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Evaluation, University of Toronto, Toronto, Ontario, Canada; and Michael J. Burns, MD, Division of Emergency Medicine, Harvard Medical School, Boston, MA doi:10.1197/j.aem.2005.02.003
3. Quang LS, Shannon MW, Woolf AD, Desai MC, Maher TJ. Pretreatment of CD-1 mice with 4-methylpyrazole blocks toxicity from the gamma-hydroxybutyrate precursor, 1,4-butanediol. Life Sci. 2002; 71:771–8. 4. Mellanby E. Alcohol: its absorption into and disappearance from the blood under different conditions. MRC Special Report Series. 1919; 15:1–48. 5. Eder AF, McGrath CM, Dowdy YG, et al. Ethylene glycol poisoning; toxicokinetic and analytic factors affecting laboratory diagnosis. Clin Chem. 1998; 44:168. 6. Sivilotti MLA, Burns MJ, McMartin KE, Brent J. Toxicokinetics of ethylene glycol during fomepizole therapy: implications for management. Ann Emerg Med. 2000; 36: 114–25.
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References 1. Paez AM, Shannon M, Maher T, Quang L. Effects of 4-methylpyrazole on ethanol neurobehavioral toxicity in CD-1 mice. Acad Emerg Med. 2004; 11:820–6. 2. Wax P, Cobaugh D, McMartin K, Brent J, META Study Group. Effect of fomepizole (4MP) on ethanol elimination in ethylene glycol and methanol poisoned patients [abstract]. J Toxicol Clin Toxicol. 1998; 36:512.
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To the Editor:—We read with interest the study by Dr. Pa´ez et al. regarding the effects of 4-methylpyrazole (4-MP) on ethanol neurotoxicity in mice in the August 2004 issue of Academic Emergency Medicine.1 The authors clearly demonstrate that the amount of ethanol required to produce inebriation is decreased in the setting of pretreatment with 4-MP. We think that this conclusion is intuitive based on the known action of 4-MP. Despite this, we disagree with the authors’ conclusion that ‘‘it may be prudent to withhold 4-MP in patients with suspected toxic alcohol ingestions until blood alcohol level results are obtained.’’ Although 4-MP is an expensive treatment, we believe that the severity of the adverse effects of toxic alcohol metabolism justifies its early use, and outweighs the risk of prolonged ethanol neurobehavioral toxicity, when there is a suspicion of a toxic alcohol ingestion. In addition, it is not clear how a positive blood alcohol level should guide a delay in treatment with 4-MP. While it is generally accepted that a serum ethanol concentration of 100 mg/dL is protective, it is not known how soon toxicity can be expected to develop as the serum ethanol concen-
tration falls below 100 mg/dL. It would be impossible to predict with any accuracy how fast one person would metabolize ethanol and reach a serum concentration of 100 mg/dL from an initial serum ethanol concentration above 100 mg/dL. Inebriated patients who receive 4-MP will remain stable and will not become more inebriated.—Beth Y. Ginsburg, MD (
[email protected]), New York University School of Medicine/New York City Poison Control Center, New York, NY; Michael Anana, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, NJ; Oliver Mayorga, MD, Albert Einstein College of Medicine/Jacobi Medical Center, New York, NY; and Robert S. Hoffman, MD, New York University School of Medicine/ New York City Poison Control Center, New York, NY doi:10.1197/j.aem.2005.02.004
Reference 1. Pa´ez AM, Shannon M, Maher T, Quang L. Effects of 4-methylpyrazole on ethanol neurobehavioral toxicity in CD-1 mice. Acad Emerg Med. 2004; 11:820–6.
Frequent Users of Emergency Department Services To the Editor:—The recent article in Academic Emergency Medicine on frequent users of the emergency department adds to the literature on this important topic.1 I am concerned, however, with an error in the discussion, where the authors note that only one program has been successful in reducing the frequency of visits by these patients to the emergency department. Our recent paper refutes this,2 because we demonstrated a reduction from 616 visits 12 months preintervention to 175 visits 12 months postintervention for 24 patients. Subsequent data show that this program has remained successful.3 I have transplanted this program elsewhere, in a citywide approach, with similar success. Key points to success remain a multidisciplinary approach, including medical and social care plans, with community support and patient
involvement.—Christopher Fernandes, MD (christopher_
[email protected]), Burlington, Ontario, Canada doi:10.1197/j.aem.2005.02.002
References 1. Ruger J, Richter C, Spitznagel E, Lewis L. Analysis of costs, length of stay, and utilization of emergency department services by frequent users: implications for health policy. Acad Emerg Med. 2004; 11:1311–7. 2. Pope D, Fernandes CMB, Bouthillette F, Etherington J. Frequent users of the emergency department: a program to improve care and reduce visits. Can Med Assoc J. 2000; 162:1017–20. 3. Grafstein E, Burton K, Innes G, Pope D, Kalla D, Stenstrom R. Evaluation of a program to address frequent emergency visits [abstract]. Can J Emerg Med. 2004; 6:17.
