Showing papers in "Clinical Toxicology in 2015"
TL;DR: Congratulations to Dr. Baselt for the publication of his 10th edition and the expansion of his classic toxicology text to cover over 1,500 medications and chemicals.
Abstract: Congratulations to Dr. Baselt for the publication of his 10th edition and the expansion of his classic toxicology text to cover over 1,500 medications and chemicals. This enduring work provides a c...
429 citations
TL;DR: These data support the continued value of PC expertise and need for specialized medical toxicology information to manage moreserious exposures, despite a decrease in calls involving less serious exposures, as well as support the near real-time, always current status of NPDS.
Abstract: Background: This is the 32nd Annual Report of the American Association of Poison Control Centers’ (AAPCC) National Poison Data System (NPDS). As of 1 January 2014, 56 of the nation’s poison centers...
399 citations
TL;DR: Analysis of two “butyrfentanyl” NPS products brought to hospital by patients showed that the 10-fold more potent fentanyl was the main active ingredient in both, alarming, given the narrow range between a safe and a lethal dose for opioids.
Abstract: Background. The supply of unregulated “new psychoactive substances” (NPS) has shown a steady increase over the past six years. This report from the Swedish STRIDA project describes analytically confirmed non-fatal intoxications involving butyrfentanyl (butyrylfentanyl) or 4-fluorobutyrfentanyl (para-fluorobutyrfentanyl), two fentanyl analogues recently introduced as NPS opioids. Study design. Observational case series of consecutive patients with suspected acute NPS exposure and requiring hospital care from all over Sweden. Patients and methods. From May 2014 to January 2015, blood and urine samples were obtained from four intoxication cases involving butyrfentanyl and one case involving 4-fluorobutyrfentanyl (men, 19–30 years) presenting in emergency departments (ED) or intensive care units (ICU). Laboratory analysis of serum and/or urine samples was performed by multi-component liquid chromatography–mass spectrometry methods. Data on clinical features were collected during consultations with the...
130 citations
TL;DR: There was a significant decrease in the perceived risk associated with occasional and regular marijuana use between 2002 and 2012, and younger age, male gender, and past month use were also associated with decreased perceived risk.
Abstract: Context. The role of a dynamic legal, medical, and social setting in affecting the perceived risk associated with smoking marijuana has not been well studied. We sought to determine whether there has been a change in the perceived risk associated with marijuana use over time. Methods. A cross-sectional study was conducted using the 2002–2012 National Survey on Drug Use and Health. Respondents were asked to classify the risk of smoking marijuana. Regression analysis and the Mann–Whitney U test were used to analyze the data. Results. A total of 614579 respondents were identified. Between 2002 and 2012, the percent of respondents who characterized regular marijuana use as being associated with “great risk” decreased from 51.3% to 40.3%, while the percent of respondents who characterized it as being associated with “no risk” increased from 5.7% to 11.7%. The percent of respondents who characterized occasional use as “great risk” decreased from 38.2% to 30.7%, while the percent of respondents who chara...
107 citations
TL;DR: The workgroup concluded that VPA is moderately dialyzable in the setting of overdose and made the following recommendations: ECTR is recommended in severe VPA poisoning, and intermittent hemoperfusion or continuous renal replacement therapy (2D) is an acceptable alternative.
Abstract: Background. The EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup presents its systematic review and clinical recommendations on the use of extracorporeal treatment (ECTR) in valproic acid (VPA) poisoning. Methods. The lead authors reviewed all of the articles from a systematic literature search, extracted the data, summarized the key findings, and proposed structured voting statements following a predetermined format. A two-round modified Delphi method was chosen to reach a consensus on voting statements and the RAND/UCLA Appropriateness Method was used to quantify disagreement. Anonymous votes were compiled, returned, and discussed in person. A second vote was conducted to determine the final workgroup recommendations. Results. The latest literature search conducted in November 2014 retrieved a total of 79 articles for final qualitative analysis, including one observational study, one uncontrolled cohort study with aggregate analysis, 70 case reports and case series, and 7 pharmacokineti...
107 citations
TL;DR: The Euro-DEN dataset provides a unique insight into the drugs involved in and clinical pattern of toxicity/outcome of acute recreational drug toxicity presentations to hospitals around Europe, complimentary to other indicators of drug-related harm and helps to build a fuller picture of the public health implications of drug use in Europe.
Abstract: Context. Despite the potential for recreational drugs and new psychoactive substances (NPSs) to cause significant morbidity and mortality, there is limited collection of systematic data on acute drug/NPS toxicity in Europe. Objective. To report data on acute drug/NPS toxicity collected by a network of sentinel centres across Europe with a specialist clinical and research interest in the acute toxicity of recreational drugs and NPS to address this knowledge gap. Methods. Sixteen sentinel centres in 10 European countries (Denmark, Estonia, France, Germany, Ireland, Norway, Poland, Spain, Switzerland and the UK) collected data on all acute drug toxicity presentations to their Emergency Rooms (ERs) for 12 months (October 2013–September 2014); information on the drug(s) involved in the presentations was on the basis of patient self-reporting. Results. Data were collected on a total of 5529 presentations involving 8709 drugs (median (interquartile range [IQR]): 1 (1–2) drugs per presentation), a median of 0.3% ...
101 citations
TL;DR: Tamadol overdose was associated with a significant risk of seizures and respiratory depression in more severe cases, both which appear to be related to the ingested dose.
Abstract: Context. Tramadol is a commonly used centrally acting analgesic associated with seizures and suspected to cause serotonin toxicity in overdose. Objective. This study sought to investigate the effects of tramadol overdose, and included evaluation for serotonin toxicity based on the Hunter Serotonin Toxicity Criteria where the seven clinical features of spontaneous clonus, inducible clonus, ocular clonus, agitation, diaphoresis, tremor and hyperreflexia are examined for in all patients taking serotonergic medications; seizures and central nervous system depression. Materials and methods. This was an observational cases series based on a retrospective review of tramadol overdoses (> 400 mg) admitted to a tertiary toxicology unit from November 2000 to June 2013. Demographic details, information on ingestion (dose and co-ingestants), clinical effects, complications (seizures, serotonin toxicity and cardiovascular effects) and intensive care unit (ICU) admission were extracted from a clinical database. ...
93 citations
TL;DR: It is demonstrated that MT-45 has opioid-like desired and unwanted effects, which suggest that long-term use may be associated with dependency as seen with other opioids.
Abstract: Introduction. 1-Cyclohexyl-4-(1,2-diphenylethyl)piperazine (MT-45) is a novel psychoactive substance available over the Internet. MT-45 is an opioid-like compound. This study provides an overview of availability, use and desired and unwanted effects of MT-45 through triangulation of available data sources. Methods. Searches of the published scientific literature and ‘grey’ information sources, using the keywords ‘MT 45’, ‘MT-45’ and ‘1-cyclohexyl-4-(1,2-diphenylethyl)piperazine’ were undertaken in June 2014 to identify information on the availability, prevalence of use and desired/unwanted effects of MT-45. In addition an Internet snapshot survey in English was undertaken in May 2014 to determine the availability and cost of MT-45. Results. In June 2014 we were unable to identify any studies reporting the prevalence of use of MT-45. The Internet snapshot study identified 17 Internet sites selling MT-45. Information on price was available from 9 sites, with the mean price of MT-45 decreased with in...
92 citations
East Carolina University1, Good Samaritan Medical Center2, University of New Mexico3, Scott & White Hospital4, LSU Health Sciences Center Shreveport5, University of California, San Diego6, Texas Tech University Health Sciences Center at El Paso7, Tucson Medical Center8, Instituto Bioclon9, National Autonomous University of Mexico10, University of Arizona11
TL;DR: Management of coagulopathic Crotalinae envenomation with longer-half-life F(ab’)2 antivenom, with or without maintenance dosing, reduced the risk of subacute coagULopathy and bleeding following treatment of en venomation.
Abstract: Background . Crotalidae Polyvalent Immune Fab (Ovine) has been the only antivenom commercially available in the US since 2007 for treatment of Crotalinae envenomation. Late coagulopathy can occur or recur after clearance of Fab antivenom, often after hospital discharge, lasting in some cases more than 2 weeks. There have been serious, even fatal, bleeding complications associated with recurrence phenomena. Frequent follow-up is required, and additional intervention or hospitalization is often necessary. F(ab ’ ) 2 immunoglobulin derivatives have longer plasma half life than do Fab. We hypothesized that F(ab ’ ) 2 antivenom would be superior to Fab in the prevention of late coagulopathy following treatment of patients with Crotalinae envenomation. Methods . We conducted a prospective, double-blind, randomized clinical trial, comparing late coagulopathy in snakebitten patients treated with F(ab ’ ) 2 with maintenance doses [F(ab ’ ) 2 /F(ab ’ ) 2 ], or F(ab ’ ) 2 with placebo maintenance doses [F(ab ’ ) 2 /placebo], versus Fab with maintenance doses [Fab/Fab]. The primary effi cacy endpoint was coagulopathy (platelet count 150 K/mm 3 , fi brinogen level 150 mg/dL) between end of maintenance dosing and day 8. Results . 121 patients were randomized at 18 clinical sites and received at least one dose of study drug. 114 completed the study. Of these, 11/37 (29.7%) in the Fab/Fab cohort experienced late coagulopathy versus 4/39 (10.3%, p 0.05) in the F(ab ’ ) 2 /F(ab ’ ) 2 cohort and 2/38 (5.3%, p 0.05) in the F(ab ’ ) 2 /placebo cohort. The lowest heterologous protein exposure was with F(ab ’ ) 2 /placebo. No serious adverse events were related to study drug. In each study arm, one patient experienced an acute serum reaction and one experienced serum sickness. Conclusions . In this study, management of coagulopathic Crotalinae envenomation with longer-half-life F(ab ’ ) 2 antivenom, with or without maintenance dosing, reduced the risk of subacute coagulopathy and bleeding following treatment of envenomation.
85 citations
TL;DR: Either poor or extensive/ultra-rapid CYP2D6 metabolisers may be exposed to toxic effects of amfetamines, opioid analgesics and antidepressants, with differences within the same pharmacological class.
Abstract: Introduction. Cytochrome P450 2D6 (CYP2D6) is a member of the cytochrome P450 (CYP) superfamily involved in the biotransformation of drugs and substances of abuse encountered in clinical toxicology...
82 citations
TL;DR: Evidence suggesting limited use of the NBOMe class of drugs as novel psychoactive substances compared with that of classical recreational drugs and other novel psycho active substances such as mephedrone is suggested.
Abstract: Introduction. The 25X-NBOMe series are N-2-methoxybenzyl analogues of the respective 2C-X substituted phenethylamine and include 25B-N(BOMe)2, 25B-NBOMe, 25C-NBOMe, 25D-NBOMe, 25E-NBOMe, 25G-NBOMe,...
TL;DR: The adverse effects noted in analytically confirmed cases of NPS intoxication involving diphenidine or MXP were similar to those reported for other dissociative substances such as ketamine and methoxetamine, but the high proportion of polysubstance use might have played a role in the intoxication and clinical features in some cases.
Abstract: Background. Diphenidine (1-(1,2-diphenylethyl)piperidine) and its 2-methoxylated derivative methoxphenidine (MXP, 2-MeO-diphenidine) are substances with dissociative effects that were recently introduced for “recreational” purpose through the online-based sale of new psychoactive substances (NPS). A number of analytically confirmed non-fatal intoxications associated with diphenidine or MXP have occurred in Sweden and were included in the STRIDA project. Study design. Observational case series of consecutive patients with admitted or suspected intake of NPS and requiring intensive treatment in an emergency room and hospitalization in Sweden. Patients and methods. Blood and urine samples were collected from intoxicated patients presenting at emergency departments all over the country. NPS analysis was performed by multi-component liquid chromatography–mass spectrometry methods. Data on clinical features were collected during telephone consultations with the Poisons Information Centre and retrieved f...
TL;DR: WBI can facilitate removal of select toxicants from the gastrointestinal tract in some patients, but there is no convincing evidence from clinical studies that it improves the outcome of poisoned patients.
Abstract: Context. A position paper on the use of whole bowel irrigation (WBI) was first published in 1997 by the American Academy of Clinical Toxicology (AACT) and the European Association of Poisons Centre...
TL;DR: There is in vitro and clinical evidence that the combined use of ILE and extracorporeal membrane oxygenation may be associated with fat deposition in the VA-ECMO circuits and increased blood clot formation.
Abstract: Context. Intravenous lipid emulsion (ILE) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are being used together or in close succession in the management of circulatory failure secondary to cardiotoxic drug poisoning. There have been reports of mechanical problems, including fat emulsion agglutination, clogging, increased blood clot formation and even cracking of parts of the machine, in patients concurrently receiving VA-ECMO and ILE as part of parenteral nutrition. Objective. To ascertain the adverse effects associated with the combined use of ILE and ECMO in the poisoned patient. Methods. PubMed and OVID (1966 to 9 June 2014) and EMBASE (1947 to 9 June 2014) were searched to identify publications relating to studies and/or case reports where ILE had been used at the same time when VA-ECMO was used – 7 were identified. In addition, the abstracts published between 2006 and 2013 inclusive of those from the North American Congress of Clinical Toxicology and the congresses of the Eu...
TL;DR: The majority of patients with analytically confirmed 3-MMC exposure had sympathomimetic features similar to those associated with mephedrone intoxication, however, the high incidence of co-exposure to other drugs makes the clinical interpretation difficult.
Abstract: Background. 3-Methylmethcathinone (3-MMC) is a synthetic cathinone stimulant structurally related to the new psychoactive substance (NPS) mephedrone (4-methylmethcathinone, 4-MMC). We describe a case series of analytically confirmed intoxications involving 3-MMC presented to emergency departments in Sweden and included in the STRIDA project. Study design. Observational case series of consecutive patients with self-reported or suspected use of NPS presenting to hospitals in Sweden between August 2012 and March 2014. Methods. NPS analysis was performed by a liquid chromatography–mass spectrometry (MS)/MS method that is updated with new substances as they appear. Data on clinical features were collected during Poisons Information Centre consultations and retrieved from medical records. Results. 3-MMC was detected in 50 (6.4%) of the 786 cases included in the STRIDA project during the 20-month study period, with the peak occurring in August 2013. The age range of patients testing positive for 3-MMC wa...
TL;DR: The long-term visual sequelae of acute methanol poisonings were clearly underestimated on discharge, suggesting a significantly higher amount of patients with long- term sequelae than earlier reported.
Abstract: Context. Visual disturbances due to the toxic effect of formic acid in acute methanol poisonings are generally transient. The subjective symptoms of visual toxicity may resolve within few weeks and fundoscopic signs of acute optic neuropathy subside within 1–2 months; therefore, the prevalence of long-term visual sequelae in the population of survivors of poisonings may be underestimated. Objective. To study the prevalence and character of long-term visual sequelae of acute methanol poisonings based on the data from the Czech mass methanol outbreak in 2012. Patients and methods. A total of 50 patients with confirmed methanol poisoning were included in this longitudinal cross-sectional study, median age: 48 (range, 23–73) years. The following tests were performed: optical coherence tomography or OCT with evaluation of the retinal nerve fibers layer (RNFL), visual evoked potentials (VEP), magnetic resonance imaging (MRI) of brain, complete ocular examination (visual acuity/field, color vision, contrast sens...
TL;DR: A coordinated response and collaboration between law enforcement, the local public health, emergency medical services and Health Center staff, were all key interventions in preventing a more substantial public health outbreak resulting from use of a novel synthetic cannabinoid compound.
Abstract: Background: Synthetic cannabinoid containing products are a public health threat as reflected by a number of outbreaks of serious adverse health effects over the past 4 years. The designer drug epi...
TL;DR: A 24-year-old woman who intentionally ingested up to 3000 mg of liquid nicotine intended for e-cigarette use died after she was found to have multiple acute infarcts, consistent with severe anoxic brain injury, on magnetic resonance imaging.
Abstract: Context: Electronic cigarette (e-cigarette) use is growing within the United States, resulting in both intentional and unintentional exposures to concentrated liquid nicotine or “e-liquid.” Nicotine has been culpable for severe poisoning and deaths in the past. However, sources of nicotine have traditionally been from cigarettes, cigars, or pesticides. Fatalities due to liquid nicotine are rare, and fatalities following ingestion of e-liquid are even scarcer. Case: We present a case of a 24-year-old woman who intentionally ingested up to 3000 mg of liquid nicotine intended for e-cigarette use. She was found in pulseless electrical activity and had return of spontaneous circulation (ROSC) after undergoing approximately 10 min of cardiopulmonary resuscitation with a blood pressure of 74/53 mmHg and a pulse rate of 106 beats/min. Despite aggressive supportive care, she ultimately died after she was found to have multiple acute infarcts, consistent with severe anoxic brain injury, on magnetic resonance imagin...
TL;DR: Although ethanol is generally associated with a higher incidence of complications, this study suggests that both antidotes are similarly effective and that ethanol should not be avoided on grounds of effectiveness.
Abstract: Context. Mass or cluster methanol poisonings are frequently reported from around the world. The comparative effectiveness of ethanol and fomepizole as antidotes for methanol poisoning is unknown due to the difficulty of performing a randomized controlled trial. Objective. During an outbreak of mass poisonings in the Czech Republic in 2012–2014, we compared the effects of antidotes on the frequency of health sequelae and mortality. Methods. The study was designed as a cross-sectional case series and quasi-case–control study. Patients with a diagnosis of methanol poisoning on admission to hospitals were identified for the study. Diagnosis was established when (i) a history of recent ingestion of illicit spirits was available and serum methanol was higher than 6.2 mmol/L (20 mg/dL), or (ii) there was a history/clinical suspicion of methanol poisoning, and serum methanol was above the limit of detection with at least two of the following: pH < 7.3, serum bicarbonate < 20 mmol/L, and anion gap or AG ≥ ...
TL;DR: A review of the peer-reviewed medical literature as it relates to metal fume fever and polymer fume Fever in order to describe their epidemiology, pathophysiology, clinical presentation, diagnosis, treatment, prevention, and prognosis.
Abstract: Introduction. Inhalational exposure to metal-containing fumes generated by welding and related processes may result in the development of the clinical syndrome known as “metal fume fever.” Polymer fume fever is a separate and distinct but related disorder that has been associated with inhalational exposure to specific fluorinated polymer products, such as polytetrafluoroethylene or Teflon®. We undertook a review of the peer-reviewed medical literature as it relates to these two disease entities in order to describe their epidemiology, pathophysiology, clinical presentation, diagnosis, treatment, prevention, and prognosis. Methodology. We performed a search of the PubMed (www.pubmed.com) and Ovid MEDLINE (ovidsp.tx.ovid.com) databases for keywords “metal fume fever,” “polymer fume fever,” and “fume fever,” covering the period 1946 to September 2014, which resulted in a total of 141 citations. Limiting the search to articles published in the English language yielded 115 citations. These 115 articles...
TL;DR: Clinical and bioanalytical data from analytically confirmed non-fatal intoxications associated with 3- and/or 4-MeO-PCP within the STRIDA project constitute an important basis for the assessment of NPS hazard and availability.
Abstract: Background. 3-Methoxy-phencyclidine (3-MeO-PCP) and 4-methoxy-phencyclidine (4-MeO-PCP) are analogs of and drug substitutes for the dissociative substance PCP (“Angel dust”), a recreational drug that was most popular in the 1970s. In Sweden, use of methoxylated PCP analogs was noted starting in mid-2013, according to statistics from the Poisons Information Centre. The objective of this case series was to present clinical and bioanalytical data from analytically confirmed non-fatal intoxications associated with 3-MeO-PCP and/or 4-MeO-PCP within the STRIDA project. Study design. Observational case series of consecutive patients with self-reported or suspected exposure to new psychoactive substances (NPS) and who require hospital care. Patients and methods. Blood and urine samples were collected from intoxicated patients presenting at emergency departments (ED) or intensive care units (ICU) all over Sweden. NPS analysis was performed by multicomponent liquid chromatographic–tandem mass spectrometric (LC–MS/M...
TL;DR: The main clinical manifestations reported in patients testing positive for MDPV included agitation, tachycardia, and hypertension, which were observed in 130 (67%), 106 (56%), and 65 (34%) cases, respectively, as well as the decline to an almost zero level.
Abstract: Context: In the recent years, there have been an increasing number of new psychoactive substances (NPS) available through marketing and sale on the Internet. The stimulant 3,4-methylenedioxypyrovalerone (MDPV) is a potent dopamine reuptake inhibitor, which can cause serious intoxications requiring intensive care and even fatality. This report from the STRIDA project presents the prevalence, laboratory results, and clinical features in a series of intoxications involving MDPV over a 5-year period. Study design: Observational case series of consecutive patients with admitted or suspected intake of NPS presented at hospitals in Sweden from 2010 to 2014. Patients and methods: Blood and/or urine samples were collected from intoxicated patients with admitted or suspected intake of NPS presenting at hospitals over the country. Analysis of NPS was performed by a liquid chromatography–tandem mass spectrometry multicomponent method. Clinical data were collected when caregivers consulted the Swedish Poisons Informat...
TL;DR: A case series of patients who presented with cardiac conduction disturbances after loperamide abuse and a subsequent hospitalization and pharmacokinetic profile of one of the patients in the case series are reported.
Abstract: A web-based study published in 2013 suggested that loperamide was being abused to attenuate the symptoms of opioid withdrawal.1 Marraffa et al recently reported a case series of patients who presented with cardiac conduction disturbances after loperamide abuse.2 This case series outlined the clinical course of 5 patients, 3 of whom experienced life-threatening arrhythmias. Isolated serum levels were reported in four of these patients. We report a subsequent hospitalization and pharmacokinetic profile of one of the patients in the case series.2 A 30-year-old male presented to an outlying facility for a syncopal episode. The initial electrocardiogram (ECG) revealed a heart rate of 60 beats per minute, a QRS measurement of 192 ms, and a QT of 704 ms. He left against medical advice, only to be found pulseless and apneic by a family member hours later. He was brought back to the outlying facility and demonstrated multiple ventricular arrhythmias, including one episode of polymorphic ventricular tachycardia. He was transferred to our facility after being defibrillated multiple times. The patient reported that he had resumed his abuse of loperamide and had been taking two hundred 2-mg tablets daily for the last seven days. He has had at least four prior hospitalizations with a similar presentation associated with loperamide abuse. The patient’s cardiac conduction disturbance was managed with a continuous infusion of isoproterenol. The conduction disturbance slowly resolved with a QRS of 96 ms and QTc of 489 ms on hospital day 9. He was discharged to an inpatient psychiatric facility on hospital day 13 with a QRS of 94 ms and a QT/QTc of 406/483 ms. Due to his prolonged toxicity we obtained serum loperamide concentrations at multiple time points to better understand his pharmacokinetic profile. The reported pharmacokinetic half-life of loperamide is approximately 9–13 h, although longer half lives up to about 40.9 h have been reported with doses of 16 mg in healthy volunteer studies.3–4 The toxicokinetics of loperamide have not been previously reported. The patient presented to our facility 20 h after his last reported 400-mg dose. On presentation his loperamide level was 120 ng/mL. His loperamide serum levels 32, 44, 57, and 70.5 h post-ingestion were 47 ng/mL, 30 ng/mL, 30 ng/mL, and 20 ng/mL, respectively (Figure 1). Published peak loperamide concentrations after doses of 2–16 mg were reported to be between 0.24 and 3.1 ng/mL and occurred 4–5.9 h after administration.5–6 His first two serum concentrations demonstrated an initial decline consistent with the reported half-life based on population kinetics (8.9 h). However, subsequent serum concentrations demonstrated a half-life of approximately 34.8 h. Interpretation of this kinetic data is complicated by the patient’s history of Crohn’s disease, multiple small bowel resections, and ileostomy. Additionally, the patient did receive a single dose of buprenorphine 12 mg sublingually and amiodarone 150 mg intravenously 35 and 38 h after his reported ingestion, respectively. No other cytochrome P450 inhibitors or inducers were given during the time frame when serum concentrations were drawn. A comprehensive drug panel including synthetic cannabinoids and designer drugs conducted on urine by NMS Labs was negative. Our patient’s ECG changes are consistent with previously published case reports.2,7 The elimination half-life observed in our patient is not consistent with the reported half-life. Loperamide is a m-receptor agonist, which may reduce gastrointestinal motility and result in delayed absorption of drug.8 Delayed absorption in the overdose setting may result in prolonged toxicity. Loperamide has also been reported to antagonize calcium channels, which may result in reduced gastrointestinal motility.9 The elimination kinetics of loperamide are not known in the overdose setting and a multicompartment pharmacokinetic model cannot be excluded. Our patient also received medications that inhibit both cytochrome P450 3A4 and 2D6 enzymatic metabolism. These enzyme families are reported to play a role in the hepatic conversion of loperamide to the N-demethyl metabolite, and inhibition might have further slowed the elimination of parent drug.10 Genetic alterations in these enzymatic pathways could also alter the kinetics of loperamide, which may explain the wide range in half-lives reported in one pharmacokinetic study.3 It is unclear what, if any, impact the patient’s altered gastrointestinal tract may have had on the kinetics of loperamide. Further kinetic studies are needed to assess the toxicokinetics of loperamide.
TL;DR: Dobutamine effectively improves hemodynamic parameters and may reduce mortality in severe scorpion envenomation and supportive treatment relying on ventilatory support and dobutamine infusion is a bridge toward recovery in the majority of patients.
Abstract: Context. Scorpion envenomation is a threat to more than 2 billion people worldwide with an annual sting number exceeding one million. Acute heart failure presenting as cardiogenic shock or pulmonar...
TL;DR: The Extracorporeal Treatments in Poisoning (ECTR) workgroup as discussed by the authors provided evidence-based recommendations on the use of ECTRs in poisoning, including theophylline.
Abstract: Background. The Extracorporeal Treatments in Poisoning workgroup was created to provide evidence-based recommendations on the use of extracorporeal treatments (ECTRs) in poisoning. Here, the workgroup presents its systematic review and recommendations for theophylline. Methods. After a systematic review of the literature, a subgroup reviewed articles, extracted data, summarized findings, and proposed structured voting statements following a pre-determined format. A two-round modified Delphi method was chosen to reach a consensus on voting statements and the RAND/UCLA Appropriateness Method was used to quantify disagreement. Anonymous votes were compiled, returned, and discussed. A second vote determined the final recommendations. Results. 141 articles were included: 6 in vitro studies, 4 animal studies, 101 case reports/case series, 7 descriptive cohorts, 4 observational studies, and 19 pharmacokinetic studies, yielding a low-to-very-low quality of evidence for all recommendations. Data on 143 pat...
TL;DR: Developing more rapid and effective tests for detection of these intoxications is essential for optimal care of patients and to examine the value and limitations of present methods to diagnose patients with possible toxic alcohol exposure.
Abstract: Context. Methanol, ethylene glycol, diethylene glycol, and propylene glycol intoxications are associated with cellular dysfunction and an increased risk of death. Adverse effects can develop quickly; thus, there is a need for methods for rapidly detecting their presence. Objective. To examine the value and limitations of present methods to diagnose patients with possible toxic alcohol exposure. Methods. I searched MEDLINE for articles published between 1969 and 2014 using the terms: toxic alcohols, serum osmolality, serum osmol gap, serum anion gap, metabolic acidosis, methanol, ethylene glycol, diethylene glycol, propylene glycol, and fomepizole. Each article was reviewed for additional references. Results. The diagnosis of toxic alcohol exposure is often made on the basis of this history and physical findings along with an increase in the serum osmol and anion gaps. However, an increase in the osmol and/or anion gaps is not always present. Definitive detection in blood requires gas or liquid chr...
TL;DR: In this sheep model, there was a high risk for cardiac arrest, by PEA, persisting up to 10 min after H2S exposure, and a very high dose of hydroxocobalamin injected very early after the cessation of H1N1 exposure, improved cardiac contractility and prevented PEA.
Abstract: Context. Severe H2S poisoning leads to death by rapid respiratory and cardiac arrest, the latter can occur within seconds or minutes in severe forms of intoxication. Objectives. To determine the time course and the nature of H2S-induced cardiac arrest and the effects of high-dose hydroxocobalamin administered after the end of sulfide exposure. Materials and methods. NaHS was infused in 16 sedated mechanically ventilated sheep to reach concentrations of H2S in the blood, which was previously found to lead to cardiac arrest within minutes following the cessation of H2S exposure. High-dose hydroxocobalamin (5 g) or saline solution was administered intravenously, 1 min after the cessation of NaHS infusion. Results. All animals were still alive at the cessation of H2S exposure. Three animals (18%) presented a cardiac arrest within 90 s and were unable to receive any antidote or vehicle. In the animals that survived long enough to receive either hydroxocobalamin or saline, 71% (5/7) died in the control ...
TL;DR: Common clinical effects of NBOMe and 2C exposures were tachycardia, agitation/irritable, hallucination/delusion, confusion, and hypertension.
Abstract: Background. Hallucinogenic designer drugs, especially NBOMe and the 2C substitute phenylethylamine series, have been increasing ubiquitous in past years. The purpose of this study is to characterize and compare clinical features of NBOMe and 2C exposures in humans. Method. This is a retrospective cohort study of all single agent exposures to NBOMe and 2C substitute phenylethlamine reported to the National Poison Data System (NPDS) from 1st September 2012 to 30th September 2014. Results. Over the study period, there were a total 341 cases including 148 NBOMe exposures and 193 2C exposures. The majority cases involved men (73.9%); median age was 18 years (Interquartile-range, 16–21). Similar clinical effects were reported in both groups including tachycardia (45.2%), agitation/irritable (44.3%), hallucination/delusion (32.0%), confusion (19.1%) and hypertension (18.5%). There were higher incidences of hallucination/delusion, single episode seizure and benzodiazepine administration in NBOMe exposures...
TL;DR: An AST/ALT ratio less than or equal to 0.4 following severe hepatoxicity from paracetamol poisoning appears to be highly predictive of recovery in patients treated with NAC, and has potential to be an indicator of safe discontinuation of NAC treatment.
Abstract: Context. Paracetamol (acetaminophen or APAP) is the most common pharmaceutical exposure in the US. Elevations in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels indicate hepatic toxicity. AST and ALT levels rise in similar proportions but later decline at different rates, with AST falling more rapidly than ALT. Objective. To determine whether the AST/ALT ratio can indicate that a patient has passed the time of peak AST concentration. Methods. We retrospectively identified cases of patients hospitalized for acute APAP poisoning by querying the pharmacy database of all patients treated with acetylcysteine (NAC) from January 1, 2001 to March 19, 2013. We included all patients with severe APAP poisoning, defined as AST or ALT greater than 1000 IU/L. Patients who were given NAC for other indications, those without APAP poisoning, and those receiving liver transplantation were excluded. We then recorded paired AST and ALT concentrations from each patient's hospital course. We ...
TL;DR: The consumption of several species of cooked fish has caused Haff disease outbreaks worldwide and the bioaccumulation of a new heat-stable, fresh, and/or brackish/ salt-water algal toxin in seafood, similar to palytoxin, but primarily myotoxic and not neurotoxic, is suspected for causing HAff disease.
Abstract: Context. Haff disease is a syndrome of myalgia and rhabdomyolysis that occurs after consuming cooked seafood. Objectives. (1) To identify the most common seafood vectors of Haff disease worldwide. (2) To describe and to compare the most commonly recurring clinical and laboratory manifestations of Haff disease. (3) To compare the Haff disease toxidrome with other similar toxidromes. Methods. Internet search engines were queried with the keywords, and selected articles were stratified by reporting Old World or New World nations. Continuous variables were reported as means with standard deviations; categorical values were reported as proportions. Results. Over 1,000 cases of Haff disease were initially described in Eastern Europe and Sweden during and following the ingestion of several species of cooked freshwater fish including burbot, pike, freshwater eel, and whitefish. More recent case reports followed consumption of cooked freshwater pomfret and boiled crayfish in China, and cooked or raw boxfis...