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Primary acute angle-closure glaucoma occurs only with closure of a preexisting narrow anterior chamber angle, found in older age groups (owing to enlargement of the lens), hyperopes, Inuits, and Asians The value of prophylactic laser therapy in high-risk populations is being assessed In the United States, about 1% of people over age 35 years have narrow anterior chamber angles, but acute glaucoma rarely develops and prophylactic therapy is not generally indicated Angle closure may be precipitated by pupillary dilation and thus can occur from sitting in a darkened theater, at times of stress or, rarely, from pharmacologic mydriasis Anticholinergic or sympathomimetic agents (eg, nebulized bronchodilators, atropine for preoperative medication, antidepressants, nasal decongestants, or tocolytics) are also causes Secondary acute angle-closure glaucoma may be observed with anterior uveitis, dislocation of the lens, or topiramate therapy Symptoms are the same as in primary acute angle-closure glaucoma, but differentiation is important because of differences in management Chronic angle-closure glaucoma is particularly common in eastern Asia It presents in the same way as open-angle glaucoma (see below)

A variety of intoxications may occur after eating certain types of fish or other seafood These include scombroid, ciguatera, paralytic shellfish, and puffer fish poisoning The mechanisms of toxicity and clinical presentations are described in Table 38 9 In the majority of cases, the seafood has a normal appearance and taste (scombroid may have a peppery taste)

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Type of Poisoning Ciguatera Mechanism Reef fish ingest toxic dinoflagellates, whose toxins accumulate in fish meat Commonly implicated fish in the United States are barracuda, jack, snapper, and grouper Clinical Presentation 1 6 hours after ingestion, victims develop abdominal pain, vomiting, and diarrhea accompanied by a variety of neurologic symptoms, including paresthesias, reversal of hot and cold sensation, vertigo, headache, and intense itching Autonomic disturbances, including hypotension and bradycardia, may occur Allergic-like (anaphylactoid) symptoms are due to histamine, usually begin within 15 90 minutes, and include skin flushing, itching, urticaria, angioedema, bronchospasm, and hypotension as well as abdominal pain, vomiting, and diarrhea Onset is usually within 30 60 minutes Initial symptoms include perioral and intraoral paresthesias Other symptoms include nausea and vomiting, headache, dizziness, dysphagia, dysarthria, ataxia, and rapidly progressive muscle weakness that may result in respiratory arrest Onset is usually within 30 40 minutes but may be as short as 10 minutes Initial perioral paresthesias are followed by headache, diaphoresis, nausea, vomiting, ataxia, and rapidly progressive muscle weakness that may result in respiratory arrest

Improper preservation of large fish results in bacterial degradation of histidine to histamine Commonly implicated fish include tuna, mahimahi, bonita, mackerel, and kingfish Dinoflagellates produce saxitoxin, which is concentrated by filter-feeding mussels and clams Saxitoxin blocks sodium conductance and neuronal transmission in skeletal muscles Tetrodotoxin is concentrated in liver, gonads, intestine, and skin Toxic effects are similar to those of saxitoxin Tetrodotoxin is also found in some North American newts and Central American frogs

Now you can create a factory calendar by selecting the factory calendar radio button from the initial maintenance screen shown in Figure 10-24 and clicking the Change button (pencil) You can specify a factory calendar ID with a short description as well as assign the holiday calendar that must be used for that factory calendar This factory calendar has a validity period and most importantly specifies what days of the week are working days This may be seen in Figure 10-28 Lastly, now that the customer-specific calendar has been created, do not forget to assign the calendar to the relevant master data for example, to the unloading points assigned to the customer master record When transporting changed factory calendars from one client to another (for example, after changing the factory calendar by increasing the factory calendar s validity date), the system will first delete all factory calendars, holiday calendars, and public holidays before re-creating them all according to the data in the transport

Caution: Abrupt respiratory arrest may occur in patients with acute paralytic shellfish and puffer fish poisoning Observe patients for at least 4 6 hours Replace fluid and electrolyte losses from gastroenteritis with intravenous saline or other crystalloid solution For recent ingestions, it may be possible to adsorb residual toxin in the gut with activated charcoal, 50 60 g orally (see p 1362)

1 Pit viper (eg, rattlesnake) envenomation A new antivenin (CroFab) has replaced the Wyeth horse serumbased product With local signs such as swelling, pain, and ecchymosis but no systemic symptoms, give 4 6 vials of crotalid antivenin (CroFab) by slow intravenous drip in 250 500 mL saline Repeated doses of 2 vials every 6 hours for up to 18 hours has been recommended For more serious envenomation with marked local effects and systemic toxicity (eg, hypotension, coagulopathy), higher doses and additional vials may be required Monitor vital signs and the blood coagulation profile Type and cross-match blood The adequacy of venom neutralization is indicated by improvement in symptoms and signs, and the rate that swelling slows Prophylactic antibiotics are not indicated after a rattlesnake bite 2 Elapid (coral snake) envenomation Give 1 2 vials of specific antivenom as soon as possible To locate antisera for exotic snakes, call a regional poison control center (800222-1222)

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