In Canada, about 1% of all emergency room (ER) visits in a given year are made by patients with a primary diagnosis of a non-traumatic, non-urgent and yet preventable condition, such as tooth decay. This percentage is typically dismissed as irrelevant. Using 2013-2014 British Columbia data on ER use from the Canadian Institute for Health Information, however, we argue that the 1% figure (and its associated cost) has to be considered beyond its percentage value. In 2013-2014 alone, 12 357 non-traumatic dental visits were made to ERs in BC representing 1% of the total number of ER visits at a cost of $154.8 million to the taxpayers (across Canada, all visits to ER cost $1.8 billion/year). But the vast majority of these dental visits are discharged while the oral problem likely persists, hence taxpayer dollars are wasted. The belief that these dental-related ER visits are insignificant within the total cost for the health care system is misleading: treatment is not given, the problem is not resolved, and yet there is a high cost to taxpayers and to the society at large. Public health resources should be reallocated.KEY WORDS: Emergency room; dental emergencies; cost; public health; policy La traduction du résumé se trouve à la fin de l'article.
Pyrimethamine is an amyl analog of 2,4-diamino-pyrimidine which binds dihydrofolate reductase and acts as a folate antagonist, preventing cell division [1,2]. It is used globally in combination with a sulfonamide for the treatment of infections such as toxoplasmosis and for infectious prophylaxis in several settings, including Pneumocystis infection in immune-compromised patients. Used alone it does not commonly cause any hematologic toxicity, although used as long-term therapy it can lead to megaloblastosis and myelosuppression by depleting folic acid stores [2,3].We report the largest series of patients experiencing severe hematological toxicity due to inadvertent pyrimethamine poisoning. In January 2012, hundreds of patients suff ering from cardiac conditions were accidentally administered high-dose pyrimethamine at the Punjab Institute for Cardiology in Lahore, Pakistan. A batch of isosorbide mononitrate tablets (Isotab, 20 mg) was contaminated with pyrimethamine 50 mg, causing more than 130 fatalities [4]. Patients were estimated to have received pyrimethamine for between 7 and 28 days, with a cumulative dose of between 1 and 4 g. For comparison, the recommended dose ranges between 25 mg weekly (for malaria prophylaxis) and 100 -200 mg, with appropriate folate supplementation, for commencing toxoplasmosis treatment, which is then followed by 25 -75 mg daily.We reviewed the clinical and laboratory parameters in a subset of patients known to have received pyrimethaminecontaminated product. All of these patients presented as diagnostic problems before the nature of contamination of the medical product was known, and underwent a bone marrow examination in Pakistan. Clinical data were provided by medical staff from the Jinnah Hospital and the Services Hospital in Lahore, Pakistan. Bone marrow aspirates were reviewed in the hematology laboratory of the Royal Free Hospital, London. Marrow samples were taken in Pakistan within 2 weeks of stopping pyrimethamine and before starting folinic acid (50 mg intravenously four times daily for 2 days and then twice daily, until a platelet count of 50 ϫ 10 9 /L was reached, followed by 15 mg three times a day, orally, until the platelet count reached 150 ϫ 10 9 /L).All samples were stained with a Romanowsky stain and a Perls stain for iron after fi xation with alcohol. No blood fi lm, data on the mean corpuscular volume or a bone marrow trephine was available for comparative analysis.Clinical and laboratory details of patients are listed in Table I. Th ere were 17 patients, with a mean age of 54.7 years (range 44 -75). Th e most common presentation was with gastrointestinal bleeding or mucocutaneous bleeding and subconjunctival ecchymosis. Five patients reported skin darkening, and one presented with abdominal pain and vomiting. Four patients in this group had infectious complications (two pneumonias and two febrile neutropenias), all of which resolved. One patient died due to their underlying cardiac disease.Mean blood counts at the time of admission were hemoglobin (Hb) 113 ...
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