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Monteiro M, Pinheiro NC, Samji V. Serotonin Syndrome: An Emerging Reality in the Emergency Department. Cureus 2023; 15:e47470. [PMID: 38021488 PMCID: PMC10660611 DOI: 10.7759/cureus.47470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 12/01/2023] Open
Abstract
Serotonin syndrome (SS) is an entity caused by interference with the serotonin metabolism and/or by medications that act as serotonin receptor agonists. The signs and symptoms are nonspecific, making the diagnosis challenging. Treatment depends on the severity of the manifestations. In mild to moderate cases, it typically resolves within the first 24 hours after initiating therapy and discontinuation of the serotoninergic medications. A 42-year-old woman with a previous history of depression was admitted to the hospital due to the voluntary ingestion of multiple tablets of escitalopram 10 mg and venlafaxine 75 mg. Physical examination showed a hyperthermic and diaphoretic patient. Tremor, agitation, bilateral ocular clonus, and spontaneous inferior limb clonus were also present. Hunter's criteria were applied, and the diagnosis of SS was assumed. Supportive and symptomatic treatments were initiated. The evolution was benign, with symptomatic remission in the first 24 hours. In the last decades, a large increase in the use of antidepressants was noted, and, as such, defining SS as rare is no longer appropriate. Delaying the treatment can dictate an increase in morbidity and mortality. It is important to highlight that the diagnosis is mainly clinical as diagnostic criteria may miss out on some cases. As such, clinical awareness of SS's multiplicity of presentations is of utmost importance.
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Affiliation(s)
| | - Nuno C Pinheiro
- Internal Medicine, Centro Hospitalar Lisboa Ocidental, Lisboa, PRT
| | - Vikesh Samji
- Internal Medicine, Hospital Egas Moniz, Lisbon, PRT
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Tansuwannarat P, Vichiensanth P, Sivarak O, Tongpoo A, Promrungsri P, Sriapha C, Wananukul W, Trakulsrichai S. A 10-Year Retrospective Analysis of Medication Errors among Adult Patients: Characteristics and Outcomes. PHARMACY 2023; 11:138. [PMID: 37736910 PMCID: PMC10514797 DOI: 10.3390/pharmacy11050138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 09/23/2023] Open
Abstract
Medication errors (MEs) are a global health problem. We conducted this study to clarify the clinical characteristics, outcomes, and factors associated with MEs that caused harm to adult patients (>15 years of age) who were managed in hospitals or healthcare facilities. We performed a 10-year retrospective study (2011-2020) by analyzing data from the Ramathibodi Poison Center (RPC) database (RPC Toxic Exposure Surveillance System). There were a total of 112 patients included in this study. Most were women (59.8%) and had underlying diseases (53.6%). The mean patient age was 50.5 years. Most MEs occurred during the afternoon shift (51.8%) and in the outpatient department (65.2%). The most common type of ME was a dose error (40.2%). Local anesthetic was the most common class of ME-related drug. Five patients died due to MEs. We analyzed the factors associated with MEs that caused patient harm, including death (categories E-I). The presence of underlying diseases was the single factor that was statistically significantly different between groups. Clinical characteristics showed no significant difference between patients aged 15-65 years and those aged >65 years. In conclusion, our findings emphasized that MEs can cause harm and even death in some adult patients. Local anesthetics were the most commonly involved in MEs. Having an underlying disease might contribute to severe consequences from MEs. Preventive measures and safety systems must be highlighted and applied to prevent or minimize the occurrence of MEs.
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Affiliation(s)
- Phantakan Tansuwannarat
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (P.P.); (C.S.); (W.W.)
| | - Piraya Vichiensanth
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
| | - Ornlatcha Sivarak
- International College, Mahidol University, Nakhon Pathom 73170, Thailand;
| | - Achara Tongpoo
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (P.P.); (C.S.); (W.W.)
| | - Puangpak Promrungsri
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (P.P.); (C.S.); (W.W.)
| | - Charuwan Sriapha
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (P.P.); (C.S.); (W.W.)
| | - Winai Wananukul
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (P.P.); (C.S.); (W.W.)
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Satariya Trakulsrichai
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (P.P.); (C.S.); (W.W.)
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
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Sharma R, Singh S, Tewari N, Dey P. A toxic shrub turned therapeutic: The dichotomy of Nerium oleander bioactivities. Toxicon 2023; 224:107047. [PMID: 36706925 DOI: 10.1016/j.toxicon.2023.107047] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 01/26/2023]
Abstract
Nerium oleander L. is a medicinal plant, used for the treatment of cancers and hyperglycemia across the world, especially in Indian sub-continent, Turkey, Morocco, and China. Although clinical studies supporting its pharmacological effects remain critically underexplored, accidental and intentional consumption of any part of the plant causes fatal toxicity in animals and humans. While the polyphenolic fraction of oleander leaves has been attributed to its pre-clinical pharmacological activities, the presence of diverse cardiac glycosides (especially oleandrin) causes apoptosis to cancer cells in vitro and results in clinical signs of oleander poisoning. Thus, the dual pharmacological and toxicological role of oleander is a perplexing dichotomy in phytotherapy. The current investigative review, therefore, intended to analyze the intrinsic and extrinsic factors that likely contribute to this conundrum. Especially by focusing on gut microbial diversity, abundance, and metabolic functions, oleander-associated pharmacological and toxicological studies have been critically analyzed to define the dual effects of oleander. Electronic databases were extensively screened for relevant research articles (including pre-clinical and clinical) related to oleander bioactivities and toxicity. Taxonomic preference was given to the plant N. oleander L. and synonymous plants as per 'The World Flora Online' database (WCSP record #135196). Discussion on yellow oleander (Cascabela thevetia (L.) Lippold) has intentionally been avoided since it is a different plant. The review indicates that the gut microbiota likely plays a key role in differentially modulating the pharmacological and toxicological effects of oleander. Other factors identified influencing the oleander bioactivities include dose and mode of treatment, cardiac glycoside pharmacokinetics, host-endogenous glycosides, plant material processing and phytochemical extraction methods, plant genotypic variations, environmental effects on the phytochemical quality and quantity, gene expression variations, host dietary patterns and co-morbidity, etc. The arguments proposed are also relevant to other medicinal plants containing toxic cardiac glycosides.
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Affiliation(s)
- Rajat Sharma
- Department of Biotechnology, Thapar Institute of Engineering and Technology, Patiala, Punjab, India.
| | - Swati Singh
- Department of Zoology, University of North Bengal, Siliguri, West Bengal, India.
| | - Nisha Tewari
- Department of Biotechnology, Thapar Institute of Engineering and Technology, Patiala, Punjab, India.
| | - Priyankar Dey
- Department of Biotechnology, Thapar Institute of Engineering and Technology, Patiala, Punjab, India.
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Greene SC, Wyatt K, Cates AL, Weiss S. Anticonvulsant fatalities reported to the American Association of Poison Control Centers 2000 - 2019. Seizure 2023; 106:1-6. [PMID: 36682209 DOI: 10.1016/j.seizure.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/02/2023] [Accepted: 01/09/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Anticonvulsants are frequently prescribed, and exposures are commonly reported to American Association of Poison Control Centers sites. The purpose of this study was to describe the epidemiology of fatalities associated with oral anticonvulsant use, including patient demographics, specific medications, and the circumstances surrounding the deaths. METHODS This was a retrospective analysis of cases coded with oral anticonvulsants as a single substance and associated with a fatal outcome reported to the AAPCC National Poison Data System from 2000 to 2019. Polydrug ingestions and parenteral exposures were excluded. Patient characteristics, circumstances of the ingestion, specific medication, and chronicity of use were described. RESULTS We identified 126 cases that were classified as fatalities associated with single anticonvulsant use. The five most implicated anticonvulsants were carbamazepine, gabapentin, lamotrigine, phenytoin, and valproic acid. The majority (68.3%) of fatal cases were suicides. Phenytoin was implicated in eight (89%) adverse reactions and seven (70%) therapeutic errors. Valproic acid caused one (11.1%) adverse reaction and was associated with one (10%) therapeutic error. Three (75%) unintentional fatalities were caused by carbamazepine. The plurality (42.1%) of fatal ingestions occurred in acute-on-chronic use. An additional 40 (31.7%) were acute. Chronic use accounted for 15 (11.9%) of fatal exposures, including 5/10 of fatalities attributed to therapeutic error. The chronicity of medication use was unknown in 18 (14.3%) of fatal ingestions. Narrative summaries were available in 14 cases. Four of the patients presented to the emergency department with minimal symptoms. The other 10 had varying degrees of central nervous system (CNS) depression. Seizures were observed in six cases. Hyperammonemia was reported in seven of nine valproic acid ingestions. CONCLUSIONS Fatalities associated with isolated anticonvulsant use are uncommon and typically occur following intentional overdoses. Fatal adverse reactions and therapeutic errors are most associated with phenytoin use and disproportionately affect elderly patients.
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Affiliation(s)
- Spencer C Greene
- Department of Clinical Sciences, University of Houston College of Medicine, 4349 Martin Luther King Blvd, Houston, TX 77004, United States.
| | - Kimberly Wyatt
- Department of Biological Sciences, Good Samaritan College, 375 Dixmyth Ave, Cincinnati, OH, 45220, United States
| | - Alexis L Cates
- Albert Einstein Health Network, Department of Emergency Medicine, Division of Medical Toxicology, 5501 Old York Road, Philadelphia, PA 19141, United States
| | - Sarah Weiss
- Department of Emergency Medicine, Reading Hospital, 420 S 5th Ave, West Reading, PA 19611, United States
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Nilotinib alleviated acetaminophen-induced acute hepatic injury in mice through inhibiting HIF-1alpha/VEGF-signaling pathway. Int Immunopharmacol 2022; 112:109268. [PMID: 36182876 DOI: 10.1016/j.intimp.2022.109268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/14/2022] [Accepted: 09/17/2022] [Indexed: 11/20/2022]
Abstract
The current study inspects the impact of nilotinib (Nil) on liver damage caused by acetaminophen (APAP). Adult male mice were pre-treated with nilotinib (Nil,5 and 10 mg/kg) orally once daily for 7 days followed by a single intraperitoneal administration of acetaminophen (APAP, 200 mg/kg) on the 7th day. The results indicated that nilotinib significantly decreased APAP-induced elevation of biochemical markers (ALT, AST, ALP, LDH, ɤ GT, and total bilirubin). Additionally, nilotinib significantly increased hepatic GSH and SOD content, while decreased MDA content. Nil significantly suppressed the expression of HIF-1α and VEGF. Histopathological examination of hepatic tissue from Nil-treated mice revealed that Nil reduced acetaminophen-induced necrosis.
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Colom Gordillo A, Martínez Sánchez L, Pretel Echaburu C, Trenchs Sainz de la Maza V, Gotzens Bersch J, Luaces Cubells C. Unintentional poisoning by cough and cold medications: Drugs with little usefulness and potential toxicity. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2022; 97:326-332. [PMID: 36153206 DOI: 10.1016/j.anpede.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 04/12/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The use of medications to relieve the symptoms of the "common cold" in children is very frequent. In addition to the lack of scientific evidence supporting its usefulness, there is evidence of potential toxicity, and serious and even fatal cases of intoxication have been described. The objective was to describe the clinical and epidemiological characteristics of the patients treated in a paediatric emergency department (PED) for suspected unintentional intoxication by a cold medicine. MATERIAL AND METHODS Observational and analytical study of patients aged less than 18 years managed in a PED for suspected unintentional poisoning by a cold medicine between July 2012 and June 2020. We classified severity according to the Poisoning Severity Score (PSS): PSS-0 = no toxicity; PSS-1 = mild toxicity; PSS-2 = moderate; PSS-3 = severe; PSS-4 = lethal. If the intoxication occurred while the patient was in active treatment with the drug, we determined whether the patient's age was in the applicable range established in the therapeutic indications provided in the summary of product characteristics. RESULTS The study included data for 63 cases. The drugs involved were decongestants and mucolytics (31; 49.2%), antitussives (26; 41.2%) and oral bronchodilators (6; 9.5%). The distribution by severity was 40 cases with PSS-0 (63.5%), 21 with PSS-1 (33.3%), 1 with PSS-2 (1.6%) and 1 with PSS-3 (1.6%). In 29 patients (46.0%) there was a history of therapeutic use; in 15 of these cases (51.7%) the age was lower than recommended in the summary of product characteristics. In 14 patients (22.2%) the intoxication was due to administration of the wrong dose by caregivers. CONCLUSION Although scientific evidence does not support the use of cold medicines in children, unintentional intoxications by these drugs keep happening, in some cases causing moderate or severe symptoms.
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Affiliation(s)
| | - Lidia Martínez Sánchez
- Área de Urgencias, Hospital Sant Joan de Déu, Barcelona, Spain; Influencia del entorno en el bienestar del niño y del adolescente, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain.
| | | | - Victoria Trenchs Sainz de la Maza
- Área de Urgencias, Hospital Sant Joan de Déu, Barcelona, Spain; Influencia del entorno en el bienestar del niño y del adolescente, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain; Departamento de Cirugía y Especialidades Médico-quirúrgicas, Facultad de Medicina i Ciencias de la Salud, Universidad de Barcelona, Barcelona, Spain
| | | | - Carles Luaces Cubells
- Área de Urgencias, Hospital Sant Joan de Déu, Barcelona, Spain; Influencia del entorno en el bienestar del niño y del adolescente, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain; Departamento de Cirugía y Especialidades Médico-quirúrgicas, Facultad de Medicina i Ciencias de la Salud, Universidad de Barcelona, Barcelona, Spain
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7
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Tansuwannarat P, Vichiensanth P, Sivarak O, Tongpoo A, Promrungsri P, Sriapha C, Wananukul W, Trakulsrichai S. Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study. Ther Clin Risk Manag 2022; 18:669-681. [PMID: 35795851 PMCID: PMC9252189 DOI: 10.2147/tcrm.s363638] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/30/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose This study was performed to evaluate the clinical characteristics of, consequences of, and factors associated with medication errors (MEs) that cause harm to pediatric patients (<15 years of age) treated in the hospital setting. Patients and Methods We performed a 10-year retrospective study (January 2011–December 2020) by analyzing data from the Ramathibodi Poison Center. MEs were classified into categories A to I according to the severity of the outcome. Results In total, 121 patients were included in the study. Most (51.24%) patients were male. Their median age was 1 year (range, 1 hour–14 years). Infants, newborns, and toddlers were the three most common age groups in which MEs were reported. Most MEs occurred during the afternoon shift [n = 60 (49.59%)] and in the inpatient department (66.12%). The most common type of MEs was a dose error (64.46%). Antibiotics, sedative agents, and bronchodilators were the three most common classes of ME drugs. Four patients died. Three deaths occurred because of a dose error. One patient was a 1-year-old girl who received an iatrogenic intravenous phenytoin overdose of 10 times the normal dose, resulting in a phenytoin level of 72.4 mcg/mL. She died 22 hours after the ME occurred. The work shift was the only factor that significantly differed between patients with category C and D MEs and those with category E to I MEs. Conclusion Small children were at highest risk for MEs. MEs induced harm and deaths in some patients. A preventive and safety system, including appropriate shift work administration, should be emphasized and implemented to prevent and/or decrease the occurrence of MEs.
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Affiliation(s)
- Phantakan Tansuwannarat
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand.,Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Piraya Vichiensanth
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ornlatcha Sivarak
- International College, Mahidol University, Nakhon Pathom, 73170, Thailand
| | - Achara Tongpoo
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Puangpak Promrungsri
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Charuwan Sriapha
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Winai Wananukul
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Satariya Trakulsrichai
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Palamar JJ. Prevalence and Correlates of GHB Use among Adults in the United States. J Psychoactive Drugs 2022:1-6. [PMID: 35616605 PMCID: PMC9699895 DOI: 10.1080/02791072.2022.2081948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Gamma-hydroxybutyrate (GHB) was a somewhat prevalent club drug two decades ago, but research has been lacking regarding the current epidemiology of use. In this study, prevalence and correlates of past-year GHB use were estimated based on noninstitutionalized US adults participating in the 2015-2020 National Survey of Drug Use and Health (N= 241,675). An estimated 0.05% (95% CI: 0.04-0.07) of adults in the US have used GHB in the past year. Compared to those age 18-25, those age 35-49 were at increased odds for use (aOR = 2.28, 95% CI: 1.02-5.10), and compared to heterosexual men, gay men in particular were at high odds for use (aOR = 27.82, 95% CI: 11.09-69.80). Those identifying as bisexual men (aOR = 3.39, 95% CI: 1.17-9.82) and lesbian/bisexual women (aOR = 3.37, 95% CI: 1.44-7.90) were also at high odds for use. Despite all drugs examined being significant correlates of use in bivariable models (ps < .001), only past-year use of methamphetamine (aOR = 15.68, 95% CI: 7.40-33.25), ketamine (aOR = 8.52, 95% CI: 2.67-27.20), and ecstasy (aOR = 4.41, 95% CI: 1.80-10.75) was associated with increased odds of use in the multivariable model. Results suggest that GHB use is currently rare, but gay men and people who use other party drugs are at particularly high risk for use.
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Affiliation(s)
- Joseph J Palamar
- New York University Grossman School of Medicine, Department of Population Health, New York, NY USA
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Colom Gordillo A, Martínez Sánchez L, Pretel Echaburu C, Trenchs Sainz de la Maza V, Gotzens Bersch J, Luaces Cubells C. Intoxicación no intencionada por anticatarrales: medicamentos poco útiles y potencialmente tóxicos. An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Zhai J, Dong X, Yan F, Guo H, Yang J. Oleandrin: A Systematic Review of its Natural Sources, Structural Properties, Detection Methods, Pharmacokinetics and Toxicology. Front Pharmacol 2022; 13:822726. [PMID: 35273501 PMCID: PMC8902680 DOI: 10.3389/fphar.2022.822726] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/02/2022] [Indexed: 12/14/2022] Open
Abstract
Oleandrin is a highly lipid-soluble cardiac glycoside isolated from the plant Nerium oleander (Apocynaceae) and is used as a traditional herbal medicine due to its excellent pharmacological properties. It is widely applied for various disease treatments, such as congestive heart failure. Recently, oleandrin has attracted widespread attention due to its extensive anti-cancer and novel anti-viral effects. However, oleandrin has a narrow therapeutic window and exhibits various toxicities, especially typical cardiotoxicity, which is often fatal. This severe toxicity and low polarity have significantly hindered its application in the clinic. This review describes natural sources, structural properties, and detection methods of oleandrin. Based on reported poisoning cases and sporadic animal experiments, the pharmacokinetic characteristics of oleandrin are summarized, so as to infer some possible phenomena, such as enterohepatic circulation. Moreover, the relevant factors affecting the pharmacokinetics of oleandrin are analyzed, and some research approaches that may ameliorate the pharmacokinetic behavior of oleandrin are proposed. With the toxicology of oleandrin being thoroughly reviewed, the development of safe clinical applications of oleandrin may be possible given potential research strategies to decrease toxicity.
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Affiliation(s)
- Jinxiao Zhai
- Institute of Forensic Medicine and Laboratory Medicine, Jining Medical University, Jining, China
| | - Xiaoru Dong
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, China
- *Correspondence: Xiaoru Dong,
| | - Fenglian Yan
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, China
| | - Hongsong Guo
- Institute of Forensic Medicine and Laboratory Medicine, Jining Medical University, Jining, China
| | - Jinling Yang
- Institute of Forensic Medicine and Laboratory Medicine, Jining Medical University, Jining, China
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Nigussie S, Demeke F, Getachew M, Amare F. Treatment outcome and associated factors among patients admitted with acute poisoning in a tertiary hospital in Eastern Ethiopia: A cross-sectional study. SAGE Open Med 2022; 10:20503121221078155. [PMID: 35198211 PMCID: PMC8859693 DOI: 10.1177/20503121221078155] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/18/2022] [Indexed: 12/05/2022] Open
Abstract
Introduction: Acute poisoning causes morbidity and mortality worldwide. There is scarce of information on acute poisoning in the study area. Objective: To assess treatment outcome and the associated factors among patients admitted with acute poisoning at Hiwot Fana Comprehensive Specialized Hospital, Eastern Ethiopia. Methods: A cross-sectional study was conducted. All acutely poisoned patients who had been admitted at the emergency department of Hiwot Fana Comprehensive Specialized Hospital from 1 January 2016 to 31 December 2020 who fulfilled the inclusion criteria of the study were included. Data were collected by review of medical records. Poor treatment outcome of acute poisoning was defined as the acutely poisoned patient was died, or survived with disability. Multivariate logistic regression analysis was used to determine factors associated with the outcome of acute poisoning. Result: A total of 175 patient’s medical records were reviewed. Of these, 150 patient’s medical records had complete information and were included in the final analysis. The majority of participants 89 (59.3%) were in the age group of 19–37 years. More than half of the participants 86 (57.3%) were females. Organophosphate was the most poisoning agent encountered in 62 cases. Acetaminophen was the predominant drug poisoning agent encountered in 10 participants. Among 30 patients managed with antidote, 18 patients were treated with atropine for organophosphate poisoning. Of all the poisoning cases admitted during the study period, 16.7% died. Participants who were poisoned by themselves were 2.4 times more likely to have poor treatment outcomes than those who were poisoned accidentally: 2.44 (95% confidence interval: 1.10–5.42). The odd of having poor treatment outcome in participants who were poisoned by drugs was 2.13 more likely: 2.13 (95% confidence interval: 1.21–3.32). Conclusion: Organophosphate was the predominant cause of acute poisoning encountered in 62 cases. The modes of poisoning and drug poisoning were significant risk factors associated with poor treatment outcomes of acute poisoning.
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Affiliation(s)
- Shambel Nigussie
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Fekade Demeke
- Department of Epidemiology, College of Medicine and Health Science, Jigjiga University, Somali, Ethiopia
| | - Melaku Getachew
- Department of Emergency and Critical Care Medicine, School of Medicine, College of Health and Medical Sciences, Haramay University, Harar, Ethiopia
| | - Firehiwot Amare
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Kamasak T, Kader Ş, Mutlu M, Özkaya K, Erduran E, Orhan F, Dilber E, Kalyoncu M, Karagüzel G, Cakır M, Bahat E, Cansu A. Amitriptyline Intoxication in Children: Twenty Years' Experience in a Tertiary Care Center in Turkey. Pediatr Emerg Care 2021; 37:e1377-e1381. [PMID: 32150000 DOI: 10.1097/pec.0000000000002055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Amitriptyline ingestion is an important cause of poisoning morbidity and mortality in Turkey and other countries. In contrast to adults, data concerning amitriptyline intoxication in children are limited. The purpose of this study was to investigate amitriptyline intoxication findings in the pediatric population, based on age groups and reported dosages. METHODS The medical records of 192 patients admitted to the Karadeniz Technical University Medical Faculty Farabi Hospital Pediatric Emergency Department, Turkey, due to amitriptyline intoxication in 1997-2017 were examined retrospectively. Patients were divided into 6 groups based on amitriptyline doses and 4 groups based on age. Complete blood count, blood glucose, serum electrolytes, renal and liver function tests, coagulation tests (prothrombin time and partial thromboplastin time), and blood gas analysis were studied in all patients. Electrocardiography was performed on all children, and chest radiography and electroencephalography on those with respiratory or central nervous system symptoms. RESULTS Amitriptyline intoxication was most frequently observed between the ages of 1 and 4 years. The most common signs and symptoms observed at time of hospital admission were lethargy and drowsiness (45.3%), sinus tachycardia (19.2%), and nausea and vomiting (13%). The most common laboratory finding was hyperglycemia (17.7). Six patients were intubated because of respiratory failure, and mechanical ventilation was initiated in these cases. One patient with amitriptyline overdose had persistent supraventricular tachycardia. Four children died due to amitriptyline intoxication. CONCLUSIONS Tricyclic antidepressant intoxication is a leading cause of mortality and morbidity in children. It is therefore particularly important to identify the clinical and laboratory findings that develop with high-dose consumption.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Elif Bahat
- Pediatric Nephrology, Karadeniz Technical University, Trabzon, Turkey
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Atemnkeng F, Shabani J, Chen L, Gala B, Ramalho J, Diaz K, Nfonoyim J. A Fatal Case of Massive Verapamil Overdose: An Overview of the Treatment Options. J Med Cases 2021; 12:373-376. [PMID: 34527109 PMCID: PMC8425808 DOI: 10.14740/jmc3763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 08/13/2021] [Indexed: 11/17/2022] Open
Abstract
Calcium channel blocker overdose is usually very fatal and challenging to manage. The patients are usually asymptomatic on admission, but deteriorate very rapidly. Currently, there is no specific antidote, and the treatment is supportive requiring high level of critical care, and may necessitate extracorporeal membrane oxygenation. The use of high-dose insulin is reported to help stabilize the blood pressure and wean off inotropes. The recommendations for supportive treatment in patients with calcium channel blocker overdose are based upon low-quality evidence reports including case series and animal studies. We present the case of a 55-year-old male with a history of atrial fibrillation who was admitted to the hospital 30 min after intentionally ingesting 80 tablets of 180 mg extended release verapamil. On admission, the patient was asymptomatic, but electrocardiogram (ECG) showed a complete heart block which necessitated a transcutaneous pacing, followed by transvenous pacemaker placement. Rapid deterioration of the patient’s hemodynamic status led to the patient getting intubated and was started on pressors as well as high-dose insulin. Despite all the aggressive measures, the patient died in less than 24 h after being admitted. We report this case to provide a brief review of the treatment options available at this time, because to date, there is no specific antidote for such overdose, and it remains very fatal despite the amount of supportive care provided.
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Affiliation(s)
| | - Jawad Shabani
- Richmond University Medical Center, Staten Island, NY, USA
| | - Lu Chen
- Richmond University Medical Center, Staten Island, NY, USA
| | - Bhavesh Gala
- Richmond University Medical Center, Staten Island, NY, USA
| | | | - Keith Diaz
- Richmond University Medical Center, Staten Island, NY, USA
| | - Jay Nfonoyim
- Richmond University Medical Center, Staten Island, NY, USA
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14
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Kader GA, Ibrahim MA, Khalifa AM, Mirza U, Rashwan EK, Abdel-Hady Z. Evaluation of vitamin C protective effect on the cerebrocortical antioxidant defense, histopathological, pro-apoptotic p53 and anti-apoptotic Bcl2 expressions against tramadol neurotoxicity in rats. J Chem Neuroanat 2021; 112:101893. [PMID: 33276071 DOI: 10.1016/j.jchemneu.2020.101893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 10/29/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Reported tramadol toxicity emphasizes the necessity to recognize its mechanism of toxicity, particularly to the brain tissue. AIM This study aimed to evaluate the protective effect of vitamin C (Vit C) in cerebrocortical toxicity mediated by tramadol in rats using biochemical and histological parameters. MATERIAL AND METHODS Forty-eight albino rats were randomly divided into eight groups, (n = 6/group) as follow: the control group received normal saline and vitamin C group received vitamin C (200 mg/kg per oral). Tramadol 50, 100, 150 groups received tramadol in doses of (50, 100 and 150 mg/kg per oral, respectively); Tramadol 50+ Vit C, 100+ Vit C, 150+ Vit C groups received vitamin C (200 mg/kg per oral) plus tramadol in doses of (50, 100 and 150 mg/kg per oral, respectively). Rats had received vitamin C and tramadol daily for 30 days. Blood and brain tissues samples were harvested for biochemical, histopathological, immunohistochemical and electron microscopic examinations. RESULTS Tramadol administration leads to a significant elevation of MDA, NO levels and a significant decrease in antioxidants parameters (CAT, SOD and GSH) in the tissues of cerebral cortices in rats which were directly proportional to the dose of tramadol. In histological investigations, tramadol-treated groups showed pyknotic pyramidal cells, multiple red neurons and shrinking red neurons with hallows around it and apoptotic cells were detected. These biochemical abnormalities and histological impairment were ameliorated in groups with tramadol low doses by the co-treatment with vitamin C. CONCLUSION vitamin C has antioxidant and anti-apoptotic potentials against tramadol neurotoxicity via suppression of oxidative stress, lipid peroxidation, structural abnormalities, and down-regulation of p53 and overexpression of Bcl2 in the nervous tissues.
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Affiliation(s)
- Ghada Abdel Kader
- Human Anatomy and Embryology Department, Faculty of Medicine, Suez Canal University, Ismailia, 41522, Egypt.
| | - Mahrous A Ibrahim
- Forensic Medicine and Clinical Toxicology, College of Medicine, Jouf University, Sakaka, 42421, Saudi Arabia; Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Suez Canal University, Ismailia, 41522, Egypt.
| | - Athar M Khalifa
- Pathology Department, College of Medicine, Jouf University, Sakaka, 42421, Saudi Arabia.
| | - Umrana Mirza
- Biochemistry Department, College of Medicine, Jouf University, Sakaka, 42421, Saudi Arabia.
| | - Eman K Rashwan
- Physiology Department, College of Medicine, Jouf University, Sakaka, 42421, Saudi Arabia; Physiology Department, Faculty of Medicine, Al-Azhar University, Assuit 71524, Egypt.
| | - Zinab Abdel-Hady
- Histology and Cell Biology Department, Faculty of Medicine, Suez Canal University, Ismailia, 41522, Egypt.
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15
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Martínez-Sánchez L, Aguilar-Salmerón R, Pi-Sala N, Gispert-Ametller MÀ, García-Peláez M, Broto-Sumalla A, de Gamarra-Martínez EF, Nogué-Xarau S. Availability in Spain of “one-pill killers” and other highly toxic drugs in infants. An Pediatr (Barc) 2020. [DOI: 10.1016/j.anpede.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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16
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Dey P. The pharmaco-toxicological conundrum of oleander: Potential role of gut microbiome. Biomed Pharmacother 2020; 129:110422. [DOI: 10.1016/j.biopha.2020.110422] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/08/2020] [Accepted: 06/14/2020] [Indexed: 02/08/2023] Open
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17
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Greene SC, Folt J, Wyatt K, Brandehoff NP. Epidemiology of fatal snakebites in the United States 1989-2018. Am J Emerg Med 2020; 45:309-316. [PMID: 33046301 DOI: 10.1016/j.ajem.2020.08.083] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND There are 5000-10,000 snake envenomations annually in the United States. Fortunately, few are fatal. In this study we review the epidemiology of fatal snakebites. METHODS Native snakebite cases from the American Association of Poison Control Centers (AAPCC) National Poison Data System from 1989 to 2018 were reviewed. Additional cases that were not reported to the AAPCC were identified by reviewing Wikipedia and by searching PubMed and online news outlets using various combinations of relevant keywords. RESULTS We identified 101 fatal bites from native snakes. Rattlesnakes accounted for 74 (90.2%) of the 82 deaths for which the species was known or which occurred where rattlesnakes are the only native crotalids. There were five fatalities attributed to copperheads, two due to cottonmouths, and one caused by an eastern coral snake. Males were disproportionately affected. The median age for victims was 40 years old. In cases for which data were available, many of the snake interactions were intentional, e.g. religious services, animal husbandry, and attempting to kill the snake. CONCLUSIONS Death following envenomation from a native U.S. snake is unlikely, particularly if medical attention is sought promptly. Rattlesnake envenomations are more likely to be fatal than bites from other species. Intentionally engaging with a venomous snake raises the risk of incurring a fatal bite, as does concurrent alcohol or drug use. Age less than 12 years old does not appear to be a risk factor for a fatal outcome, while elderly patients may have a slightly increased risk of death.
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Affiliation(s)
- Spencer C Greene
- Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, 3525 Southern Blvd, Dayton, OH 45429, United States of America; Bayou City Medical Toxicology & Emergency Medicine Consultants, 6711 Stella Link Rd. #313, Houston, TX 77005, United States of America.
| | - Jason Folt
- Department of Emergency Medicine, Henry Ford Health System, 2799 West Grand Boulevard, CFP-258, Detroit, MI 48202, United States of America
| | - Kimberly Wyatt
- Department of Biological Sciences, University of Cincinnati, 614 Rieveschl Hall, Cincinnati, OH 45221-0006, United States of America
| | - Nicklaus P Brandehoff
- Rocky Mountain Poison and Drug Center, 1391 Speer Blvd #600, Denver, CO 80204, United States of America; Department of Emergency Medicine, University of Colorado School of Medicine, 12401 East 17th Avenue, Aurora, CO 80045, United States of America
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18
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Boadu O, Gombolay GY, Caviness VS, El Saleeby CM. Intoxication From Accidental Marijuana Ingestion in Pediatric Patients: What May Lie Ahead. Pediatr Emerg Care 2020; 36:e349-e354. [PMID: 29406477 DOI: 10.1097/pec.0000000000001420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Marijuana is the most commonly used illicit drug. In young children, there are relatively few reports in the literature of acute marijuana intoxication. Here, we describe the case of a previously healthy 2-year-old girl who presented with clinical seizures. A urine toxicology screen showed elevated levels of tetrahydrocannabinol. The source of the drug was not identified. After a short stay in the hospital, the patient fully recovered with only supportive measures. In this report, we also summarize all domestic and international cases of marijuana intoxication in children younger than 6 years, in conjunction with the number of exposures in children of similar age identified by the US National Poison Data System. This report highlights what is becoming a more common problem. As cannabis continues to be decriminalized across the United States with its increasingly diverse modes of delivery, the potential for accidental exposure in infants and young children also rises. Clinicians should now routinely consider marijuana intoxication in children who present with acute neurological abnormalities.
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Affiliation(s)
- Osei Boadu
- From the University of Rochester School of Medicine and Dentistry, Rochester, NY
| | | | | | - Chadi M El Saleeby
- Department of Pediatrics.,Hospital Medicine.,Infectious Diseases, Massachusetts General Hospital for Children, Harvard Medical School, Boston, MA
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19
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Martínez-Sánchez L, Aguilar-Salmerón R, Pi-Sala N, Gispert-Ametller MÀ, García-Peláez M, Broto-Sumalla A, Fernández de Gamarra-Martínez E, Nogué-Xarau S. [Availability in Spain of "one pill killers" and other highly toxic drugs in infants]. An Pediatr (Barc) 2020; 93:380-395. [PMID: 32284232 DOI: 10.1016/j.anpedi.2020.02.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 02/14/2020] [Accepted: 02/17/2020] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To prepare a list of highly toxic drugs in infants (HTDs) marketed in Spain, comparing those that reach the lethal dose in a child of 10kg with the ingestion of 1 to 3 units. METHOD HTDs are defined as those capable of causing severe or lethal poisoning in children less than 8-year-old. Severe poisoning is considered as that corresponding to Grade 3 in the Poisoning Severity Score classification and to the "major effects" category in publications in the American Association of Poison Control Centers. A literature review was carried out on the annual reports of the American Association of Poison Control Centers, as well as in PubMed, between January 2000 and February 2019 (Keywords "severe", "fatal", "life-threatening", "poisoning", "child", "paediatric", "toxicological emergency"). An observational, retrospective study was also conducted on infants less than 8-year-old that were seen in a Paediatric Emergency Department due to suspected drug poisoning between July 2012 and June 2018. The active ingredients responsible marketed in Spain were selected, and the lethal or highly toxic doses were determined. The number of units (pills) necessary to reach this dose in children of 10kg was calculated. RESULTS A total of 7 HTD groups were identified: analgesics; psychotropics and other medication used in neurological disorders; catarrh decongestants - cough -antihistamine - asthma drugs; cardiovascular drugs; antibiotics, topical preparations, and other drugs. In 29 active ingredients, the ingestion of a single pill could cause death in 10kg infant, in another 13, the ingestion of 2 pills could cause death, as well as the ingestion of 3 pills in 10 cases. CONCLUSION There are numerous HTDs marketed in Spain, some of which are available in potentially fatal presentations with few pills.
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Affiliation(s)
- Lidia Martínez-Sánchez
- Servicio de Urgencias, Hospital Sant Joan de Déu, Barcelona, España; Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España
| | - Raquel Aguilar-Salmerón
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Hospital Universitari de Girona Doctor Josep Trueta, Girona, España.
| | - Núria Pi-Sala
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Clínica Girona, Girona, España
| | - Maria Àngels Gispert-Ametller
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Urgencias, Hospital Universitari de Girona Doctor Josep Trueta, Girona, España
| | - Milagros García-Peláez
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Hospital ASEPEYO Sant Cugat, Sant Cugat del Vallès, España
| | - Antoni Broto-Sumalla
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Consorci Sanitari de Terrassa, Barcelona, España
| | - Edurne Fernández de Gamarra-Martínez
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Santiago Nogué-Xarau
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Unidad de Toxicología Clínica, Servicio de Urgencias, Hospital Clínic, Barcelona, España
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20
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Vajda J, McAdams RJ, Roberts KJ, Zhu M, McKenzie LB. Cosmetic-Related Injuries Treated in US Emergency Departments: 2002 to 2016. Clin Pediatr (Phila) 2019; 58:1493-1501. [PMID: 31203655 DOI: 10.1177/0009922819850492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A retrospective analysis was conducted by using data from the National Electronic Injury Surveillance System for children <5 years who were treated in US emergency departments (EDs) from 2002-2016) for a cosmetic-related injury. An estimated 64 686 (95% confidence interval = 53 037-76 335) children were treated in EDs for cosmetic-related injuries during the 15-year study period. There was no significant change in the rate (slope = 1.1 per 10 000 children per year, P = .95) of injuries over the study period. Injuries were most commonly associated with nail care (28.3%), hair care (27.0%), skin care (25.0%), and fragrance (12.7%) products. Children aged <2 years were most frequently injured (59.3%), and poisoning was the most common diagnosis (86.2%). To our knowledge, this is the first study to use a nationally representative sample to describe the epidemiology of cosmetic-related injuries among children aged <5 years. Unintentional exposure to cosmetics is an important source of injury for young children.
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Affiliation(s)
- Jordan Vajda
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Rebecca J McAdams
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Kristin J Roberts
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Motao Zhu
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,The Ohio State University College of Medicine, Columbus, OH, USA
| | - Lara B McKenzie
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,The Ohio State University College of Medicine, Columbus, OH, USA
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21
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Scotton WJ, Hill LJ, Williams AC, Barnes NM. Serotonin Syndrome: Pathophysiology, Clinical Features, Management, and Potential Future Directions. Int J Tryptophan Res 2019; 12:1178646919873925. [PMID: 31523132 PMCID: PMC6734608 DOI: 10.1177/1178646919873925] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/13/2019] [Indexed: 12/18/2022] Open
Abstract
Serotonin syndrome (SS) (also referred to as serotonin toxicity) is a potentially life-threatening drug-induced toxidrome associated with increased serotonergic activity in both the peripheral (PNS) and central nervous systems (CNS). It is characterised by a dose-relevant spectrum of clinical findings related to the level of free serotonin (5-hydroxytryptamine [5-HT]), or 5-HT receptor activation (predominantly the 5-HT1A and 5-HT2A subtypes), which include neuromuscular abnormalities, autonomic hyperactivity, and mental state changes. Severe SS is only usually precipitated by the simultaneous initiation of 2 or more serotonergic drugs, but the syndrome can also occur after the initiation of a single serotonergic drug in a susceptible individual, the addition of a second or third agent to long-standing doses of a maintenance serotonergic drug, or after an overdose. The combination of a monoamine oxidase inhibitor (MAOI), in particular MAO-A inhibitors that preferentially inhibit the metabolism of 5-HT, with serotonergic drugs is especially dangerous, and may lead to the most severe form of the syndrome, and occasionally death. This review describes our current understanding of the pathophysiology, clinical presentation and management of SS, and summarises some of the drugs and interactions that may precipitate the condition. We also discuss the newer novel psychoactive substances (NPSs), a growing public health concern due to their increased availability and use, and their potential risk to evoke the syndrome. Finally, we discuss whether the inhibition of tryptophan hydroxylase (TPH), in particular the neuronal isoform (TPH2), may provide an opportunity to pharmacologically target central 5-HT synthesis, and so develop new treatments for severe, life-threatening SS.
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Affiliation(s)
- William J Scotton
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Lisa J Hill
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Adrian C Williams
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Nicholas M Barnes
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
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22
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Ekşi MŞ, Turgut VU, Özcan-Ekşi EE, Güngör A, Tükel Turgut FN, Pamir MN. Serotonin Syndrome Following Tramadol and Gabapentin Use After Spine Surgery. World Neurosurg 2019; 126:261-263. [DOI: 10.1016/j.wneu.2019.03.092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 10/27/2022]
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23
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The Serotonin Syndrome: From Molecular Mechanisms to Clinical Practice. Int J Mol Sci 2019; 20:ijms20092288. [PMID: 31075831 PMCID: PMC6539562 DOI: 10.3390/ijms20092288] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/04/2019] [Accepted: 05/07/2019] [Indexed: 12/12/2022] Open
Abstract
The serotonin syndrome is a medication-induced condition resulting from serotonergic hyperactivity, usually involving antidepressant medications. As the number of patients experiencing medically-treated major depressive disorder increases, so does the population at risk for experiencing serotonin syndrome. Excessive synaptic stimulation of 5-HT2A receptors results in autonomic and neuromuscular aberrations with potentially life-threatening consequences. In this review, we will outline the molecular basis of the disease and describe how pharmacologic agents that are in common clinical use can interfere with normal serotonergic pathways to result in a potentially fatal outcome. Given that serotonin syndrome can imitate other clinical conditions, an understanding of the molecular context of this condition is essential for its detection and in order to prevent rapid clinical deterioration.
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24
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Leonard JB, Klein-Schwartz W. The others: characterizing "other" therapeutic errors reported to a poison center. Clin Toxicol (Phila) 2019; 57:652-656. [PMID: 30600728 DOI: 10.1080/15563650.2018.1538520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Therapeutic errors are costly and result in unplanned hospital visits. Recent poison center studies on therapeutic errors have focused on coded data from either the National Poison Data System (NPDS) or individual poison centers. Approximately 21% of therapeutic errors reported to NPDS are coded as "other incorrect dose" (OI) or "other/unknown therapeutic error" (OU). The purpose of this study was to characterize errors coded as OI or OU reported to a single poison center. Methods: Retrospective, single poison center chart review was conducted of therapeutic error exposures with at least one scenario coded as OI or OU seen in or referred to hospitals from 1/1/2000 to 9/30/2017. Cases were reviewed and re-coded to predefined or newly created scenarios. Results: A total of 3413 cases were identified. There were 726 cases assessed as not therapeutic errors and re-coded as either intentional misuse (430), adverse reaction drug (204), or other non-therapeutic errors (82). Of the remaining cases, 1726 cases were re-coded to one of the 16 existing therapeutic error scenarios. After re-coding, there remained 971 coded as OI or OU. Most were due to double, triple, quadruple, or higher than recommended dose (477/971); an additional common error was mistaken strength (81/971). The remaining scenarios occurred in fewer than 50 cases each with greater than 40 different scenarios such that additional coded scenarios would not be feasible. Conclusions: Most cases coded as OI or OU could be recoded as one of the NPDS predefined therapeutic error scenarios or non-error reasons for exposure. Considering the large proportion of double dose cases and the unique errors associated with mistaken strengths of tablets, these scenarios could be appropriate to add as new predefined coding scenarios, which would aid in future research and patient counseling.
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Affiliation(s)
- James B Leonard
- a Department of Pharmacy Practice and Science, Maryland Poison Center , University of Maryland School of Pharmacy , Baltimore , MD , USA
| | - Wendy Klein-Schwartz
- a Department of Pharmacy Practice and Science, Maryland Poison Center , University of Maryland School of Pharmacy , Baltimore , MD , USA
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Abstract
Ingestion of wild and potentially toxic mushrooms is common in the United States and many other parts of the world. US poison centers have been logging cases of mushroom exposure in The National Poison Data System (NPDS) annual publications for over 30 years. This study compiles and analyzes US mushroom exposures as reported by the NPDS from 1999 to 2016. Over the last 18 years, 133 700 cases (7428/year) of mushroom exposure, mostly by ingestion, have been reported. Cases are most frequently unintentional (83%, P < 0.001); cause no or only minor harm (86%, P < 0.001); and in children <6 years old (62%, P < 0.001). Approximately 704 (39/year) exposures have resulted in major harm. Fifty-two (2.9/year) fatalities have been reported, mostly from cyclopeptide (68-89%)-producing mushrooms ingested by older adults unintentionally. The vast majority of reported ingestions resulted in no or minor harm, although some groups of mushroom toxins or irritants, such as cyclopepides, ibotenic acid, and monomethylhydrazine, have been deadly. Misidentification of edible mushroom species appears to be the most common cause and may be preventable through education.
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Affiliation(s)
- William E Brandenburg
- a Family Medicine Residency of Idaho , RTT Caldwell, 777 N. Raymond Street, Boise , Idaho 83704-9251.,b West Valley Medical Center , 1717 Arlington Avenue, Caldwell , Idaho 83605
| | - Karlee J Ward
- c Pediatric Intensive Care Unit, Saint Luke's Hospital , 190 E Bannock Street, Boise , Idaho 83712
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26
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Detection of α-, β-, and γ-amanitin in urine by LC-MS/MS using 15N 10-α-amanitin as the internal standard. Toxicon 2018; 152:71-77. [PMID: 30071219 DOI: 10.1016/j.toxicon.2018.07.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/16/2018] [Accepted: 07/24/2018] [Indexed: 01/21/2023]
Abstract
The majority of fatalities from poisonous mushroom ingestion are caused by amatoxins. To prevent liver failure or death, it is critical to accurately and rapidly diagnose amatoxin exposure. We have developed a liquid chromatography tandem mass spectrometry method to detect α-, β-, and γ-amanitin in urine to meet this need. Two internal standard candidates were evaluated, including an isotopically labeled 15N10-α-amanitin and a modified amanitin methionine sulfoxide synthetic peptide. Using the 15N10-α-amanitin internal standard, precision and accuracy of α-amanitin in pooled urine was ≤5.49% and between 100 and 106%, respectively, with a reportable range from 1-200 ng/mL. β- and γ-Amanitin were most accurately quantitated in pooled urine using external calibration, resulting in precision ≤17.2% and accuracy between 99 and 105% with calibration ranges from 2.5-200 ng/mL and 1.0-200 ng/mL, respectively. The presented urinary diagnostic test is the first method to use an isotopically labeled α-amanitin with the ability to detect and confirm human exposures to α-, β-, and γ-amanitin.
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Schulte J, Kleinschmidt KC, Domanski K, Smith EA, Haynes A, Roth B. Differences Between Snakebites with Concomitant Use of Alcohol or Drugs and Single Snakebites. South Med J 2018; 111:113-117. [PMID: 29394429 DOI: 10.14423/smj.0000000000000760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Published reports have suggested that the concurrent use of alcohol or drugs occurs among some snakebite victims, but no national assessment of such data exists. METHODS We used data from US poison control centers collected during telephone calls in calendar years 2000-2013 to compare snake envenomations with concomitant use of drugs, alcohol, or both to snakebites lacking such use. RESULTS A total of 608 snakebites with 659 instances of concomitant alcohol/drug use were reported, which represent approximately 1% of 92,751 snakebites reported to US poison control centers. An annual mean of 48 snakebites with concomitant use of alcohol/drugs was reported, compared with a mean of 6625 snakebites per year with no concomitant use of alcohol/drugs. Most cases involved men, peaked during the summer months, and involved copperheads or rattlesnakes, which mirrored overall trends. Snakebite victims who also used alcohol/drugs were more likely than victims with only a snakebite reported to be bitten by rattlesnakes, to be admitted to the hospital, and die. Alcohol was the most common reported concomitant substance, but other substances were reported. CONCLUSIONS Snakebites with concomitant use of alcohol/drugs are uncommon, accounting for approximately 1% of the snakebite envenomations reported annually to US poison control centers; however, snakebite victims also reporting alcohol/drug use are more likely to be bitten by rattlesnakes, be admitted to a healthcare facility, and die.
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Affiliation(s)
- Joann Schulte
- From the North Texas Poison Control Center, Parkland Health and Hospital System, Dallas, and the Division of Medical Toxicology, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Kurt C Kleinschmidt
- From the North Texas Poison Control Center, Parkland Health and Hospital System, Dallas, and the Division of Medical Toxicology, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Kristina Domanski
- From the North Texas Poison Control Center, Parkland Health and Hospital System, Dallas, and the Division of Medical Toxicology, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Eric Anthony Smith
- From the North Texas Poison Control Center, Parkland Health and Hospital System, Dallas, and the Division of Medical Toxicology, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Ashley Haynes
- From the North Texas Poison Control Center, Parkland Health and Hospital System, Dallas, and the Division of Medical Toxicology, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Brett Roth
- From the North Texas Poison Control Center, Parkland Health and Hospital System, Dallas, and the Division of Medical Toxicology, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
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Ramachandran V, Ding B, George R, Novakovic M. Conservative management of severe serotonin syndrome with coma, myoclonus, and crossed-extensor reflex complicated by hepatic encephalopathy. Proc (Bayl Univ Med Cent) 2018; 31:112-114. [DOI: 10.1080/08998280.2017.1400874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Vignesh Ramachandran
- Office of Student Affairs, School of Medicine, Baylor College of Medicine, Houston, Texas
| | - Belicia Ding
- Office of Student Affairs, School of Medicine, Baylor College of Medicine, Houston, Texas
| | - Rollin George
- Department of Medicine, Baylor College of Medicine, Houston, Texas
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Reimer D, Smith M, Ali S. Deliberate self-poisoning with long-acting anticoagulant rodenticides. BMJ Case Rep 2017; 2017:bcr-2017-222170. [PMID: 29269364 DOI: 10.1136/bcr-2017-222170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Long-acting anticoagulant rodenticides, also called superwarfarins, are known for their greater potency, longer half-life and delayed onset of symptoms. Cases of superwarfarin poisoning can pose a diagnostic and clinical challenge due to a wide array of presentations and prolonged severe coagulopathy requiring months of high-dose oral vitamin K therapy. The most common presentation of long-acting anticoagulant rodenticide poisoning is mucocutaneous bleeding, with other common presentations including haematuria, gingival bleeding, epistaxis and gastrointestinal bleeding. We discuss a case of deliberate self-poisoning with long-acting anticoagulant rodenticides presenting with haematuria and coagulation values above measurable limits. This case is important as it required immediate and maintenance therapy in order to prevent profound bleeding, as well as the evaluation of the patient's psychosocial factors to ensure medical compliance and to prevent refractory complications or repeated self-harm.
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Affiliation(s)
- Danielle Reimer
- College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Melissa Smith
- College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Sayed Ali
- Department of Medicine, Orlando Veterans Affairs Medical Center, Orlando, Florida, USA
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Chan YC, Fung HT, Lee CK, Tsui SH, Ngan HK, Sy MY, Tse ML, Kam CW, Wong GCK, Tong HK, Lit ACH, Wong TW, Lau FL. A Prospective Epidemiological Study of Acute Poisoning in Hong Kong. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790501200305] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To update our epidemiological knowledge of acute poisoning in Hong Kong. Methods A multi-centred prospective study was conducted for six months in six major accident and emergency departments in Hong Kong. A specially designed form was used to collect demographic data, type of poison involved, cause of poisoning, management, disposal as well as final outcome of the poisoned patients. Results A total of 1,467 patients (male: 588, female: 879) were included in the study. Most of them were young adults (32% were between 20 and 40 years old). Suicidal attempt (64%) was the most common cause of poisoning. Notably, 379 (26%) patients took more than one poison. Among the 2,007 counts of poison taken, sleeping pills (24%) and analgesics (18%) were the most commonly used drugs and paracetamol was the commonest single ingredient involved in poisoning. Most patients were treated with supportive measures, and about 40% and 15% of the patients were given gastrointestinal decontamination and specific antidotes respectively in their management, in which activated charcoal and N-acetylcysteine were the most common. Concerning disposal from the emergency department, 91% of the poisoned cases required in-patient management. Most patients had an uneventful recovery but 5 (0.3%) had significant disability and 21 (1.4%) died. Suicidal carbon monoxide poisoning was the leading cause of mortality in our study. Conclusions Most acute poisonings in Hong Kong were suicidal in nature and paracetamol was the commonest agent. Activated charcoal was the most commonly used decontamination method and most patients had an uneventful recovery.
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Affiliation(s)
| | - HT Fung
- Tuen Mun Hospital, Accident & Emergency Department, Tsing Chung Koon Road, Tuen Mun, N.T., Hong Kong
| | - CK Lee
- Queen Elizabeth Hospital, Accident & Emergency Department, 30 Gascoigne Road, Kowloon, Hong Kong
| | - SH Tsui
- Queen Mary Hospital, Accident & Emergency Department, Pokfulam Road, Hong Kong
| | - HK Ngan
- Yan Chai Hospital, Accident & Emergency Department, Tsuen Wan, N.T., Hong Kong
| | - MY Sy
- Pamela Youde Nethersole Eastern Hospital, Accident & Emergency Department, 3 Lok Man Road, Chaiwan, Hong Kong
| | | | - CW Kam
- Tuen Mun Hospital, Accident & Emergency Department, Tsing Chung Koon Road, Tuen Mun, N.T., Hong Kong
| | - GCK Wong
- North District Hospital, Accident & Emergency Department, 9 Po Kin Road, Sheung Shui, N.T., Hong Kong
| | - HK Tong
- Queen Mary Hospital, Accident & Emergency Department, Pokfulam Road, Hong Kong
| | - ACH Lit
- Yan Chai Hospital, Accident & Emergency Department, Tsuen Wan, N.T., Hong Kong
| | - TW Wong
- Pamela Youde Nethersole Eastern Hospital, Accident & Emergency Department, 3 Lok Man Road, Chaiwan, Hong Kong
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Anderson BD, Seung H, Klein-Schwartz W. Trends in types of calls managed by U.S. poison centers 2000-2015. Clin Toxicol (Phila) 2017; 56:640-645. [PMID: 29205070 DOI: 10.1080/15563650.2017.1410170] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
AIM The number of cases reported to poison centers has decreased since 2008 but there is evidence that the complexity of calls is increasing. OBJECTIVES The objectives are to evaluate national poison center data for trends in reason and how these changes effect management site, medical outcomes, and poison center workload. METHODS Data regarding reason, age, management site, and medical outcome were extracted from annual reports of the National Poison Data System from 2000 to 2015. The proportion of cases by year were determined for unintentional and intentional exposures. Analysis of data from a single poison center from 2005 to 2015 compared the number of interactions between poison center staff and callers for unintentional versus intentional reasons. RESULTS Trend analyses found that from 2000 to 2015 the percent of unintentional cases decreased (from 85.9 to 78.4%, p < .0001) and the percent of intentional cases increased (from 11.3 to 17.6%, p < .0001). Age distribution changed with a decrease in children <13 years of age and increase in adolescents and adults. In these latter two age groups, the proportion due to intentional exposure increased while unintentional declined. The distribution of management sites changed over the 16-year period, with a decrease in non-HCF cases and significant increase in percent of cases treated in a HCF. The frequencies of moderate effect, major effect, and death were significantly higher for intentional exposures than for unintentional exposures. Analysis of data entry notes from a single center showed that the mean number of notes per unintentional case (1.61 ± 0.08) was significantly different from the mean number of notes per intentional case (9.23 ± 0.68) (p < .0001). DISCUSSION Poison centers are managing more intentional exposures and fewer unintentional exposures. Intentional exposures require more poison center staff expertise and time. CONCLUSION Looking only at poison center total call volume may not be an adequate method to gauge productivity.
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Affiliation(s)
- Bruce D Anderson
- a Department of Pharmacy Practice and Science , University of Maryland School of Pharmacy , Baltimore , MA , USA
| | - Hyunuk Seung
- a Department of Pharmacy Practice and Science , University of Maryland School of Pharmacy , Baltimore , MA , USA
| | - Wendy Klein-Schwartz
- a Department of Pharmacy Practice and Science , University of Maryland School of Pharmacy , Baltimore , MA , USA
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Affiliation(s)
- Dimitri A Cozanitis
- Department of Anaesthesiology & Intensive Care Medicine, Institute of Clinical Medicine, Helsinki University, Finland.
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Uddin MF, Alweis R, Shah SR, Lateef N, Shahnawaz W, Ochani RK, Dharani AM, Shah SA. Controversies in Serotonin Syndrome Diagnosis and Management: A Review. J Clin Diagn Res 2017; 11:OE05-OE07. [PMID: 29207768 DOI: 10.7860/jcdr/2017/29473.10696] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 08/23/2017] [Indexed: 11/24/2022]
Abstract
Over the past few years, Serotonin Syndrome (SS) has become a significant clinical concern. Over the last decade, United States saw a surge in antidepressant use. SS characteristically presents as the triad of altered mental status, autonomic dysfunction and neuromuscular excitation. Symptoms vary from patient to patient with mild cases presenting with subacute symptoms and severe cases progressing rapidly to death. Due to the protean manifestations of the syndrome along with non-specific prodromal, SS can easily be misdiagnosed if not carefully assessed. In severe cases, SS can be mistaken as neuroleptic malignant syndrome while mild cases are mostly misattributed to other causes such as flu. SS is a clinical diagnosis and therefore, requires a thorough review of medications and physical examination. Given the protean nature of this toxicologic syndrome various criteria were defined which includes Sternbach's, Radomski and Hunter's criteria. Keeping in mind the wide symptoms of serotonin syndrome from being barely perceptible to lethal emphasis there is a need to treat the syndrome on urgent basis. Mainstay for treatment of serotonin syndrome is to discontinue the offending drug. Improvement is seen in most patients within 24 hours.
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Affiliation(s)
- Mohd Faisal Uddin
- Internal Medicine Resident, Deccan College of Medical Sciences, Hyderabad, India
| | - Richard Alweis
- Associate Professor, Department of Medicine, Rochester Regional Health System, Rochester, NewYork, USA
| | - Syed Raza Shah
- Internal Medicine Resident, Department of North Florida Regional Medical Center, University of Central Florida (Gainesville), Gainesville, USA
| | - Noman Lateef
- Internal Medicine Resident, Dow University of Health Sciences (DUHS), Karachi, Pakistan
| | - Waqas Shahnawaz
- Postgraduate Student, Agha Khan University Hospital, Karachi, Pakistan
| | - Rohan Kumar Ochani
- Postgraduate Student, Dow University of Health Sciences (DUHS), Karachi, Pakistan
| | - Amin Muhammad Dharani
- Internal Medicine Resident, Dow University of Health Sciences (DUHS), Karachi, Pakistan
| | - Syed Arbab Shah
- Internal Medicine Resident, Ziauddin Medical University Hospital, Karachi, Pakistan
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Kao R, Landry Y, Chick G, Leung A. Bilateral blindness secondary to optic nerve ischemia from severe amlodipine overdose: a case report. J Med Case Rep 2017; 11:211. [PMID: 28768527 PMCID: PMC5541695 DOI: 10.1186/s13256-017-1374-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 07/02/2017] [Indexed: 12/02/2022] Open
Abstract
Background Calcium channel blockers are commonly prescribed medications; calcium channel blocker overdose is becoming increasingly prevalent. The typical presentation of a calcium channel blocker overdose is hypotension and decreased level of consciousness. We describe a case of a calcium channel blocker overdose that led to bilateral cortical blindness, a presentation that has not previously been reported. Case presentation A 49-year-old white woman with known bilateral early optic atrophy presented to our hospital with hypotension and obtundation following a known ingestion of 150 mg of amlodipine. She was transferred to our intensive care unit where she was intubated, mechanically ventilated, and required maximal vasopressor support (norepinephrine 40 mcg/minute, epinephrine 40 mcg/minute, and vasopressin 2.4 units/hour) along with intravenously administered crystalloid boluses. Despite these measures, she continued to deteriorate with persistent hypotension and tachycardia, as well as anuria. Intralipid emulsion therapy was subsequently administered to which no initial response was observed. A chest X-ray revealed diffuse pulmonary edema; intravenous diuresis as well as continuous renal replacement therapy was initiated. Following the initiation of continuous renal replacement therapy, her oxygen requirements as well as urine output began to improve, and 3 days later she was liberated from mechanical ventilation. Following extubation, she complained of new onset visual impairment, specifically seeing only red-green colors, but no objects. An ophthalmologic examination revealed that this was due to bilateral optic atrophy from prolonged hypotension during the first 24 hours after the overdose. Conclusion Persistent hypotension in the setting of a calcium channel blocker overdose can lead to worsening optic atrophy resulting in bilateral cortical blindness.
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Affiliation(s)
- Raymond Kao
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada. .,Division of Critical Care, Department of Medicine, London Health Sciences Centre, Western University, London, ON, Canada.
| | - Yves Landry
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Division of Critical Care, Department of Medicine, London Health Sciences Centre, Western University, London, ON, Canada
| | - Genevieve Chick
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Division of Critical Care, Department of Medicine, London Health Sciences Centre, Western University, London, ON, Canada
| | - Andrew Leung
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Department of Radiology, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
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Perwitasari DA, Prasasti D, Supadmi W, Jaikishin SAD, Wiraagni IA. Impact of organophosphate exposure on farmers' health in Kulon Progo, Yogyakarta: Perspectives of physical, emotional and social health. SAGE Open Med 2017; 5:2050312117719092. [PMID: 28839934 PMCID: PMC5548316 DOI: 10.1177/2050312117719092] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/07/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The exposure of organophosphate could be caused by the absorption in some parts of the body like skin and breath. Toxicity may cause nausea, vomiting and dizziness which are not too specific related with the pesticide toxicity. The purpose of this study is to understand the association between organophosphate exposure and farmers' health in Kulon Progo County from the perspectives of physical, emotional and social health. METHODS This study was conducted using descriptive observational design. The blood sample was collected during harvesting periods in 2016. The inclusion criterion of farmers was using organophosphate-contained pesticide during the planting period of red onion. The farmers who had renal disease, liver disease and cancer were excluded. The organophosphate exposure parameters were the duration and frequency of pesticide application, width of the area, serum cholinesterase activity and the completeness of personal protective equipment. RESULTS Among 84 farmers, most of them were male (85.7%), and the mean age was 49.1 (standard deviation: 12.5) years; 71.4% of the subjects experienced tremor, 17.86% experienced dizziness and 8.33% subjects experienced nausea-vomiting after pesticide application. According to the pesticide application, in average, subjects used pesticide 1.4 h/day with the area of 1.285 m2. The frequency of pesticide used is three times per week. Around 97.6% subjects used incomplete personal protective equipment. The average of serum cholinesterase activity in subjects with tremor is higher than subjects without tremor (p > 0.05). There is a significant association between serum cholinesterase activity and creatinine content (p < 0.05). The farmers' quality-of-life domain scores are lower than the scores of the normal population in Yogyakarta. CONCLUSION Organophosphate exposure may affect the farmers' physical health and quality of life.
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Affiliation(s)
| | - Dian Prasasti
- Faculty of Pharmacy, Universitas Ahmad Dahlan, Yogyakarta, Indonesia
| | - Woro Supadmi
- Faculty of Pharmacy, Universitas Ahmad Dahlan, Yogyakarta, Indonesia
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Warner ME, Naranjo J, Pollard EM, Weingarten TN, Warner MA, Sprung J. Serotonergic medications, herbal supplements, and perioperative serotonin syndrome. Can J Anaesth 2017; 64:940-946. [PMID: 28667541 DOI: 10.1007/s12630-017-0918-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/10/2017] [Accepted: 06/16/2017] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Perioperative use of serotonergic agents increases the risk of serotonin syndrome. We describe the occurrence of serotonin syndrome after fentanyl use in two patients taking multiple serotonergic agents. CLINICAL FEATURES Two patients who had been taking multiple serotonergic medications or herbal supplements (one patient taking fluoxetine, turmeric supplement, and acyclovir; the other taking fluoxetine and trazodone) developed serotonin syndrome perioperatively when undergoing outpatient procedures. Both experienced acute loss of consciousness and generalized myoclonus after receiving fentanyl. In one patient, the serotonin syndrome promptly resolved after naloxone administration. In the other patient, the onset of serotonin syndrome was delayed and manifested after discharge, most likely attributed to the intraoperative use of midazolam for sedation. CONCLUSION Even small doses of fentanyl administered to patients taking multiple serotonergic medications and herbal supplements may trigger serotonin syndrome. Prompt reversal of serotonin toxicity in one patient by naloxone illustrates the likely opioid-mediated pathogenesis of serotonin syndrome in this case. It also highlights that taking serotonergic agents concomitantly can produce the compounding effect that causes serotonin syndrome. The delayed presentation of serotonin syndrome in the patient who received a large dose of midazolam suggests that outpatients taking multiple serotonergic drugs who receive benzodiazepines may require longer postprocedural monitoring.
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Affiliation(s)
- Mary E Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Julian Naranjo
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Emily M Pollard
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mark A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Kamboj AK, Spiller HA, Casavant MJ, Hodges NL, Chounthirath T, Smith GA. Non–Health Care Facility Cardiovascular Medication Errors in the United States. Ann Pharmacother 2017; 51:825-833. [DOI: 10.1177/1060028017714271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Prior studies have not examined national trends and characteristics of unintentional non–health care facility (HCF) medication errors associated with cardiovascular drugs. Objective: To investigate non-HCF medication errors associated with cardiovascular drugs reported to poison control centers in the United States. Methods: A retrospective analysis of non-HCF medication errors associated with cardiovascular drugs from 2000 to 2012 was conducted using the National Poison Data System database. Results: There were 278 444 medication errors associated with cardiovascular drugs reported to US poison control centers during the study period, averaging 21 419 exposures annually. The overall rate of cardiovascular medication errors per 100 000 population increased 104.6% from 2000 to 2012 ( P < 0.001) and the highest rates were among older adults. Most cases (83.6%) did not require treatment at a HCF. Serious medical outcomes were reported in 4.0% of exposures. The cardiovascular drugs most commonly implicated in medication errors were β-blockers (28.2%), calcium antagonists (17.7%), and angiotensin-converting enzyme inhibitors (15.9%). Most of the 114 deaths were associated with cardiac glycosides (47.4%) or calcium antagonists (29.8%). Most medication errors involved taking or being given a medication twice (52.6%). Conclusions: This study describes characteristics and trends of non-HCF cardiovascular medication errors over a 13-year period in the United States. The number and rate of cardiovascular medication errors increased steadily from 2000 to 2012, with the highest error rates among older adults. Further research is needed to identify prevention strategies for these errors, with a particular focus on the older adult population.
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Affiliation(s)
- Amrit K. Kamboj
- Center for Injury Research and Policy of the Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
- Mayo Clinic, Rochester, MN, USA
| | - Henry A. Spiller
- The Ohio State University College of Medicine, Columbus, OH, USA
- Central Ohio Poison Center, Columbus, OH
| | - Marcel J. Casavant
- Center for Injury Research and Policy of the Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
- Central Ohio Poison Center, Columbus, OH
| | - Nichole L. Hodges
- Center for Injury Research and Policy of the Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Thiphalak Chounthirath
- Center for Injury Research and Policy of the Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Gary A. Smith
- Center for Injury Research and Policy of the Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
- Child Injury Prevention Alliance, Columbus, OH, USA
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Armenian P, Fleurat M, Mittendorf G, Olson KR. Unintentional Pediatric Cocaine Exposures Result in Worse Outcomes than Other Unintentional Pediatric Poisonings. J Emerg Med 2017; 52:825-832. [DOI: 10.1016/j.jemermed.2017.03.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 02/20/2017] [Accepted: 03/08/2017] [Indexed: 01/21/2023]
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Abstract
Poisoning through pediatric skin leading to acute systemic symptoms is a relatively uncommonly reported phenomenon. Systemic toxicity through the skin typically occurs by direct contact between therapeutic or non-therapeutic topical agents and the skin. Though uncommon, poisoning through pediatric skin can have significant consequences and must be recognized so the offending agent may be discontinued and appropriate treatment initiated. We performed a literature search for all article types between 1950 and April 2016 to provide a single source of detectable cases of acute toxicity in pediatric patients due to percutaneous exposure. This literature review discusses relevant pediatric skin physiology along with reports of poisoning events that resulted in systemic signs and symptoms and even death to provide a comprehensive report on causes of pediatric poisoning through the skin.
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Wojciechowski VV, Calina D, Tsarouhas K, Pivnik AV, Sergievich AA, Kodintsev VV, Filatova EA, Ozcagli E, Docea AO, Arsene AL, Gofita E, Tsitsimpikou C, Tsatsakis AM, Golokhvast KS. A guide to acquired vitamin K coagulophathy diagnosis and treatment: the Russian perspective. ACTA ACUST UNITED AC 2017; 25:10. [PMID: 28416008 PMCID: PMC5393004 DOI: 10.1186/s40199-017-0175-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/06/2017] [Indexed: 01/05/2023]
Abstract
Abstract Physicians often come across with cases of vitamin K antagonists–dependent coagulopathy for reasons such as accidental use of the vitamin K antagonists (VKA), excessive administration of prescribed anticoagulants of indirect action or not reported administration of vitamin K antagonists due to memory impairment and/or other mental disorders, even deliberate use thereof (attempt to murder or suicide). Rodenticide-poisoning (coumarins, warfarins) via food or occupational accidents are difficult to diagnose. This article discusses different types of acquired vitamin K-dependent coagulopathy. Differential diagnosis is primarily based on patient statements before additional causes of vitamin K deficiency are explored. Even when pathological vitamin K deficiency is not determined, appropriate and urgent medical treatment is necessary: administration of fresh frozen plasma or concentrated factors of the prothrombin complex, administration of vitamin K remedies along with symptomatic therapy. With early diagnosis and prescription of appropriate therapy, prognosis is favorable. Graphical abstract Reasons for vitamin K antagonists–dependent coagulopathy cases![]()
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Affiliation(s)
- Valery V Wojciechowski
- Department of Hospital Therapy and Pharmacology, Amur State Medical Academy, 675000, Blagoveshchensk, Russia
| | - Daniela Calina
- Department of Clinical Pharmacy, University of Medicine and Pharmacy of Craiova, Petru Rares, 200349, Craiova, Romania
| | | | - Alexander V Pivnik
- Department of Hematology-Oncology and Secondary Immunodeficient Diseases, D.D. Pletnev Moscow Clinical Research and Practical Centre of Health Department, 111123, Moscow, Russia
| | - Alexander A Sergievich
- School of Arts, Culture and Sports, Far Eastern Federal University, 690022, Vladivostok, Russia
| | - Vladimir V Kodintsev
- School of Biomedicine, Far Eastern Federal University, 690022, Vladivostok, Russia
| | - Ekaterina A Filatova
- Department of Hematology, Amur Regional Clinical Hospital, 675000, Blagoveshchensk, Russia
| | - Eren Ozcagli
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Istanbul University, Beyazit, Istanbul, 34116, Turkey
| | - Anca Oana Docea
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, Petru Rares, 200349, Craiova, Romania
| | - Andreea Letitia Arsene
- Department of Pharmaceutical Microbiology, Faculty of Pharmacy, "Carol Davila" University of Medicine and Pharmacy, 6, TraianVuia Street, sector 2, 020956, Bucharest, Romania
| | - Eliza Gofita
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, Petru Rares, 200349, Craiova, Romania
| | - Christina Tsitsimpikou
- Department of Hazardous Substances, General Chemical State Laboratory of Greece, Mixtures & Articles, 16 An. Tsocha Str, Athens, 115121, Greece
| | - Aristidis M Tsatsakis
- SEC Nanotechnology, Far Eastern Federal University, 690022, Vladivostok, Russia. .,Forensic Sciences and Toxicology Department, Medical School, University of Crete, P.O. Box 1393, 71003, Heraklion, Crete, Greece. .,Scientific Educational Center of Nanotechnology, Federal Scientific Center of Hygiene, Far Eastern Federal University, F.F. Erisman, Moscow, 690950, Russian Federation.
| | - Kirill S Golokhvast
- SEC Nanotechnology, Far Eastern Federal University, 690022, Vladivostok, Russia.
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41
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Tomasi S, Roberts KJ, Stull J, Spiller HA, McKenzie LB. Pediatric Exposures to Veterinary Pharmaceuticals. Pediatrics 2017; 139:peds.2016-1496. [PMID: 28167514 DOI: 10.1542/peds.2016-1496] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe the epidemiology of veterinary pharmaceutical-related exposures to children based on calls to a regional poison control center. METHODS A retrospective analysis of pediatric (≤19 years of age) exposures to pharmaceutical products intended for animal use, managed by a regional poison control center from 1999 through 2013, was conducted. Case narratives were reviewed and coded for exposure-related circumstances and intended species. Descriptive statistics were generated. RESULTS From 1999 through 2013, the Central Ohio Poison Center received 1431 calls that related to a veterinary pharmaceutical exposure for children ≤19 years of age. Most of the pediatric calls (87.6%) involved children ≤5 years of age. Exploratory behavior was the most common exposure-related circumstance (61.4%) and ingestion accounted for the exposure route in 93% of cases. Substances commonly associated with exposures included: veterinary drugs without human equivalent (17.3%), antimicrobial agents (14.8%), and antiparasitics (14.6%). Based on substance and quantity, the majority of exposures (96.9%) were not expected to result in long-term or lasting health effects and were managed at home (94.1%). A total of 80 cases (5.6%) were referred to a health care facility, and 2 cases resulted in a moderate health effect. CONCLUSIONS Children ≤5 years of age are most at risk for veterinary pharmaceutical-related exposures. Although most exposures do not result in a serious medical outcome, efforts to increase public awareness, appropriate product dispensing procedures, and attention to home storage practices may reduce the risk of veterinary pharmaceutical exposures to young children.
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Affiliation(s)
- Suzanne Tomasi
- Center for Injury Research and Policy, The Research Institute, and.,Department of Veterinary Preventive Medicine, College of Veterinary Medicine
| | | | - Jason Stull
- Department of Veterinary Preventive Medicine, College of Veterinary Medicine
| | - Henry A Spiller
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, Ohio; and
| | - Lara B McKenzie
- Center for Injury Research and Policy, The Research Institute, and.,Department of Pediatrics, College of Medicine, and.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
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42
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Chung JY, Kim BG, Lee BK, Moon JD, Sakong J, Jeon MJ, Park JD, Choi BS, Kim NS, Yu SD, Seo JW, Ye BJ, Lim HJ, Hong YS. Urinary arsenic species concentration in residents living near abandoned metal mines in South Korea. Ann Occup Environ Med 2016; 28:67. [PMID: 27895924 PMCID: PMC5120503 DOI: 10.1186/s40557-016-0150-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 11/07/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Arsenic is a carcinogenic heavy metal that has a species-dependent health effects and abandoned metal mines are a source of significant arsenic exposure. Therefore, the aims of this study were to analyze urinary arsenic species and their concentration in residents living near abandoned metal mines and to monitor the environmental health effects of abandoned metal mines in Korea. METHODS This study was performed in 2014 to assess urinary arsenic excretion patterns of residents living near abandoned metal mines in South Korea. Demographic data such as gender, age, mine working history, period of residency, dietary patterns, smoking and alcohol use, and type of potable water consumed were obtaining using a questionnaire. Informed consent was also obtained from all study subjects (n = 119). Urinary arsenic species were quantified using high performance liquid chromatography (HPLC) and inductively coupled plasma mass spectrometry (ICP/MS). RESULTS The geometric mean of urinary arsenic (sum of dimethylarsinic acid, monomethylarsonic acid, As3+, and As5+) concentration was determined to be 131.98 μg/L (geometric mean; 95% CI, 116.72-149.23) while urinary inorganic arsenic (As3+ and As5+) concentration was 0.81 μg/L (95% CI, 0.53-1.23). 66.3% (n = 79) and 21.8% (n = 26) of these samples exceeded ATSDR reference values for urinary arsenic (>100 μg/L) and inorganic arsenic (>10 μg/L), respectively. Mean urinary arsenic concentrations (geometric mean, GM) were higher in women then in men, and increased with age. Of the five regions evaluated, while four regions had inorganic arsenic concentrations less than 0.40 μg/L, one region showed a significantly higher concentration (GM 15.48 μg/L; 95% CI, 7.51-31.91) which investigates further studies to identify etiological factors. CONCLUSION We propose that the observed elevation in urinary arsenic concentration in residents living near abandoned metal mines may be due to environmental contamination from the abandoned metal mine. TRIAL REGISTRATION Not Applicable (We do not have health care intervention on human participants).
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Affiliation(s)
- Jin-Yong Chung
- Heavy Metal Exposure Environmental Health Center, Dong-A University, Busan, Korea
| | - Byoung-Gwon Kim
- Heavy Metal Exposure Environmental Health Center, Dong-A University, Busan, Korea ; Department of Preventive Medicine, College of Medicine, Dong-A University, 26, Daesingongwon-ro, Seo-gu, Busan, Korea
| | | | - Jai-Dong Moon
- Department of Preventive and Occupational Medicine, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Joon Sakong
- Department of Preventive Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | - Man Joong Jeon
- Department of Preventive Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jung-Duck Park
- Department of Preventive Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Byung-Sun Choi
- Department of Preventive Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Nam-Soo Kim
- Institute of Environmental and Occupational Medicine, College of Medicine, Soonchunhyang University, Asan, Chungnam Korea
| | - Seung-Do Yu
- National Institute of Environmental Research, Incheon, Korea
| | - Jung-Wook Seo
- Heavy Metal Exposure Environmental Health Center, Dong-A University, Busan, Korea
| | - Byeong-Jin Ye
- Heavy Metal Exposure Environmental Health Center, Dong-A University, Busan, Korea ; Department of Occupational and Environmental Medicine, Dong-A University Hospital, Busan, Korea
| | - Hyoun-Ju Lim
- Heavy Metal Exposure Environmental Health Center, Dong-A University, Busan, Korea
| | - Young-Seoub Hong
- Heavy Metal Exposure Environmental Health Center, Dong-A University, Busan, Korea ; Department of Preventive Medicine, College of Medicine, Dong-A University, 26, Daesingongwon-ro, Seo-gu, Busan, Korea
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43
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Pajoumand A, Shadnia S, Efricheh H, Mandegary A, Hassanian-Moghadam H, Abdollahi M. A retrospective study of mushroom poisoning in Iran. Hum Exp Toxicol 2016; 24:609-13. [PMID: 16408613 DOI: 10.1191/0960327105ht572oa] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The objective of this study was to describe the pattern of mushroom poisoning in adults admitted to the Loghman Hakim Hospital Poison Center from 1992 to 2002. All patients ≥ 12 years of age were included in the study. The frequency of mushroom poisoning with respect to age, sex, season, reason, place of residence, latent phase, clinical and laboratory findings, treatment, and outcome of patients was investigated. Of the 72 421 poisoning cases admitted to Loghman-Hakim Hospital Poison Center from 1992 to 2002, only 37 were poisoned by consumption of toxic mushrooms. As some of the patients' files were incomplete, only 25 files were included in the study. Of this number, 68% were male. The patients' age ranged between 12 and 65 years, with a mean of 31 years of age. All cases were accidental and mostly from Tehran (36%) and the northern provinces (rainy woodlands) of Iran (32%). Autumn was the most common season for poisoning with a frequency of 80%. The latent phase of poisonings was between 0.5 and 12 hours. The most frequently reported symptoms were vomiting (84%), nausea (60%), abdominal pain (60%) and diarrhea (40%). Jaundice was observed in 44% of cases, with a 50% rate of hepatic encephalopathy. A total of 66% of patients were discharged and the duration range of hospitalization was 1-12 days. In conclusion, people should be more informed of the dangers posed by wild mushrooms. Training of physicians and nurses in the accurate diagnosis and management of patients poisoned with poisonous mushrooms would improve the rate of survival.
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Affiliation(s)
- A Pajoumand
- Loghman-Hakim Hospital Poison Center, Faculty of Medicine, Shaheed-Beheshti University of Medical Sciences, Tehran, Iran
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44
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Chukkambotla S, Hurst T. Ethylene Glycol Poisoning - A Challenge for the Intensivist. J Intensive Care Soc 2016. [DOI: 10.1177/175114370700800312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Srikanth Chukkambotla
- Specialist Registrar Anaesthesia & Intensive Care Blackpool Victoria Hospital Blackpool
| | - Tom Hurst
- Specialist Registrar Anaesthesia & Intensive Care Blackpool Victoria Hospital Blackpool
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45
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Greenwald PW, Farmer BM, O'Neill M, Essner RA, Flomenbaum NE. Increasing frequency and fatality of poison control center reported exposures involving medication and multiple substances: data from reports of the American Association of Poison Control Centers 1984–2013. Clin Toxicol (Phila) 2016; 54:590-6. [DOI: 10.1080/15563650.2016.1183777] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
| | - Brenna M. Farmer
- Weill Cornell Medical Center, Emergency Medicine, New York, NY, USA
| | - Matthew O'Neill
- Weill Cornell Medical Center, Emergency Medicine, New York, NY, USA
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46
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Anseeuw K, Mowry JB, Burdmann EA, Ghannoum M, Hoffman RS, Gosselin S, Lavergne V, Nolin TD. Extracorporeal Treatment in Phenytoin Poisoning: Systematic Review and Recommendations from the EXTRIP (Extracorporeal Treatments in Poisoning) Workgroup. Am J Kidney Dis 2015; 67:187-97. [PMID: 26578149 DOI: 10.1053/j.ajkd.2015.08.031] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 08/28/2015] [Indexed: 01/12/2023]
Abstract
The Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup conducted a systematic literature review using a standardized process to develop evidence-based recommendations on the use of extracorporeal treatment (ECTR) in patients with phenytoin poisoning. The authors reviewed all articles, extracted data, summarized findings, and proposed structured voting statements following a predetermined format. A 2-round modified Delphi method was used to reach a consensus on voting statements, and the RAND/UCLA Appropriateness Method was used to quantify disagreement. 51 articles met the inclusion criteria. Only case reports, case series, and pharmacokinetic studies were identified, yielding a very low quality of evidence. Clinical data from 31 patients and toxicokinetic grading from 46 patients were abstracted. The workgroup concluded that phenytoin is moderately dialyzable (level of evidence = C) despite its high protein binding and made the following recommendations. ECTR would be reasonable in select cases of severe phenytoin poisoning (neutral recommendation, 3D). ECTR is suggested if prolonged coma is present or expected (graded 2D) and it would be reasonable if prolonged incapacitating ataxia is present or expected (graded 3D). If ECTR is used, it should be discontinued when clinical improvement is apparent (graded 1D). The preferred ECTR modality in phenytoin poisoning is intermittent hemodialysis (graded 1D), but hemoperfusion is an acceptable alternative if hemodialysis is not available (graded 1D). In summary, phenytoin appears to be amenable to extracorporeal removal. However, because of the low incidence of irreversible tissue injury or death related to phenytoin poisoning and the relatively limited effect of ECTR on phenytoin removal, the workgroup proposed the use of ECTR only in very select patients with severe phenytoin poisoning.
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Affiliation(s)
- Kurt Anseeuw
- Campus Stuivenberg, Emergency Medicine, Antwerpen, Belgium
| | - James B Mowry
- Indiana University Health, Indiana Poison Center, Indianapolis, IN
| | - Emmanuel A Burdmann
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Marc Ghannoum
- Department of Nephrology, Verdun Hospital, University of Montreal, Verdun, QC, Canada
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY
| | - Sophie Gosselin
- Department of Emergency Medicine, Medical Toxicology Division, McGill University Health Centre & Department of Medicine, McGill University, Montreal, QC, Canada
| | - Valery Lavergne
- Department of Medical Biology, Sacre-Coeur Hospital, University of Montreal, Montreal, QC, Canada
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA; Renal Electrolyte Division, Department of Medicine, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA.
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47
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Paul S, Giri AK. Epimutagenesis: A prospective mechanism to remediate arsenic-induced toxicity. ENVIRONMENT INTERNATIONAL 2015; 81:8-17. [PMID: 25898228 DOI: 10.1016/j.envint.2015.04.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 03/30/2015] [Accepted: 04/10/2015] [Indexed: 06/04/2023]
Abstract
Arsenic toxicity is a global issue, addressed by the World Health Organization as one of the major natural calamities faced by humans. More than 137 million individuals in 70 nations are affected by arsenic mainly through drinking water and also through diet. Chronic arsenic exposure leads to various types of patho-physiological end points in humans including cancers. Arsenic, a xenobiotic substance, is biotransformed in the body to its methylated species by using the physiological S-adenosyl methionine (SAM). SAM dictates methylation status of the genome and arsenic metabolism leads to depletion of SAM leading to an epigenetic disequilibrium. Since epigenetics is one of the major phenomenon at the interface between the environment and human health impact, its disequilibrium by arsenic inflicts upon the chromatin compaction, gene expression, genomic stability and a host of biomolecular interactions, the interactome within the cell. Since arsenic is not mutagenic but is carcinogenic in nature, arsenic induced epimutagenesis has come to the forefront since it determines the transcriptional and genomic integrity of the cell. Arsenic toxicity brings forth several pathophysiological manifestations like dermatological non-cancerous, pre-cancerous and cancerous lesions, peripheral neuropathy, DNA damage, respiratory disorders and cancers of several internal organs. Recently, several diseases of similar manifestations have been explained with the relevant epigenetic perspectives regarding the possible molecular mechanism for their onset. Hence, in the current review, we comprehensively try to intercalate the information on arsenic-induced epigenetic alterations of DNA, histones and microRNA so as to understand whether the arsenic-induced toxic manifestations are brought about by the epigenetic changes. We highlight the need to understand the aspect of epimutagenesis and subsequent alterations in the cellular interactome due to arsenic-induced molecular changes, which may be utilized to develop putative therapeutic strategies targeting both oxidative potential and epimutagenesis in humans.
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Affiliation(s)
- Somnath Paul
- Molecular and Human Genetics Division, CSIR-Indian Institute of Chemical Biology, Kolkata 700032, India
| | - Ashok K Giri
- Molecular and Human Genetics Division, CSIR-Indian Institute of Chemical Biology, Kolkata 700032, India.
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Long-Acting Anticoagulant Rodenticide (Superwarfarin) Poisoning: A Review of Its Historical Development, Epidemiology, and Clinical Management. Transfus Med Rev 2015; 29:250-8. [PMID: 26239439 DOI: 10.1016/j.tmrv.2015.06.002] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 06/11/2015] [Accepted: 06/14/2015] [Indexed: 01/21/2023]
Abstract
Long-acting anticoagulant rodenticides (LAARs) inhibit vitamin K epoxide reductase (VKOR). Related bleeding may present a diagnostic challenge and require administration of blood component therapy, hemostatic agents, and vitamin K. This article intends to provide the reader a comprehensive understanding of LAAR poisoning. An exhaustive literature search of PubMed, Science Direct, US National Library of Medicine Toxicology Data Network, and Google Scholar yielded 174 reported cases of LAAR poisoning from which clinical data were extracted and reviewed. In addition, 25 years of epidemiologic data from the American Association of Poison Control Centers was reviewed. In the United States, on average, there were 10413 exposures reported with 2750 patients treated annually. For 25 years, there were 315951 exposures reported with nearly 90% among children and more than 100000 patients treated in a health care facility. Fortunately, only 2% of all exposures result in morbidity or mortality. Inhalational, transcutaneous, and oral routes of exposure have been documented. Most exposures are unintentional. The most frequently reported bleeding sites are mucocutaneous, with hematuria being the most common feature. Deaths were most commonly associated with intracranial hemorrhage. Long-acting anticoagulant rodenticide-induced paradoxical thrombosis and thrombotic complications accompanying hemostatic therapy have also been observed. Most patients present with coagulation assay values beyond measurable limits. Long-acting anticoagulant rodenticides have an extremely high affinity for VKOR compared with warfarin, characterized by rebound coagulopathy and bleeding after initial treatment and the need for high-dose, long-term therapy with vitamin K1. Treatment of acute hemorrhagic symptoms often required intravenous vitamin K1 in excess of 50 to 100 mg; chronic maintenance with 100 mg PO vitamin K1 daily was the most frequently used dose required to suppress coagulopathy. Treatment courses averaged 168 days. Adjunctive hemostatic therapy with recombinant factor VIIa and prothrombin complex concentrate has been reported, and phenobarbital has been used to expedite LAAR metabolism.
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49
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Death by band-aid: fatal misuse of transdermal fentanyl patch. Int J Legal Med 2015; 129:1247-52. [PMID: 26055040 DOI: 10.1007/s00414-015-1209-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 05/21/2015] [Indexed: 12/15/2022]
Abstract
We present a case of fatal intoxication by the application of a transdermal fentanyl patch upon a superficial bleeding abrasion of a 2-year-old girl. The grandmother discovered the body of the child in bed at approximately 7 a.m. External examination revealed a properly developed, nourished, and hydrated child, with some vomit in the nostrils and inside the mouth. There was no evidence of trauma besides small contusions and abrasions on the knees, with a patch placed over the largest abrasion. Closer inspection revealed that this was transdermal fentanyl patch. Internal examination and microscopic analysis revealed regurgitation of stomach content, cerebral and pulmonary edema, and liver congestion. Toxicology analysis revealed trace levels of fentanyl in the blood just above the limit of detection (2 ng/mL), while concentrations in the urine, liver, and kidney were approximately 102, 28, and 10 ng/mL, respectively. Investigation discovered that the child injured her knee while playing the evening before. The grandmother applied the patch to cover the injury, unaware that she had used a fentanyl transdermal patch instead of simple band-aid. Although fatal intoxications are uncommon among young children in high-income countries, it is of major interest to raise awareness of such events especially since a great majority of these are preventable. The presented case points at the need for more thorough education of users and more strict rules in prescribing and handling of this potent medicine. As well, we find this case to be a useful contribution to the evaluation of postmortem fentanyl concentrations in fatal intoxication in a small child.
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50
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Song HK, Shim KN, Yun HW, Tae CH, Kim SE, Jung HK, Jung SA, Yoo K. [Caustic injury of upper gastrointestinal tract: 20 year experience at a tertiary referral center]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 65:12-20. [PMID: 25603849 DOI: 10.4166/kjg.2015.65.1.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND/AIMS Caustic ingestion can cause severe injury to upper gastrointestinal tract. There were few studies about clinical characteristics and treatments of caustic injury in Korea. We investigated the changes in clinical features of caustic injury over the past 20 years including pattern of endoscopic mucosal injury and treatment modality. METHODS This study was a retrospective review of medical records from patients with caustic injury from September 1993 through December 2012. Patients were classified into two groups based on the year when caustic ingestion occurred: patients who visited the hospital from 1993 to 2002 (early group) and patients who visited the hospital from 2003 to 2012 (late group). RESULTS A total 140 patients were included (early group [n=50] vs. late group [n=90]). Annual number of caustic ingestions did not show decreasing tendency over the past 20 years. Alkali ingestion increased (20.0% vs. 65.6%, p<0.001) and cases with more than grade 2b of esophageal mucosal injury decreased (41.3% vs. 20.7%, p=0.012) in late group. There were no differences between two groups in sex, age, proportion of accidental ingestion, and systemic/gastrointestinal complications. Use of gastric lavage (p<0.01) and broad spectrum antibiotics (p=0.03) decreased in late group. However, there was no difference in use of steroid between two groups. CONCLUSIONS In this study, overall caustic ingestion did not decrease and ingestion of alkali agents increased over the past 20 years. Tighter legislation on caustic agents is required and we need to be alert to the best management of caustic injury.
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Affiliation(s)
- Hye Kyung Song
- Department of Health Promotion Medicine, Ewha Womans University Medical Center Mokdong Hospital, Seoul, Korea
| | - Ki Nam Shim
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hye Won Yun
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seong Eun Kim
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hye Kyung Jung
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Sung Ae Jung
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kwon Yoo
- Department of Health Promotion Medicine, Ewha Womans University Medical Center Mokdong Hospital, Seoul, Korea
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