Toxic alcohol ingestions: clinical features, diagnosis, and management

Outcomes of death and prolonged renal insufficiency in ethylene glycol poisoned patients

BACKGROUND

Despite the severity of ethylene glycol intoxication, there is a paucity of studies that analyze prognostic factors. This study aims to determine prognostic factors with impact on core outcomes like death and prolonged kidney injury (KI) in ethylene glycol poisoned patients.

METHODS

We retrospectively assessed prevalence, clinical and biochemical features in one large data set from two regional hospitals from the North-East region of Romania, between January 2012 and October 2017. Secondly, we compared prognostic factors of cases treated with dialysis plus antidote (N = 28 patients) with cases who received antidote only and supportive therapy (N = 28 patients).

RESULTS

Of the 56 cases included, 16 deaths (28.57%) were recorded. The symptomatology at admission was more severe among patients requiring hemodialysis: a lower mean value for initial pH, lower initial alkaline reserve (AR) and higher mean values for initial serum creatinine (Cr1). The data analysis (survivors/deceased) showed a correlation between pH, Glasgow Coma Score (GCS), and increased mortality. In addition, we found a correlation between initial mean values for pH, AR (mmol/L), Cr1 (mg/dL), and peak Cr24 (mg/dL) with outcomes of RI or death.

CONCLUSIONS

Compared with survivors, patients who died or had prolonged kidney injury were more likely to exhibit clinical signs such as coma, seizures, and acidosis. Hemodialysis and antidote should be started early and continued until acidosis is corrected.

Detecting methanol in hand sanitizers

The coronavirus disease 2019 (COVID-19) pandemic has increased dramatically the demand for hand sanitizers. A major concern is methanol adulteration that caused more than 700 fatalities in Iran and U.S.A. (since February 2020). In response, the U.S. Food and Drug Administration has restricted the methanol content in sanitizers to 0.063 vol% and blacklisted 212 products (as of November 20, 2020). Here, we present a low-cost, handheld, and smartphone-assisted device that detects methanol selectively in sanitizers between 0.01 and 100 vol% within two minutes. It features a nanoporous polymer column that separates methanol selectively from confounders by adsorption. A chemoresistive gas sensor detects the methanol. When tested on commercial sanitizers (total 76 samples), methanol was quantified in excellent (R2 = 0.99) agreement to "gold standard" gas chromatography. Importantly, methanol quantification was hardly interfered by sanitizer composition and viscosity. This device meets an urgent need for on-site methanol screening by authorities, health professionals, and even laymen.

Toxic Alcohol Ingestion: A Case Report and Review of Management Pathways

Toxic alcohol ingestion can be fatal or produce irreversible tissue damage and hence timely recognition and treatment are very important. The physician has to often rely on clinical features and different lab values in order to derive the possible causative agent consumed. Gas chromatography is the definitive diagnostic test to detect the toxic alcohol but is unfortunately not available to run in house in most hospital laboratories in the acute clinical setting. We present a 41-year-old gentleman who was brought to the ED for further evaluation of vomiting and upper abdominal pain. Our clinical impression was that the patient had possible mixed toxic alcohol ingestion. General principles and treatment of alcohol intoxication include gastric lavage or use of activated charcoal. Administration of ethanol or fomepizole to delay or prevent generation of toxic metabolites needs to be initiated while sufficient alcohol remains and metabolized and measurement of blood alcohol concentrations and/or serum osmolality can be helpful. Dialysis is helpful in removing unmetabolized alcohol and possibly toxic metabolites and delivering base to patients to ameliorate metabolic acidosis.

A novel metabolic disorder in the degradation pathway of endogenous methanol due to a mutation in the gene of alcohol dehydrogenase

BACKGROUND

A small amount of methanol is produced endogenously in the human body but it is efficiently metabolized by alcohol dehydrogenase (ADH) and other enzymes, and the products eliminated without harm. In this study, we present a new entity of inborn error of methanol metabolism due to a mutation in the ADH1C gene coding for the γ subunit that is part of several ADH isoenzymes.

RESULTS

This disorder was discovered in an 11.58-year-old boy. During one 9-month hospital admission, he had periods of 1-4 days during which he was comatose, and between these periods he was sometimes verbose and euphoric, and had ataxia, dysarthria. Following hemodialysis treatments, he became conscious and appeared healthy. Organ evaluations and his laboratory tests were normal. Toxicological evaluation of his blood showed a high methanol level [12.2 mg/dL (3.8 mmol/L), normal range up to 3.5 mg/dL (1.09 mmol/L) while the formaldehyde level was undetectable. The finding of liver function tests that were within normal limits, coupled with a normal eye examination and size of the liver, elevated blood methanol levels and an undetectable formaldehyde level, suggested ADH insufficiency. Adding zinc to the drug regimen 15 mg/daily dramatically reduced the patient's methanol level and alleviated the abnormal symptoms. When zinc supplementation was discontinued, the patient relapsed into a coma and hemodialysis was once again required. A homozygous mutation in ADH1C gene located at exon 3 was found, and both parents were heterozygous for this mutation.

CONCLUSION

Accumulation of methanol due to mutation in ADH1C gene may result in drunkenness and ataxia, and leads to coma. This condition can be successfully treated with zinc supplementation as the cofactor of ADH.

SkinBug: an artificial intelligence approach to predict human skin microbiome-mediated metabolism of biotics and xenobiotics

In addition to being pivotal for the host health, the skin microbiome possesses a large reservoir of metabolic enzymes, which can metabolize molecules (cosmetics, medicines, pollutants, etc.) that form a major part of the skin exposome. Therefore, to predict the complete metabolism of any molecule by skin microbiome, a curated database of metabolic enzymes (1,094,153), reactions, and substrates from ∼900 bacterial species from 19 different skin sites were used to develop “SkinBug.” It integrates machine learning, neural networks, and chemoinformatics methods, and displays a multiclass multilabel accuracy of up to 82.4% and binary accuracy of up to 90.0%. SkinBug predicts all possible metabolic reactions and associated enzymes, reaction centers, skin microbiome species harboring the enzyme, and the respective skin sites. Thus, SkinBug will be an indispensable tool to predict xenobiotic/biotic metabolism by skin microbiome and will find applications in exposome and microbiome studies, dermatology, and skin cancer research.

•

SkinBug is AI/ML-based tool to predict metabolism of molecules by Skin microbiome

•

Database of 1,094,153 metabolic enzymes from 897 pangenomes of skin microbiome

•

Predicts enzymes, bacterial species, and skin sites for the predicted reactions

•

82.4% multilabel and 90.0% binary accuracy, and validated on 28 diverse real cases

Screening Methanol Poisoning with a Portable Breath Detector

Methanol poisoning outbreaks after consumption of adulterated alcohol frequently overwhelm health care facilities in developing countries. Here, we present how a recently developed low-cost and handheld breath detector can serve as a noninvasive and rapid diagnostic tool for methanol poisoning. The detector combines a separation column and a micromachined chemoresistive gas sensor fully integrated into a device that communicates wirelessly with a smartphone. The performance of the detector is validated with methanol-spiked breath of 20 volunteers (105 breath samples) after consumption of alcoholic beverages. Breath methanol concentrations were quantified accurately within 2 min in the full breath-relevant range (10-1000 ppm) in excellent agreement (R² = 0.966) with benchtop mass spectrometry. Bland-Altman analysis revealed sufficient limits of agreement (95% confidence intervals), promising to indicate reliably the clinical need for antidote and hemodialysis treatment. This simple-in-use detector features high diagnostic capability for accurate measurement of methanol in spiked breath, promising for rapid screening of methanol poisoning and assessment of severity. It can be applied readily by first responders to distinguish methanol from ethanol poisoning and monitor in real time the subsequent hospital treatment.

Oral Ethanol Treatment for Ethylene Glycol Intoxication

Ethylene glycol is an odorless, sweet-tasting liquid found in industrial solutions such as antifreeze and windshield wiper fluid. Brake fluid, an automobile transmission liquid, contains poisonous alcohols such as glycol ethers and ethylene glycols. The toxicity of ethylene glycol is associated with toxic metabolite production by the liver enzyme alcohol dehydrogenase. Administration of either intravenous ethanol or fomepizole, both of which competitively inhibit ethylene glycol metabolism by alcohol dehydrogenase and can prevent the production and accumulation of the toxic metabolites, can be used as an antidote. A 42-year-old male car mechanic was transferred to our hospital after accidentally ingesting approximately 100 mL of brake fluid. Immediately after ingestion, he threw up most of the ingested liquid; however, he complained of nausea and throat pain and was moved to our emergency department. The patient was successfully treated with administration of oral ethanol in the form of whisky through a nasogastric tube since neither intravenous ethanol nor fomepizole was available in our hospital at the time of his presentation. Our case demonstrates that oral ethanol can be used as an alternative treatment for patients with ethylene glycol intoxication.

Methanol in Grape Derived, Fruit and Honey Spirits: A Critical Review on Source, Quality Control, and Legal Limits

Spirits are alcoholic beverages commonly consumed in European countries. Their raw materials are diverse and include fruits, cereals, honey, sugar cane, or grape pomace. The main aim of this work is to present and discuss the source, quality control, and legal limits of methanol in spirits produced using fruit and honey spirits. The impact of the raw material, alcoholic fermentation, and the distillation process and aging process on the characteristics and quality of the final distilled beverage are discussed. In addition, a critical view of the legal aspects related to the volatile composition of these distillates, the origin and presence of methanol, and the techniques used for quantification are also described. The methanol levels found in the different types of spirits are those expected based on the specific raw materials of each and, almost in all studies, respect the legal limits.

Using Humidity to Control the Morphology and Properties of Electrospun BioPEGylated Polyhydroxybutyrate Scaffolds

Electrospinning produces nanofibrous scaffolds with potential for tissue engineering and wound repair. Spinning parameters control scaffold morphology and properties. BioPEGylation of polyhydroxybutyrate (PHB) introduces terminal hydrophilic groups into the hydrophobic chain, making this natural-synthetic hybrid copolymer more susceptible to humidity. Varying the humidity from 10 to 50% RH during electrospinning had a relatively little effect on polyhydroxybutyrate (PHB) average fiber and pore diameters, which remained around 3.0 and 8.7 μm, respectively. In contrast, fiber and pore diameters for electrospun bioPEGylated PHB scaffolds varied significantly with humidity, peaking at 30% RH (5.5 and 14.1 μm, respectively). While scaffolds showed little change, hydrophobicity decreased linearly with humidity during electrospinning. Compared to solvent-cast films, electrospun scaffolds showed significantly greater average cell spread. A 108% increase for olfactory ensheathing cells (OECs) cultivated on bioPEGylated PHB scaffolds was proportionally greater than their counterparts on electrospun PHB scaffolds, (70%). OECS grown on BioPEGylated PHB scaffolds were over twice the size, 260 ± 20 μm diameter, than those on PHB electrospun scaffolds, 110 ± 18 μm diameter. Electrospun scaffolds also promoted cell health compared to their solvent-cast counterparts, with increases in the mitochondrial activity of 165 ± 13 and 196 ± 13% for PHB and bioPEGylated PHB, respectively. OECS cultivated on electrospun scaffolds of bioPEGylated PHB had significantly better membrane integrities compared to their counterparts on solvent-cast films, 47 ± 5% reducing to 17 ± 6%. The combination of bioPEGylation and humidity during electrospinning permitted significant controllable changes to scaffold morphology and properties. These changes resulted in the significantly greater promotion of cell growth on electrospun bioPEGylated PHB scaffolds compared to their solvent-cast counterparts and electrospun PHB.

Identification of Potential Biomarkers in the Cervicovaginal Fluid by Metabolic Profiling for Preterm Birth

During pregnancy, dysbiosis in the vaginal microbiota directly affects the metabolic profiles, which might impact preterm birth (PTB). In this study, we performed cervicovaginal fluid (CVF) metabolic profiling using nuclear magnetic resonance (NMR) spectroscopy and identified the metabolic markers for predicting PTB. In this nested case-control study, 43 South Korean pregnant women with PTB (n = 22), and term birth (TB; n = 21) were enrolled with their demographic profiles, and CVF samples were collected by vaginal swabs. The PTB group had two subgroups based on post-CVF sampling birth: PTB less than (PTB < 7 d) and more than 7 days (PTB ≥ 7 d). We observed significant differences in the gestational age at birth (GAB), cervical length (CL), and neonatal birth weight among the groups. The principal component analysis (PCA), and partial least square discriminant analysis (PLS-DA) scatter plot showed the separation between the PTB < 7 d group, and the TB group. Out of 28 identified metabolites, acetone, ethanol, ethylene glycol, formate, glycolate, isopropanol, methanol, and trimethylamine N-oxide (TMAO) were significantly increased in the PTB group compared with the TB group. The ROC curve analysis revealed that the acetone, ethylene glycol, formate, glycolate, isopropanol, methanol, and TMAO had the best predictive values for PTB. Additionally, the correlation analysis of these metabolites showed a strong negative correlation with GAB and CL. These metabolites could be beneficial markers for the clinical application of PTB prediction.

Gut instincts: vitamin D/vitamin D receptor and microbiome in neurodevelopment disorders

The gut microbiome regulates a relationship with the brain known as the gut–microbiota–brain (GMB) axis. This interaction is influenced by immune cells, microbial metabolites and neurotransmitters. Recent findings show gut dysbiosis is prevalent in autism spectrum disorder (ASD) as well as attention deficit hyperactivity disorder (ADHD). There are previously established negative correlations among vitamin D, vitamin D receptor (VDR) levels and severity of ASD as well as ADHD. Both vitamin D and VDR are known to regulate homeostasis in the brain and the intestinal microbiome. This review summarizes the growing relationship between vitamin D/VDR signalling and the GMB axis in ASD and ADHD. We focus on current publications and summarize the progress of GMB in neurodevelopmental disorders, describe effects and mechanisms of vitamin D/VDR in regulating the microbiome and synoptically highlight the potential applications of targeting vitamin D/VDR signalling in neurodevelopment disorders.

Euglycemic Ketoacidosis

PURPOSE OF REVIEW

Diabetic ketoacidosis is a life-threatening complication of diabetes characterized by hyperglycemia, acidosis, and ketosis. Ketoacidosis may occur with blood glucose level < 200 mg/dl (improperly defined as euglycemic ketoacidosis, euKA) and also in people without diabetes. The absence of marked hyperglycemia can delay diagnosis and treatment, resulting in potential serious adverse outcomes.

RECENT FINDINGS

Recently, with the wide clinical use of sodium glucose co-transporter 2 inhibitors (SGLT2i), euKA has come back into the spotlight. Use of SGLT2i use can predispose to the development of ketoacidosis with relatively low or normal levels of blood glucose. This condition, however, can occur, in the absence of diabetes, in settings such as pregnancy, restriction on caloric intake, glycogen storage diseases or defective gluconeogenesis (alcohol abuse or chronic liver disease), and cocaine abuse. euKA is a challenging diagnosis for most physicians who may be misled by the presence of normal glycemia or mild hyperglycemia. In this article, we review pathophysiology, etiologies, clinical presentation and the management of euKA.

Formaldehyde Reacts with Amino Acids and Peptides with a Potential Role in Acute Methanol Intoxication

Methanol, an aliphatic alcohol widely used in the industry, causes acute and chronic intoxications associated with severe long-term health damage, including permanent visual impairment, brain damage, mainly necrosis of the basal ganglia and high mortality due to cancer. However, the role of formaldehyde, an intermediate metabolite of methanol oxidation, in methanol toxicity remains unclear. Thus, we studied the reactivity of several amino acids and peptides in the presence of formaldehyde by identifying products by direct infusion electrospray high-resolution mass spectrometry (MS) and matrix-assisted laser desorption-ionization MS. Cysteine, homocysteine and two peptides, CG and CGAG, provided cyclic products with a +12 amu mass shift with respect to the original compounds. The proposed structures of the products were confirmed by high-resolution tandem MS. Moreover, the formation of the products with +12 amu mass shift was also shown for two biologically relevant peptides, fragments of ipilimumab, which is a human IgG1 monoclonal antibody against cytotoxic T-lymphocyte-associated protein 4. Overall, our experimental results indicate that formaldehyde reacts with some amino acids and peptides, yielding covalently modified structures. Such chemical modifications may induce undesirable changes in the properties and function of vital biomolecules (e.g., hormones, enzymes) and consequently pathogenesis.

Data on the relationship between acetone, ethylene glycol, isopropanol, methanol, and propylene glycol serum/plasma concentrations and osmolal gaps in patients at an academic medical center

Ingestion of toxic alcohols other than ethanol (ethylene glycol, methanol, isopropanol, and propylene glycol) can cause life-threatening complications including altered level of consciousness, respiratory depression, and organ damage from metabolites. Many hospitals lack the ability to specifically analyze these compounds using gas chromatography, gas chromatography/mass spectrometry, or by enzymatic assays for ethylene glycol. Consequently, the presence of these compounds in blood is often ascertained indirectly by laboratory testing for acid-base status, osmolal gap, and anion gap. In the related research article, we analyzed 260 samples originating from 158 unique patients that had osmolal gap and specific testing for toxic alcohols performed on serum/plasma at an academic medical center central clinical laboratory. The data in this article provide the patient demographic, osmolal gap (and associated laboratory tests needed for this calculation), ethanol concentration by enzymatic assay, specific testing for toxic alcohols (ethylene glycol, isopropanol, methanol, propylene glycol) and acetone, anion gap, clinical history, antidotal treatment, and estimated timing of ingestion. The analyzed data is provided in the supplementary tables included in this article. Bias plots of osmolal gap estimations are included in a figure. The dataset reported is related to the research article entitled "Correlation of Osmolal Gap with Measured Concentrations of Acetone, Ethylene Glycol, Isopropanol, Methanol, and Propylene Glycol in Patients at an Academic Medical Center" [1].

Educational Case: Ethylene Glycol Poisoning

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.¹

Health-related quality of life determinants in survivors of a mass methanol poisoning outbreak: six-year prospective cohort study

Purpose: The effect of acute methanol poisoning on the follow-up quality of life of survivors in mass poisoning outbreaks is not known. The objective of this is to study the impact of visual and central nervous system (CNS) sequelae of methanol poisoning on long-term health-related quality of life (QoL) of survivors, its clinical determinants, and dynamics.Materials and methods: A total of 54 patients with confirmed methanol poisoning (mean age 46.7 ± 13.4 years, 9 females) were examined consequently three times within six-year prospective cohort study and compared to 23 controls with the history of chronic alcohol abuse. The following tests were performed: SF-36 QoL questionnaire, visual evoked potentials (VEP) of optic nerve, ocular examination with retinal nerve fiber layer (RNFL) thickness measurement, brain magnetic resonance imaging (MRI), and biochemical and toxicological tests.Results: Acute methanol poisoning led to significant decrease in physical component summary (PCS) compared to PCS of age-adjusted controls (mean score with SD 46.8 ± 11.0 versus 52.3 ± 9.4 points; p = .003). In 17/40 (42.5%) patients with three rounds of examination, signs of severe disability (≤30 points in at least one score) were present six years after discharge, with negative dynamics of PCS score during the observation period. The patients with abnormal RNFL thickness had lower PCS (mean difference 10.5 points; 95%CI 3.5-17.5, p = .004) and mental component summary score (9.5 points; 95%CI 1.9-17.1, p = .015) compared to the patients with normal RNFL. Signs of physical and mental adaptation to long-term visual sequelae were registered with gradual reduction of difference in most of physical and mental components scores compared to the patients with normal RNFL during six years of observation. Signs of hemorrhagic brain lesions were associated with permanent decrease of PCS score (mean difference 7.4 points; 95%CI 0.6-14.0; p = .033), bodily pain (8.7 points; 95%CI 1.6-17.6; p = .018), and social functioning (8.2 points; 95%CI 3.0-17.4; p = .005) six years after discharge. No effect of type of antidote (fomepizole versus ethanol) and extracorporeal enhanced elimination modality (intermittent hemodialysis versus continuous renal replacement therapy) applied in hospital on long-term QoL was found (all p > .05).Conclusion: Acute methanol poisoning was associated with a significant decrease of health-related quality of life of survivors persisting for at least six years after discharge. The more pronounced decrease in QoL scores was observed in the patients with hemorrhagic brain lesions and visual sequelae of poisoning with abnormal RNFL thickness.

Correlation of osmolal gap with measured concentrations of acetone, ethylene glycol, isopropanol, methanol, and propylene glycol in patients at an academic medical center

The ingestion of toxic alcohols including methanol, ethylene glycol, and isopropanol remains a significant public health problem. These compounds can cause central nervous system depression and, for methanol and ethylene glycol, organ damage from toxic metabolites. The presence of these compounds in serum/plasma can often be determined and monitored by measuring the osmolal gap (OG). However, other compounds originating from endogenous or exogenous sources, such as propylene glycol and acetone, can also increase the OG. Conversion factors can be used to estimate specific concentrations of acetone and toxic alcohols from OG. In this retrospective study, data were analyzed for 260 samples originating from 158 unique patients that had determination of both OG and concentrations for toxic alcohols at an academic medical center central laboratory. Specific analysis included gas chromatography (acetone, isopropanol, methanol, ethylene glycol, propylene glycol) and/or enzymatic assay (ethylene glycol). Many samples also contained ethanol. The data was grouped by type of ingestion. The present study analyzed the relationship between the OG calculated from measured plasma/serum osmolality and the OG estimated by applying conversion factors to measured concentrations of the different compounds. The correlations tend to be linear and vary by compound, with methanol and ethylene glycol having the highest R2 values of 0.93 and 0.95, respectively, consistent with other published studies. Higher variability was seen for the data for isopropanol and acetone. For each of the data subsets, the estimated toxic alcohol concentration calculated using conversion factors from OG tends to overestimate the actual concentration of the compound. Overall, the present study demonstrates the generally linear relationship between OG determined by osmolality and the OG estimated using measured concentrations of acetone and toxic alcohols.

Acute toxic kidney injury

Substances toxic to the kidney are legion in the modern world. The sheer number and variety, their mutual interactions and, metabolism within the body are a challenge to research. Moreover, the kidney is especially prone to injury owing to its physiology. Acute kidney injury (AKI) induced by poisonous or primarily nephrotoxic substances, may be community acquired with ingestion or inhalation or nosocomial. Many nephrotoxic plants, animal poisons, medications, chemicals and illicit drugs can induce AKI by varying pathophysiological pathways. Moreover, the epidemiology of toxic AKI varies depending on country, regions within countries, socioeconomic status and health care facilities. In this review, we have selected nephrotoxic insults due to medication, plants, animal including snake venom toxicity, environmental, (agri)chemicals and also illicit drugs. We conclude with a section on diagnosis, clinical presentation and management of poisoning accompanied by various organ dysfunction and AKI.

The arterial blood gas algorithm: Proposal of a systematic approach to analysis of acid-base disorders

Abnormalities in the acid-base balance are common clinical problems and can have deleterious effects on cellular function and be a clue to various disorders. Therefore, it is important for the clinician to make a precise diagnosis of the acid-base disorder(s) present for a proper treatment. Three approaches have been proposed to evaluate acid-base disorders: a bicarbonate-centric approach; the Stewart approach, and the base excess approach. Although the latter two have many adherents, we will only discuss the bicarbonate-centric approach. This approach is simpler to utilize at the bedside, has a physiological evaluation of the acid-base disorder, presents an easily understandable approach to assess severity, and provides a more solid foundation for the development of effective therapies. Therefore, the following discussion will be limited to an examination of this approach. In this case-centric review, important new concepts will be introduced first; their benefits and limitations discussed; and then their utilization to analyze actual cases will be shown. A systematic approach algorithm that incorporates these new concepts has been generated and will be highlighted.

Renal replacement therapy in the management of intoxications in children: recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) workgroup

BACKGROUND

Intentional or unintentional ingestions among children and adolescents are common. There are a number of ingestions amenable to renal replacement therapy (RRT).

METHODS

We systematically searched PubMed/Medline, Embase, and Cochrane databases for literature regarding drugs/intoxicants and treatment with RRT in pediatric populations. Two experts from the PCRRT (Pediatric Continuous Renal Replacement Therapy) workgroup assessed titles, abstracts, and full-text articles for extraction of data. The data from the literature search was shared with the PCRRT workgroup and two expert toxicologists, and expert panel recommendations were developed.

RESULTS AND CONCLUSIONS

We have presented the recommendations concerning the use of RRTs for treatment of intoxications with toxic alcohols, lithium, vancomycin, theophylline, barbiturates, metformin, carbamazepine, methotrexate, phenytoin, acetaminophen, salicylates, valproic acid, and aminoglycosides.

Analysis of fomepizole safety based on a 16-year post-marketing experience in France

Introduction: Fomepizole has been recommended as first-line antidote to treat ethylene glycol and methanol poisoning. Despite more than 30 years of utilization, the safety of fomepizole when used clinically has not been well documented. Based on the long-standing clinical experience with fomepizole in France, we investigated its safety profile in patients treated for suspected toxic alcohol poisoning.Methods: We designed a 16-year post-marketing study to evaluate the indications for fomepizole prescriptions and to investigate its safety. Data were retrospectively collected using a standardized questionnaire sent each month by post to each French hospital that ordered fomepizole during the month before. The response rate to our survey was 59%.Results: Five hundred and thirty-six patients [188 females/348 males; age, 46 years [34-55] (median [25th-75th percentiles])] were treated with fomepizole [cumulative dose, 18.6 mg/kg [15.5-26.3] (1,268 mg [900-2,100])]. Ethylene glycol/methanol poisoning was confirmed in 275 patients (51%) while a nontoxic exposure was diagnosed in 147 patients (27%). Toxic alcohol poisoning was misdiagnosed in the remaining 114 patients (21%), before the assessment of an alternative poisoning or non-poisoning diagnosis. Fifty adverse reactions were attributed to fomepizole in 36 patients (7%) including general reactions (N = 22), local reactions (N = 22) and laboratory test impairments (N = 6). All were considered mild and transient. None required stopping fomepizole. The most frequent adverse effects were injection site pain/burning (N = 13), nausea/vomiting (N = 8), vessel puncture site inflammation (N = 7), drowsiness/confusion (N = 5) and serum aminotransferase elevation (N = 3). None of the fatalities (N = 37, 7%) or persistent symptoms on discharge (N = 9; 2%) was related to fomepizole.Conclusion: Our longitudinal cohort study supports the safety of fomepizole administered to treat presumed EG and methanol poisoning.

Extracorporeal Removal of Poisons and Toxins

Extracorporeal therapies have been used to remove toxins from the body for over 50 years and have a greater role than ever before in the treatment of poisonings. Improvements in technology have resulted in increased efficacy of removing drugs and other toxins with hemodialysis, and newer extracorporeal therapy modalities have expanded the role of extracorporeal supportive care of poisoned patients. However, despite these changes, for at least the past three decades the most frequently dialyzed poisons remain salicylates, toxic alcohols, and lithium; in addition, the extracorporeal treatment of choice for therapeutic removal of nearly all poisonings remains intermittent hemodialysis. For the clinician, consideration of extracorporeal therapy in the treatment of a poisoning depends upon the characteristics of toxins amenable to extracorporeal removal (e.g., molecular mass, volume of distribution, protein binding), choice of extracorporeal treatment modality for a given poisoning, and when the benefit of the procedure justifies additive risk. Given the relative rarity of poisonings treated with extracorporeal therapies, the level of evidence for extracorporeal treatment of poisoning is not robust; however, extracorporeal treatment of a number of individual toxins have been systematically reviewed within the current decade by the Extracorporeal Treatment in Poisoning workgroup, which has published treatment recommendations with an improved evidence base. Some of these recommendations are discussed, as well as management of a small number of relevant poisonings where extracorporeal therapy use may be considered.

Rising above helium: A hydrogen carrier gas chromatography flame ionization detection (GC-FID) method for the simultaneous quantification of toxic alcohols and ethylene glycol in human plasma specimens

Here we validate a GC, Flame Ionization Detection (GC-FID), liquid injection method using hydrogen as a carrier gas combining analysis of toxic volatile alcohols (VA): methanol, ethanol, isopropanol, acetone, as well as glycols, ethylene glycol (EG) and propylene glycol (PG), in a single method.

METHODOLOGY

200 μL of calibrator, QC, or patient specimen were deproteinized with 400 μL of acetonitrile containing internal standards (10 mmol/L N-propyl alcohol for VA and 2.5 mmol/L 1,2-butanediol for glycols). GC-FID analysis using hydrogen carrier gas and nitrogen makeup gas utilized an Agilent 7890 system equipped with Agilent 7683 liquid autosampler on a 30 m × 530 μm RTX-200 fused silica column. Method validation included repeatability, recovery, carryover, linearity, lower limit of quantification (LLOQ), accuracy, selectivity and measurement uncertainty.

RESULTS

The 8.3 min from injection to injection reduced time of analysis by 45% over a previously reported method using Helium carrier gas with no loss in resolution. Within-run and Between-run variability were ≤1.4% and ≤6.8% respectively. Recovery was 100% within a 95% confidence interval. Carryover was negligible for all but EG. LLOQ was <1 mmol/L for all analytes. The upper range of linearity was 120 mmol/L for methanol, ethanol and isopropanol, 100 mmol/L for acetone and 50 mmol/L for EG. Analytes demonstrated acceptable accuracy and measurement uncertainty using College of American Pathologists (CAP) criteria. Toluene can cause a false positive EG, while benzene, xylene and 1,3 butanediol can cause false negative EG.

CONCLUSIONS

Converting from Helium to Hydrogen carrier gas benefits patient care through a reduction in turnaround time and provides a cost savings to the laboratory.

Delta Neutrophil Index is Useful to Predict Poor Outcomes in Male Patients with Alcoholic Ketoacidosis

Background

Alcoholic ketoacidosis (AKA) is known as a benign disease, but the related mortality reported in Korea is high. Acidosis and alcohol change the immunity profile, and these changes can be identified early using the delta neutrophil index (DNI). We aimed to evaluate the use of DNI and other standard laboratory parameters as predictors of prognosis in AKA patients.

Methods

One hundred eighteen males with AKA were evaluated at the Wonju Severance Christian hospital between 2009 and 2014. We performed a retrospective analysis of demographic, clinical, and laboratory parameters data. Receiver operating characteristic curves (ROC) and multivariate Cox regression was used to identify renal survival and mortality.

Results

Survival patients had lower initial DNI levels than non-survival patients (4.8±6.4 vs 11.4±12.5, p<0.001). In multivariate-adjusted Cox regression analysis, higher initial increased DNI (HR 1.044, 95% CI 1.003-1.086, p=0.035), and lower initial pH (HR 0.044, 95% CI 0.004-0.452, p=0.008) were risk factors for dialysis during hospitalization. Further, higher initial DNI level (HR 1.037; 95% CI 1.006-1.069; p=0.018), lower initial pH (HR 0.049; 95% CI 0.008-0.312; p=0.001) and lower initial glomerular filtration rate (GFR) (HR 0.981; 95% CI 0.964-0.999; p=0.033) were predictors of mortality. A DNI value of 4.5% was selected as the cut-off value for poor prognosis and Kaplan-Meier plots showed that AKA patients with an initial level DNI ≥4.5% had lower cumulative survival rates than AKA patients with an initial DNI <4.5%.

Conclusion

Increased initial serum DNI levels may help to predict renal survival and prognosis in male AKA patients.

Erythropoietin in Treatment of Methanol Optic Neuropathy

BACKGROUND

Methanol poisoning can cause an optic neuropathy that is usually severe and irreversible and often occurs after ingestion of illicit or homemade alcoholic beverages. In this study, we evaluated the potential neuroprotective effect of erythropoietin (EPO) on visual acuity (VA) in patients with methanol optic neuropathy.

METHODS

In a prospective, noncomparative interventional case series, consecutive patients with methanol optic neuropathy after alcoholic beverage ingestion were included. All patients initially received systemic therapy including metabolic stabilization and detoxification. Treatment with intravenous recombinant human EPO consisted of 20,000 units/day for 3 successive days. Depending on clinical response, some patients received a second course of EPO. VA, funduscopy, and spectral domain optical coherence tomography were assessed during the study. Main outcome measure was VA.

RESULTS

Thirty-two eyes of 16 patients with methanol optic neuropathy were included. Mean age was 34.2 years (±13.3 years). The mean time interval between methanol ingestion and treatment with intravenous EPO was 9.1 days (±5.56 days). Mean follow-up after treatment was 7.5 months (±5.88 months). Median VA in the better eye of each patient before treatment was light perception (range: 3.90-0.60 logMAR). Median last acuity after treatment in the best eye was 1.00 logMAR (range: 3.90-0.00 logMAR). VA significantly increased in the last follow-up examination (P < 0.0001). Age and time to EPO treatment after methanol ingestion were not significantly related to final VA. No ocular or systemic complications occurred in our patient cohort.

CONCLUSIONS

Intravenous EPO appears to improve VA in patients with methanol optic neuropathy and may represent a promising treatment for this disorder.

The Diagnosis and Management of Toxic Alcohol Poisoning in the Emergency Department: A Review Article

Context:

This review discusses the range of clinical presentations seen with poisonings by the major toxic alcohols--methanol, ethylene glycol, and isopropyl alcohol. It outlines a straightforward diagnostic strategy and discusses in detail the current treatment recommendations.

Evidence acquisition:

The authors conducted a literature search of primary and secondary sources related to the topic. For treatment recommendations, search restrictions included articles published between 2008 and 2019. For background information, search restrictions included articles written from 1990 – present.

Results:

This review discusses in detail how the diagnosis can be made via clinical signs, symptoms, and laboratory values as well as the most recent treatment recommendations. This paper will also discuss the limitations of the emergency department workup and how the absence of particular laboratory findings does not necessarily rule out the diagnosis.

Conclusion:

Poisoning with methanol, ethylene glycol, and isopropanol present diagnostic and therapeutic challenges to emergency physicians. Toxic alcohol poisonings lead to an elevated osmolar gap and, with the exception of Isopropanol, a metabolic acidosis. In order for the timely initiation of life-saving treatment, emergency physicians need a solid understanding of the pathophysiology, clinical presentation, laboratory workup, and treatment.

Near fatal intoxication by nicotine and propylene glycol injection: a case report of an e-liquid poisoning

BACKGROUND

Concern about intoxication by e-liquid is growing as calls to poison control centers have increased since their introduction. Only three cases of intoxication by injection have been reported worldwide. Our case is unique because of the precise follow-up of a patient who survived a lethal dose of self-injected e-liquid, without other co-intoxication.

CASE PRESENTATION

A 51-year-old male presented to the Emergency Department after injecting himself intravenously (IV) in the forearm with 10 mL of e-liquid (1000 mg of nicotine diluted in propylene glycol). An agitation phase was followed by coma and bradypnoea requiring mechanical ventilation. The patient developed a transitory neurological impairment with the appearance of tetraparesis, gaze palsy and myoclonus due to nicotinic syndrome. The arterial blood gas (ABG) analysis confirmed uncompensated lactic acidosis with an elevated anion gap, which is an expected effect of propylene glycol. The toxicology screen indicated the presence of nicotine and cotinine in the blood and excluded the presence of concomitant intoxication. The patient recovered without sequelae.

CONCLUSION

Even a small quantity of intravenous (IV) e-liquid can lead to an acute intoxication and fatal outcomes due to the toxic effects of nicotine. This case might help emergency doctors cope with acute intoxication by injection of e-liquid and increase their comprehension of the two main substances, nicotine and propylene glycol with overview of their pharmacodynamics and kinetic effects.

Accidental transdermal methanol poisoning presenting to a regional emergency department

Learning Points:

•

The role of the clinical laboratory in diagnosing acid-base disorders

Acid-base homeostasis is fundamental for life. The body is exceptionally sensitive to changes in pH, and as a result, potent mechanisms exist to regulate the body's acid-base balance to maintain it in a very narrow range. Accurate and timely interpretation of an acid-base disorder can be lifesaving but establishing a correct diagnosis may be challenging. The underlying cause of the acid-base disorder is generally responsible for a patient's signs and symptoms, but laboratory results and their integration into the clinical picture is crucial. Important acid-base parameters are often available within minutes in the acute hospital care setting, and with basic knowledge it should be easy to establish the diagnosis with a stepwise approach. Unfortunately, many caveats exist, beginning in the pre-analytical phase. In the post-analytical phase, studies on the arterial reference pH are scarce and therefore many different reference values are used in the literature without any solid evidence. The prediction models that are currently used to assess the acid-base status are approximations that are mostly based on older studies with several limitations. The two most commonly used methods are the physiological method and the base excess method, both easy to use. The secondary response equations in the base excess method are the most convenient. Evaluation of acid-base disorders should always include the assessment of electrolytes and the anion gap. A major limitation of the current acid-base laboratory tests available is the lack of rapid point-of-care laboratory tests to diagnose intoxications with toxic alcohols. These intoxications can be fatal if not recognized and treated within minutes to hours. The surrogate use of the osmolal gap is often an inadequate substitute in this respect. This article reviews the role of the clinical laboratory to evaluate acid-base disorders.

Severe methanol poisoning with neurological sequelae: implications for diagnosis and management

A 22-year-old woman presented with methanol toxicity manifesting as headache, reduced conscious state and visual change after consuming home-made grappa. She progressed to a coma with fixed mydriasis and severe acidaemia (pH 6.55). She was treated with empirical antidote administration (intravenous ethanol) and enhanced elimination through haemodialysis. She survived despite her delayed presentation but developed significant neurological sequelae, including visual impairment. We provide an overview of key elements of diagnosis and recent updates in treatment recommendations.

Clinical use of plasma lactate concentration. Part 1: Physiology, pathophysiology, and measurement

OBJECTIVE

To review the current literature with respect to the physiology, pathophysiology, and measurement of lactate.

DATA SOURCES

Data were sourced from veterinary and human clinical trials, retrospective studies, experimental studies, and review articles. Articles were retrieved without date restrictions and were sourced primarily via PubMed, Scopus, and CAB Abstracts as well as by manual selection.

HUMAN AND VETERINARY DATA SYNTHESIS

Lactate is an important energy storage molecule, the production of which preserves cellular energy production and mitigates the acidosis from ATP hydrolysis. Although the most common cause of hyperlactatemia is inadequate tissue oxygen delivery, hyperlactatemia can, and does occur in the face of apparently adequate oxygen supply. At a cellular level, the pathogenesis of hyperlactatemia varies widely depending on the underlying cause. Microcirculatory dysfunction, mitochondrial dysfunction, and epinephrine-mediated stimulation of Na⁺ -K⁺ -ATPase pumps are likely important contributors to hyperlactatemia in critically ill patients. Ultimately, hyperlactatemia is a marker of altered cellular bioenergetics.

CONCLUSION

The etiology of hyperlactatemia is complex and multifactorial. Understanding the relevant pathophysiology is helpful when characterizing hyperlactatemia in clinical patients.

Pathophysiology and aetiology of hypoglycaemic crises

Hypoglycaemia is a common, life-threatening complication that occurs as a component of a wide variety of disease processes. Despite its frequent occurrence, information concerning the aetiology, characteristics and outcomes of hypoglycaemic crises in veterinary medicine is limited. This review summarises the current understanding of the pathophysiology of hypoglycaemia, the body's counter-regulatory response, underlying aetiologies, diagnosis and treatment. Disease mechanisms are discussed and published evidence in veterinary literature regarding prognostic indicators, prevalence, diagnosis and treatment is examined for hypoglycaemia-related disease processes including insulinoma, glucose-lowering toxins and medications.

Association between acute methanol poisoning and subsequent mortality: a nationwide study in Taiwan

BACKGROUND

Methanol poisoning (MP) often causes acute mortality and morbidities; however, the association between MP and subsequent mortality has not been well studied.

METHODS

We conducted a nationwide population-based cohort study by identifying 621 participants with MP from the Nationwide Poisoning Database and 6210 participants without MP from the Longitudinal Health Insurance Database 2000 by matching the index date at a 1:10 ratio between 1999 and 2012. Comparison of the mortality rate between the two cohorts was performed by following up until 2013.

RESULTS

A total of 249 (40%) participants with MP and 154 (2.5%) participants without MP died during the follow-up (p < 0.001). Statistic analysis showed that participants with MP had a higher risk for mortality than did the participants without MP (adjusted hazard ratio [AHR]: 13.48; 95% confidence interval [CI]: 10.76-16.88). The risk of mortality was highest in the first 6 months after MP (AHR: 480.34; 95% CI: 117.55-1962.75). Hypertension, chronic obstructive pulmonary disease, liver disease, malignancy, drug abuse, and lower monthly income also predicted mortality.

CONCLUSIONS

MP was associated with increased subsequent mortality. Close follow-up for comorbidity control and socioeconomic assistance are suggested for patients with MP.

Evaluation of the effects of glucose on osmolal gap using freezing point depression and vapor pressure methods

The measurement of serum osmolality, and the calculation of osmolal gap (OG) from a calculated osmolality are widely used in clinical and emergency medicine. In this study, the possible effects of blood glucose on OG were investigated by freezing point depression and vapor pressure methods. The concentrations of sodium, glucose, blood urea nitrogen and osmolalities of 2640 samples were measured. There were two methods for calculating serum osmolality: freezing point depression method (n = 2399) and vapor pressure method (n = 241). The OG was positively associated with glucose in glucose 110-450 mg/dL (r = 0.191, p < 0.001) and glucose > 450 mg/dL (r = 0.372, p < 0.001), but not in glucose < 110 mg/dL (r = 0.017, p = 0.711) in freezing point depression method. However, OG had no correlation with glucose regardless of glucose level in vapor pressure method. In freezing point depression method, compared with the groups of glucose <110 and 110-450 mg/dL, the group with glucose >450 mg/dL had higher OG (p < 0.001) and higher prevalence of OG > 10 mOsm/Kg H₂O (p < 0.001). Our study demonstrated that OG is impacted by increasing blood glucose concentration using freezing point depression method, special attention should be made to blood glucose concentrations when using freezing point depression method to determine OG.

Oxygenated Volatile Organic Compounds (Anti-freezing Agents) in Decorative Water-based Paints Marketed in Nigeria

BACKGROUND

Consumer products such as paints are a potentially significant source of volatile organic compounds (VOCs) and oxygenated VOCs. Paints for construction and household use have been rapidly changing from oil-based to water-based paints and are one of the commonly identified sources of oxygenated VOCs in indoor environments.

OBJECTIVES

Four different anti-freezing agents were identified and analyzed in 174 waterbased paint samples, purchased from popular paint markets in two metropolitan cities in Nigeria, Lagos and Ibadan.

METHODS

Paint samples were solvent extracted using acetonitrile and milli-Q water. Antifreezing agents in the extracts were identified and quantified using gas chromatography (GC)-mass spectrometry and a GC-flame ionization detector, respectively.

DISCUSSION

Four different anti-freezing agents were identified in the samples, ethylene glycol, diethylene glycol, triethylene glycol and propylene glycol. Their levels ranged from 1,000-1,980 ppm, diethylene glycol; 1,000-3,900 ppm, triethylene glycol; 1,090-2,510 ppm, propylene glycol and 1,350-2,710 ppm, ethylene glycol. Levels of anti-freezing agents in all of the paint samples were above the permissible limits of the European Union for VOCs in paints of 500 ppm. Results of multivariate statistical analyses clearly showed that triethylene glycol was the most commonly used anti-freezing agent in paints despite its numerous harmful health effects.

CONCLUSIONS

We concluded that water-based paints marketed in Nigeria contain high concentrations of anti-freezing agents, which have harmful environmental and human health effects, especially to sensitive individuals such as children.

COMPETING INTERESTS

The authors declare no competing financial interests.

Protective effects of Rutin against methanol induced acute toxic optic neuropathy: an experimental study

AIM

To determine the effects of Rutin on methanol induced optic neuropathy and compare the results with the effects of ethanol.

METHODS

Totally 30 rats were divided into 5 groups, with 6 rats in each group as follows: healthy controls (C), methotrexate (MTX), methotrexate+methanol (MTM), methotrexate+methanol+ethanol (MTME) and methotrexate+ methanol+Rutin (MTMR). In all rabbits except those of the control group, MTX, diluted in sterile serum physiologic, 0.3 mg/kg per oral was applied for 7d by the aid of a tube. After this procedure to the rats of MTM, MTME and MTMR groups, 20% methanol with a dose of 3 g/kg per oral was given by the aid of a tube. In MTME group, 4h after the application of methanol, 20% ethanol was applied by the same way with a dose of 0.5 g/kg. On the other hand, in MTMR group 4h after the application of methanol, Rutin, which was dissolved in distilled water, was applied by the same way with a dose of 50 mg/kg.

RESULTS

There were statistically significant differences in tissue 8-hydroxy-2 deoxyguanine (8-OHdG), interleukin-1β (IL-1β), tumor necrosis factor-alpha (TNF-α), malondialdehyde (MDA), myeloperoxidase (MPO). glutathione peroxidase (tGSH) and superoxide dismutase (SOD) levels between groups (P<0.001). In MTMR group tissue 8-OHdG, IL-1β, MDA, and MPO levels were similar with the healthy controls but significantly different than the other groups. In histopathological evaluations, in MTX group there was moderate focal destruction, hemorrhage and decrease in number of astrocytes and oligodendrocytes; in MTM group there was severe destruction and edema with decrease in number of astrocytes and oligodendrocytes; in MTME group there was mild hemorrhage, mild edema, mildly dilated blood vessels with congestion while in MTMR group, optic nerve tissue was resembling the healthy controls.

CONCLUSION

Rutin may prevent methanol-induced optic neuropathy via anti-inflammatory effects and decreasing the oxidative stress. New treatment options are warranted in this disease to avoid loss of vision in patients.

Toxic alcohol diagnosis and management: an emergency medicine review

Toxic alcohols are a group of substances containing a hydroxyl group not meant to be ingested. They are the cause of a significant number of accidental and non-accidental exposures. Toxic alcohol poisoning can be associated with a significant degree of morbidity and mortality if not promptly recognized and treated. This review describes the clinical presentation and an approach to the recognition and management for toxic alcohol poisoning. Toxic alcohols classically refer to a group of alcohols not meant for ingestion. Methanol, ethylene glycol, and isopropyl alcohol are readily available in common hardware and household materials. Toxic alcohols are ingested for a variety of reasons including accidental exposures, intentional inebriation, homicide and suicide. The patient with an altered mental status or concerning history warrants consideration of this potentially deadly ingestion. Treatment considerations include alcohol dehydrogenase blockade and hemodialysis. Toxic alcohol poisoning can be an elusive diagnosis. This review evaluates toxic alcohol poisoning signs and symptoms and an approach to diagnosis and management.