POISONING: FOOD INGESTED

What is poisoning by ingestion?

Poisoning by ingestion refers to the oral intake of a harmful substance that, even in small amounts, can damage tissues, disturb bodily functions, and possibly cause death. Immediate injury results when the poison excoriates soft tissues, as with a strong acid or alkali. A delayed response occurs when the poison is absorbed into the bloodstream and causes systemic symptoms.


Substances commonly ingested include over the counter medications (such as acetaminophen or iron supplements), household cleaning products, or parts of houseplants. Ingested poisoning may be accidental or intentional. Permanent multiorgan damage may result from initial loss of airway, breathing, and circulation, and from specific organ toxicity.

Which Germs Are to Blame?

Foods from animals, raw foods, and unwashed vegetables all can contain germs that cause food poisoning. The most likely source is food from animals, like meat, poultry (such as chicken), eggs, milk, and shellfish (such as shrimp).

Some of the most common bacteria are:

1. Salmonella (say: sal-meh-nel-uh)
2. Listeria (say: lis-teer-ee-uh)
3. Campylobacter (say: kam-pe-low-bak-ter)
4. E. coli (say: ee kole-eye)

What Will the Doctor Do?

If you go to the doctor, he or she will ask you a lot of questions about how you're feeling, when you first felt sick, what you ate in the past few days, and if anyone else you know is also sick. The doctor might also take a sample of your stool (poop) and urine (pee) to test for possible germs that might have caused food poisoning.

The type of treatment you'll get for food poisoning will depend on the specific germ that is making you sick. The doctor might give you medicine, but most of the time someone who has food poisoning doesn't need to take medicine.

It's also rare that a kid with food poisoning would need to go to the hospital. Usually, only people who get really dehydrated have to go to the hospital. Being dehydrated means your body has lost too much fluid due to diarrhea and vomiting. A dehydrated person can get fluids and medicine through an IV at the hospital. To keep from getting dehydrated, try to keep drinking fluids when you are sick.

You may also need to go to the hospital if you have blood in your poop. If you do see blood in your poop, you should definitely tell your parents about it.

How to Fight the Germs

Many things can be done to prevent food poisoning. These precautions should be taken at every stage a food takes — from preparation to cooking to storing leftovers. A lot of this responsibility falls on grown-ups, but kids can help fight germs, too. One of the best ways is to wash your hands if you're helping to prepare foods.

When should you wash? Before you start helping — so germs from your hands don't get on the food — and after so you don't pass along germs from the food to yourself or anyone else. If you don't, here's how germs can travel:

1. You help make hamburger patties.
2. You get bad bacteria from the raw ground beef on your hands.
3. You hold your little sister's hand.
4. She uses that hand to eat a snack.
5. Now the bacteria have made it inside and can make her sick.

Other steps you can take to keep your food safe include:

1. Wash fruits and vegetables well before eating them.
2. Only eat foods that are properly cooked. If you cut into chicken and it looks pink and raw inside, tell a grown-up.
3. Look at what you're eating and smell it, too. If something looks or smells different from normal, check with an adult before eating or drinking it. Milk is a good example. If you've ever had a sip of sour milk, you know you never want to taste that again! Mold (which can be green, pink, white, or brown) is also often a sign that food has spoiled.
4. If you're going to eat leftovers, ask a grown-up for help heating them up. By heating them, you can kill bacteria that grew while it was in the fridge.
5. Check the date. Lots of packaged foods have expiration dates or "sell by" dates. Don't eat a food if today's date is after the expiration date. Use it before it expires. Some of these dates are "sell by," which means that the food should leave store shelves by that time. Ask an adult for help deciding if it's past the sell by date.
6. Cover and refrigerate food right away. Bacteria get a good chance to grow in foods that sit at room temperature. By putting food in the fridge, you're putting the chill on those bad germs!

ECTOPIC PREGNANCY: ASSESSMENT AND TREATMENT

What is an ectopic pregnancy?

Ectopic pregnancy is gestation located outside the uterine cavity. The fertilized ovum implants outside of the uterus, usually in the fallopian tube. Predisposing factors include adhesions of the tube, salpingitis, congenital and development anomalies of the fallopian tube, previous ectopic pregnancy, use of an intrauterine device for more than 2 years, multiple induced abortions, menstrual reflux, and decreased tubal motility.


Assessment:
1. Abdominal or pelvic pain
2. Amenorrhea in 75% of cases.
3. Vaginal bleeding. usually scarity and dark
4. Uterine size is usually similar to what it would be in a normally implanted pregnancy.
5. Abdominal tenderness on palpation
6. Nausea, vomiting, or faintness may be present.
7. Pelvic examination shows a pelvic mass, posterior or lateral to the uterus, and cervical pain on movement of the cervix.

Treatment:


The treatment of ectopic pregnancy was limited to surgery. With evolving experience with methotrexate, the treatment of selected ectopic pregnancies has been revolutionized. Medical therapy of ectopic pregnancy is appealing over surgical options for a number of reasons, including eliminating morbidity from surgery and general anesthesia, potentially less tubal damage, and less cost and need for hospitalization. Measures of current trends in the management of ectopic pregnancy in the United States from 2002-2007 indicate that the percentage of patients treated with methotrexate increased from 11.1% to 35.1%.

Methotrexate is an antimetabolite chemotherapeutic agent that binds to the enzyme dihydrofolate reductase, which is involved in the synthesis of purine nucleotides. This interferes with DNA synthesis and disrupts cell multiplication. Methotrexate has long been known to be effective in the treatment of leukemias, lymphomas, and carcinomas of the head, neck, breast, ovary, and bladder. It has also been used as an immunosuppressive agent in the prevention of graft versus host disease and in the treatment of severe psoriasis and rheumatoid arthritis. Its effectiveness on trophoblastic tissue has been well established and is derived from experience gained in using methotrexate in the treatment of hydatiform moles and choriocarcinomas. Methotrexate is used in the treatment of ectopic pregnancy as single or multiple intramuscular injections.

Adverse effects associated with the use of methotrexate can be divided into drug adverse effects and treatment effects. Drug adverse effects include nausea, vomiting, stomatitis, diarrhea, gastric distress, and dizziness. Transient elevation in liver enzymes is also known to occur. Serious reactions, such as bone marrow suppression, dermatitis, pleuritis, pneumonitis, and alopecia, can occur with higher doses and are rare with doses used in the treatment of ectopic pregnancy. Treatment effects of methotrexate include an increase in abdominal pain (occurring in up to two thirds of patients), an increase in bhCG levels during first 1-3 days of treatment, and vaginal bleeding or spotting.

In determining whether a patient is a candidate for medical therapy, a number of factors must be considered. She must be hemodynamically stable, with no signs or symptoms of active bleeding or hemoperitoneum. Furthermore, she must be reliable, compliant, and able to return for follow-up. Another factor is size of the gestation, which should not exceed 3.5 cm at its greatest dimension on US measurement. She should not have any contraindications to the use of methotrexate.

A bhCG level of greater than 15,000 IU/L, fetal cardiac activity, and free fluid in the cul-de-sac on US (presumably representing tubal rupture) are contraindications. Although patients with bhCG levels above 15,000 IU/L and fetal cardiac activity have been treated successfully with methotrexate, these patients require much greater surveillance and carry a higher risk of subsequent operative intervention. There is an inverse association between bhCG levels and successful medical management of an ectopic pregnancy. A systematic review by Menon et al, including 503 women, confirmed that there is a substantial increase in failure of medical management of ectopic pregnancy with single dose methotrexate when the initial bhCG is above 5,000 IU/L.

Contraindications to the use of methotrexate include documented hypersensitivity to methotrexate; breastfeeding; immunodeficiency; alcoholism; alcoholic liver disease or any liver disease; blood dyscrasias; leukopenia; thrombocytopenia; anemia; active pulmonary disease; peptic ulcer disease; and renal, hepatic, or hematologic dysfunction. However, in each case, the risk of surgery must be weighed against any relative contraindication.

A number of accepted protocols with injected methotrexate exist for the treatment of ectopic pregnancy. Initial experience used multiple doses of methotrexate with leucovorin to minimize adverse effects. Leucovorin is folinic acid that is the end product of the reaction catalyzed by dihydrofolate reductase, the same enzyme inhibited by methotrexate. Normal dividing cells preferentially absorb leucovorin; hence, it decreases the action of methotrexate, thereby decreasing its systemic adverse effects. This regimen involves administration of methotrexate as 1 mg/kg IM on days 0, 2, 4, and 6, followed by 4 doses of leucovorin as 0.1 mg/kg on days 1, 3, 5, and 7. Because of higher incidence of adverse effects and the increased need for patient motivation and compliance, the multiple dosage regimen has fallen out of favor in the United States.

The more popular regimen today is the single dose injection. It involves injection of methotrexate as 50 mg/m2 IM in a single injection or as a divided dose injected into each buttock. Studies comparing the multiple methotrexate dosage regimen to the single dosage regimen have demonstrated the 2 methods to be similar in efficacy. With smaller dosing and fewer injections, fewer adverse effects are anticipated and the use of leucovorin can be abandoned.

Prior to injection of methotrexate, the patient must be counseled extensively on the risks, benefits, adverse effects, and the possibility of failure of medical therapy, which would result in tubal rupture necessitating surgery. Patients should be aware of the signs and symptoms associated with tubal rupture and be advised to contact their physician with significantly worsening abdominal pain or tenderness, heavy vaginal bleeding, dizziness, tachycardia, palpitations, or syncope.

Most patients experience at least one episode of increased abdominal pain, which usually occurs 2-3 days after the injection. Increased abdominal pain is believed to be caused by the separation of the pregnancy from the implanted site. It can be differentiated from tubal rupture in that it is milder, of limited duration (lasting 24-48 h), and is not associated with signs of acute abdomen or hemodynamic instability.

Advise patients to avoid alcoholic beverages, vitamins containing folic acid, nonsteroidal anti-inflammatory drugs, and sexual intercourse until advised otherwise. A signed written consent demonstrating the patient's comprehension of the course of treatment must be obtained. Provide an information pamphlet to all patients receiving methotrexate; the pamphlet should include a list of adverse effects, a schedule of follow-up visits, and a method of contacting the physician or the hospital in case of emergency.

Before initiating therapy, draw blood to determine baseline laboratory values for renal, hepatic, and bone marrow function, as well as a baseline bhCG level. Determine blood type, Rhesus (Rh) factor, and the presence of antibodies. Patients who are Rh negative should receive Rh immune globulin. Obtain repeat bhCG levels 4 days and 7 days after the methotrexate injection. An initial increase in bhCG levels often occurs by the third day and is not a cause for alarm. A decline in bhCG levels of at least 15% from days 4-7 postinjection indicates a successful medical response. Other effective monitoring protocols have also been reported.[9] The patient's bhCG levels should be measured weekly until they become undetectable.

Failure of medical treatment is defined when bhCG levels increase, plateau, or fail to decrease adequately by 15% from days 4-7 postinjection. At this time, surgical intervention may be warranted. A repeat single dose of methotrexate can also be a viable option after reevaluation of the patients' indications and contraindications (including repeat US) for medical therapy.

Treatment with methotrexate is an especially attractive option when the pregnancy is located on the cervix, ovary, or in the interstitial or the cornual portion of the tube. Surgical treatment in these cases is often associated with increased risk of hemorrhage, often resulting in hysterectomy or oophorectomy.


Ectopic pregnancy. A 12-week interstitial gestation, which eventually resulted in a hysterectomy. Courtesy of Deidra Gundy, MD, Department of Obstetrics and Gynecology at MCPHU.

Ectopic pregnancy. A 12-week interstitial gestation, which eventually resulted in a hysterectomy. Courtesy of Deidra Gundy, MD, Department of Obstetrics and Gynecology at MCPHU.
Successful medical treatment using methotrexate has been reported in the literature with good subsequent reproductive outcomes. By avoiding surgery, the risk of tubal injury is reduced.

The use of oral methotrexate currently is under investigation, and, while preliminary reports show promising results, efficacy remains to be established. Direct local injection (salpingocentesis) of methotrexate into the ectopic pregnancy under laparoscopic or US guidance has also been reported in the literature; however, reports from these studies have yielded inconsistent results, and its advantage over intramuscular injection remains to be established.

The medical treatment of ectopic pregnancy requires compulsive compliance. The physician must emphasize the importance of patient follow-up and have patient information on hand, including the patient's home address, telephone numbers at home and work, and the means to reach a contact person in case attempts to reach the patient directly are unsuccessful. Proper documentation of attempts to reach the patient, including records of telephone calls and certified mail are important medical-legal considerations.

RED RASH ON LEGS

A red rash is nothing but a skin rash that is red in color, that could occur on specific body parts as well as on the whole body. A rash is an immune response that appears on the surface of the skin due to a variety of reasons. Red rashes are, for most of the time, itchy, however, they could also be asymptomatic at times. Such rashes are common reactions to a variety of conditions, hence, they could be confused with a lot of diseases.

People who suffer from red rash on legs may also complain of itching and display a rash that is bumpy and swollen at times. Mostly though, they just appear after a brief summer stroll or a good session of hiking and trekking, where the person's leg may come in contact with a mildly poisonous bush or shrub. We will now discuss the possible reasons behind such sudden onslaughts of skin rashes on legs.

Causes of Red Rash on Legs

Here are some of the main reasons why people suffer from a red rash on legs.

Dermatitis
There are several forms of dermatitis that can cause a red rash on the legs. Atopic dermatitis is said to be one of the primary reasons behind such a rash that can be found on the legs of children, which is typically located behind the knees and thighs of the children and sometimes in adults as well. There is another sort of dermatitis known as contact dermatitis which occurs due to irritants like excessive bathing, remaining in soapy water for a longer period of time, and having allergic reactions to some cosmetics and soap solutions.

Eczema
Not very uncommon, eczema also contributes a lot to developing a red rash on one's legs. There are several types of eczema that affect only some specific regions of the leg, like varicose eczema, which is observed to be prevalent on the line of the varicose veins; this type of rash is swollen and itchy. Another type of eczema that causes this condition is venous eczema, which is also called gravitational dermatitis. It appears due to valvular damage to the leg's veins, like prolonged standing or too much walking.

Golfer's Vasculitis
It can be described as a heat rash that is provoked by prolonged walking, standing, or running. It is most often seen on the calf region and just above the sock line. This red patch is not itchy or inflammatory, and is observed in people above the age of 50, because they are more prone to getting this red rash on their legs. It is caused due to vein irritation that is caused by prolonged contact with heat and sunlight. Fortunately, this rash disappears just as quickly as it appears.

Skin Disorders
There are various skin disorders that can cause such a red rash on legs, which need to be properly evaluated if they don't fade within a few days of their occurrence. Tinea corporis (ringworm), folliculitis, psoriasis, prurigo nodularis, lichen simplex (neurodermatitis), edema, pretibial myxoedema, non-venous leg ulcers, necrobiosis lipoidica, capillaritis, panniculitis, cholinergic urticaria (hives), prickly heat or heat rash, and itchy legs syndrome, which is caused by excessive exercise, etc. are some of the skin disorders that can cause a red rash on legs.

Skin Allergies
There are chances that due to several allergies towards certain foreign factors, plants like poison ivy, poison oak, insect bites, bee bites, etc., can cause a red rash on the legs that differ in appearance as per the type of the rash. An allergic red rash on the legs is usually itchy, bumpy, irritating, and placed at the exact contact point of the irritant. If not treated on time, such rashes can turn into fluid filled blisters. There are chances of food allergies that can cause red rashes on leg as well as the entire body of the affected person. In such cases you have to get it examined in order to plot out a treatment schedule you need to follow.

Treatment for Red Rash on Legs

As I mentioned earlier, before deciding the path of the treatment, one must identify the exact reason behind the red rash on the legs or elsewhere on the body. On observing that the rash hasn't reduced within hours, it is always best to consult a skin care specialist and let him decide the reason behind the skin rash. A skin patch test and physical examinations are likely to be performed before he prescribes any medication.

A home remedy is also one of the better choices for curing red rashes on legs. Aloe vera, olive oil, cornstarch, oatmeal, several herbs, essential oils that have anti-inflammatory effects, and fruits and vegetables that are anti-inflammatory, are worth trying as remedies. Following the prescribed medication like antibiotics and other creams and lotions religiously with the mentioned home remedies, will show quick and positive effects.

So, this was all about a red rash on legs. This condition is not always a reason for worry as long as it disappears in a short time span. Usually if the rash happens to be indication of something serious, then it is normally accompanied by other symptoms as well that are hard to ignore. Hence, along with the rash as soon as you notice something amiss with your body, get yourself checked immediately.

WERNICKE-KORSAKOFF SYNDROME

What is a Wernicke-Korsakoff syndrome?

This disease, notably frequent among chronic alcoholics, is due to a deficiency of vitamin B₁ or thiamine. 

The poor diet of alcoholics who are suffering from this syndrome leads to lesions and increased microhemorrhages in the mammillary bodies, thalamus and brainstem. This syndrome can also be associated with diseases of the GI tract when there is inadequate thiamine absorption. 


Neurologic symptoms include confusion, memory loss, impaired movements and peripheral neuropathy.  Immediate administration of thiamine is usually successful in treating the symptoms, but sometimes permanent memory loss occurs.

Korsakoff's syndrome is a brain disorder usually associated with heavy alcohol consumption over a long period. Historically it has also been called 'Korsakoff's psychosis', although this can be confusing, as there are no true psychotic symptoms in the medical sense. Sometimes it is referred to as 'alcohol amnestic syndrome' − 'amnestic' meaning loss of memory − although in rare cases alcohol is not the cause. Although Korsakoff's syndrome is not strictly speaking a dementia, people with the condition experience loss of short-term memory. This factsheet outlines the causes, symptoms and treatment of the syndrome.

What causes Korsakoff's syndrome?

Korsakoff's syndrome is caused by lack of thiamine (vitamin B1), which affects the brain and nervous system. Thiamine deficiency is often seen in people who consume excessive amounts of alcohol. This is because:

• Many heavy drinkers have poor eating habits. Their nutrition is inadequate, and does not contain essential vitamins.
• Alcohol can inflame the stomach lining and impede the body's ability to absorb the key vitamins it receives.
• Korsakoff's syndrome may also occur in other conditions where there is severe malnutrition, but this is extremely rare in the UK.

Korsakoff's syndrome is part of Wernicke-Korsakoff syndrome, which consists of two separate but related stages: Wernicke's encephalopathy and Korsakoff's syndrome. However, not all cases of Korsakoff's syndrome are preceded by an episode of Wernicke's. 

How does Wernicke's encephalopathy develop?

An encephalopathy is a disorder affecting the brain. Wernicke's encephalopathy usually develops suddenly. There are three main symptoms, though these are not always present, so diagnosis may be difficult. They are:

involuntary, jerky eye movements or paralysis of muscles moving the eyes poor balance, staggering gait or inability to walk drowsiness and confusion.

If Wernicke's is suspected, immediate treatment is essential. Treatment consists of high doses of thiamine injected into a vein or muscle. If treatment is carried out in time, most symptoms should be reversed in a few hours. However, if Wernicke's is left untreated, or is not treated in time, brain damage may result. In some cases the person may die.

How does Korsakoff's syndrome develop?

If Wernicke's encephalopathy is untreated, or is not treated soon enough, Korsakoff's syndrome may follow. It is likely to develop gradually. Brain damage occurs in important small areas in the mid part of the brain, resulting in severe short-term memory loss. Many other abilities may remain intact.

What are the symptoms of Korsakoff's syndrome?

The main symptom is memory loss - particularly of events arising after the onset of the condition. Sometimes, memories of the more distant past can also be affected. Other symptoms may include: difficulty in acquiring new information or learning new skills change in personality − at one extreme the person may show apathy (unconcern, lack of emotional reaction), or at the other, talkative and repetitive behaviour lack of insight into the condition. Even a person with great gaps in their memory may believe that their memory is functioning normally confabulation − inventing events to fill the gaps in memory. For example, a patient who has been in hospital for several weeks may talk convincingly about having just visited his auntie on the south coast earlier that day. This is more common in the early stages of the illness.

This symptom is probably behind the historical use of the term 'psychosis' in Korsakoff's. Medically, psychosis means the presence of delusions representing fixed false beliefs, or hallucinations. In Korsakoff's, the confabulations can seem so fanciful that they could be seen as delusional. However, rather than being fixed, the content of confabulations comes and goes, and is in fact memory-related. Although psychotic thoughts and confabulations alike involve a lack of insight by the person involved, confabulation does not respond to antipsychotic medication.

People usually retain skills that they acquired before developing the disorder, so they are often able to manage with appropriate support.

How is Korsakoff's syndrome diagnosed?

Korsakoff's syndrome cannot be diagnosed until the person has abstained from alcohol for at least four-to-five weeks, to enable the acute symptoms of alcohol withdrawal to subside.

Psychological tests of the person's memory and other abilities will then be carried out to see whether they may have Korsakoff's syndrome or some other condition. They will also be observed to see whether their condition progresses without alcohol. If their condition does not change, they may be diagnosed with a form of dementia, such as Alzheimer's disease. It is possible to have both Korsakoff's syndrome and a dementia.

Who is affected by the syndrome?

Those affected tend to be men between the ages of 45 and 65 with a long history of alcohol misuse, though it is possible to have Korsakoff's syndrome at an older or a younger age.

Women can also be affected. They tend to develop Korsakoff's syndrome at a slightly younger age than men, as they appear to be more vulnerable to the impact of alcohol. It has been suggested that whereas it may take around 20 years for a man to develop Korsakoff's syndrome, it may take about half that time for a woman.

It is not yet clear why some heavy drinkers develop Korsakoff's syndrome and others do not, although this may relate to diet.

How is it treated?

• The progress of Korsakoff's syndrome can be completely halted if the person:
• completely abstains from alcohol
• adopts a healthy diet and takes vitamin supplements.
• While it remains unclear whether additional thiamine helps people improve once the brain damage has already occurred, it may help prevent further damage from occurring.

What is the prognosis?

Any improvement usually occurs within a period of up to two years. It has been estimated that about a quarter of those affected make a very good recovery. About half make a partial recovery and need support to manage their lives. An further quarter make no recovery, and may need long-term care. If the person continues to drink heavily and has poor nutrition, Korsakoff's syndrome is likely to continue to progress.

Other problems associated with heavy drinking

• Alcohol can have a harmful effect on nerve cells in the brain cortex. A wide range of skills and abilities can be affected by this. This is sometimes known as alcoholic dementia. However, if the person abstains from alcohol completely then deterioration ceases, and there is often some recovery over time. At present, much research is being carried out into alcoholic dementia and how it may overlap with Korsakoff's syndrome.
• There may be physical disorders associated with drinking, such as damage to the liver or damage to nerves in the legs and arms.
• People with drinking problems are more likely to have experienced head injuries due to accidents, fights or epileptic seizures.
• Korsakoff's syndrome patients have often lived an unhealthy lifestyle, which increases their risk of developing vascular problems and hence vascular dementia (see Factsheet 402, What is vascular dementia?).