Melamine Plasticizer Malachite green Herbal poisoning Slimming agents psychosis Iodine-deficient Infant formula Mushroom Poisoning
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1 Melamine Plasticizer Malachite green Herbal poisoning Slimming agents psychosis Iodine-deficient Infant formula Mushroom Poisoning.
2 HA Convention 2013 Outbreaks of Hypoglycaemia Dr Tony Mak, Consultant HA Toxicology Reference Laboratory Princess Margaret Hospital
3 Hypoglycaemia Clinical Tachycardia Sweating Lethargy Confusion Dizziness Seizures Athetosis Neuro. deficits Coma Death Biochemical Confirmation Blood / plasma glucose By Lab or H stix
4 Hypoglycaemia: causes I. Underproduction of glucose A. Hormone deficiencies - hypopituitarism - adrenal insufficiency - catecholamine deficiency - Glucagon deficiency B. Enzyme defects - Glucose-6-phosphatase - Liver phosphorylase - Pyruvate carboxylase - Phosphoenolpyruvate decarboxykinase - Fructose-1,6-diphosphatase - Glycogen synthase C. Substrate deficiency - Ketotic hypoglycaemia of infancy - Severe malnutrition, muscle wasting - Late pregnancy D. Acquired liver disease - Severe hepatitis - Cirrhosis E. Drugs - Alcohol - Propoanololo - Salicylates II. Overutilisation of glucose A. Hyperinsulinism - Insulinoma - Exogenous insulin - Sulphonylureas - Drugs: quinine, disopyramide - Endotoxic shock B. Appropriate insulin levels - Extrapancreatic tumours - Systemic carnitine deficiency - Beta oxidation defects -
5 Hypoglycaemia: Unintentional ingestion of Sulphonylureas Diagnostic challenge Public health challenge
6 Sudden Confusion F/88, consulted a GP, who prescribed: Cimetidine Prochlorperazine Chlodiazepoxide Mylanta Simethicone The patient was found drowsy H stix in A&E: 1.6 mmol/l
7 Sudden Confusion - Analysis Prescribed: Cimetidine Prochlorperazine Chlodiazepoxide Mylanta Simethicone Laboratory: Cimetidine Prochlorperazine Chlodiazepoxide Mylanta Gliclazide A cluster of similar cases... All consulted the same GP! Drug dispensing error? tified Department of Health Contacted all potentially affected cases
8 Dispensing gliclazide in lieu of simethicone by a GP >200 patients were affected 5 deaths; 2 died of misadventure A simple case: stopped and eliminated a big problem
9 More hypoglycaemia cases requests for hypoglycaemic agents Developed analysis for All sulphonylureas in HK & the mainland
10 More hypoglycaemia cases F/78; Old age home resident General condition; DM Dull looking H stix ~1 mmol/l Analysis: glibenclamide Medication incident
11 More hypoglycaemia cases Jun 05 Mar 06: drug-induced hypoglycaemia Without Hx of such drug use, but Hypoglycaemics were found N=23; 9 were old-age home residents Hong Kong Med J 2006;12:334-8
12 Old age home drug administration errors
13 More hypoglycaemia cases Old age homes: drug administration standard? FHB: SWD + DH + HA Monitoring system Enhanced surveillance, training, guidelines To control the problem
14 Monitoring System Total 163 cases; >20 cases/year OAH (with CGAT) / General population: 4x OAH (without CGAT) / OAH (with CGA): 4x OAH (without CGAT) / General population: 16x
15 More hypoglycaemia cases t an outbreak An on-going problem! Poor caring standard t entirely a medical problem More a social problem A resources distribution/utilization problem
16 Yet more hypoglycaemia cases Dec 2007 Many unexplained low blood sugar cases
17 Hypoglycaemia - Cases Late Early Mid January December M/86 M/76 M/69 Unexplained hypoglycaemia Lived with family, independent diabetes Drug induced? using any drugs Urine TRL: was found
18 Yet more hypoglycaemia cases Date Sex Age Diabetes Drug Hx Findings 11/12/07 M 86 25/12/07 M 53 27/12/07 M 66 05/01/08 M 76 08/01/08 M 53 13/01/08 M 74? 15/01/08 M 80 16/01/08 M 69 17/01/08 M 51 19/01/08 M 53 24/01/08 M 78
19 Yet more hypoglycaemia cases Date Sex Age Diabetes Drug Hx Findings 11/12/07 M 86 25/12/07 M 53 27/12/07 M 66 05/01/08 M 76 08/01/08 M 53 13/01/08 M 74 15/01/08 M 80 16/01/08 M 69 17/01/08 M 51 19/01/08 M 53 24/01/08 M 78? 25/01/08 M 44 YES!
20 Yet more hypoglycaemia cases 25/01/2008 M/44 Low blood sugar, after taking Sexual function enhancement drug Purchased in Sheung Shui package, no name
21 Yet more hypoglycaemia cases 31/01/2008 Analysis: Sildenafil (Viagra) (Daonil) ( mg/capsule = 32 to 46 tablets!)
22
23 1/02/2008 Date Sex Age Diabetes Drug Hx Condition 11/12/07 M 86 25/12/07 M 53 27/12/07 M 66 05/01/08 M 76 08/01/08 M 53? Died 13/01/08 M 74 15/01/08 M 80 16/01/08 M 69 17/01/08 M 51 ICU 19/01/08 M 53 Discharged 24/01/08 M 78 25/01/08 M 44 Yes! Discharged
24 1/02/2008 Date Drug Hx Condition Results 11/12/07 27/12/07 ** tified DH ** <24hr after the 1 st case was confirmed: 25/12/07 Important, on-going poisoning outbreak! 05/01/08 08/01/08? Died + Sildenafil 13/01/08 15/01/08 16/01/08 17/01/08 ICU + Sildenafil 19/01/08 Discharged + Sildenafil 24/01/08 25/01/08 Yes! Discharged + Sildenafil
25 Yet more hypoglycaemia cases 05/02/2008 Press conference by DH + HA
26 06/02/2008 (Chinese NY eve) Soundbite: Half a tablet can kill!
27 Number of Patients Numerous publicity by DH Dec-07 Feb-08 Apr-08 Jun-08 Aug-08 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Press Conference
28 Summary: N = 85 Age: 72 (39-87) Re-admission: 8 One patient was admitted for 3 times!
29 Outcome Fully recovered 63 Died 3 Vegetative state 1 Cognitive impairment 1 First 68 patients
30 Drug history: Kind Total = 68; 25 (37%) denied Nangen Zengzhangsu 男根增長素 12 Jiu Bian Wang 九鞭王 5 Lu Quan 鹿泉 2 San Bian Wan 三鞭丸 1 Yellow capsule ( fake viagra 假偉哥 ) 1 Unnamed red-yellow capsule 9 Unnamed brick red rhomboid tablet 8 Unnamed blue rhomboid tablet 1 Herbal wine 1 First 68 patients
31 男根增長素三鞭丸 name, no package 鹿泉 九鞭王 name, no package
32 Drug history: Source Friends 17 Pharmacies (mainland China) 10 Pharmacies (Hong Kong) 3 Peddlers (mainland China) 2 Peddlers (Hong Kong) 4 Unknown 2 First 68 patients
33 Discussion 1. Formulation never encountered 2. Why? 3. Single source of raw material? 4. Psychology of the patients - impotence: embarrassing - concealed drug history - street drug: prescription/natural/cheap - mild cases would have been missed
34 Discussion Singapore: 10 deaths We have saved some lives. Soundbite: Half a tablet can kill!
35 Concluding remarks 3 outbreaks in 4 years, 3 different nature: Drug dispensing error (by GP) Drug administration error (in OAH) Counterfeiting drugs (source?) HKPCN units collaboration: Controlled and minimized the harm We need your support!
36 Hospital Authority Toxicology Reference Laboratory
37 Hospital Authority Toxicology Reference Laboratory Best Original Paper Award - Hong Kong Med J
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