Henry A Spiller

Kentucky Regional Poison Control Center

Publications

  • Amlodipine Fatality in an Infant with Postmortem Blood Levels.

    Henry A Spiller, Beth A Milliner, George M Bosse

    Journal of medical toxicology : official journal of the American College of Medical Toxicology. 01/2012;

    INTRODUCTION: Amlodipine is a dihydropyridine calcium channel blocker used in the treatment of hypertension and angina pectoris. Toxic effects reported from amlodipine include hypotension, reflex tachycardia, metabolic acidosis, and pulmonary edema. We report a rare fatality in an infant after inges... [more] INTRODUCTION: Amlodipine is a dihydropyridine calcium channel blocker used in the treatment of hypertension and angina pectoris. Toxic effects reported from amlodipine include hypotension, reflex tachycardia, metabolic acidosis, and pulmonary edema. We report a rare fatality in an infant after ingestion of amlodipine with benazepril, with postmortem blood concentrations. CASE REPORT: An 11-month-old, 10.88-kg boy ingested 10 to 45 mg amlodipine with 40 to 180 mg benazepril. No action was taken initially because the parents believed only one or two capsules had been ingested. A later count revealed a maximum of nine capsules missing. The child was observed at home and vomited once with possible capsule fragments. Forty-five minutes post-ingestion, the child was noted to be suddenly unresponsive and was brought the local emergency department by a private vehicle. Upon arrival (90 min post-ingestion), the child was unresponsive with the following vital signs HR 133 bpm, BP 67/42 mmHg, respiratory rate 40/min, and temperature 97.5°F. Pertinent abnormal laboratory values were HCO(3) 13 mmol/l and glucose 302 mg/dl. The child was placed on oxygen via a non-rebreather mask and was intubated 45 min post-arrival. The patient became progressively bradycardic, and 55 min after arrival, the patient was in asystole with no palpable blood pressure. Resuscitation measures included chest compressions, epinephrine atropine, sodium bicarbonate, and calcium gluconate. Rescue insulin therapy was begun with 4 units IVP followed by 10 units per hour. Resuscitation efforts persisted for 1 h without success. An autopsy revealed pulmonary edema and no gross or microscopic evidence of natural disease. Stomach contents revealed food matter with small white fragments. Analysis of postmortem heart blood showed amlodipine 1,300 ng/ml (therapeutic <20 ng/ml). Benazepril levels were not available. DISCUSSION: We believe this is the first reported fatality in an infant from amlodipine. While benazepril may have contributed, ACE inhibitors have not been previously associated with rapid cardiovascular collapse. CONCLUSION: Small doses of amlodipine (0.9 to 4.1 mg/kg) may produce rapid and fatal cardiovascular collapse in an infant.
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    Drug-Facilitated Sexual Assault Using Tetrahydrozoline.

    Henry A Spiller, Dennis J Siewert

    Journal of forensic sciences. 12/2011;

      Drug-facilitated sexual assault (DFSA) has been defined as the use of a chemical agent to facilitate a sexual assault. We report two cases of the use of tetrahydrozoline for DFSA. We believe this is the first report with urinary quantification of tetrahydrozoline levels postassault. Blood and urin... [more]   Drug-facilitated sexual assault (DFSA) has been defined as the use of a chemical agent to facilitate a sexual assault. We report two cases of the use of tetrahydrozoline for DFSA. We believe this is the first report with urinary quantification of tetrahydrozoline levels postassault. Blood and urine were obtained c. 20 h postexposure in two cases of reported DFSA. Tetrahydrozoline was not detected in blood but was identified in urine in both victims. After initial identification in the urine using the 2010 update to the AAFS mass spectrometry database library, tetrahydrozoline was quantified at 114 and 150 ng/mL, respectively, using GC/MS. Two unique clinical features reported in these cases were intermittent periods of consciousness and postexposure vomiting. Use of GC/MS was successful in identifying tetrahydrozoline in the 100 ng/mL range up to 20 h postexposure. For victims with late presentation, urine may be a better sample for evaluation for tetrahydrozoline.
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    Clinical experience with and analytical confirmation of "bath salts" and "legal highs" (synthetic cathinones) in the United States.

    Henry A Spiller, Mark L Ryan, Robert G Weston, Joanne Jansen

    Clinical toxicology (Philadelphia, Pa.). 07/2011; 49(6):499-505.

    Recently, there has been a worldwide rise in the popularity and abuse of synthetic cathinones. In 2009 and 2010, a significant rise in the abuse of a new group of synthetic cathinones was reported in Western Europe. In 2010, the rapid emergence of a new drug of abuse, referred to as bath salts or &q... [more] Recently, there has been a worldwide rise in the popularity and abuse of synthetic cathinones. In 2009 and 2010, a significant rise in the abuse of a new group of synthetic cathinones was reported in Western Europe. In 2010, the rapid emergence of a new drug of abuse, referred to as bath salts or "legal high," occurred in the USA. The growing number of cases along with the alarming severity of the effects caused by the abuse of these substances prompted significant concern from both healthcare providers and legal authorities. We report the experience of the first 8 months of two regional poison centers after the emergence of a new group of substances of abuse. This was a retrospective case series of patients reported to two poison centers with exposures to bath salts. Additionally, 15 "product samples" were obtained and analyzed for drug content using GC/MS. There were 236 patients of which 184 (78%) were male. Age range was 16-64 years (mean 29 years, SD 9.4). All cases were intentional abuse. There were 37 separate "brand" names identified. Clinical effects were primarily neurological and cardiovascular and included: agitation (n = 194), combative behavior (n = 134), tachycardia (n = 132), hallucinations (n = 94), paranoia (n = 86), confusion (n = 83), chest pain (n = 40), myoclonus (n = 45), hypertension (n = 41), mydriasis (n = 31), CPK elevations (n = 22), hypokalemia (n = 10), and blurred vision (n = 7). Severe medical outcomes included death (n = 1), major (n = 8), and moderate (n = 130). Therapies included benzodiazepines (n = 125), antipsychotics (n = 47), and propofol (n = 10). Primary dispositions of patients were: 116 (49%) treated and released from ED, 50 (21%) admitted to critical care, 29 (12%) admitted to psych, and 28 (12%) lost to follow up. Nineteen patients had blood and/or urine analyzed using GC/MS. MDPV was detected in 13 of 17 live patients (range 24-241 ng/mL, mean 58 ng/mL). The four samples with no drug detected, reported last use of bath salts >20 h prior to presentation. Three of five patients had MDPV detected in urine (range 34-1386 ng/mL, mean 856 ng/mL). No mephedrone or methylone was detected in any sample. Quantitative analysis performed on postmortem samples detected MDPV in blood at 170 ng/mL and in urine at 1400 ng/mL. No other synthetic cathinones were detected. This is the first report of MDPV exposures with quantitative blood level confirmation. Clinical effects displayed a sympathomimetic syndrome, including psychotic episodes often requiring sedation, movement disorders, and tachycardia. Within 8 months of their appearance, 16 states had added synthetic cathinones to the controlled substances list as a Schedule I drug. We report the emergence of a new group of substances of abuse in the USA, known as bath salts, with quantitative results in 18 patients. State and federal authorities used timely information from poison centers on the bath salt outbreak during investigations to help track the extent of use and the effects occurring from these new drugs. Close collaboration between state authorities and poison centers enhanced a rapid response, including legislation.
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    Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers.

    Henry A Spiller, Douglas J Borys, Mark L Ryan, Tama S Sawyer, Brooke L Wilson

    The Annals of pharmacotherapy. 01/2011; 45(1):17-22.

    Adverse drug events in the ambulatory care setting are not uncommon and can cause significant morbidity. Little research has been published on the management of adverse drug events involving insulin in the outpatient setting. To analyze data on patients with unintentional therapeutic errors involvin... [more] Adverse drug events in the ambulatory care setting are not uncommon and can cause significant morbidity. Little research has been published on the management of adverse drug events involving insulin in the outpatient setting. To analyze data on patients with unintentional therapeutic errors involving insulin managed by 9 regional poison control centers. A retrospective search was performed for all records involving insulin at 9 poison centers, covering the population of 4 states for the years 2000-2009. A subgroup of the study population was selected with a reason for exposure of "unintentional-therapeutic error." There were 3819 insulin exposures reported, with an increase in the annual incidence of insulin exposures of 279% (from 170 to 645 patients/year) and a mean annual increase of 18%. Of the insulin exposures, 2584 were unintentional therapeutic errors (68%). The percentage of all insulin exposures that were unintentional therapeutic errors increased progressively, from 41% to 78%. There was a 495% increase in annual incidence of unintentional therapeutic errors involving insulin, with a mean annual increase of 28%. Unintentional therapeutic errors involving insulin occurred primarily in adults >40 years (73%), with 63% occurring in women. There was a pronounced increase in unintentional therapeutic errors involving insulin in the later evening hours, with 71% occurring between 1800 and 2400 and reaching a peak at 2200. The majority (n = 1803; 70%) of patients were managed in a non-health-care facility location, primarily their own residence. This is the first report of an increasing trend of insulin-related unintentional therapeutic errors in the ambulatory setting. Our study highlights a number of striking features, including: (1) a consistent and dramatic increase of unintentional therapeutic errors involving insulin over the 10-year period, (2) a high incidence of unintentional therapeutic errors involving insulin in the late evening hours, and (3) a high incidence of unintentional therapeutic errors involving insulin involving adults >40 years and females. With their 24/7 availability, poison centers appear to be an increasingly important resource for patients experiencing unintentional therapeutic errors involving insulin.
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    Is elevated creatinine a reliable marker for methanol toxicity in nitromethane-containing model fuel ingestions in children?

    Pradeep Padmanabhan, Henry A Spiller, Mitchell P Ross, George M Bosse

    Clinical toxicology (Philadelphia, Pa.). 01/2011; 49(1):45-7.

    In the absence of a rapid serum methanol level estimation, it is difficult to assess the risk from unintentional childhood ingestion of model fuels containing methanol and nitromethane (MFNM). Previous reports have documented false elevations of serum creatinine from the nitromethane in these fuels,... [more] In the absence of a rapid serum methanol level estimation, it is difficult to assess the risk from unintentional childhood ingestion of model fuels containing methanol and nitromethane (MFNM). Previous reports have documented false elevations of serum creatinine from the nitromethane in these fuels, suggesting its utility as a readily available marker of significant methanol ingestion. We performed a 2-year retrospective chart review of cases of ingestion of MFNM in children, with both a methanol level and measured creatinine level. Seven children, ages 19 months to 3 years, ingested MFNM. All seven children were seen in a hospital and had measured methanol and creatinine levels. All blood samples for methanol and creatinine were drawn within 3 hours of ingestion with methanol estimation delayed up to 24 hours. Creatinine ranged from 0.39 (0.034 mmol/l) to 10.7 mg/dl (0.95 mmol/l). All methanol levels were <10 mg/dl (0.31 mmol/l) or reported as negative. Fomepizole was initiated empirically in two patients due to delay in obtaining methanol analysis results. Transient elevations of creatinine occurred in five of the seven children. Blood urea nitrogen was within normal limits, and there was no history of renal impairment in these children, suggesting the elevated creatinine was mostly related to nitromethane ingestion. No child had a significantly elevated methanol level. Elevated creatinine level, as measured by Jaffe colorimetric method, is not a reliable marker for elevated methanol levels after unintentional ingestion of MFNM.
  • Benzonatate Ingestion Reported to the National Poison Center Database System (NPDS).

    Mark L Winter, Henry A Spiller, Jill R K Griffith

    Journal of medical toxicology : official journal of the American College of Medical Toxicology. 12/2010; 6(4):398-402.

    Little has been published on benzonatate ingestion, with the few case reports suggesting significant risk of seizures after poisoning. A 7-year retrospective review of all single substance ingestion of benzonatate reported to the National Poison Center Database System (NPDS) from 2000 to 2006. In th... [more] Little has been published on benzonatate ingestion, with the few case reports suggesting significant risk of seizures after poisoning. A 7-year retrospective review of all single substance ingestion of benzonatate reported to the National Poison Center Database System (NPDS) from 2000 to 2006. In this review, there were 2,172 patients, of which 1,280 (58%) were female. Mean age was 20 years, with 676 (30%) <6 years. Serious outcomes occurred in 116 (moderate, n = 81, 4%; major, n = 31, 1%; and death, n = 4, 0.2%). Mean age of those with serious outcome was 21 years, with 41 (35%) in children less than 6 years old. Forty-nine percent (1,084) patients were treated in a healthcare facility (HCF) of which 148 (7%) were admitted for medical care. Clinically significant effects that were documented included tachycardia (n = 31, 1%), agitation (n = 30, 1%), seizure (n = 23, 1%), coma (n = 14, 0.6%), ventricular dysrhythmia (n = 9, 0.4%), cardiac arrest (n = 8, 0.3%), hypotension (n = 7, 0.3%), and asystole (n = 6, 0.2%). Of patients with seizures reported, eight patients (0.4%) had multiple/discrete seizures and two had status epilepticus documented. Dysrhythmias but not seizures occurred in all fatalities in this review. Significant CNS and cardiac effects occurred in a small subset of this study (<1%), while half the patients received direct medical care in an HCF. No correlation between age and severity of medical outcome was detected by statistical analysis. A prospective study to better evaluate potential HCF triage criteria such as dosage, age, or preexisting conditions may be warranted. The fatalities from this study were due to dysrhythmias rather than seizures as previously reported in previous case reports. There were no clinical correlations between severity of outcomes and dose ingested. A median dose of 200 mg or greater suggests a potential for producing serious outcomes in a benzonatate exposure.
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    Use of antivenom for snakebites reported to United States poison centers.

    Henry A Spiller, George M Bosse, Mark L Ryan

    The American journal of emergency medicine. 09/2010; 28(7):780-5.

    In 2001, a new antivenin was introduced to the United States and became widely available in the snakebite season of 2002. We investigated what impact this may have had on snakebite treatment and medical outcome. The study used a retrospective review of all snakebites to humans reported to the Nation... [more] In 2001, a new antivenin was introduced to the United States and became widely available in the snakebite season of 2002. We investigated what impact this may have had on snakebite treatment and medical outcome. The study used a retrospective review of all snakebites to humans reported to the National Poison Center Database System from 2000 to 2007. During the 8 years, there were 37,760 snakebites, with a mean of 4720 bites per year. There was a 27% increase in bites reported to a Poison center for the 8-year period and an overall 13.5% increase in the use of antivenin. The 2 categories primarily responsible for the increased use of antivenin were copperhead and crotaline-unknown. Rattlesnake bites remained the category most frequently treated with antivenin with a mean 52.5% treatment rate and only moderate increase for the 8 years. There was no change in the percentage or number of patients with a major outcome (mean, 3.8%) or death (mean, 0.5%). There was a decrease in patients with a minor outcome and an increase in patients with a moderate outcome. The new antivenin is reported to have a reduced potential for adverse reactions. This may have had a role in the decision of which snakebite victims received antivenin. With the introduction of a new antivenin, there has been a dramatic increase in the number of snakebite patients treated with antivenin. This has been most noticeable in snake bite categories that were less frequently treated with antivenin in the past.
  • Epidemiological trends of suicide and attempted suicide by poisoning in the US: 2000-2008.

    Henry A Spiller, Savitri Appana, Guy N Brock

    Legal medicine (Tokyo, Japan). 07/2010; 12(4):177-83.

    In the US the suicide rate on a population basis has risen and fallen over time between approximately 10 and 12 per 100,000 population. The recent trend toward an increased rate has been paralleled by an increase in emergency department visits for attempted suicide. The purpose of this study was to ... [more] In the US the suicide rate on a population basis has risen and fallen over time between approximately 10 and 12 per 100,000 population. The recent trend toward an increased rate has been paralleled by an increase in emergency department visits for attempted suicide. The purpose of this study was to examine trends in suspected suicide (SS) cases reported to the National Poison Data System (NPDS), over a 9-year period (2000-2008). Data were obtained from NPDS, for all human patients between the years 2000 and 2008 with the reason for poisoning exposure recorded as "Intentional - Suspected Suicide" (ISS). Additionally, population sizes were obtained from the US Census Bureau as single annual counts by age and sex bands for the 2000-2008. There were 1,672,324 human exposures reported to substances with the reason of SS. Sixty-five percent (1,084,669) were female. The average age of a patient was 30 years with the age groups 13-19 and 20-29 years reporting the highest SS events, 26.4% and 25.7%, respectively. From 2000 to 2008, the estimated rate of SS increased from 72.6 to 82.8 per 1000 human exposure cases. On a population basis, the estimated rate of SS increased from 55.8 to 67.9 per 100,000 population (p for trend <0.001). The relative risk of human exposures for reason of SS compared to human exposures for any other reason being reported to the NPDS is 1.13 (95% CI: [1.122-1.135], p < 0.001) for every 10 years. The relative risk for females vs. males was 1.82 for having SS as a reason for exposure (p < 0.001). However, females were also 0.82 times less likely to experience a severe medical outcome (SMO) compared to males (95% CI: [0.81-0.83], p < 0.001). We noted an increasing risk of a SMO or fatality increasing with age. Based on the total human exposure cases reported to the NPDS, there was a suggested trend of an increase in SS rates of 13% in the next 10 years. There was a greater incidence of SS in females and younger age groups. However, the odds of a SMO or fatality were higher for males and increased with increasing age.
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    Acute ethanol poisoning in a 4-year-old as a result of ethanol-based hand-sanitizer ingestion.

    Jeffrey S Engel, Henry A Spiller

    Pediatric emergency care. 07/2010; 26(7):508-9.

    Alcohol-based hand sanitizers have become widely available because of widespread usage in schools, hospitals, and workplaces and by consumers. We report what we believe is the first unintentional ingestion in a small child producing significant intoxication. A 4-year-old 14-kg girl was brought to th... [more] Alcohol-based hand sanitizers have become widely available because of widespread usage in schools, hospitals, and workplaces and by consumers. We report what we believe is the first unintentional ingestion in a small child producing significant intoxication. A 4-year-old 14-kg girl was brought to the emergency department with altered mental status after a history of ingesting an alcohol-based hand sanitizer. Physical examination revealed an obtunded child with periods of hypoventilation and a hematoma in the central portion of her forehead from a fall at home that occurred after the ingestion. Abnormal vital signs included a heart rate of 139 beats/min and temperature of 96.3 degrees F, decreasing to 93.6 degrees F. Abnormal laboratory values consisted of potassium of 2.6 mEq/L and a serum alcohol of 243 mg/dL. A computed tomography scan of her brain without contrast showed no acute intracranial abnormality. A urine drug screen for common drugs of abuse was reported as negative. The child was intubated, placed on mechanical ventilation, and admitted for medical care. She recovered over the next day without sequelae. As with other potentially toxic products, we would recommend caution and direct supervision of use when this product is available to young children.
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    Effect of scheduling tramadol as a controlled substance on poison center exposures to tramadol.

    Henry A Spiller, J M Scaglione, Alfred Aleguas, Howell Foster, Lynn Durback-Morris, Elizabeth J Scharman, S David Baker

    The Annals of pharmacotherapy. 06/2010; 44(6):1016-21.

    There is limited information on the effect of scheduling a drug as a controlled substance with comparable data from both a pre-scheduling and post-scheduling time period. To investigate the temporal changes on poisoning cases involving tramadol in 4 states: 2 states where it has been scheduled and 2... [more] There is limited information on the effect of scheduling a drug as a controlled substance with comparable data from both a pre-scheduling and post-scheduling time period. To investigate the temporal changes on poisoning cases involving tramadol in 4 states: 2 states where it has been scheduled and 2 where it is not scheduled. Databases were searched for all cases involving tramadol reported from 2003 through 2009 at 6 regional poison centers that served Arkansas, Kentucky, Ohio, and West Virginia. To allow for comparison based on population, state population estimates were obtained from the US Census Bureau. Over the 7-year study period, the number of tramadol cases increased from 401 per year to 1009 cases per year. The mean annual increase in tramadol cases for all 4 states ranged from 8.8% to 14.1%. Post-scheduling in Arkansas and Kentucky, there was a mean decrease in cases of 4% and 31%, respectively. During this same period, the comparison states of West Virginia and Ohio showed a continued increase of 14% and 23%, respectively. The mean annual increase in tramadol cases per 100,000 population for all 4 states ranged from 16% to 31%. Post-scheduling of tramadol, there was an annual decrease in tramadol human exposures of 5% to 31% in Arkansas and Kentucky, respectively. During this same period, West Virginia and Ohio showed a continued annual increase of 14%. The decrease in the number of cases of tramadol exposure following its addition to the schedule of controlled substances in Kentucky and Arkansas suggests that adding a drug to the schedule of controlled substances may result in a decrease in poisoning exposures related to that drug.
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    Unintentional ingestion of bupropion in children.

    Henry A Spiller, George M Bosse, Michael Beuhler, Ted Gray, S David Baker

    The Journal of emergency medicine. 04/2010; 38(3):332-6.

    The incidence of seizures after unintentional bupropion ingestion in children aged < 6 years has been reported as 0.2%. However, in many poison centers, > 80% of these patients are referred to the Emergency Department (ED) for evaluation. To evaluate if all unintentional pediatric bupropion in... [more] The incidence of seizures after unintentional bupropion ingestion in children aged < 6 years has been reported as 0.2%. However, in many poison centers, > 80% of these patients are referred to the Emergency Department (ED) for evaluation. To evaluate if all unintentional pediatric bupropion ingestions require referral to a health care facility (HCF), or what fraction of these could be managed safely at home. A retrospective chart review was conducted of all bupropion ingestions in children aged < 6 years for 2000-2006 from four regional poison centers. Exclusion criteria were lack of follow-up or multiple drug ingestion. Of 407 patients, 209 (51%) were male. Mean age was 2.2 years (SD +/- 1.0). There were 329 patients (81%) seen in a HCF, of which 143 (35%) were hospitalized; 77 patients (19%) were observed at home. Symptoms occurred in 73 patients (18%): sinus tachycardia (n = 50), nausea/vomiting (n = 32), hyperactivity (n = 17), seizure (n = 3), hallucinations (n = 2), and hypertension (n = 2). The mean heart rate of patients with sinus tachycardia (n = 50, 12.3%) was 137 beats/min (SD +/- 13), with a range of 112-172 beats/min. Mean dosage of those with tachycardia was 24 mg/kg. In the 2 patients with hypertension, the maximum recorded blood pressures were 145/80 mm Hg (2-year-old boy) and 137/90 mm Hg (2-year-old girl), with heart rates of 122 and 125 beats/min, respectively. Dose ingested and patient weight was known for 218 patients. Mean dosage ingested was 12.2 mg/kg, with a range of 2.6-64 mg/kg. Eighty-eight percent of patients with a known dosage ingested < 20 mg/kg. A high percentage of children continue to be seen in a HCF. Concern from the higher incidence of severe effects seen with intentional adult exposures may be one of the reasons for this cautious approach. Conclusion: Unintentional pediatric bupropion ingestions resulted in clinical effects that rarely required any HCF intervention. Isolated unintentional bupropion ingestion of <or= 10 mg/kg may not require referral to a health care facility.
  • A case of hypercalcemia and gastric necrosis from hot pack ingestion.

    Pradeep Padmanabhan, Henry A Spiller, George M Bosse

    Journal of medical toxicology : official journal of the American College of Medical Toxicology. 04/2010; 6(2):139-42.

    Hot packs (instant hot compresses) are frequently used to relieve pain. We report a patient who had significant complications from ingestion of a hot pack containing calcium salts. A 35-year-old male swallowed three hot packs, and developed hematemesis, severe abdominal pain, and hypercalcemia (21.1... [more] Hot packs (instant hot compresses) are frequently used to relieve pain. We report a patient who had significant complications from ingestion of a hot pack containing calcium salts. A 35-year-old male swallowed three hot packs, and developed hematemesis, severe abdominal pain, and hypercalcemia (21.1 mg/dl). He developed diffuse gastric necrosis requiring gastrectomy and colonic interposition. Hypercalcemia was treated with intravenous fluids, pamidronate, and calcitonin. A Medline search revealed no prior report on hot pack ingestion though ingestion of calcium salts has been reported. Hot packs can potentially cause significant injury both from an exothermic reaction and hypercalcemia. Ingestions of calcium salts can result in necrosis of the stomach. Management includes aggressive treatment of hypercalcemia, supportive care and upper gastrointestinal endoscopy.
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    Surveillance of methadone-related poisonings in Kentucky using multiple data sources.

    Terry L Bunn, Lei Yu, Henry A Spiller, Michael Singleton

    Pharmacoepidemiology and drug safety. 02/2010; 19(2):124-31.

    The methadone poisoning death rate for Kentucky in the year 2005 was the sixth highest in the US and increased 17-fold from 1999 to 2005. The purpose of this study was to identify and characterize methadone related poisonings in Kentucky using multiple data sources: inpatient hospitalization dischar... [more] The methadone poisoning death rate for Kentucky in the year 2005 was the sixth highest in the US and increased 17-fold from 1999 to 2005. The purpose of this study was to identify and characterize methadone related poisonings in Kentucky using multiple data sources: inpatient hospitalization discharge data, poison control center data, vital statistics mortality data, and Kentucky All Schedule Prescription Electronic Reporting (KASPER) data. A descriptive analysis study was performed on Kentucky inpatient hospitalization discharge data, Kentucky Regional Poison Center (KRPC) data, Kentucky vital statistics mortality data, and KASPER data. While methadone prescription rates decreased from a peak of 27 prescriptions per 1000 population in the year 2003 to 21 in 2007, there was a statistically significant increase in inpatient hospitalization rates, and KRPC call rates (years 2001-2007), and in mortality rates (years 2001-2005). The highest methadone related inpatient hospitalization rates and mortality rates were observed in the rural Appalachian region of Kentucky. Inpatient methadone related hospitalizations occurred most frequently among males from 25 to 34 years of age and among females from 35 to 44 years of age. Medicare and Medicaid were billed for over half of the patients over the age of 34 hospitalized for methadone related poisoning. The expected payer source for six of the inpatient hospitalization patients was workers' compensation, mostly due to unintentional methadone poisonings at work. Utilizing multiple data sources, the results of this study show that unintentional and intentional methadone related poisonings are a continuing and escalating problem in Kentucky, particularly in the Appalachian region.
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    Poison Centers Detect an Unexpectedly Frequent Number of Adverse Drug Reactions to Lisdexamfetamine (July/August).

    Henry A Spiller, Jill Rk Griffith, Deborah L Anderson, Julie A Weber, Alfred Aleguas

    The Annals of pharmacotherapy. 08/2008;

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    Multiple seizures after bupropion overdose in a small child.

    Henry A Spiller, Scott E Schaeffer

    Pediatric emergency care. 07/2008; 24(7):474-5.

    Unintentional ingestion of bupropion in young children has generally resulted in limited toxicity. We report a case of pediatric bupropion ingestion resulting in multiple seizures. The patient experienced hallucinations, agitation, vomiting, tachycardia and seizures after ingestion of 1050 (48 mg/kg... [more] Unintentional ingestion of bupropion in young children has generally resulted in limited toxicity. We report a case of pediatric bupropion ingestion resulting in multiple seizures. The patient experienced hallucinations, agitation, vomiting, tachycardia and seizures after ingestion of 1050 (48 mg/kg) of extended-release bupropion. The potential for severe toxicity in the setting of pediatric overdose should be recognized.
  • A fatal case of venlafaxine overdose.

    George M Bosse, Henry A Spiller, Aaron M Collins

    Journal of medical toxicology : official journal of the American College of Medical Toxicology. 04/2008; 4(1):18-20.

    Introduction: Based on its primary action of serotonin reuptake inhibition, venlafaxine overdose would be expected to result in serotonergic effects. Case Report: A 40 year old male ingested venlafaxine without co-ingestants in a suicide attempt. The patient developed refractory ventricular fibrilla... [more] Introduction: Based on its primary action of serotonin reuptake inhibition, venlafaxine overdose would be expected to result in serotonergic effects. Case Report: A 40 year old male ingested venlafaxine without co-ingestants in a suicide attempt. The patient developed refractory ventricular fibrillation and expired approximately 9 hours post-ingestion. ECG monitoring revealed significant QRS and QTC interval prolongation prior to his demise. Discussion: A literature review of venlafaxine overdose cases and investigation into its mechanism of action was conducted. The potential for sodium channel blockade and implications for therapy are discussed.
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    The effect of poison control center consultation on accidental poisoning inpatient hospitalizations with preexisting medical conditions.

    Terry L Bunn, Svetla Slavova, Henry A Spiller, Jonathan Colvin, Arne Bathke, Valerie J Nicholson

    Journal of toxicology and environmental health. Part A. 02/2008; 71(4):283-8.

    In 2005, the Kentucky Poison Control Center (PCC) recorded 46,625 poisoning calls; 27% received hospital treatment. Probabilistic data linkage of accidental poisoning inpatient hospital (IPH) discharge data and PCC data (years 2000-2004) was performed. This study compared IPH with/without preexistin... [more] In 2005, the Kentucky Poison Control Center (PCC) recorded 46,625 poisoning calls; 27% received hospital treatment. Probabilistic data linkage of accidental poisoning inpatient hospital (IPH) discharge data and PCC data (years 2000-2004) was performed. This study compared IPH with/without preexisting medical conditions and IPH with/without PCC consultation, examining total length of stay and total hospitalization charges. When compared to the IPH reference group with no preexisting medical conditions and who did not consult the PCC (mean charges = $8748, mean length of stay = 3.2 d), PCC consultation without a preexisting medical condition was significantly associated with decreased total hospitalization charges and decreased length of stay (mean charges = $4999, mean length of stay = 1.9 d). When the patient had a preexisting medical condition, PCC consultation was still associated with decreased total hospitalization charges and length of stay (mean charges = $8145, mean length of stay = 2.4 d) compared to those patients with a preexisting medical condition who did not consult the PCC (mean charges = $10,607, mean length of stay = 3.6 d). These results suggest that after accounting for a patient's age and gender, consultation with the PCC is significantly associated with reduced total hospitalization charges and reduced length of stay for IPH, and this association holds for patients with and without a preexisting medical condition.
  • Fatal bupropion overdose with post mortem blood concentrations.

    Henry A Spiller, Edward Bottei, Linda Kalin

    Forensic science, medicine, and pathology. 01/2008; 4(1):47-50.

    We report five cases of fatal bupropion overdose with post mortem bupropion concentrations ranging from 3.1 to >20 mg/L. Four patients had ingested a sustained-release formulation of bupropion and had evidence of pill "bodies" in their stomach with significantly elevated blood bupropion... [more] We report five cases of fatal bupropion overdose with post mortem bupropion concentrations ranging from 3.1 to >20 mg/L. Four patients had ingested a sustained-release formulation of bupropion and had evidence of pill "bodies" in their stomach with significantly elevated blood bupropion concentrations. The pills found in these patients may represent the residual matrix/shell with significant portions of the actual bupropion released and absorbed by the patients.
  • 2.45
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    Evaluation of centrally acting cholinesterase inhibitor exposures in adults.

    Keith R McCain, Tama S Sawyer, Henry A Spiller

    The Annals of pharmacotherapy. 11/2007; 41(10):1632-7.

    BACKGROUND: There are 4 centrally acting cholinesterase inhibitors (CA-ChEI) available in the US: tacrine, galantamine, rivastigmine, and donepezil. Documented clinical experience involving exposure to these agents is limited. The lack of information makes decisions involving excessive or unintended... [more] BACKGROUND: There are 4 centrally acting cholinesterase inhibitors (CA-ChEI) available in the US: tacrine, galantamine, rivastigmine, and donepezil. Documented clinical experience involving exposure to these agents is limited. The lack of information makes decisions involving excessive or unintended CA-ChEI exposure difficult. OBJECTIVE: To assess the effects, demographics, and outcomes of CA-ChEI exposures reported to US poison centers. METHODS: A retrospective review of the Toxic Exposure Surveillance System of the American Association of Poison Control Centers data of acute and acute-onchronic exposures involving only a CA-ChEI in patients 19 years of age or older with documented medical outcomes from 2000-2005 was performed. RESULTS: There were 1026 records that met criteria for this study. Patients aged 70-89 years made up 73% of reports; 69% of the patients were female. Moderate (197) and major outcomes (20) accounted for 21% of exposures. There were no deaths. Clinical effects that occurred in 5% or more of patients included vomiting (34%), nausea (28%), diarrhea (12%), dizziness/vertigo (9.9%), drowsiness/lethargy (7.7%), diaphoresis (7.4%), tremor (5.2%), and bradycardia (5%). Patients were admitted to the hospital in 19% of all exposures. Of those patients, 42% were admitted to a critical care unit. The majority (65%) of exposures were attributed to unintentional therapeutic error. Patients received at least one form of therapy in 47% of exposures, including intravenous fluid (111), antiemetic (48), atropine (17), benzodiazepine (15), oxygen (14), antihypertensive (4), pralidoxime (4), intubation (3), antihistamine (2), antiarrhythmic (1), anticonvulsant (1), and pacemaker (1). CONCLUSIONS: The majority of patients evaluated in this retrospective study experienced no or mild effect; however, significant or life-threatening effects were observed in a small group of patients and an appreciable number of patients were admitted to a healthcare facility.
  • 2.10
    Impact points
    Two fatal cases of selenium toxicity.

    Henry A Spiller, Eric Pfiefer

    Forensic science international. 09/2007; 171(1):67-72.

    Two patients, a 36-year-old female and a 36-year-old male, separately experienced new onset nausea, vomiting, diarrhea, abdominal pain, muscle weakness and pallor. Over a period of 14-16 h these symptoms continue and progress to include hypotension refractory to therapy, pulmonary edema and cardiova... [more] Two patients, a 36-year-old female and a 36-year-old male, separately experienced new onset nausea, vomiting, diarrhea, abdominal pain, muscle weakness and pallor. Over a period of 14-16 h these symptoms continue and progress to include hypotension refractory to therapy, pulmonary edema and cardiovascular collapse. Autopsies show hemorrhagic pulmonary edema, splenomegaly and lack of anatomical cause for sudden death. Postmortem analysis, in one case post-embalming and exhumation, revealed elevated selenium concentrations and a determination of the cause of death. These two cases present several important features associated with selenium toxicity, two of which are previously unreported: (1) selenium as a potential homicidal agent, (2) the toxidrome and time frame of selenium toxicity, (3) selenium determination in exhumed, embalmed tissues, (4) postmortem urinary selenium concentration, and (5) decrease in tissue concentrations over time.
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