The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

Diabetic autonomic neuropathy

Paraquat dichloride (methyl viologen; PQ) is an effective and widely used herbicide that has a proven safety record when appropriately applied to eliminate weeds. However, over the last decades, there have been numerous fatalities, mainly caused by accidental or voluntary ingestion. PQ poisoning is an extremely frustrating condition to manage clinically, due to the elevated morbidity and mortality observed so far and due to the lack of effective treatments to be used in humans. PQ mainly accumulates in the lung (pulmonary concentrations can be 6 to 10 times higher than those in the plasma), where it is retained even when blood levels start to decrease. The pulmonary effects can be explained by the participation of the polyamine transport system abundantly expressed in the membrane of alveolar cells type I, II, and Clara cells. Further downstream at the toxicodynamic level, the main molecular mechanism of PQ toxicity is based on redox cycling and intracellular oxidative stress generation. With this review we aimed to collect and describe the most pertinent and significant findings published in established scientific publications since the discovery of PQ, focusing on the most recent developments related to PQ lung toxicity and their relevance to the treatment of human poisonings. Considerable space is also dedicated to techniques for prognosis prediction, since these could allow development of rigorous clinical protocols that may produce comparable data for the evaluation of proposed therapies.

Paraquat Poisonings: Mechanisms of Lung Toxicity, Clinical Features, and Treatment

Renal osteodystrophy

Cadmium poisoning has been reported from many parts of the world. It is one of the global health problems that affect many organs and in some cases it can cause deaths annually. Long-term exposure to cadmium through air, water, soil, and food leads to cancer and organ system toxicity such as skeletal, urinary, reproductive, cardiovascular, central and peripheral nervous, and respiratory systems. Cadmium levels can be measured in the blood, urine, hair, nail and saliva samples. Patients with cadmium toxicity need gastrointestinal tract irrigation, supportive care, and chemical decontamination traditional-based chelation therapy with appropriate new chelating agents and nanoparticle-based antidotes. Furthermore it has been likewise recommended to determine the level of food contamination and suspicious areas, consider public education and awareness programs for the exposed people to prevent cadmium poisoning.

Cadmium toxicity and treatment: An update.

BACKGROUND Paraquat (PQ) is a non-selective herbicide that generates reactive oxygen species in vivo We hypothesized that acute kidney injury (AKI) in patients with acute PQ poisoning would provide a model for the clinical features of ROS-induced AKI METHODS From January 2007 to December 2007, 278 patients with acute PQ intoxication were included in the study AKI was defined based on the RIFLE classification The serial changes of creatinine (Cr), the incidence of AKI and the mortality according to the RIFLE classification were analysed RESULTS An initial serum Cr >12 mg/dL was a significant predictor of mortality [odds ratio 900, 95% CI (4747, 17061), P < 001] The incidence of AKI was 514% among the 173 patients who had an initial serum Cr < or =12 mg/dL Among them, 347% were the failure group and oliguric AKI was observed in 10 patients The average peak serum Cr level, among the 13 survivors in the failure group, was 438 mg/dL at the fifth day, after ingestion, and their Cr level normalized within 3 weeks None of the 13 survivors had permanent loss of renal function The estimated amount of PQ ingestion was a predictor of the incidence of AKI The mortality risk was significantly higher in the failure group than in the group without failure CONCLUSION The clinical feature was characterized by fully developed AKI at the fifth day after PQ ingestion and normalized within 3 weeks without exception

/pdf/the-clinical-features-of-acute-kidney-injury-in-patients-266iq8s8vd.pdf

The clinical features of acute kidney injury in patients with acute paraquat intoxication

Objectives. Paraquat poisoning by ingestion is often fatal. Many studies have investigated treatment modalities and predictor parameters, but there is no standard treatment. Plasma paraquat concentration seems a valid predictable parameter of survival. In order to achieve uniform treatment, including extracorporeal elimination and antioxidant therapy, the outcome of paraquat poisoning based on plasma paraquat level needs to be investigated. Methods. This study included 375 paraquat poisoning patients who were diagnosed by means of plasma paraquat concentration within 24 hours after ingestion in the Institute of Pesticide Poisoning of Soonchunhyang University Cheonan Hospital, Korea, from January 2005 to December 2006. All patients were treated according to a uniform protocol including extracorporeal elimination and antioxidant therapy. Plasma paraquat concentration was measured by high-performance liquid chromatography. Results. The mean age of the paraquat-intoxicated patients was 48.42 ± 6.75. One hundr...

Association between plasma paraquat level and outcome of paraquat poisoning in 375 paraquat poisoning patients.

Paraquat (PQ) has known negative human health effects, but continues to be commonly used worldwide as a herbicide. Our clinical data shows that the main prognostic factor is the time required to achieve a negative urine dithionite test. Patient survival is a 100% when the area affected by ground glass opacity is <20% of the total lung volume on high-resolution computed tomography imaging 7 days post-PQ ingestion. The incidence of acute kidney injury is approximately 50%. The average serum creatinine level reaches its peak around 5 days post-ingestion, and usually normalizes within 3 weeks. We obtain two connecting lines from the highest PQ level for the survivors and the lowest PQ level among the non-survivors at a given time. Patients with a PQ level between these two lines are considered treatable. The following treatment modalities are recommended to preserve kidney function: 1) extracorporeal elimination, 2) intravenous antioxidant administration, 3) diuresis with a fluid, and 4) cytotoxic drugs. In conclusion, this review provides a general overview on the diagnostic procedure and treatment modality of acute PQ intoxication, while focusing on our clinical experience.

/pdf/diagnostic-and-therapeutic-approach-for-acute-paraquat-2vr4kuyqbv.pdf

Diagnostic and Therapeutic Approach for Acute Paraquat Intoxication

Background: Glyphosate, one of the most commonly used herbicides worldwide, has been considered as minimally toxic to humans. However, clinical toxicologists occasionally encounter cases of severe systemic toxicity. The purpose of this study was to determine the effect of glyphosate-surfactants (“glyphosate-surfactant toxicity”) in patients with acute glyphosate intoxication. Methods: In all, 107 patients (69 men and 38 women, aged 52.3 ± 15.5 years) with acute glyphosate intoxication were enrolled in this study. From their medical records, we identified the formulation of ingested glyphosate products and derived clinical parameters, which focused on clinical outcome, admission days, duration in the intensive care unit, development of respiratory failure, cardiovascular deterioration, renal failure, altered mental status, and convulsions. The effect of surfactants on clinical complications was also assessed. Results: For surfactant ingestion volumes of 8 mL, the incidence of clinical complications was (in...

Surfactant volume is an essential element in human toxicity in acute glyphosate herbicide intoxication.

Background/Aims
Paraquat (PQ) has been used in suicide attempts; an estimated 2,000 toxic ingestions occur annually, with 60-70% mortality. We sought to determine why PQ is such a common agent for suicide attempts in Korea.

/pdf/paraquat-intoxication-in-subjects-who-attempt-suicide-why-5fb35ie0sv.pdf

Hyo-Wook Gil

Papers

The clinical features of acute kidney injury in patients with acute paraquat intoxication

Association between plasma paraquat level and outcome of paraquat poisoning in 375 paraquat poisoning patients.

Diagnostic and Therapeutic Approach for Acute Paraquat Intoxication

Surfactant volume is an essential element in human toxicity in acute glyphosate herbicide intoxication.

Paraquat intoxication in subjects who attempt suicide: why they chose paraquat.