. Pregnant women attempted suicide mostly within the first trimester of gestation. The most common agents used for suicidal attempt were medical drugs.
doi:10.5152/jtgga.2011.51
PMCID: PMC3939249  PMID: 24591994
Poisoning; pregnancy; emergency service
14.  Needlestick and infection with horse vaccine 
BMJ Case Reports  2010;2010:bcr1120092444.
This report describes a case of accidental needlestick injury involving a live equine vaccination, Equilis StrepE. A vet presented herself to the Emergency Department having accidentally injected herself with an equine vaccination. Her left thumb (injury site) was inflamed and had lymphangitis progressing proximally along her left arm. Her inflammatory markers were not raised. The swelling, erythma and lymphangitis had improved markedly with intravenous antibiotics. She had no sequelae at follow-up. Equilis StrepE is a vaccine for submucosal administration containing a modified live avirulent strain of Streptococcus equi subspecies equi (Strain TW). Group C streptococci infections are pathogenic in horses and uncommon in humans. A search of the literature revealed no prior case report of similar adverse reaction to this vaccine. The vaccine may have harmful effect on human health, if injected accidentally but more evidence needs to be collected.
doi:10.1136/bcr.11.2009.2444
PMCID: PMC3028239  PMID: 22767480
15.  Role of the pharmacist in pre-exposure chemoprophylaxis (PrEP) therapy for HIV prevention 
Pharmacy Practice  2009;7(1):11-18.
With a global estimate of 2.5 million new infections of HIV occurring yearly, discovering novel methods to help stem the spread of the virus is critical. The use of antiretroviral chemoprophylaxis for preventing HIV after accidental or occupational exposure and in maternal to fetal transmission has become a widely accepted method to combat HIV.
Based on this success, pre-exposure chemoprophylaxis (PrEP) is being explored in at-risk patient populations such as injecting drug users, female sex workers and men who have sex with men. This off-label and unmonitored use has created a need for education and intervention by pharmacists and other healthcare professionals.
Pharmacists should educate themselves on PrEP and be prepared to counsel patients about their means of obtaining it (e.g. borrowing or sharing medications and ordering from disreputable Internet pharmacies). They should also be proactive about medication therapy management in these patients due to clinically important drug interactions with PrEP medications. Only one trial exploring the safety and efficacy of tenofovir as PrEP has been completed thus far. However, five ongoing trials are in various stages and two additional studies are scheduled for the near future. Unfortunately, studies in this arena have met with many challenges that have threatened to derail progress. Ethical controversy surrounding post-trial care of participants who seroconvert during studies, as well as concerns over emerging viral resistance and logistical site problems, have already halted several PrEP trials. Information about these early trials has already filtered down to affected individuals who are experimenting with this unproven therapy as an “evening before pill”. The potential for PrEP is promising; however, more extensive trials are necessary to establish its safety and efficacy. Pharmacists are well-positioned to play a key role in helping patients make choices about PrEP, managing their therapy, and developing policy with an eye towards the future.
PMCID: PMC4139751  PMID: 25147587
Acquired Immunodeficiency Syndrome; Chemoprevention; United States
16.  Chronological Variations of Children Poisoning Causes in Zahedan, South of Iran 
Background:
Poisoning is a common pediatric emergency among children and adolescents in the Emergency Department of Zahedan University of Medical Sciences hospital.
Objectives:
The aim of this study was comparing the characteristics and variations of pediatric poisoning between two retrospective studies (1998 and 2008). We hypothesized that the epidemiology of pediatric patients admitted for poisoning is related to variations of environmental agents and drug usage.
Patients and Methods:
Records of 170 patients from 1998 and 147 from 2008 with acute poisoning were retrospectively evaluated and compared.
Results:
Poisoning mostly occurred in children younger than five years old via oral route (72.94%-87%) and by single exposure (94.12%-96.6%). It was also noted that 86.8%-90% of cases were accidentally poisoned. Drugs were the most common poisoning agents in both studies (52.94% and 37.41%, respectively) and analgesics-antipyretics were the most common poisoning drugs. Drug poisoning was more common among children under five years old in both the studies. Neurological signs including lethargy and coma were the main presenting signs. About 80%-95% of cases were referred to the hospital within three hours of poisoning and supportive-symptomatic therapy was provided to them; charcoal/naloxone was administered for most of the patients (26.2% in 2008 and 21% in 1998). Mortality rate due to drug poisoning was 3-4 cases in both studies; but, non-drug poisoning mortality rate was higher.
Conclusions:
Preventable accidental poisoning is a significant cause of morbidity in children in developing countries. The study provided information on evolving trends and the need for increasing awareness about potential toxins as well as appropriate storage of toxins in the house to reduce the occurrence of accidental poisoning.
doi:10.5812/ijhrba.19223
PMCID: PMC4295125  PMID: 25632384
Poisoning; Emergency Medical Services; Chronology
17.  Successful resuscitation of an elderly man with deep accidental hypothermia using portable extracorporeal circulation in the emergency department: a case report 
Introduction
Deep accidental hypothermia (body temperature below 28°C) is rare and has a high mortality rate. Successful resuscitation usually occurs in the young, but a prompt intervention using a portable extracorporeal cardiopulmonary circulation device can also provide a good outcome for older persons.
Case presentation
We report the successful resuscitation of an 82-year-old male from deep accidental hypothermia using portable extracorporeal circulation in the emergency department.
Conclusion
This successful resuscitation of an 82-year-old patient demonstrates that a prompt intervention by a medical team that trains together, using a mobile cardiopulmonary bypass device via a percutaneous approach, can potentially provide good outcomes for all victims of deep accidental hypothermia, both in the operating suites and the emergency department.
doi:10.1186/1752-1947-2-150
PMCID: PMC2396176  PMID: 18471286
18.  Effect of prostaglandin E1 on pulmonary circulation in pulmonary atresia. A quantitative morphometric study. 
British Heart Journal  1980;43(3):306-314.
The structural effect of prostaglandin E1 on the pulmonary circulation in pulmonary atresia has been studied by applying quantitative morphometric techniques to the injected and inflated lungs of eight babies who had received prostaglandin E1 for between 30 hours and 12 days. The most striking effect was on the pulmonary arterial smooth muscle. Relative arterial medial thickness was reduced and muscle did not extend as far along the arterial pathway as compared with the normal and with untreated cases of pulmonary atresia, dying at a similar age. The reduction in muscularity tended to increase the longer the duration of infusion. In all cases the thin arterial media was less compact than normal, and localised aneurysmal dilatations occurred, varying in extent and severity between cases. The preacinar arteries were dilated in comparison with the untreated cases, but, by contrast, the intra-acinar arteries remained abnormally small. The number of intra-acinar arteries per unit area of lung was greater in prostaglandin E1 treated than in untreated cases. Infusion of prostaglandin E1 is now the ideal emergency treatment for pulmonary atresia, but the findings in the present study suggest that it should be given for as short a time as possible before the pulmonary blood flow is increased by surgical treatment.
Images
PMCID: PMC482280  PMID: 7437177
19.  Selective intra-arterial administration of 18F-FDG to the rat brain — effects on hemispheric uptake 
Neuroradiology  2014;56(5):375-380.
Introduction
The purpose of this study was to investigate the radioligand uptake and iodine contrast distribution in the intra- and extracranial circulation of the rat, after intra-arterial injections to the common carotid artery and different parts of the internal carotid artery.
Methods
All animal experiments were carried out in accordance with Karolinska Institutet’s guidelines and were approved by the local laboratory animal ethics committee. We used clinical neurointerventional systems to place microcatheters in the extra- or intracranial carotid artery of 15 Sprague–Dawley rats. Here, injection dynamics of iodine contrast was assessed using digital subtraction angiography. Maintaining the catheter position, the animals were placed in a micro PET and small-animal positron emission tomography (PET) was used to analyze injections [2-18F]-2-fluoro-2-deoxy-d-glucose (18F-FDG).
Results
Microcatheters had to be placed in the intracranial carotid artery (iICA) for the infusate to distribute to the brain. Selective injection via the iICA resulted in a 9-fold higher uptake of 18F-FDG in the injected hemisphere (p < 0.005) compared to both intravenous and more proximal carotid artery injections. Furthermore, selective injection gave a dramatically improved contrast between the brain and extracranial tissue.
Conclusion
Intra-arterial injection increases the cerebral uptake of a radiotracer dramatically compared to systemic injection. This technique has potential applications for endovascular treatment of malignancies allowing intra-interventional modifications of injection strategy, based on information on tumor perfusion and risk to surrounding normal parenchyma. Furthermore the technique may increase diagnostic sensitivity and avoid problems due to peripheral pharmacological barriers and first passage metabolism of labile tracers.
doi:10.1007/s00234-014-1335-1
PMCID: PMC4015060  PMID: 24526140
Intra-arterial; Endovascular intervention; 18F-FDG; Radiotracer
20.  Absolute Lymphocyte Count as a Predictor of Mortality in Emergency Department Patients with Paraquat Poisoning 
PLoS ONE  2013;8(10):e78160.
Background
Paraquat (PQ) is a potent, highly toxic and widely used herbicide. The major medical problems associated with PQ are accidental or suicidal ingestion. There are several prognostic markers of PQ poisoning, with the serum PQ concentration considered to be the best indicator of outcome. However, the measurement of such markers is limited in many hospitals.
Objective
The present study was conducted to investigate the association of absolute lymphocyte count (ALC) and the 30-day mortality rate in patients with PQ poisoning.
Methods
We performed a retrospective analysis of patients admitted to the emergency department after paraquat poisoning between January 2010 and April 2013. Independent risk factors including ALC for 30-day mortality were determined. The ALC was categorized in quartiles as ≤1700, 1700 to 3200, 3200 to 5000, and >5000. Univariate and multivariate Cox proportional hazard analysis were performed to determine the independent risk factors for mortality.
Results
A total of 136 patients were included in the study, and the 30-day mortality was 73.5%. ALC was significantly higher in nonsurvivors than in survivors. The highest ALC quartile (ALC>5000; hazard ratio, 2.58; 95% CI, 1.08–6.21) was associated with increased mortality in multivariate analysis. In addition, old age, lower arterial PaCO2, increased peripheral neutrophil count, and high serum levels of creatinine were associated with mortality.
Conclusion
The absolute lymphocyte count is associated with the 30-day mortality rate in patients with paraquat poisoning.
doi:10.1371/journal.pone.0078160
PMCID: PMC3813447  PMID: 24205140
21.  Fifteen years of preclinical and clinical experiences about biotherapy treatment of lesions induced by accidental irradiation and radiotherapy 
World Journal of Stem Cells  2013;5(3):68-72.
High dose radiation exposures involving medical treatments or accidental irradiation may lead to extended damage to the irradiated tissue. Alleviation or even eradication of irradiation induced adverse events is therefore crucial. Because developments in cell therapy have brought some hope for the treatment of tissues damages induced by irradiation, the Institute for Radiation and Nuclear Safety contributed to establish the clinical guidelines for the management of accidentally irradiated victims and to provide the best supportive care to patients all over the world. In the past 15 years, we contributed to develop and test cell therapy for protection against radiation side effects in several animal models, and we proposed mechanisms to explain the benefit brought by this new therapeutic approach. We established the proof of concept that mesenchymal stem cells (MSCs) migrate to damaged tissues in the nonobese diabetic/severe combined immunodeficiency immunotolerant mice model and in non-human primate after radiation exposure. We showed that the intravenous injection of MSCs sustains hematopoiesis after total body irradiation, improves wound healing after radiodermatitis and protects gut function from irradiation damages. Thanks to a tight collaboration with clinicians from several French hospitals, we report successful treatments of therapeutic/accidental radiation damages in several victims with MSC infusions for hematopoiesis correction, radio-induced burns, gastrointestinal disorders and protection homeostatic functions of gut management after radio-therapy.
doi:10.4252/wjsc.v5.i3.68
PMCID: PMC3744132  PMID: 23951388
Mesenchymal stem cells; Radiotherapy; Cell therapy; Stem cells; Healthy tissue; Tumor; Radiation
22.  Abnormally increased uptake of 18F-FDG in the forearm and hand following intra-arterial injection — hot forearm and hot hand signs 
The British Journal of Radiology  2009;82(984):995-999.
The aim of this study is to describe the appearance of intra-arterial administration of 18F-fluorodeoxyglucose (18F-FDG). The effect of this finding on the standard uptake values (SUVs) is also briefly discussed. Three cases of 18F-FDG positron emission tomography (PET) scans, detected over 2 years (2004–2006), with different presentations producing hot forearm and hot hand signs are described. It was shown that intra-arterial injections of 18F-FDG producing “the hot forearm sign” and the hot hand sign” are similar to the glove pattern of uptake noted following intra-arterial administration of technetium-99m methylene diphosphonate. Following intra-arterial injection, uptake of 18F-FDG is accentuated by hypoxia and exercise. A comparison is also made with the pattern of soft-tissue uptake seen following true intravenous injections with similar pre-injection vein enhancement techniques to the intra-arterial injections. Evaluation of the maximum intensity projection (MIP) and transaxial PET/CT fusion images of the arm, forearm and hand helps to confirm the diagnosis. Hands are often not included in PET/CT imaging and therefore cases might be missed. In conclusion, intra-arterial injection of 18F-FDG produces a “hot forearm sign” and “hot hand sign”. Hands are often not included in PET/CT imaging, and therefore the presence of hot forearm sign should suggest further investigation. It should be mentioned in the radiology report, as it may alter the sensitivity and specificity of the SUV value.
doi:10.1259/bjr/62898427
PMCID: PMC3473382  PMID: 19470569
23.  Intraprocedural Angiographic CT as a Valuable Tool in the Course of Endovascular Treatment of Direct Sinus Cavernous Fistulas 
Interventional Neuroradiology  2012;18(3):326-332.
Summary
This investigation aimed to demonstrate the potential of intraprocedural angiographic CT in monitoring complex endovascular coil embolization of direct carotid cavernous fistulas.
Angiographic CT was performed as a dual rotational 5 s run with intraarterial contrast medium injection in two patients during endovascular coil embolization of direct carotid cavernous fistulas. Intraprocedural angiographic CT was considered helpful if conventional 2D series were not conclusive concerning coil position or if a precise delineation of the parent artery was impossible due to a complex anatomy or overlying coil material. During postprocessing multiplanar reformatted and dual volume images of angiographic CT were reconstructed.
Angiographic CT turned out to be superior in the intraprocedural visualization of accidental coil migration into the parent artery where conventional 2D-DSA series failed to reliably detect coil protrusion. The delineation of coil protrusion by angiographic CT allowed immediate correct coil repositioning to prevent parent artery compromising.
Angiographic CT can function as a valuable intraprocedurally feasible tool during complex coil embolizations of direct carotid cavernous fistulas. It allows the precise visualization of the cerebral vasculature and any accidental coil protrusion can be determined accurately in cases where conventional 2D-DSA series are unclear or compromised. Thus angiographic CT might contribute substantially to reduce procedural complications and to increase safety in the management of endovascular treatment of direct carotid cavernous fistulas.
PMCID: PMC3442308  PMID: 22958773
carotid cavernous fistula, endovascular approach, transarterial coil embolization, intraprocedural angiographic CT
24.  Assessment of Prevalence and Mortality Incidences Due to Poisoning in a South Indian Tertiary Care Teaching Hospital 
WHO reports estimate poisoning as one of the most common causes of increased morbidity and mortality rate world-wide. Various agents such as pesticides, drugs have been used for intentional and accidental poisoning in different countries. In the Indian scenario, pesticides are the most commonly used poisoning agents. To assess the prevalence and mortality incidence rate due to various poisoning agents a retrospective and prospective study conducted over a period of nine months in a tertiary care teaching hospital. Retrospective data of poisoning cases was collected from the medical records section and the prospective data of poisoning cases was collected from the emergency and causality departments. A total of 1045 poisoning related admissions were identified during the period January 2005 to September 2008. Among them, 68.40% of cases were due to intentional poisoning and 31.60% were due to accidental poisoning. Of the poisoning related admissions, 84.4% of patients recovered, whereas in 7.6% of cases condition did not improve. Mortality rate was observed 4%. Intentional poisoning was observed more in male population (60.2%) in the age group of 18-29 years. Accidental poisoning was seen more in children in the age group of 1-3 years. Incidence of overall poisoning cases were high due to pesticides (39.5%) followed by medicines (26.1%), household products (22.1%), environmental poisoning (12.1%) and heavy metals (0.2%). It was observed that availability of centralised poison information centre and treatment protocols will improvise poison management practices in tertiary care hospitals by the clinicians.
doi:10.4103/0250-474X.78525
PMCID: PMC3116303  PMID: 21694990
Drugs; incidence; house hold products; pesticide; poisoning agent; prevalence
25.  Study on drug related hospital admissions in a tertiary care hospital in South India 
Background and objectives
Accidental and intentional poisonings or drug overdoses constitute a significant source of aggregate morbidity, mortality, and health care expenditure. Studies evaluating drug related hospitalization have estimated that approximately 5–10% of all hospital admissions are drug related. The present study was carried out to investigate type, nature and incidence of drug related admissions in our hospital settings.
Method
A hospital based retrospective study was conducted in 575 cases of drug related admissions. The case records of patients admitted in various clinical departments of Amrita Institute of Medical Sciences (AIMS) Hospital during last 8 years (January 2002–December 2009) were collected and analyzed.
Results
During the retrospective study, the total number of drug related cases reported were 575. Out of these, 35.5% cases were induced by central nervous system (CNS) drugs, 19.8% were by cardiovascular system (CVS) drugs, 12.3% were by NSAIDs, 11.3% were by antibiotics and 9.9% were by anticoagulants, 11.3% by other drugs which includes hormones, cytotoxic drugs, hypolipidemics, etc. Four hundred and forty cases were admitted to emergency department. Common drug related problems resulting in hospital visits were due to intentional, accidental and overdose. The incidence of drug related hospital admissions was found to be 0.20%.
Conclusion
The most of the accidental and suicidal cases were reported are by CNS drugs. Psychiatric patients intentionally taking medicines as suicidal attempt and as a part of their illness. As drug related problems are so significant, increased awareness and enhanced collaborative efforts among patients, physicians, pharmacists and caregivers within community and hospital have the potential to minimize the impact of this problem.
doi:10.1016/j.jsps.2011.04.004
PMCID: PMC3745191  PMID: 23960769
Drug related problem; Hospital admission; Poisoning; Over dose

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