Acute Poisoning During Pregnancy: Observations from the Toxicology Investigators Consortium

Cannabinoid Poisoning-Related Emergency Department Visits and Inpatient Hospitalizations in Kentucky, 2017 to 2019

Background and objectives: Cannabis is the most used federally illicit substance. Due to widespread medicinal use and state-level legalization, public perceptions of cannabis have shifted toward the assumption that cannabis is safe. However, cannabinoids can cause adverse medical complications that may lead people to seek treatment. This study characterized cannabinoid poisoning-related medical encounters, poisoning involving cannabinoids and other psychoactive substances, and cannabinoid poisoning-related cardiac complications. Methods: Administrative billing data for emergency department visits and inpatient hospitalizations in acute care facilities with a discharge date from January 1, 2017 to December 31, 2019 were used to characterize cannabinoid poisoning events in Kentucky, identified by ICD-10-CM diagnosis code T40.7X. Results: There were 1,490 encounters of cannabinoid poisoning; patients were primarily non-Hispanic White males, ages 15-44, who had Medicaid and lived in a metropolitan area. Of those, 31.21% involved poisoning with a second psychoactive substance, primarily stimulants and/or opioids, and 17.72% experienced a cardiac complication. Cannabinoid-polydrug poisoning was associated with inpatient treatment (χ2=199.18, p < 0.001) and cardiac complications (χ2=4.58, p < 0.001). Discussion and Conclusions: These results are consistent with other state-level data. Patients who were diagnosed with cannabis-polydrug poisoning, compared to cannabis alone poisoning, had greater odds of hospital admission and cardiac complications, and longer length of hospital stays. Scientific Significance: The health risks of cannabinoid use must be more broadly recognized, while timely and accurate data need to be shared to guide policies on cannabis access. Future research on cannabinoid poisoning should consider the involvement of other psychoactive drugs.

Over-the-counter drug use in suicidal/self-harm behavior: Scoping review

Background and aims

Minor physical ailments are treated with over-the-counter (OTC) medications. The availability of OTC drugs helps reduce waiting times and ease the suffering of many. Suicidal behavior includes suicidal ideation, attempts, and completed suicides and affects people of all ages, religions, and cultures. This study aims to review use of OTC drugs for self-harm and suicidal attempts.

Methods

We reviewed English language publications from the beginning of time to October 2021 on OTC drug use for suicidal behavior.

Results

Twenty-seven studies met the eligibility criteria, and 1,816,228 participants were reported in these publications. OTC analgesics and sedatives/hypnotics were frequently used for suicidal behavior. Females and young people mainly were reported to self-harm using OTC medications. An increase in OTC analgesic use for self-harm in adolescents during the school months was reported. Elderly persons use hypnotics more frequently for suicidal attempts. Persons with major psychiatric disorders were reported to use OTC for suicidal behavior.

Conclusion

The available information shows that the prevention strategies should focus on OTC analgesics and hypnotic use among women, the young, the elderly, and persons with mental health disorders.

Minimum Data Set for a Poisoning Registry: A Systematic Review

Poisoning, as a well-known medical condition, puts everyone at risk. As a data management tool, a registry plays an important role in monitoring the poisoned patients. Having a poisoning minimum data set is a major requirement for creating a poisoning registry. Therefore, the present systematic review was conducted in 2019 to identify the minimum data set for a poisoning registry. Searches were performed in four scientific databases, i.e., PubMed, Scopus, Web of Science, and Embase. The keywords used in the searches included minimum data set, "poison", and "registry". Two researchers independently evaluated the titles, abstracts, and texts of the papers. The data were collected from the related papers. Ultimately, the minimum data set was identified for the poisoning registry. Data elements extracted from the sources were classified into two general categories: administrative data and clinical data. Ninety-eight data elements in the administrative data category were subdivided into three sections: general data, admission data, and discharge data. One-hundred and thirty-one data elements in the clinical data category were subdivided into five sections: clinical observation data, clinical assessment data, past medical history data, diagnosis data, and treatment plan data. The minimum data set is a prerequisite for creating and using a poisoning registry and data system. It is suggested to evaluate and use the poisoning minimum data set in accordance with the national laws, needs, and standards based on the opinion of the local experts.

Exposures in pregnant patients reported to United States Poison Centers

BACKGROUND

Limited data describe poisoning exposures in pregnant women. Previous studies are limited to inpatient populations, those seen only by toxicologists, or single poison centers. This study aimed to describe poison exposures reported to U.S. poison control centers in pregnant patients compared to non-pregnant controls.

METHODS

This was a retrospective observational study of exposures reported to the American Association of Poison Control Centers National Poison Data System from 2000 through 2019. Pregnant patients were included from 15-44 years along with a random sampling of 5:1 age and year matched control group of non-pregnant exposures. Demographics, primary substance, and known medical outcomes were described. Chi square analysis was performed for comparisons.

RESULTS

From 2000 to 2019, a total of 131,619 pregnant cases and 658,095 non-pregnant controls were identified. The median age was 27 years (IQR: 22, 31) for the matched groups. For known trimester of pregnancy: 29.8, 37.0, and 28.2% were in the first, second, and third trimester, respectively. Most common exposures were analgesics and cleaning products. Intentional exposures were more common in non-pregnant compared to pregnant cases (41.2 vs 21.9%; OR 2.71, 95% CI 2.67-2.75), mostly self-harm attempts (31.5 vs. 15.8%). Notably, there was a large discrepancy in the proportion of environmental exposures, with fewer in non-pregnant controls compared with pregnant cases (3.8 vs. 12.1%; OR 0.29, 95% CI 0.28-0.29). More non-pregnant cases had multiple substance exposures compared with pregnant cases (22.2 vs. 10.9%; OR 2.34, 95% CI 2.29-2.38). There were more moderate effect outcomes in non-pregnant compared with pregnant cases (13.2 vs. 6.3%; OR 2.25, 95% CI 2.20-2.30).

CONCLUSIONS

Outcomes of poisoning exposures in pregnant patients reported to U.S. poison centers are less serious compared to non-pregnant controls, likely due to the lower rates of intentional abuse and self-harm exposures and greater number of minimally toxic environmental exposures.

The establishment of a medical toxicology consulting service for advancing care of poisoning and overdose in Qatar

Objectives: The State of Qatar, in recent decades, underwent rapid, and substantial population growth. The country's emergency medicine (EM) needs are met by government-operated facilities of the Hamad Medical Corporation (HMC), which see virtually all acute-care cases in adults and children. In 2017, emergency departments (ED) established the Medical Toxicology Consulting Service (MTCS). This report aims to outline the MTCS's initial 100 cases’ experience and report salient findings that can help ongoing national strategies in meeting Qatar's medical toxicology needs. Methods: The study setting is Qatar, and the clinical base for the MTCS was the country's sole level I center, Hamad General Hospital. The MTCS group is composed of six physicians, all with advanced training in medical toxicology. The study group is composed of the first 100 consecutive cases of the MTCS registry. Registry entry was triggered by in-person consultation, telephone consultation, or identification of cases by daily MTCS rounder surveillance of the ED's electronic tracking board. Results: The MTCS institution identified a significant number of medical toxicology cases within the national hospital system. The trends of poisoning in this study showed a median age of 30 years (range 1–81 years, IQR 22–36 years). Fourteen patients were < 18 years old. The median interval between exposure and ED presentation was 2 hours, with a range of 15 minutes to 24 hours (IQR 1–3 hours). Most patients (71%, 95% CI, 51%–80%) were symptomatic because they were exposed. The MTCS recommended therapeutic intervention in over a third of cases (36%, 95% CI, 27%–46%). Decontamination procedures were ordered in 8% of cases (95% CI, 4%–15%) and specific therapies recommended in 13 cases (13%, 95% CI, 7%–21%). Conclusions: The study highlighted that the availability of experts in medical toxicology, such as with a poison center or toxicology consultation service, results in significant resource conservation in the management of poisoned patients.

Acetaminophen in late pregnancy and potential for in utero closure of the ductus arteriosus-a pharmacokinetic evaluation and critical review of the literature

Acetaminophen has become a novel treatment option for patent ductus arteriosus closure in premature infants. This raises concerns about whether acetaminophen should be avoided in late pregnancy, similar to nonsteroidal anti-inflammatory drugs, because of the risk of in utero ductus arteriosus closure. This article critically evaluated the literature reporting an association between acetaminophen use and in utero ductus arteriosus closure and provided a comparative pharmacokinetic analysis of fetal acetaminophen exposure in pregnancy vs drug levels in neonates, with the goal of making an expert recommendation regarding its safety. Here, 1 prospective cohort study and 12 case reports and series evaluating the risk of premature ductus arteriosus closure with prenatal acetaminophen use were reported and overall do not suggest causation. Pharmacokinetic studies showed that acetaminophen fetal transplacental exposures are well below the levels shown to close the ductus arteriosus in neonates. Short-term use of acetaminophen in the third trimester of pregnancy poses a negligible risk of premature ductus arteriosus closure and can still be considered safe in the third trimester of pregnancy at recommended doses.

Prevalence and characteristics of pregnancy- and lactation-related calls to the National Poison Centre in Belgium: A retrospective analysis of calls from 2012 to 2017

RATIONALE, AIMS, AND OBJECTIVE

In the absence of a Teratology Information Service in Belgium, the National Poison Centre might act as a substitute centre for answering pregnancy- and lactation-related questions regarding medication use. The aim of this study was to define the prevalence and characteristics of pregnancy- and lactation-related calls to the National Poison Centre in Belgium, as well as the type of health products involved during these calls.

METHOD

A retrospective, descriptive study on pregnancy- and lactation-related calls involving health products received by the Belgian Poison Centre between January 2012 and December 2017 was performed. Health products were categorized as registered medicines or non-registered health products; medicines were further classified according to the Anatomical Therapeutic Chemical classification system.

RESULTS

The Poison Centre annually received about 361 calls related to pregnancy and lactation. Pregnant and lactating women mainly called the Poison Centre themselves in case of exposure, while relatives were the predominant type of caller when preventive information was requested. The Poison Centre was mostly contacted for information about medicines and especially for preventive questions during lactation. Many questions involved over-the-counter medicines such as paracetamol and ibuprofen. Given the safety issues related to some involved products (eg, ibuprofen, zolpidem, benzodiazepines, and pseudoephedrine), seeking for advice was justified.

CONCLUSIONS

The Belgian Poison Centre received almost daily calls from patients and health care professionals on medication exposure during pregnancy and lactation. These findings underline the importance of evidence-based counselling of pregnant and lactating women and should encourage health care professionals to engage themselves more actively when counselling on the rational use of medicines during pregnancy and lactation. The findings also contribute to the ongoing discussion to establish a Teratology Information Service in Belgium.

Acute poisoning in pregnancy: a province-wide perspective from a poison center

Background: Poisoning in pregnancy can cause maternal and neonatal morbidity and mortality, but few data detail such events. Herein, we describe poisoning exposures in pregnant women identified by a large Canadian Poison Centre.Methods: This retrospective study evaluated poisoning exposures in pregnant women aged 12-60 years, reported to the Ontario Poison Centre from 2010 to 2017. Exposures were identified from the Poison Centre database by calls received, in which the patient was also reported to be pregnant. We collected patient demographics (age, trimester, and location), as well as information about the poisoning exposure (number and type of substances, route of exposure, reason for exposure, decontamination, and treatment recommendations).Results: There were 1716 cases of poisoning exposures during pregnancy over the eight-year study period, representing 0.28% of all 619,539 calls over the period. Median maternal age was 29 years (IQR 25-33), and exposures were most frequent in the second trimester of pregnancy (41%). Unintentional exposures (n = 1397) accounted for 81% of all calls. Of the 18% of calls (n = 305) for intentional exposures, 71% (n = 219) were suspected attempted suicides. Intentional exposures were more frequent in the first (OR 2.64, 95% CI 1.85-3.76) and second trimesters (OR 1.61, 95% CI 1.13-2.28), relative to third trimester. The associated risk of intentional exposures was more likely in women aged ≤19 years (OR 21.41, 95% CI 12.75-35.94) and 20-29 years (OR 3.72, 95% CI 2.70-5.14), relative to women ≥30 years old.Conclusions: Intentional poisoning exposures in pregnancy most commonly involve young women in the first two trimesters. Population-based studies are needed to further examine risk factors for overdose, poisoning, and self-harm in pregnancy, as well as perinatal outcomes.

The Toxicology Investigators Consortium Case Registry-the 2015 Experience

The American College of Medical Toxicology established the Toxicology Investigators Consortium (ToxIC) Case Registry in 2010. The Registry contains all medical toxicology consultations performed at participating sites. The Registry has continued to grow since its inception, and as of December 31, 2015, contains 43,099 cases. This is the sixth annual report of the ToxIC Registry, summarizing the additional 8115 cases entered in 2015. Cases were identified by a query of the Registry for all cases entered between January 1 and December 31, 2015. Specific data reviewed for analysis included demographics (age, race, gender), source of consultation, reason for consultation, agents and agent classes involved in exposures, signs, symptoms, clinical findings, fatalities, and treatment. By the end of 2015, there were 50 active sites, consisting of 101 separate health-care facilities; 51.2 % of cases involved females. Adults between the ages of 19 and 65 made up the majority (64.2 %) of Registry cases. Caucasian race was the most commonly reported (55.6 %); 9.6 % of cases were identified as Hispanic ethnicity. Inpatient and emergency department referrals were by far the most common referral sources (92.9 %). Intentional pharmaceutical exposures remained the most frequent reason for consultation, making up 52.3 % of cases. Of these intentional pharmaceutical exposures, 69 % represented an attempt at self-harm, and 85.6 % of these were a suicide attempt. Nonopioid analgesics, sedative-hypnotics, and antidepressant agents were the most commonly reported agent classes in 2015. Almost one-third of Registry cases involved a diagnosed toxidrome (32.8 %), with a sedative-hypnotic toxidrome being the most frequently described. Significant vital sign abnormalities were recorded in 25.3 % of cases. There were 98 fatalities reported in the Registry (1.2 %). Adverse drug reactions were reported in 4.3 % of cases. Toxicological treatment was given in 65.3 % of cases, with 33.0 % receiving specific antidotal therapy. Exposure characteristics and trends overall were similar to prior years. While treatment interventions were required in the majority of cases, fatalities were rare.