2001 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System

Indian Society of Critical Care Medicine Position Statement: Approach to a Patient with Poisoning in the Emergency Room and Intensive Care Unit

Poisoning and its aftermath are globally observed and acknowledged concerns. India has a large burden of "self-harm/suicides" with 12.4/per 100,000 population committing suicide. Consumption of poisonous substances is the second most common mode of self-harm in India. Patients present to both public and private institutions in a critically ill state. The Indian Society of Critical Care Medicine (ISCCM) and Indian College of Critical Care Medicine (ICCCM) decided to address common and contentious issues related to poisoning by developing a position statement that is expected to be appropriate in the Indian scenario by the constitution of an "expert group" to provide a "set of statements" aimed at addressing the common issues faced by intensivists in their practice in managing such patients. The structured approach, framework, and process adopted in developing the position statement on the approach to poisoning have been detailed in this statement. The formation of an expert advisory panel was followed by a literature search, and multiple sessions of consensus-building exercises to reach the current statement presented below. The statement consists of relevant questions with possible answers thereof. Each answer was further weighed against the data and evidence available in the literature. Recommendations were made using a simplified score to make the statement qualitatively meaningful.

How to cite this article

Rungta N, Ray B, Bhalla A, DP Samaddar, Paul G, Prasad S, et al. Indian Society of Critical Care Medicine Position Statement: Approach to a Patient with Poisoning in the Emergency Room and Intensive Care Unit. Indian J Crit Care Med 2024;28(S2):S217-S232.

Comparison of decision tree with common machine learning models for prediction of biguanide and sulfonylurea poisoning in the United States: an analysis of the National Poison Data System

BACKGROUND

Biguanides and sulfonylurea are two classes of anti-diabetic medications that have commonly been prescribed all around the world. Diagnosis of biguanide and sulfonylurea exposures is based on history taking and physical examination; thus, physicians might misdiagnose these two different clinical settings. We aimed to conduct a study to develop a model based on decision tree analysis to help physicians better diagnose these poisoning cases.

METHODS

The National Poison Data System was used for this six-year retrospective cohort study.The decision tree model, common machine learning models multi layers perceptron, stochastic gradient descent (SGD), Adaboosting classiefier, linear support vector machine and ensembling methods including bagging, voting and stacking methods were used. The confusion matrix, precision, recall, specificity, f1-score, and accuracy were reported to evaluate the model's performance.

RESULTS

Of 6183 participants, 3336 patients (54.0%) were identified as biguanides exposures, and the remaining were those with sulfonylureas exposures. The decision tree model showed that the most important clinical findings defining biguanide and sulfonylurea exposures were hypoglycemia, abdominal pain, acidosis, diaphoresis, tremor, vomiting, diarrhea, age, and reasons for exposure. The specificity, precision, recall, f1-score, and accuracy of all models were greater than 86%, 89%, 88%, and 88%, respectively. The lowest values belong to SGD model. The decision tree model has a sensitivity (recall) of 93.3%, specificity of 92.8%, precision of 93.4%, f1_score of 93.3%, and accuracy of 93.3%.

CONCLUSION

Our results indicated that machine learning methods including decision tree and ensembling methods provide a precise prediction model to diagnose biguanides and sulfonylureas exposure.

Considerations for Satisfactory Sedation during Dental Implant Surgery

Implant surgery is a lengthy dental procedure, and sedation is often used to reduce discomfort. The effectiveness of sedation has traditionally been evaluated in terms of patient and surgeon satisfaction, but the most important goal is not to induce a deep sleep in the patient, but rather to ensure that the surgery is performed safely and as planned. Additionally, adequate pain control is a necessary requirement for patient and surgeon satisfaction. Most patients undergoing implant surgery are middle-aged or older, and a relatively large number of them have cardiovascular disease. Infiltration anesthesia using articaine or lidocaine in combination with adrenaline is widely used, but its use in patients with cardiovascular disease is limited because of adrenaline's effects on the cardiovascular system. The use of long-acting local anesthetics and the potential efficacy of ultrasound-guided jaw nerve block have been investigated to enhance analgesia without resorting to adrenaline. Midazolam and propofol are usually used for sedation, but dexmedetomidine, which causes less respiratory depression, and the ultrashort-acting benzodiazepine remimazolam are emerging as potential alternatives. Monitoring of anesthetic depth using electroencephalography is effective in maintaining a constant level of sedation. In addition, sedation promotes the stabilization of heart rate and blood pressure, reducing the risks associated with adrenaline and allowing for safer management.

Reinforcing effect of tramadol in the rat

Tramadol is one of the most commonly prescribed analgesic opioids in various pharmacopeias. Tramadol has been linked to abuse in recent clinical investigations. However, the behavioral effects and neural substrates of the drug have not been well characterized in preclinical studies. As a result, the present study investigated the effects of tramadol on behavioral sensitizations in rats. Its impacts on cellular and molecular alterations in the brain were also investigated. In conditioned place preference (CPP) paradigm, tramadol induced behavioral as well as motor sensitizations. These effects were dramatically reduced by intraperitoneal administration of naltrexone, an opioid receptor antagonist. Tramadol caused changes in several molecular markers (pERK1/2, Δ-FosB, PKCγ, PKMζ GAD67) in the anterior cingulate cortex, which could indicate an increase in excitation within this structure. Tramadol is demonstrated in the present study to be a reinforcing drug in rats, as it increased both behavioral and motor sensitizations. Tramadol's effects are most likely due to the high levels of excitation it causes in the brain, which is mostly caused by the activation of opioid receptors.

Anticonvulsant fatalities reported to the American Association of Poison Control Centers 2000 - 2019

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.

Intracellular Quantum Sensing of Free-Radical Generation Induced by Acetaminophen (APAP) in the Cytosol, in Mitochondria and the Nucleus of Macrophages

Acetaminophen overdoses cause cell injury in the liver. It is widely accepted that liver toxicity is initiated by the reactive N-acetyl-para-aminophenol (APAP) metabolite N-acetyl-p-benzoquinone imine (NAPQI), which first depletes glutathione and then irreversibly binds to mitochondrial proteins and nuclear DNA. As a consequence, mitochondrial respiration is inhibited, and DNA strands break. NAPQI also promotes the oxidative stress since glutathione is one of the main free-radical scavengers in the cell. However, so far it is unknown where exactly free radicals are generated. In this study, we used relaxometry, a novel technique that allows nanoscale magnetic resonance imaging detection of free radicals. The method is based on fluorescent nanodiamonds, which change their optical properties based on their magnetic surrounding. To achieve subcellular resolution, these nanodiamonds were targeted to cellular locations, that is, the cytoplasm, mitochondria, and the nucleus. Since relaxometry is sensitive to spin noise from radicals, we were able to measure the radical load in these different organelles. For the first time, we measured APAP-induced free-radical production in an organelle-specific manner, which helps predict and better understand cellular toxicity.

Unintentional poisoning by cough and cold medications: Drugs with little usefulness and potential toxicity

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.

An Epidemiological Survey Regarding Ticks and Tick-Borne Diseases among Livestock Owners in Punjab, Pakistan: A One Health Context

Recent global changes have led to an increase in the spread of ticks and tick-borne diseases (TBDs) affecting domestic ruminants and humans, with an annual loss of US $13.9–$18.7 billion. The current study determined the perception and practices of livestock farmers regarding tick infestation. A total of 112 livestock farms were surveyed in Punjab, Pakistan, among which animals from 42 (37.5%) farms were infested with ticks. Only 28.6% (n = 32) of the dairy farmers were consulting veterinarians for ticks control, while 86.7% (n = 97) of the respondents did not consider biosecurity measures in the control of tick transmission. Most of the respondents, 71.4% (n = 80), did not consider manual tick removal from their animals (i.e., by hand, followed by physically crushing) as a risky practice for spreading zoonotic diseases. Improper disposal of bottles of acaricides in the farm drainage was also observed, putting the environment and aquatic life at risk. These wrong practices may contribute to high disease burdens and economic losses, increasing the possibility of transmission of zoonotic TBDs and pollution of the environment. Therefore, an integrated One Health approach is required for the control of TBDs through environmentally friendly approaches.

Tick Preventive Behaviors and Practices Adopted by Medical Students from Poland, Germany, and Thailand in Relation to Socio-Demographic Conditions and Their Knowledge of Ticks and Tick-Borne Diseases

Given the high medical importance of ticks, we analyzed the most common preventive behaviors and practices adopted by medical students from Poland, Germany, and Thailand, and the level of their knowledge of ticks and tick-borne diseases. A survey consisting of 19 questions was conducted among 636 randomly selected students. The study showed that the Polish and German students preferred inspection of the body on their return home (86.9% and 63.5%, respectively) and wearing protective clothes (79.8% and 32.3%, respectively) as part of prophylaxis. The Thai students most often chose wearing protective clothes (54.7%) and preventive behavior in tick habitats (42.7%). Approximately 7% of the Polish medical students and as many as 22% of the German and Thai respondents did not use any means of prevention. Our analyses suggest that the use of preventive methods and respondents' behaviors depend on socio-demographic factors and the level of health education. The insufficient practical implementation of tick prevention measures by the medical students suggests a need for verification of health education programs in schools as well as effective popularization and educational activities. It is also necessary to develop a public health protection strategy against the effects of tick bites.

Epidemiology of fatal snakebites in the United States 1989-2018

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.

Intoxication From Accidental Marijuana Ingestion in Pediatric Patients: What May Lie Ahead

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.

Association of alprazolam with major cardiovascular events in patients with hypertension

RATIONALE

Anxiety is a mediator for emotional reactivity and acute blood pressure elevations, which are associated with an increased risk of cardiovascular death. Alprazolam is a common medication for anxiolysis. We hypothesized that alprazolam usage can reduce the risk of major adverse cardiovascular events (MACEs) in patients with hypertension.

METHODS

A retrospective cohort study was performed using datasets from Taiwanese Health and Welfare Data. Patients with hypertension were divided into exposed (Alprazolam-exposed) and control groups (non-Alprazolam-exposed) with 1:1 propensity score matching. The study endpoint was the occurrence of MACE. Adjusted hazard ratio (aHR) of MACE risk was estimated using the multiple Cox proportional hazard model. Age-stratified analysis was performed to evaluate the interaction of age and alprazolam use with MACEs.

RESULTS

The study cohort consisted of 335 517 alprazolam-exposed patients and 1:1 PSM controls. The mean age was 63.62 ± 12.71 years in the Alprazolam-exposed population. Alprazolam exposure was significantly associated with reduced risk of MACEs (aHR = 0.965, 95% CI = 0.954-0.977), including ischemic stroke (aHR = 0.958, 95% CI = 0.940-0.976), hemorrhagic stroke (aHR = 0.856, 95% CI = 0.821-0.892), myocardial infarction (aHR = 0.933, 95% CI = 0.900-0.968), sudden cardiac death (aHR = 0.955, 95% CI = 0.916-0.996), and all-cause mortality (aHR = 0.921, 95% CI = 0.909-0.932). In the age-subgroup analysis, alprazolam showed the greatest risk reduction effect in hemorrhagic stroke for patients aged <65 years (aHR = 0.779, 95% CI = 0.727-0.835).

CONCLUSION

Alprazolam usage in patients with hypertension was associated with a slightly reduced risk of MACEs and all-cause mortality, and up to 22% reduced risk of hemorrhagic stroke was observed in alprazolam users aged <65 years.

Oenantha Crocata: A Case Report of Multiple Poisoning with Fatal Outcome

BACKGROUND

Plant poisonings are uncommon in adults, and rarely fatal. Oenantha crocata is a toxic plant growing in the humid grasslands of North America and Western Europe.

CASE REPORT

We report here two adults who ingested Oenantha crocata roots, having mistaken them for edible tuberous radish. One developed vomiting and needed only 24 h symptomatic treatment, whereas the other suffered prolonged convulsions, cardiac arrest, and severe metabolic acidosis, leading to a fatal outcome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Cases of poisoning with Oenantha crocata are rare and destabilizing. With increased interest in "natural" foods and team building by survival training, medical teams should be aware of the management for such poisoning.

[Availability in Spain of "one pill killers" and other highly toxic drugs in infants]

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.

Conservative treatment of caustic oesophageal injuries in children: 15 years of experience in a tertiary care paediatric centre

INTRODUCTION

Endoscopic dilatation is good choice of conservative treatment for caustic digestive tract injuries in children.

AIM

To set up a strategy of management of caustic digestive tract injury based on our experience and literature review.

MATERIAL AND METHODS

We retrospectively analysed medical records of 34 paediatric patients who were admitted to the Centre of Paediatric Surgery of the Children's Hospital between 2000 and 2017. Age at presentation, gender, anatomic location, circumstances and distribution of injury, early and late complications, clinical signs, and the first aid were analysed. Upper gastrointestinal (GI) endoscopy was performed within 12-24 h after ingestion in all cases. The Zargar classification system was used to grade the severity of the injury. Fisher's exact test was used for statistical analysis, with p < 0.05 considered as the limit of statistical significance.

RESULTS

The upper GI endoscopy revealed caustic injuries in 5 (15%) and 8 (23%) patients were classified as grade IIa and IIb, respectively. Oesophageal and ventricle caustic injuries in 3 (9%) and 2 (6%) patients were classified as grade IIIa and IIIb, respectively. Thirteen patients with grade IIa and IIIb injuries suffered permanent damage and required repeated dilatation. All patients underwent stricture treatment using late or early endoscopic dilatation of the oesophagus. An average of 15 dilatation procedures were required to achieve a satisfactory lumen.

CONCLUSIONS

Our experience of 34 children revealed that endoscopic dilatation may be required as a primary treatment for oesophageal strictures.

PYP1-4 peptide from Pyropia yezoensis protects against acetaminophen-induced hepatotoxicity in HepG2 cells

Acetaminophen (APAP) is a widely used analgesic and antipyretic. It is safe at normal treatment doses; however, APAP overdose is a major cause of acute liver and kidney failure. A variety of methods to reduce the damage caused by APAP overdose have previously been evaluated. The protein-rich seaweed Pyropia yezoensis has antioxidant, antitumor and anti-inflammatory activities, and protects against cytotoxicity. However, little is known regarding the protective effects of P. yezoensis peptide against APAP-induced hepatotoxicity. The present study investigated the ability of P. yezoensis peptide (PYP1-4) to ameliorate the damage caused by APAP-induced hepatotoxicity using HepG2 as the model cell line in addition to the signaling pathways involved. Briefly, cell viability, nitric oxide, reactive oxygen species and apoptosis assays were performed in conjunction with western blot analysis and reverse transcription-quantitative PCR. First, the present study revealed the minimum toxic concentration of APAP (15 mM) and the resting concentration of PYP1-4 (0–500 ng/ml). Administration of PYP1-4 to APAP-induced cells decreased the nitric oxide and reactive oxygen species levels, and restored the levels of antioxidant-associated proteins (catalase, heme oxygenase 1, superoxide dismutase 2 and quinone oxidoreductase 1). PYP1-4 increased the translocation of nuclear factor, erythroid 2 like 2 to the nucleus and the activities of glycogen synthase kinase-3β, Akt and AMP-activated protein kinase. In addition, APAP induced apoptosis; however, PYP1-4 inhibited apoptosis by modulating the levels of pro-apoptotic markers (Bad), anti-apoptotic markers (Bcl-2 and BH3 interacting domain death agonist), caspases and poly (ADP-ribose) polymerase 1. Subsequently, the insulin-like growth factor 1 receptor signaling pathway was investigated to determine whether PYP1-4 treatment restored the levels of cell growth-associated factors during APAP-induced hepatotoxicity. PYP1-4 treatment impacted the levels of components of the insulin receptor substrate 1/PI3K/Akt and Ras/Raf/ERK signaling pathways, and promoted cell survival. Therefore, the P. yezoensis peptide PYP1-4 may be useful for preventing APAP-induced hepatotoxicity.

Cosmetic-Related Injuries Treated in US Emergency Departments: 2002 to 2016

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.

Toxicological profile of Amanita virosa - A narrative review

•

Globally, mushroom poisoning leads to a considerable number of deaths annually. However, no definite antidote has been introduced yet.

•

A mushroom-poisoning outbreak occurred in 2018 in Iran; this overview presents geographical distribution of Amanita virosa along with studies reporting A. virosa poisonings.

•

Also, main toxins of A. virosa, their toxicity mechanisms and pharmacological management of mushroom-poisoned individuals are presented.

Mushrooms account for a part of human diet due to their exquisite taste and protein content as well as their promising health effects unveiled by scientific research. Toxic and non-toxic mushrooms frequently share considerable morphological similarities, which mislead the collectors/consumers, resulting in mycotoxicity. Numerous mushroom species are considered “poisonous” as they produce dangerous toxins. For instance, members of the genus Amanita, especially A. phalloides, A. virosa and A. verna, are responsible for severe and even life-threatening noxious consequences. Globally, mushroom poisoning is a crucial healthcare issue as it leads to a considerable number of deaths annually. However, no definite antidote has been introduced to treat this poisoning. The present article discusses the characteristics of A. virosa in terms of epidemiology, mechanisms of toxicity, poisoning features and management.

Mushroom poisoning epidemiology in the United States

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.

Differences Between Snakebites with Concomitant Use of Alcohol or Drugs and Single Snakebites

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.

Trends in types of calls managed by U.S. poison centers 2000-2015

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.

Dietary Supplement Adverse Event Report Data From the FDA Center for Food Safety and Applied Nutrition Adverse Event Reporting System (CAERS), 2004-2013

Background: The Food and Drug Administration (FDA)’s Center for Food Safety and Applied Nutrition (CFSAN) oversees the safety of the nation’s foods, dietary supplements, and cosmetic products. Objective: To present a descriptive analysis of the 2004-2013 dietary supplement adverse event report (AER) data from CAERS and evaluate the 2006 Dietary Supplements and Nonprescription Drug Consumer Protection Act as pertaining to dietary supplements adverse events reporting. Methods: We queried CAERS for data from the 2004-2013 AERs specifying at least 1 suspected dietary supplement product. We extracted the product name(s), the symptom(s) reported, age, sex, and serious adverse event outcomes. We examined time trends for mandatory and voluntary reporting and performed analysis using SAS v9.4 and R v3.3.0 software. Results: Of the total AERs (n = 15 430) received from January 1, 2004, through December 31, 2013, indicating at least 1 suspected dietary supplement product, 66.9% were mandatory, 32.2% were voluntary, and 0.9% were both mandatory and voluntary. Reported serious outcomes included death, life-threatening conditions, hospitalizations, congenital anomalies/birth defects and events requiring interventions to prevent permanent impairments (5.1%). The dietary supplement adverse event reporting rate in the United States was estimated at ~2% based on CAERS data. Conclusions: This study characterizes CAERS dietary supplement adverse event data for the 2004-2013 period and estimates a reporting rate of 2% for dietary supplement adverse events based on CAERS data. The findings show that the 2006 Dietary Supplements and Nonprescription Drug Consumer Protection Act had a substantial impact on the reporting of adverse events.

A guide to acquired vitamin K coagulophathy diagnosis and treatment: the Russian perspective

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

Pediatric Exposures to Veterinary Pharmaceuticals

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.

Potential of Alginate Encapsulated Ferric Saccharate Microemulsions to Ameliorate Iron Deficiency in Mice

Iron deficiency is one of the most prominent mineral deficiencies around the world, which especially affects large population of women and children. Development of new technologies to combat iron deficiency is on high demand. Therefore, we developed alginate microcapsule with encapsulated iron that had better oral iron bioavailability. Microcapsules containing iron with varying ratios of sodium alginate ferric(III)-saccharide were prepared using emulsification method. In vitro studies with Caco-2 cells suggested that newly synthesized microemulsions had better iron bioavailability as compared to commercially available iron dextran formulations. Ferrozine in vitro assay showed that alginate-encapsulated ferric galactose microemulsion (AFGM) had highest iron bioavailability in comparison to other four ferric saccharate microemulsions, namely AFGlM, AFMM, AFSM, and AFFM synthesized in our laboratory. Mice studies also suggested that AFGM showed higher iron absorption as indicated by increased serum iron, hemoglobin, and other hematopoietic measures with almost no toxicity at tested doses. Development of iron-loaded microemulsions leads to higher bioavailability of iron and can provide alternative strategies to treat iron deficiency.

The Use of Focus Groups to Plan Poison Prevention Education Programs for Low-Income Populations

Children younger than 5 are at greatest risk for unintentional poisonings. Children in low-income situations are particularly vulnerable for exposures to potential poisons. Focus groups were conducted at a Women, Infants, and Children (WIC) program located in a large urban public hospital in New York City to gain information from low-income parents of young children about real and perceived barriers to calling the local poison control center, resources for poison prevention messages, and ideas about public awareness campaigns. All focus group members were low-income parents of young children. Most participants reported that they would call 911 in the event of a poisoning due to child welfare and self-efficacy issues. Health education theory using the social-cognitive theory provides a framework for developing future poison prevention programs to address identified issues with parents of young children.

Redox Nanoparticle Therapeutics for Acetaminophen-Induced Hepatotoxicity in Mice

The purpose of this study was to evaluate the hepatoprotective effect of an antioxidative nanoparticle (RNP(N)) recently developed against APAP-induced hepatotoxicity in mice. The effects of oral administration of RNP(N) to APAP-treated mice were assessed for various biochemical liver function parameters: alanine transaminase (ALT) activity, aspartate transaminase (AST) activity, alkaline phosphatase (ALP) activity, prothrombin time, and serum albumin (ALB) level. The treatment effects were assessed in terms of free radical parameters: malondialdehyde (MDA) accumulation, glutathione peroxidase (GPx) activity, % inhibition of superoxide anion (O2 (-∙)), and histopathological examination. The N-acetylcysteine (NAC)-treated group exhibited an enhanced prothrombin time relative to the control group, while RNP(N) did not prolong prothrombin time. The RNP(N)-treated animals exhibited lower levels of ALT, AST, and ALP, while increased ALB levels were measured in these animals compared to those in the other groups. The RNP(N)-treated animals furthermore exhibited improved MDA levels, GPx activity, and % inhibition of O2 (-∙), which relate to oxidative damage. Histological staining of liver tissues from RNP(N)-treated animals did not reveal any microscopic changes relative to the other groups. The findings of this study suggest that RNP(N) possesses effective hepatoprotective properties and does not exhibit the notable adverse effects associated with NAC treatment.

Antiretroviral Drug Exposures Reported to Texas Poison Centers

Background. A number of different antiretroviral drugs are used to manage patients with human immunodeficiency virus (HIV). Objective. This study describes antiretroviral drug exposures reported to a large statewide poison center system. Methods. Cases were all antiretroviral drug exposures reported to the Texas Poison Center Network during 2000 to 2014. The distribution of cases was determined for various demographic and clinical factors. Results. Of a total of 632 exposures, the most commonly reported drugs were emtricitabine–tenofovir combination (17.1%), efavirenz–emtricitabine–tenofovir combination (13.8%), ritonavir (10.9%), lamivudine–zidovudine combination (10.3%), and efavirenz (10.1%). The annual number of antiretroviral drug exposures increased from 34 in 2000 to 67 in 2014. Males comprised 67.9% of the patients; 72.2% were 20 years or older. The exposures were 58.5% unintentional and 37.5% intentional. Only antiretroviral drugs were reported in 440 of the exposures. Of these exposures, 62.5% were managed on site, 28.0% were already at or en route to a health care facility when the poison center was contacted, and 8.6% were referred to a health care facility. The exposures were not serious in 88.7% of these cases. The most frequently reported adverse clinical effects were vomiting (5.7%), nausea (4.8%), dizziness/vertigo (3.2%), and drowsiness/lethargy (3.2%). Conclusions. The most commonly reported antiretroviral drugs were emtricitabine–tenofovir combination and efavirenz–emtricitabine–tenofovir combination. The patients were most likely to be adults and males. The exposures tended to be unintentional. Of those exposures involving only antiretroviral drugs, the majority of the exposures were not serious and could be managed outside of a health care facility.

Long-Acting Anticoagulant Rodenticide (Superwarfarin) Poisoning: A Review of Its Historical Development, Epidemiology, and Clinical Management

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.

Model for end-stage liver disease score as a predictor of short-term outcome in patients with drug-induced liver injury

OBJECTIVES

The purposes of this study were to investigate the clinical presentation, cause and outcome of drug-induced liver injury (DILI) and to evaluate the predictive value of the model for end-stage liver disease (MELD) score in DILI.

METHODS

Patients diagnosed with DILI between January 1, 2010 and December 31, 2012 in the Emergency Department at Asan Medical Center in Seoul, Korea were analyzed retrospectively. The primary end point was poor outcome, defined as liver transplantation or death within 30 days of the initial hospital visit.

RESULTS

Of 213 patients, 13.1% had a 30-day poor outcome. Folk remedies were the most common cause of DILI in 147 patients (69%). Univariate logistic regression analysis showed that multiple drugs (odds ratio [OR] 2.30, 95% confidence interval [CI]: 1.03-5.15), concurrent alcohol consumption (OR 3.69, 95% CI: 1.03-13.18), white blood cell (WBC) count (OR 1.17, 95% CI: 1.07-1.28), hemoglobin (Hb) (OR 0.60, 95% CI: 0.49-0.74), platelet count (OR 0.993, 95% CI: 0.987-0.998), total bilirubin (OR 1.09, 95% CI: 1.06-1.13) and MELD (OR 1.23, 95% CI: 1.15-1.32) were significantly associated with 30-day poor outcomes. Multivariate analysis showed that the MELD (OR 1.21, 95% CI: 1.12-1.30) and Hb (OR 0.77, 95% CI: 0.61-0.98) were independent predictors of poor outcome. For 30-day mortality, the c-statistics for MELD alone and for combination of MELD and Hb were 0.93 (95% CI: 0.89-0.97) and 0.94 (95% CI: 0.90-0.97), respectively.

CONCLUSION

The outcome of patients with DILI was poor. MELD score and Hb were reliable predictors of short-term outcome in patients with DILI.

Antiepileptic drug poisoning: Three-year experience

INTRODUCTION

Antiepileptic drugs, which are also called anticonvulsants, are used in the therapy and prophylaxis of epileptic seizures. The purpose of this paper was to investigate the relevant epidemiological data and to determine which of these drugs was the most frequent cause of intoxication. Another purpose of this study was to determine the neurological, cardiac, and biochemical problems caused by antiepileptics.

MATERIAL AND METHOD

This retrospective study included 95 consecutive patients under 18 years of age with antiepileptic intoxication, presenting to and being followed-up in, the Toxicology Unit between January 2010 and February 2013. The data were obtained by screening the patient files.

RESULTS

Of the cases, 67 (70.5%) were self-poisoned by first generation antiepileptics (FGAEs) and 28 (29.5%) by second generation antiepileptics (SGAEs). The Glasgow Coma Scale (GCS) scores and the serum lactate levels of the patients poisoned by FGAEs and SGAEs on admission to emergency department were 15 (25th: 12; 75th: 15; 95th: 15; IQR: 3) and 1.9 (25th: 1.4; 75th: 3.1; 95th: 5.6; IQR: 1.7), and 15 (25th: 14.3; 75th: 15; 95th: 15; IQR: 0.75) and 1.07 (25th: 0.9; 75th: 1.6; 95th: 5.5; IQR: 0.71), respectively. The serum lactate levels of patients poisoned by FGAEs were significantly higher (p < 0.001). Among the cases poisoned by carbamazepine, the most frequent cause of intoxication, the GCS score was significantly lower and serum lactate level was significantly higher in the group with high serum levels of carbamazepine (p = 0.004 and p < 0.001, respectively). In cases poisoned by valproic acid (VPA), the second frequent cause of intoxication, there was neither a significant association between the serum VPA level and the GCS score, nor between the serum lactate level and the systolic blood pressure (p = 0.470, p = 0.897, and p = 0.088, respectively). However, there was a positive correlation between the serum VPA level and the serum ammonia level (kk = 0.742, p < 0.001).

CONCLUSION

First generation antiepileptics are more toxic than SGAEs. In patients with serum carbamazepine level, particularly those over 30 mg/L, serious disorders of consciousness, cardiovascular toxicity, and metabolic disorders may occur. In VPA intoxication, there is a positive correlation between the serum VPA levels and ammonia levels. On account of this finding, one should be more careful about hyperammonemic hepatic encephalopathy as the serum VPA level rises.

A review on the efficacy and safety of gabapentin in the treatment of chronic cough

INTRODUCTION

Effective antitussives available to control cough are limited. Consolidation among different afferent branches of the vagus nerve is needed to bring about cough. A general, widely accepted view is that the chronic increase in the sensitivity of the cough reflex is associated with inflammatory hypersensitivity such as from gastro-esophageal reflux disease. There is increasing evidence that an important mechanism is a sensory disorder of the laryngeal branches of the vagus nerve. Neuromodulating drugs are effectively used in the treatment of chronic pain and neuropathic disorders and may have a role in the treatment of refractory chronic cough (CC).

AREAS COVERED

Current evidence on the efficacy and safety of gabapentin in the treatment of CC is reviewed. Relevant randomized controlled trials, case reports and reviews were identified through a PubMed search of English-language literature referring to cough, sensory neuropathy and gabapentin over the last 10 years.

EXPERT OPINION

Gabapentin appears to be effective and well tolerated in the treatment of CC and in other sensory neuropathic disorders. Relevant clinical trials investigating its efficacy and safety profile in the treatment of cough are limited and further studies are needed. Gabapentin has been shown to cause minimal to no toxicity in overdose.

Patterns of Acute Poisoning in Childhood in Zagazig, Egypt: An Epidemiological Study

Background. Acute poisoning represents one of the most common medical emergencies in childhood. In view of paucity of literature on accidental poisoning among children in Egypt, this study was designed to describe the pattern of childhood poisoning in Zagazig University Hospitals. Patients and Methods. This retrospective study included 300 children up to 12 years with acute poisoning admitted to the Pediatric Department and Poisoning Treatment Unit, Zagazig University Hospitals, from January 2011 to August 2012. Complete epidemiological and clinical data were recorded and analyzed. Results. Three hundred of poisoned children were enrolled in this study. Children from 1 to 6 years were more liable to poisoning (81%). More boys than girls were poisoned at all age groups. The majority of all cases (99%) were due to accidental poisoning. Overall, 32% of the poisoned cases were living in Zagazig city while 68% were living in the rural areas. The presenting symptoms were classic in 60% of the cases. Pesticides, therapeutic drugs, and cleaning and disinfectant agents were the most frequent poisoning agents (28.7%, 22.7%, and 17.0%, resp.). In 86.0% of cases, observation with or without supportive measures together with decontamination and specific antidote therapy whenever needed was sufficient. Conclusion. Most of the poisonings were due to accidental ingestions by infants and young children. Pesticides and medications were the most commonly involved agents.

Coral snake bites and envenomation in children: a case series

OBJECTIVE

North America is home to 2 families of venomous snakes, Crotalinae (pit viper family) and Elapidae (coral snake family). Although there are several published reports describing and reviewing the management of pit viper snakebites in children, there are no recent similar publications detailing the clinical course and management of coral snake envenomation.

METHODS

Our case series describes the hospital course of children with coral snake bites admitted to our regional pediatric intensive care. We also reviewed prior published case reports of coral snake bites in the United States.

RESULTS

We identified 4 patients with either confirmed or suspected coral snake envenomation from our hospital's records. In 2 cases, the snakebite occurred after apparent provocation. Antivenom was administered to 3 patients. The regional venom response team was consulted for management advice and supplied the antivenom. One patient had a prolonged hospital course, which was complicated by respiratory failure, bulbar palsy, and ataxia. All survived to discharge.

CONCLUSIONS

Admission to pediatric intensive care is warranted after all Eastern coral snake bites. A specialized regional or national venom response team can be a useful resource for management advice and as a source of antivenom.

Use of sanitizing products: safety practices and risk situations

OBJECTIVES

to evaluate the handling and risk factors for poisoning and/or digestive tract injuries associated with the use of sanitizing products at home.

METHODS

interviews were conducted in 419 households from different regions, collecting epidemiological data from residents and risk habits related to the use and storage of cleaning products.

RESULTS

sanitizing products considered to be a health risk were found in 98% of the households where the research was conducted, and in 54% of cases, they were stored in places easily accessible to children. Lye was found in 19%, followed by illicit products in 39% of homes. In 13% of households, people produced soap, and in 12% they stored products in non-original containers. The use of illicit products and the manufacture of handmade soap were associated with lower educational level of the household owners and with the regions and socioeconomic classes with lower purchasing power.

CONCLUSIONS

risk practices such as inadequate storage, manufacturing, and use of sanitizing products by the population evidence the need for public health policies, including educational measures, as a means of preventing accidents.

A review of the literature on the validity of mass casualty triage systems with a focus on chemical exposures

INTRODUCTION

Mass casualty incidents (MCIs) include natural (eg, earthquake) or human (eg, terrorism or technical) events. They produce an imbalance between medical needs and resources necessitating the use of triage strategies. Triage of casualties must be performed accurately and efficiently if providers are to do the greatest good for the greatest number. There is limited research on the validation of triage system efficacy in determining the priority of care for victims of MCI, particularly those involving chemicals.

OBJECTIVE

To review the literature on the validation of current triage systems to assign on-site treatment status codes to victims of mass casualties, particularly those involving chemicals, using actual patient outcomes.

METHODS

The focus of this article is a systematic review of the literature to describe the influences of MCIs, particularly those involving chemicals, on current triage systems related to the on-site assignment of treatment status codes to a victim and the validation of the assigned code using actual patient outcomes.

RESULTS

There is extensive literature published on triage systems used for MCI but only four articles used actual outcome data to validate mass casualty triage outcomes including three for chemical events. Currently, the amount and type of data collected are not consistent or standardized and definitions are not universal.

CONCLUSIONS

Current literature does not provide needed evidence on the validity of triage systems for MCI in particular those involving chemicals. Well designed studies are needed to validate the reliability, sensitivity, and specificity of triage systems used for MCI including those involving chemicals.

New insights into root causes of pediatric accidental unsupervised ingestions of over-the-counter medications

CONTEXT

Changes to regulations, packaging, and labeling and ongoing educational efforts are intended to support appropriate use of medicines. Yet annually poison centers receive > 500 000 reports of accidental or unsupervised exposure to medicines for children under 6 years of age.

OBJECTIVE

To identify root (i.e., fundamental and preventable) causes of accidental unsupervised ingestions (AUIs), we designed a questionnaire and conducted a follow-up survey of caregivers who contacted McNeil Consumer Healthcare (McNeil) following an AUI by a child under 12 years of age.

METHODS

Reports received between 1 October 2008 and 22 January 2009 were screened retrospectively for specific Medical Dictionary of Regulatory Activities (MedDRA) Preferred Terms relating to AUIs. Using the questionnaire, we collected information about the child, caregiver, medicines involved in AUI, management of AUI, and storage location of medicines.

RESULTS

Two hundred twenty reports met inclusion criteria and attempts to contact these caregivers were made throughout a 2-week period in March 2009; caregivers completed the questionnaire for 45 reports. All AUIs occurred in children under 7 years and 56% were boys. In 56% of AUI cases, the child involved was the intended recipient of the medicine; in 71%, a pediatric medicine was involved. Most AUIs occurred in the child's home; most caregivers reported not observing the AUI. Sixty percent of caregivers reported that the medicine involved in AUI was not in the normal storage location when AUI occurred. Among children involved in AUIs, 84% did not experience any symptoms. Seven children experienced mild, self-limiting symptoms which resolved. AUIs often occurred < 24 h after last therapeutic use when the medicine was removed from its normal storage location.

CONCLUSIONS

These new insights may help guide-targeted interventions and educational efforts to focus caregivers' attention to reengaging childproofing mechanisms and returning medicines to a secure location, high and out of sight, immediately after use.

Glycocapture-assisted global quantitative proteomics (gagQP) reveals multiorgan responses in serum toxicoproteome

Blood is an ideal window for viewing our health and disease status. Because blood circulates throughout the entire body and carries secreted, shed, and excreted signature proteins from every organ and tissue type, it is thus possible to use the blood proteome to achieve a comprehensive assessment of multiple-organ physiology and pathology. To date, the blood proteome has been frequently examined for diseases of individual organs; studies on compound insults impacting multiple organs are, however, elusive. We believe that a characterization of peripheral blood for organ-specific proteins affords a powerful strategy to allow early detection, staging, and monitoring of diseases and their treatments at a whole-body level. In this paper we test this hypothesis by examining a mouse model of acetaminophen (APAP)-induced hepatic and extra-hepatic toxicity. We used a glycocapture-assisted global quantitative proteomics (gagQP) approach to study serum proteins and validated our results using Western blot. We discovered in mouse sera both hepatic and extra-hepatic organ-specific proteins. From our validation, it was determined that selected organ-specific proteins had changed their blood concentration during the course of toxicity development and recovery. Interestingly, the peak responding time of proteins specific to different organs varied in a time-course study. The collected molecular information shed light on a complex, dynamic, yet interweaving, multiorgan-enrolled APAP toxicity. The developed technique as well as the identified protein markers is translational to human studies. We hope our work can broaden the utility of blood proteomics in diagnosis and research of the whole-body response to pathogenic cues.

Metabolic and toxicological considerations of the opioid replacement therapy and analgesic drugs: methadone and buprenorphine

INTRODUCTION

Methadone and buprenorphine are maintenance replacement therapies for opioid dependence; they are also used for pain management. Methadone and buprenorphine (to a lesser extent) have seen sharp increases in mortality associated with their use. They have distinct routes of metabolism (mostly cytochrome P450 dependent), and distinct pharmacologic activity of metabolites. As such, metabolism may play a role in differences in their toxicity.

AREAS COVERED

This article reviews peer-reviewed literature obtained from PubMed searches and literature referenced within. The review considers first an overview of drug use and mortality over the past decade. It then provides extensive detail on the in vitro and in vivo human metabolism of methadone and buprenorphine. Using both human and experimental animal studies it then presents the pharmacodynamic activity of parent drug and metabolites at the mu-opioid receptor, as P-glycoprotein substrates and plasma/brain concentration ratios, and activity at the hERG K(+) channel. Lessons learned from drug interaction studies in humans are then examined in an attempt to bring together the combined information.

EXPERT OPINION

The use and misuse of these drugs contributes to the epidemic in opioid-associated mortalities. A better understanding of metabolism-, transport- and co-medication-induced changes will contribute to their safer use.