Faculty Bibliography

BACKGROUND: Isolated cases of camphor-induced seizures have been reported in young children after gastrointestinal, dermal, and inhalation exposure. In 1982, after a series of unintentional ingestions of camphor products, the US Food and Drug Administration restricted the camphor content to <11% in some products intended for medicinal use. Camphor products intended for use as pesticides must be registered with the US Environmental Protection Agency. Still, many imported camphor-containing products fail to meet Food and Drug Administration and Environmental Protection Agency requirements for labeling and content. OBJECTIVE: To describe a cluster of cases of camphor-associated seizure activity resulting from the availability of imported camphor products in certain ethnic populations that use it as a natural remedy. METHODS: We present 3 cases of seizures associated with imported, illegally sold camphor in young children who presented to a large, urban children's hospital in Bronx, New York, during a 2-week period. RESULTS: The children's ages ranged from 15 to 36 months. Two children ingested camphor, and 1 child was exposed through repetitive rubbing of camphor on her skin. All 3 patients required pharmacologic intervention to terminate the seizures. One patient required bag-valve-mask ventilation for transient respiratory depression. All 3 patients had leukocytosis, and 2 patients had hyperglycemia. Exposure occurred as a result of using camphor for spiritual purposes, cold remedy, or pest control. After identification of these cases, the New York City Department of Health released a public health warning to keep camphor products away from children. Similar warnings were issued later by other state health departments. CONCLUSIONS: These cases highlight the toxicity associated with camphor usage in the community and that inappropriate use of illegally sold camphor products is an important public health issue. Camphor may be a common, yet unrecognized, source of seizures in children in certain ethnic populations that use it as a natural remedy. Efforts are needed to educate the communities about the hazards of using camphor products and to limit the illegal availability of these products

The athletic performance supplement industry is a multibillion-dollar business and one popular category claims to increase nitric oxide (NO) production. We report three patients presenting to the emergency department with adverse effects. A 33-year-old man presented with palpitations, dizziness, vomiting, and syncope, after the use of NO(2) platinum. His examination and electrocardiogram (ECG) were normal. The dizziness persisted, requiring admission overnight. A 21-year-old man with palpitations and near syncope had used a 'nitric oxide' supplement. He was tachycardic to 115 bpm with otherwise normal examination. Laboratory values including methemoglobin, and ECG were unremarkable. He was treated with 1 L of saline with no change in heart rate. He was admitted for observation. A 24-year-old man presented after taking NO-Xplode with palpitations and a headache. His examination, laboratory values, and ECG were normal. He was discharged. The purported active ingredient in these products is arginine alpha-ketoglutarate (AAKG), which is claimed to increase NO production by supplying the precursor L-arginine. The symptoms could be due to vasodilation from increased levels of NO, though other etiologies cannot be excluded. AAKG containing supplements may be associated with adverse effects requiring hospital admission

Evidence-based guidelines do not exist for the treatment of patients with chronic mild-moderate digoxin toxicity. We sought to evaluate differences among specialists in the use of digoxin-specific antibody fragments and the decision to admit these patients. A sample of cardiologists, emergency physicians, and medical toxicologists was surveyed. The survey detailed four hypothetical cases of chronic digoxin toxicity created by consensus among authors. All cases had the same digoxin concentration, but signs and symptoms varied in an attempt to explore four different thresholds. For each scenario, clinicians made decisions about admission and treatment. Survey response varied: cardiologists 17%, emergency physicians 6.7%, and toxicologists 39%. Statistically significant difference was found in the administration of Fab among cardiologists (67%), emergency physicians (82%), or toxicologists (91.5%) and admission rate (cardiologists 34%, emergency physicians 28%, and toxicologists 46%). Differences exist among clinicians of various specialties regarding treatment of chronic digoxin toxicity. These differences may reflect diverse perspectives or knowledge gaps and may translate into excess cost or less than ideal care. Exploring these differences may improve patient care, improve interactions among providers, and set the stage for development of consensus guidelines and research