Georgetown doctors test milk thistle to counter amanitin toxins in the liver
SAN DIEGO – On September 12, 2011, a Springfield, Virginia man arrived at MedStar Georgetown University Hospital (MGUH) in the early stages of liver failure. The man had mistakenly eaten poisonous mushrooms, handpicked from his yard. He would be the first of four patients in the course of two weeks to seek treatment at MGUH for mushroom (amanitin) poisoning. Their clinical course, management, and outcomes were presented today at Digestive Disease Week (DDW) in San Diego, the largest international gathering of physicians and researchers in the field of gastroenterology, hepatology, endoscopy and gastrointestinal surgery.
“When the Virginia man arrived at his local emergency department, a clinical diagnosis of mushroom poisoning was made,” recalls Jacqueline Laurin, M.D., a transplant hepatologist at the Georgetown Transplant Institute, a part of MGUH and Georgetown University Medical Center.
“He had eaten the mushrooms, gotten very ill and his liver enzymes were very elevated with signs of severe liver dysfunction,” Laurin recalls. The man was transferred to MGUH because in some cases, a liver transplant is necessary following amanitin poisoning.
Laurin’s team called the local Poison Control Center who in turn, put them in contact with a California physician who is the principal investigator for a study using the IV preparation of milk thistle seeds (silibinin) in the United States for amanitin poisoning. Arrangements were made to have the drug flown and then couriered to the hospital where it arrived within hours. The patient received silibinin that evening.
Because silibinin is not yet approved by the U.S. Food and Drug Administration (FDA), physicians would only be able to offer it to one patient under the FDA’s “emergency use” one-time exemption. Any future treatment with silibinin would require administration as part of a clinical study with approval of Georgetown University Medical Center’s Institutional Review Board, a committee charged with the protection of humans in research studies.
“We knew it wasn’t out of the realm of possibility that another person could show up with mushroom poisoning and without a study in place, we wouldn’t have the option of offering the silibinin,” Laurin explains.
At that time, mushrooms were cropping up in yards and parks in the Washington, DC area in greater numbers than usual because of increased rainfall for the season.
One week later, and before the protocol could be completed, a second patient with mushroom poisoning arrived at Georgetown.
The patient’s status prompted an emergency meeting of the Institutional Review Board comprised of clinical and non-clinical members from the Medical Center and MGUH, who approved the protocol, thus allowing the second patient to be treated with the same IV preparation of milk thistle, silibinin, as the first patient received.
A few days later, two more patients arrived – friends who had mistaken the poisonous mushrooms as innocuous. They too received silibinin.
Laurin says the initial clinical presentation of amanitin poisoning mimics gastroenteritis in the form of nausea, vomiting, abdominal pain, and diarrhea followed by a period of apparent recovery then the development of acute hepatitis and jaundice.
“Early recognition of mushroom ingestion as a cause of acute hepatitis is paramount to initiate treatment and hopefully preventing progression to acute liver failure, liver transplant, or death,” she says.
There is no standard guideline for treating people with acute hepatitis from mushroom toxicity. “Without a standard treatment, aggressive hydration to remove the amanitin toxin is one of few ways to reduce damage to the liver,” Laurin explains. “For our recent amanitin patients, all received intravenous silibinin. We also placed a nasobiliary drain in two of the patients in an attempt to disrupt the enterohepatic pathway of amanitin and remove amanitin toxins from the body.”
“Because our hospital is affiliated with Georgetown University Medical Center, our treatment options include agents in clinical studies,” explained Maiyen Tran Hawkins, D.O., a gastroenterology fellow in the transplant hepatology inpatient service and lead author of the DDW abstract. “That access and our team approach allowed us to quickly and successfully deliver a multi-modality treatment with IV silibinin and ERCP for nasobiliary drainage placement. We were able to prevent liver failure and all patients fully recovered without significant consequence.”
Hawkins presented the clinical course, management, and outcomes of the four cases during a poster session at DDW.
“While these results appear promising, we need to know much more about silibinin, such as the timing for delivering it, what dose is most effective and whether or not a nasobiliary drainage is even necessary in combination with silibinin,” explains Laurin. “I think we can point to this case series as a treatment success, but clearly more work and education needs to be done to reduce morbidity and death from amanitin poisoning.”
Additional authors on the DDW abstract include Marco Paez, B.S., and Michael E. Goldberg, D.O. The authors report having no personal financial interests related to this work.
DDW is the largest international gathering of physicians, researchers and academics in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery. Jointly sponsored by the American Association for the Study of Liver Diseases, the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy and the Society for Surgery of the Alimentary Tract, DDW takes place May 19 – 22, 2012, at the San Diego Convention Center. The meeting showcases more than 5,000 abstracts and hundreds of lectures on the latest advances in GI research, medicine and technology. For more information, visit www.ddw.org.
About Georgetown University Medical Center
Georgetown University Medical Center is an internationally recognized academic medical center with a three-part mission of research, teaching and patient care (through MedStar Health). GUMC’s mission is carried out with a strong emphasis on public service and a dedication to the Catholic, Jesuit principle of cura personalis — or “care of the whole person.” The Medical Center includes the School of Medicine and the School of Nursing & Health Studies, both nationally ranked; Georgetown Lombardi Comprehensive Cancer Center, designated as a comprehensive cancer center by the National Cancer Institute; and the Biomedical Graduate Research Organization (BGRO), which accounts for the majority of externally funded research at GUMC including a Clinical Translation and Science Award from the National Institutes of Health. In fiscal year 2010-11, GUMC accounted for 85 percent of the university’s sponsored research funding.
Title: Use of intravenous silibinin and nasobiliary drainage as treatment for mushroom toxicity
Poster Session: Sunday, May 20, 2012; 8:00 a.m. to 5:00 p.m.
Presentation Time: Noon to 2:00 p.m.
San Diego Convention Center, Halls C-G
The incidence of contrast material-induced nephropathy (CIN) is low in
patients with stage 3 or 4 chronic kidney disease who underwent treatment
in accordance with current guidelines; however, risk of CIN is increased
in patients with heart failure, low body mass index, or repeated
administration of contrast material.
Heart failure, low BMI, and repeated contrast material administration were identified as risk factors for CIN under the current treatment strategy. The low incidence of CIN supports the use of hydration as a preventive measure in patients at high risk for CIN.
Atypical femoral fractures were associated with bisphosphonate use; longer duration of treatment resulted in augmented risk. The incidence of atypical fractures increased over a 12-year period, but the absolute number of such fractures is very small.
The following is a first-person account about a recent disaster drill. What makes this different is that the author, a FF/NREMT-I, was one of the “victims”. Here is an edited version of his report. (PPR)
Brian Cress, NREMT-I
I recently had an opportunity to participate in a Disaster Drill involving the Lucas County Port Authority, Local Fire Departments, and the United States Air National Guard Fire Division located at the 180th fighter wing housed atToledoExpressAirport. This drill was to simulate a Plane Crash atToledoExpressAirport. My role: Victim! Being an AdvancedEMT and working with many members of the local fire departments who participated, I was able to gain a new perspective and fully understand why these drills and simulations are so important
From the Rescuer’s perspective, drills like this are important to maintain readiness, skills proficiency, enhance interdisciplinary and inter-department communication, and to continue learning about how to deal with these types of incidents more proficiently. However, rarely do these people get to experience the scenario from the victim’s side.
When the drill began, the scene was relatively calm. Planners lit “burn-boxes” to simulate burning wreckage. They also staged a few victims and positioned many mannequins outside of our “airplane” for the first responders to observe as they approached the scene. From the time the Port Authority Fire Department, and 180th ANG Fire Division arrived and began to suppress the fires, to the time I was rescued was about 7 minuets, but with a fake plastic knife sticking out of my chest and uncontrolled bleeding from the leg, that time to rescue seemed much longer; HOURS longer.
There was chaos on the airplane, people bleeding, screaming, and confused patients with head injuries were wandering around trying to help other victims. I began to go unconscious on the floor of the airplane when an 180th ANG Firefighter picked up my “patient card” (vital signs and listed injuries). The Rescuer informed me this was a drill and they had the option to carry me or I could walk if that would be more comfortable. I wasn’t going to let them off that easily, I told him I could probably walk with help. I was escorted to the end of the airplane where I was met by another 180th ANG firefighter who threw my arm around her and helped me limp to a triage area. She set me down and began to turn to walk away and I begged her not to leave. For “Pete’s sake” I had a knife sticking from my chest and my leg would not stop bleeding!
As an AEMT I understood what was going on. That firefighter who had escorted me was not responsible for patient care. Her job was only to get the victims off of the plane, and to the triage area so that Paramedics could triage and treat them appropriately. However, as a victim, I could not believe that this rescuer, my saving angel, was going to leave me after just rescuing me from a burning plane!
Eventually after much begging, this firefighter politely informed me that there were other people still on the airplane that needed help. Reluctantly I stopped screaming for her to stay and she took that opportunity to return to her duties onboard the airplane.
Now looking around, and seeing only one person near me with a clipboard and many other firefighters and probably paramedics standing around I began screaming again for somebody to “PLEASE HELP ME!!!” I was taking this acting a little further than the other volunteer victims, but I was having fun with it and it caught some of the rescuers off guard. Nobody responded to me, so I took matters into my own hands, I began crawling on my good leg and hands to the ambulances that were staged about 50 meters away. I got about 15 feet away from where I originally lay before a paramedic finally came over and addressed me and my injuries, he told me just to hold on and don’t crawl any farther, that he’d be right back. I again screamed for him not to leave and to please help me. Regardless, he walked away and returned seconds later with a red ribbon, and began to tie it around my arm. Playing along as the victim I began asking questions “what does that mean” “am I going to die” “why isn’t anybody helping me”?
The triage tag colors are one way to communicate patient criticality to arriving rescuers. Understandingly, this is not well known to the general public, but this can be quite a frightening for people who find themselves in this situation with a colored band being tied around their arm.
Less than a minute later a team of paramedics came over and asked if I could walk. Again I told them I could try but I would need some help. They opted to place me on a stretcher and take me out that way. At this time, I thought I was home free, going to an ambulance on my way to a hospital to receive definitive care, however a short 30 feet away; they lowered the stretcher and placed me next to a red flag.
I was now to the point of being “upset”; TWICE I have been rescued from danger and dropped off yards away to wait for further evaluation. I became louder with my screaming, breathing faster, complaining of more pain, and trying to get more rescuers’ attention. I was worried I would “Die” here on the tarmac and I was never going to get into an ambulance. A group of three Paramedic/Firefighters from a local fire department walked by with an empty stretcher. I reached out and grabbed the bunker pants of one of the firefighters and begged for help.
Immediately she knelt down and started talking to me, assuring me everything was going to be ok, started asking me questions to calm me down. “Where were you going on the airplane? Were your friends with you. Do you see them? What’s your name? When is your birthday? Where are you from?” She was doing a excellent job in distracting me from my mission to get into an ambulance, She explained to me what was going on and that more people were coming to help “right now”.
Then I asked her the tough one; “Am I going to die? I can’t die, not like this!” She told me to look her in the eyes and she said, “Not if I can help it, I am here to help YOU”. This BLEW me away, I was taught never to tell a patient they were not going to die, somewhat about not instilling false hope, something about liability if family or close friends were to hear you say that, and the patient die later.
However, I appreciated it. This woman had finally given me what I was looking for, somebody who cared about ME and cared about treating my injuries. She instilled a sense of hope and calm in the chaos that was occurring around me.
She stayed with me until my care was transferred to a Registered Nurse (RN) and a Paramedic from a local hospital’s ambulance service. They quickly addressed my open chest wound and leg injury, and backboarded me for “c-spine” precautions. However, I was still quite scared at this point. They were wrapping the knife, tying bandages and talking in lingo that I’m not sure I would know if I didn’t have prior training. As a victim I’m glad somebody stayed there to keep me calm and talk me through what was going on.
After I was back boarded, the ambulance crew left to treat other patients and my patient card was examined. I was to be transferred to a local hospital by another ambulance crew who loaded me up in their ambulance. I was moved onto their cot, and began moving toward the ambulance. I was loaded into the ambulance and placed on the Cardiac Monitor.
I stopped my “act” until we were about 2 minuets away from the hospital. I was unloaded and rolled through the doors of the ER, and started screaming again! This was approximately 45 min to an hour later than I was initially assessed.
Typical of actual disasters, there was no radio contact made with ER personnel informing them of my imminent arrival. To say the least the staff that met me at the door was quite shocked and confused. Quickly they realized this was part of the drill that was being conducted. Nevertheless, they began to treat me as if I were a real patient in danger. A youngCNP(Certified Nurse Practitioner) met me and followed me into my room with about 3 other nurses. Because I was wearing my Camera, they recognized this was part of the exercise but he continued to treat me as if I were a true patient of his. He assessed my wounds, listened to lung sounds, palpated my abdomen, and preformed a rapid trauma assessment. After he was done making his observations, he wrote a treatment plan, which would have outlined the course of care I would have under gone if this had been a real scenario.
At this point the Exercise had concluded for me. I quickly got up and thanked the clinicians for their excellent service. I cleaned myself up, hitched a ride back to the Airport. I drove home that night, contemplating how I was going to explain all that had happened. It was truly an eye opening experience and I was truly privileged to be able to take part and experience this disaster from a perspective I’ve never had before.
There are two things I would like to address. They may relate more to healthcare providers, but they still serve a purpose for the general public.
Provide better patient communication: This one is pretty much cut and dry. Providers NEED to have better communication with their patients, not only in a disaster but in a controlled hospital setting as well. You may not know what type of day this person is having, or what all of their concerns and fears are. Put this in your mind; you are on a cruise, and suddenly your ship hits an iceberg. Can you imagine the chaos and the confusion that would be rampant on board? Just as it is important for a ship’s captain to convey information about what is going on to the passengers, it is NECESSARY and IMPORTANT for you to provide information to your patient.
Providing Hope to the patient, telling the patient he or she “will not die”. This is a very debatable topic that has very many variables and conditions. For that reason, I am going to give you my opinion based only on my scenario described above. In this situation, it was OK for my rescuer to tell me “I would not die if she could help it.” As I stated above, this gave me a true sense of hope and faith in a situation where I was beginning to deteriorate. Sometimes it is hope, or something to live for that makes the difference between Life and Death in a patient that is critically ill. If I was Sue (my rescuer), I would have done the same thing, no questions asked.
I also want to address the situation that a patient is mortally wounded and it is obvious that the patient will not survive. I believe it is our duty to provide these patients with the comfort and assurance that we would like to receive ourselves if that was us on our death bed. I can understand the fact that sometimes there will be a lack of resources, or personnel in a disaster, but it’s just as important to understand that these are human beings asking for our help.
According to the Kubler-Ross model1, there are five stages of grief that a person will go through in order to cope with a situation:
Using this model, in our disaster situation we realize that a patient may not live long enough to go through all five stages. Depending on the situation these steps could take minuets or years to develop. As a victim playing my role in this disaster I went through three of these stages. 1. Denial, “this isn’t happening to me” “I’m not hurt that bad” I quickly moved on to anger while waiting for the rescuers to help me “WHY ISN’T ANYBODY HELPING ME!?!?” And finally I moved onto Bargaining “Please don’t let me die, I’m not a bad person”.
So back to the topic, when addressing a person who is mortally wounded, they may be to the acceptance phase already. These patients will generally be subdued and may seem “out of it.” It is important to ask these patients if they would like you to stay with them or if they have any religious preferences. However a patient who is in an earlier phase such as bargaining or anger may be very difficult to deal with and may require a false sense of hope in order to calm them down. It’s important to remember that just because YOU may want the honest truth no matter how gruesome, some people cannot deal with that or would choose not to deal with that. I am not telling you to flat out lie to your patient, or your patient’s family that may be with them. I am asking you to please provide the best care for your patient. Be a true patient advocate and do what is best for THEM. I think there is a “golden rule” or something we all learned as kids? Oh yeah, that’s right. Treat others as you wish to be treated.
Lastly, I would like to personally thank all of the Departments and agencies involved in this Drill and congratulate them on an exercise well done! I would also like to thank the volunteers that played victims alongside myself, without these volunteers, drills like this would be MUCH less realistic and therefore less beneficial.
1 Broom, Sarah M. “Milestones.” Time Aug 2004. 3rd May 2012
An 85-year-old white man with a known history of hypertension and stage III chronic kidney disease presented to the Emergency Department complaining of dark stools, shortness of breath, and abdominal pain. The patient recently started dabigatran 150mg twice daily for new-onset atrial fibrillation. An upper gastrointestinal endoscopy identified non-specific gastritis with hemorrhage. It was determined to be probable using the Naranjo Probability Scale that gastrointestinal hemorrhaging was a result of dabigatran therapy. Fresh frozen plasma was used to reverse the dabigatran-induced coagulopathy.
“……In Michigan, the number of fires fell to 33,421 in 2010; in 1977, the total was 82,297, reports the National Fire Protection Association.
But while fire calls dropped, EMS responses reached new heights as fire departments have transformed into medical first responders. According to the NFPA, fire responses accounted for about 4 percent of calls in cities of more than 50,000 in 2008, compared to more than 70 percent for EMS and false alarms.
Two of Michigan’s largest cities –Grand Rapids and Lansing– illustrate the trend.
The Grand Rapids Fire Department reported 19,634 calls in its 2010 annual report, including 12,601 emergency medical service calls and 689 fires extinguished. Lansing reported 16,769 calls, with 14,507 being EMS calls and only 398 fire calls……”
Heart disease and stroke deaths drop significantly for people with diabetes
Healthier lifestyles, better disease management are helping people live longer
Death rates for people with diabetes dropped substantially from 1997 to 2006, especially deaths related to heart disease and stroke, according to researchers at the Centers for Disease Control and Prevention and the National Institutes of Health.
Deaths from all causes declined by 23 percent, and deaths related to heart disease and stroke dropped by 40 percent, according to the study published today in the journal Diabetes Care (http://care.diabetesjournals.org/content/35/6/1252.full). Scientists evaluated 1997-2004 National Health Interview Survey data from nearly 250,000 adults who were linked to the National Death Index. Although adults with diabetes still are more likely to die younger than those who do not have the disease, the gap is narrowing.
Improved medical treatment for cardiovascular disease, better management of diabetes, and some healthy lifestyle changes contributed to the decline. People with diabetes were less likely to smoke and more likely to be physically active than in the past. Better control of high blood pressure and high cholesterol also may have contributed to improved health. However, obesity levels among people with diabetes continued to increase.
“Taking care of your heart through healthy lifestyle choices is making a difference, but Americans continue to die from a disease that can be prevented,” said Ann Albright, Ph.D., R.D., director of CDC’s Division of Diabetes Translation. “Although the cardiovascular disease death rate for people with diabetes has dropped, it is still twice as high as for adults without diabetes.”
Previous studies have found that rates of heart disease and stroke are declining for all U.S. adults. Those rates are dropping faster for people with diabetes compared to adults without diabetes. Recent CDC studies also have found declining rates of kidney failure, amputation of feet and legs, and hospitalization for heart disease and stroke among people with diabetes.
Because people with diabetes are living longer and the rate of new cases being diagnosed is increasing, scientists expect the total number of people with the disease will continue to rise. The number of Americans diagnosed with diabetes has more than tripled since 1980, primarily due to type 2 diabetes, which is closely linked to a rise in obesity, inactivity and older age. CDC estimates that 25.8 million Americans have diabetes, and 7 million of them do not know they have the disease.
CDC and its partners are working on a variety of initiatives to prevent type 2 diabetes and to reduce its complications. CDC leads the National Diabetes Prevention Program, a public-private partnership designed to bring evidence-based programs for preventing type 2 diabetes to communities. The program supports establishing a network of lifestyle-change classes for overweight or obese people at high risk of developing type 2 diabetes.
“Diabetes carries significant personal and financial costs for individuals, their families, and the health care systems that treat them,” said Edward W. Gregg, Ph.D., the study’s lead author and chief of epidemiology and statistics in CDC’s Division of Diabetes Translation. “As the number of people with diabetes increases, it will be more important than ever to manage the disease to reduce complications and premature deaths.”
Controlling levels of blood sugar (glucose), cholesterol and blood pressure helps people with diabetes reduce the chance of developing serious complications, including heart disease, stroke, blindness and kidney disease.
In 2001, the National Diabetes Education Program (NDEP), a joint effort of CDC and NIH with the support of more than 200 partners, developed a campaign to raise awareness of the link between diabetes and heart disease and reinforce the importance of a comprehensive diabetes care plan that focuses on the ABCs of diabetes – A1C (a measure of blood glucose control over a two- to three-month period), Blood pressure and Cholesterol. For more information, visit www.YourDiabetesInfo.org or call toll-free 1-888-693-NDEP (1-888-693-6337).
Last year CDC and the Centers for Medicare & Medicaid Services launched Million Hearts, an initiative to prevent 1 million heart attacks and strokes over the next five years. The initiative focuses on two main goals: empowering Americans to make healthy choices and improving care for people, focusing on aspirin for people at risk, blood pressure control, cholesterol management and smoking cessation. More than 2 million heart attacks and strokes occur every year, and treatment for these conditions and other vascular diseases account for about 1 of every 6 health care dollars. Up to 20 percent of deaths from heart attack and 13 percent of deaths from stroke are attributable to diabetes or prediabetes. For more information on Million Hearts, visit http://millionhearts.hhs.gov.
Diabetes was the seventh leading cause of death in 2009 and is the leading cause of new cases of kidney failure, blindness among adults younger than 75, and amputation of feet and legs not related to injury. People with diagnosed diabetes have medical costs that are more than twice as high as for people without the disease. The total costs of diabetes are an estimated $174 billion annually, including $116 billion in direct medical costs.