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Simon M, Kaplan S, Muschler K, Hoyte C, Brent J. The role of QRS complex prolongation in predicting severe toxicity in single-xenobiotic overdose. Clin Toxicol (Phila) 2024; 62:32-38. [PMID: 38329803 DOI: 10.1080/15563650.2024.2307356] [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: 11/29/2023] [Accepted: 01/15/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE The QRS complex duration is commonly used to prognosticate severity, predict outcomes, and indicate treatment in overdose. However, literature to support this practice is mixed in tricyclic antidepressant overdoses and absent in non-tricyclic antidepressant overdoses. Our objective was to assess the validity of QRS complex duration as a prognostic marker in overdose. METHODS This was a secondary analysis of cases reported to the Toxicology Investigators Consortium between January 1, 2010, and December 31, 2022. Cases were assessed to determine the six xenobiotics most associated with QRS complex prolongation. All cases involving these six xenobiotics, regardless of QRS complex duration, constituted the study cohort. Inclusion criteria were cases of patients older than 12 years old with single-xenobiotic exposures. Clinical outcomes evaluated were seizure, ventricular dysrhythmia, metabolic acidosis, and death. RESULTS Of 94,939 total cases, diphenhydramine, amitriptyline, bupropion, quetiapine, nortriptyline, and cocaine were most associated with QRS complex prolongation. Inclusion criteria were met by 4,655 cases of exposure to these xenobiotics. QRS complex prolongation was associated with increased odds ratio of seizure in all included xenobiotics, of ventricular dysrhythmia in all included xenobiotics except nortriptyline, and of metabolic acidosis or death in all included xenobiotics except nortriptyline and quetiapine. A normal QRS complex duration had a negative predictive value of greater than or equal to 93.0 percent of developing metabolic acidosis and 98.0 percent of developing a ventricular dysrhythmia or death from the xenobiotics studied. DISCUSSION This study demonstrates that patients with QRS complex prolongation from all six xenobiotics studied had an increased prevalence and odds of developing severe outcomes. Furthermore, patients who did not develop QRS complex prolongation were unlikely to develop a ventricular dysrhythmia, metabolic acidosis, or death. These findings were noted in six xenobiotics that mechanistically can cause QRS complex prolongation through sodium channel or gap junction inhibition. CONCLUSION Identification of patients at risk for severe outcomes after overdose can be aided by measuring the QRS complex duration. If prospectively validated, these outcomes have implications on risk stratification, disposition level of care, and appropriateness of treatments.
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Affiliation(s)
- Mark Simon
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Sabrina Kaplan
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Karen Muschler
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, University of CO, Aurora, CO, USA
| | - Jeffrey Brent
- Department of Emergency Medicine, University of CO, Aurora, CO, USA
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Cooper J, Duffull SB, Isbister GK. Predicting serotonin toxicity in serotonin reuptake inhibitor overdose. Clin Toxicol (Phila) 2023; 61:22-28. [PMID: 36444913 DOI: 10.1080/15563650.2022.2151455] [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: 12/02/2022]
Abstract
AIMS We aimed to investigate the frequency of serotonin toxicity following overdose of antidepressants that inhibit serotonin reuptake and the factors that influence the probability of serotonin toxicity occurring. METHODS This was a retrospective cohort study of overdoses that included selective serotonin reuptake inhibitors (SSRIs) (70%) and serotonin norepinephrine reuptake inhibitors (SNRIs) (30%) admitted to a tertiary toxicology unit over 23 years. A multivariate mixed effects logistic regression model using NONMEM (7.2.0) was used to determine factors that influenced the probability of serotonin toxicity occurring. RESULTS There were 1978 overdoses in 1520 patients; median age 33 y (range: 13-86 years) and 64% female. Median defined daily dose equivalent (DDD) was 15 (1-420). Co-ingestants were taken in 1678/1978 (85%) overdoses: 11 co-ingested the monoamine oxidase-A inhibitor (MAOI) moclobemide, 99 (5%) co-ingested olanzapine, 58 (3%) co-ingested risperidone and 417 co-ingested a benzodiazepine (21%). Serotonin toxicity occurred in 269 overdoses (13.6%). The probability of serotonin toxicity increased slightly per 10 DDD units dose [OR, 1.01; 95% confidence intervals (CIs): 0.93-1.10], increased for an SNRI vs. an SSRI [OR, 1.07; 95% CI: 0.99-1.15], and markedly increased with co-ingestion of moclobemide [OR, 33.12; 95% CI: 7.5-147]. The probability decreased per 10 y age [OR, 0.84; 95% CI: 0.74-0.95], and with co-ingestion of the serotonin 2 A receptor (5-HT2A) antagonists olanzapine [OR, 0.40; 95% CI: 0.17-0.94] or risperidone [OR, 0.13; 95% CI: 0.02-0.99]. The probability of serotonin toxicity was 12.5% at 1 DDD (therapeutic), 12.7% at 15 DDDs and 19% at 420 DDDs. In overdoses of the median dose of 15 DDDs, co-ingestion of moclobemide increased the probability to 83%, and co-ingestion of olanzapine or risperidone decreased it to 5.5% and 1.8%, respectively. CONCLUSIONS Serotonin toxicity is common following SSRI/SNRI overdose. Although dose increases probability, this was only a small effect. Co-ingestion with olanzapine or risperidone reduced the risk 2-6-fold, and moclobemide increased the risk 5-fold.
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Affiliation(s)
- Joyce Cooper
- Clinical Toxicology Research Group, University of Newcastle, Townsville, Australia.,Division of Tropical Health & Medicine, James Cook University, Townsville, Australia
| | | | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Townsville, Australia.,Department of Clinical Toxicology, Calvary Mater Newcastle, Newcastle, Australia
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The use of metaraminol as a vasopressor in critically unwell patients: a narrative review and a survey of UK practice. J Crit Care Med (Targu Mures) 2022; 8:193-203. [PMID: 36062042 PMCID: PMC9396948 DOI: 10.2478/jccm-2022-0017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/14/2022] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background
Major international guidelines state that norepinephrine should be used as the first-line vasopressor to achieve adequate blood pressure in patients with hypotension or shock. However, recent observational studies report that in the United Kingdom and Australia, metaraminol is often used as second line medication for cardiovascular support.
Aim of the study
The aim of this study was to carry out a systematic review of metaraminol use for management of shock in critically unwell patients and carry out a survey evaluating whether UK critical care units use metaraminol and under which circumstances.
Methods
A systematic review literature search was conducted. A short telephone survey consisting of 6 questions regarding metaraminol use was conducted across 30 UK critical care units which included a mix of tertiary and district general intensive care units.
Results
Twenty-six of thirty contacted centres responded to our survey. Metaraminol was used in 88% of them in various settings and circumstances (emergency department, theatres, medical emergencies on medical wards), with 67% reporting use of metaraminol infusions in the critical care setting. The systematic literature review revealed several case reports and only two studies conducted in the last 20 years investigating the effect of metaraminol as a stand-alone vasopressor. Both studies focused on different aspects of metaraminol use and the data was incomparable, hence we decided not to perform a meta-analysis.
Conclusions
Metaraminol is widely used as a vasopressor inside and outside of the critical care setting in the UK despite limited evidence supporting its safety and efficacy for treating shock. Further service evaluation, observational studies and prospective randomised controlled trials are warranted to validate the role and safety profile of metaraminol in the treatment of the critically unwell patient.
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Hong N, Liu C, Gao J, Han L, Chang F, Gong M, Su L. State of the Art of Machine Learning-Enabled Clinical Decision Support in Intensive Care Units: Literature Review. JMIR Med Inform 2022; 10:e28781. [PMID: 35238790 PMCID: PMC8931648 DOI: 10.2196/28781] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/02/2021] [Accepted: 12/01/2021] [Indexed: 12/23/2022] Open
Abstract
Background Modern clinical care in intensive care units is full of rich data, and machine learning has great potential to support clinical decision-making. The development of intelligent machine learning–based clinical decision support systems is facing great opportunities and challenges. Clinical decision support systems may directly help clinicians accurately diagnose, predict outcomes, identify risk events, or decide treatments at the point of care. Objective We aimed to review the research and application of machine learning–enabled clinical decision support studies in intensive care units to help clinicians, researchers, developers, and policy makers better understand the advantages and limitations of machine learning–supported diagnosis, outcome prediction, risk event identification, and intensive care unit point-of-care recommendations. Methods We searched papers published in the PubMed database between January 1980 and October 2020. We defined selection criteria to identify papers that focused on machine learning–enabled clinical decision support studies in intensive care units and reviewed the following aspects: research topics, study cohorts, machine learning models, analysis variables, and evaluation metrics. Results A total of 643 papers were collected, and using our selection criteria, 97 studies were found. Studies were categorized into 4 topics—monitoring, detection, and diagnosis (13/97, 13.4%), early identification of clinical events (32/97, 33.0%), outcome prediction and prognosis assessment (46/97, 47.6%), and treatment decision (6/97, 6.2%). Of the 97 papers, 82 (84.5%) studies used data from adult patients, 9 (9.3%) studies used data from pediatric patients, and 6 (6.2%) studies used data from neonates. We found that 65 (67.0%) studies used data from a single center, and 32 (33.0%) studies used a multicenter data set; 88 (90.7%) studies used supervised learning, 3 (3.1%) studies used unsupervised learning, and 6 (6.2%) studies used reinforcement learning. Clinical variable categories, starting with the most frequently used, were demographic (n=74), laboratory values (n=59), vital signs (n=55), scores (n=48), ventilation parameters (n=43), comorbidities (n=27), medications (n=18), outcome (n=14), fluid balance (n=13), nonmedicine therapy (n=10), symptoms (n=7), and medical history (n=4). The most frequently adopted evaluation metrics for clinical data modeling studies included area under the receiver operating characteristic curve (n=61), sensitivity (n=51), specificity (n=41), accuracy (n=29), and positive predictive value (n=23). Conclusions Early identification of clinical and outcome prediction and prognosis assessment contributed to approximately 80% of studies included in this review. Using new algorithms to solve intensive care unit clinical problems by developing reinforcement learning, active learning, and time-series analysis methods for clinical decision support will be greater development prospects in the future.
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Affiliation(s)
- Na Hong
- Digital Health China Technologies Ltd Co, Beijing, China
| | - Chun Liu
- Digital Health China Technologies Ltd Co, Beijing, China
| | - Jianwei Gao
- Digital Health China Technologies Ltd Co, Beijing, China
| | - Lin Han
- Digital Health China Technologies Ltd Co, Beijing, China
| | | | - Mengchun Gong
- Digital Health China Technologies Ltd Co, Beijing, China
| | - Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Hoegberg LCG, Shepherd G, Wood DM, Johnson J, Hoffman RS, Caravati EM, Chan WL, Smith SW, Olson KR, Gosselin S. Systematic review on the use of activated charcoal for gastrointestinal decontamination following acute oral overdose. Clin Toxicol (Phila) 2021; 59:1196-1227. [PMID: 34424785 DOI: 10.1080/15563650.2021.1961144] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The use of activated charcoal in poisoning remains both a pillar of modern toxicology and a source of debate. Following the publication of the joint position statements on the use of single-dose and multiple-dose activated charcoal by the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists, the routine use of activated charcoal declined. Over subsequent years, many new pharmaceuticals became available in modified or alternative-release formulations and additional data on gastric emptying time in poisoning was published, challenging previous assumptions about absorption kinetics. The American Academy of Clinical Toxicology, the European Association of Poison Centres and Clinical Toxicologists and the Asia Pacific Association of Medical Toxicology founded the Clinical Toxicology Recommendations Collaborative to create a framework for evidence-based recommendations for the management of poisoned patients. The activated charcoal workgroup of the Clinical Toxicology Recommendations Collaborative was tasked with reviewing systematically the evidence pertaining to the use of activated charcoal in poisoning in order to update the previous recommendations. OBJECTIVES The main objective was: Does oral activated charcoal given to adults or children prevent toxicity or improve clinical outcome and survival of poisoned patients compared to those who do not receive charcoal? Secondary objectives were to evaluate pharmacokinetic outcomes, the role of cathartics, and adverse events to charcoal administration. This systematic review summarizes the available evidence on the efficacy of activated charcoal. METHODS A medical librarian created a systematic search strategy for Medline (Ovid), subsequently translated for Embase (via Ovid), CINAHL (via EBSCO), BIOSIS Previews (via Ovid), Web of Science, Scopus, and the Cochrane Library/DARE. All databases were searched from inception to December 31, 2019. There were no language limitations. One author screened all citations identified in the search based on predefined inclusion/exclusion criteria. Excluded citations were confirmed by an additional author and remaining articles were obtained in full text and evaluated by at least two authors for inclusion. All authors cross-referenced full-text articles to identify articles missed in the searches. Data from included articles were extracted by the authors on a standardized spreadsheet and two authors used the GRADE methodology to independently assess the quality and risk of bias of each included study. RESULTS From 22,950 titles originally identified, the final data set consisted of 296 human studies, 118 animal studies, and 145 in vitro studies. Also included were 71 human and two animal studies that reported adverse events. The quality was judged to have a Low or Very Low GRADE in 469 (83%) of the studies. Ninety studies were judged to be of Moderate or High GRADE. The higher GRADE studies reported on the following drugs: paracetamol (acetaminophen), phenobarbital, carbamazepine, cardiac glycosides (digoxin and oleander), ethanol, iron, salicylates, theophylline, tricyclic antidepressants, and valproate. Data on newer pharmaceuticals not reviewed in the previous American Academy of Clinical Toxicology/European Association of Poison Centres and Clinical Toxicologists statements such as quetiapine, olanzapine, citalopram, and Factor Xa inhibitors were included. No studies on the optimal dosing for either single-dose or multiple-dose activated charcoal were found. In the reviewed clinical data, the time of administration of the first dose of charcoal was beyond one hour in 97% (n = 1006 individuals), beyond two hours in 36% (n = 491 individuals), and beyond 12 h in 4% (n = 43 individuals) whereas the timing of the first dose in controlled studies was within one hour of ingestion in 48% (n = 2359 individuals) and beyond two hours in 36% (n = 484) of individuals. CONCLUSIONS This systematic review found heterogenous data. The higher GRADE data was focused on a few select poisonings, while studies that addressed patients with unknown and or mixed ingestions were hampered by low rates of clinically meaningful toxicity or death. Despite these limitations, they reported a benefit of activated charcoal beyond one hour in many clinical scenarios.
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Affiliation(s)
- Lotte C G Hoegberg
- Department of Anesthesiology, The Danish Poisons Information Centre, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Greene Shepherd
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jami Johnson
- Oklahoma Center for Poison and Drug Information, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - E Martin Caravati
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Wui Ling Chan
- Department of Emergency Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Silas W Smith
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Kent R Olson
- California Poison Control System, San Francisco Division, University of California, San Francisco, California
| | - Sophie Gosselin
- Emergency Department CISSS Montérégie Centre, Greenfield Park, Canada.,Centre antipoison du Québec, Québec, Canada.,Department of Emergency Medicine, McGill Faculty of Medicine, Montreal, Canada
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Crofton AK, Harris K, Wylie C, Isoardi KZ. Unintentional paediatric iron poisoning: A retrospective case series. Emerg Med Australas 2021; 33:1044-1048. [PMID: 34121325 DOI: 10.1111/1742-6723.13806] [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: 11/28/2020] [Accepted: 04/21/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Iron poisoning is a historically important cause of paediatric morbidity and mortality. In recent decades, public health measures have considerably reduced paediatric iron exposures. We investigated unintentional paediatric iron poisoning in children with the aim of developing an assessment approach specific for this group. METHODS This was a retrospective observational study of unintentional iron poisoning in children (<7 years old) referred to either a state-wide poisons information service or a tertiary clinical toxicology unit from 1 January 2015 to 16 February 2020. Patients were identified from prospective databases maintained by both services, and data were extracted from these in addition to the medical record. RESULTS There were 54 children included in the study (29 [54%] male; median age 2 years (range 8 months to 4 years). The median suspected dose of elemental iron ingested was 72 mg/kg (IQR 41-140 mg/kg). Seventeen (31%) children were symptomatic. There were no cases of severe toxicity. Children symptomatic with gastrointestinal toxicity had a median suspected dose ingested of 60 mg/kg (IQR 38-150 mg/kg) that was similar to asymptomatic children (81 mg/kg [IQR 41-143 mg/kg], P = 0.809). The median peak iron concentration was 49 μmol/L (IQR 13.5-67.5 μmol/L, range 4-75 μmol/L). Symptomatic children had a significantly higher median peak serum iron concentration of 66 μmol/L (IQR 54-68 μmol/L) compared to 12 μmol/L (IQR 9-15 μmol/L) in asymptomatic children (P < 0.001). CONCLUSION Unintentional paediatric iron poisoning is uncommon and largely benign. Suspected dose ingested is a poor predictor of toxicity. Targeting investigations and interventions to symptomatic children should reduce unnecessary assessment and management while still safely managing the exposure.
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Affiliation(s)
- Andrew K Crofton
- Department of Emergency Medicine, Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Keith Harris
- Department of Emergency Medicine, Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Poisons Information Centre, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Carol Wylie
- Queensland Poisons Information Centre, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Katherine Z Isoardi
- Department of Emergency Medicine, Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Poisons Information Centre, Queensland Children's Hospital, Brisbane, Queensland, Australia
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Abstract
PURPOSE/BACKGROUND Quetiapine is a relatively new atypical antipsychotic with fewer adverse effects. It is increasingly prescribed to patients. The purpose of this study was to describe the cases of poisoning observed at the western France Poison Control Centre and identify potential risk factors that increase the severity of the cases. METHODS This was a retrospective study of self-poisoning with quetiapine as reported by the western France Poison Control Centre between 2007 and 2017. RESULTS There were 372 cases of quetiapine poisoning. Circumstances are known in 367 of 372 cases. There were 75 cases of null severity (grade 0), 133 cases of mild severity (grade 1), 85 cases of moderate severity (grade 2), and 79 cases of high severity (grade 3). Five deaths were listed in this series. The most commonly observed symptoms were neurological and cardiovascular in nature (drowsiness, coma, tachycardia, hypotension). Of these cases, 79.8% included voluntary ingestions. Among 302 cases with coagents, the most common coagents were benzodiazepines (56%), other psychotropic drugs (41%), and antidepressants (37%). An evaluated ingested dose 1500 mg or greater and 2 or more coagents increase the risk of severe poisoning. In particular, concomitant ingestion of benzodiazepines and antidepressants with quetiapine was associated with high severity (odds ratio, 2.478 [confidence interval, 1.3-4.723]; odds ratio, 1.820 [confidence interval, 1.010-3.316]). CONCLUSIONS Quetiapine may lead to severe poisoning for which there is currently no specific treatment. Patients and practitioners should be aware of this when quetiapine is prescribed, particularly when used in combination with other medications, and in order to deal with cases of poisoning.
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Acer O, Berger P. Coma prolongé suite à une intoxication à la quétiapine : influence des co-ingestions. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2019. [DOI: 10.1016/j.toxac.2019.03.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cairns R, Karanges EA, Wong A, Brown JA, Robinson J, Pearson SA, Dawson AH, Buckley NA. Trends in self-poisoning and psychotropic drug use in people aged 5-19 years: a population-based retrospective cohort study in Australia. BMJ Open 2019; 9:e026001. [PMID: 30787095 PMCID: PMC6398641 DOI: 10.1136/bmjopen-2018-026001] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To characterise trends in self-poisoning and psychotropic medicine use in young Australians. DESIGN Population-based retrospective cohort study. SETTING Calls taken by the New South Wales and Victorian Poisons Information Centres (2006-2016, accounting for 70% of Australian poisoning calls); medicine dispensings in the 10% sample of Australian Pharmaceutical Benefits Scheme data (July 2012 to June 2016). PARTICIPANTS People aged 5-19 years. MAIN OUTCOME MEASURES Yearly trends in intentional poisoning exposure calls, substances taken in intentional poisonings, a prevalence of psychotropic use (dispensing of antidepressants, antipsychotics, benzodiazepines and medicines for attention deficit hyperactivity disorder (ADHD)). RESULTS There were 33 501 intentional poisonings in people aged 5-19 years, with an increase of 8.39% per year (95% CI 6.08% to 10.74%, p<0.0001), with a 98% increase overall, 2006-2016. This effect was driven by increased poisonings in those born after 1997, suggesting a birth cohort effect. Females outnumbered males 3:1. Substances most commonly taken in self-poisonings were paracetamol, ibuprofen, fluoxetine, ethanol, quetiapine, paracetamol/opioid combinations, sertraline and escitalopram. Psychotropic dispensing also increased, with selective serotonin reuptake inhibitors (SSRIs) increasing 40% and 35% July 2012 to June 2016 in those aged 5-14 and 15-19, respectively. Fluoxetine was the most dispensed SSRI. Antipsychotics increased by 13% and 10%, while ADHD medication dispensing increased by 16% and 10%, in those aged 5-14 and 15-19, respectively. Conversely, dispensing of benzodiazepines to these age groups decreased by 4% and 5%, respectively. CONCLUSIONS Our results signal a generation that is increasingly engaging in self-harm and is increasingly prescribed psychotropic medications. These findings indicate growing mental distress in this cohort. Since people who self-harm are at increased risk of suicide later in life, these results may foretell future increases in suicide rates in Australia.
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Affiliation(s)
- Rose Cairns
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, Australia
| | - Emily A Karanges
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Anselm Wong
- Victorian Poisons Information Centre and Austin Toxicology Service, Austin Health, Heidelberg, Victoria, Australia
| | - Jared A Brown
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Jeff Robinson
- Victorian Poisons Information Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew H Dawson
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas A Buckley
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Pharmacology, University of Sydney, Sydney, New South Wales, Australia
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Taylor L, Graudins A. Extended-release quetiapine overdose is associated with delayed onset of toxicity compared to immediate-release quetiapine overdose. Emerg Med Australas 2018; 31:562-568. [PMID: 30485698 DOI: 10.1111/1742-6723.13205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 09/04/2018] [Accepted: 10/15/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES There are currently no studies comparing toxicity after extended-release (XR) and immediate-release (IR) quetiapine overdose. To compare the time course of toxicity of XR and IR quetiapine overdose. METHODS Retrospective analysis of toxicology unit consultations from July 2013 to April 2016. Information extracted included demographics, type of ingestion (IR, XR, mixed formulation, dose, tablet count, time to presentation, sedative co-ingestants), lowest Glasgow coma score (GCS), time to lowest GCS, fastest pulse, lowest systolic blood pressure, and time to recovery from sedation. RESULTS There were 256 presentations in 210 patients. Females 86% (n = 181), median age 30.5 years (IQR 23-43). Median quetiapine dose for the whole cohort was 2 g (IQR 1-5). Sedating co-ingestants were seen in 61% of presentations. Comparison of IR (n = 43) and XR quetiapine (n = 23) ingestions without sedating co-ingestants revealed a larger median ingested dose for XR formulation: 5.7 g versus 1.75 g (P = 0.004) and larger median tablet strength (XR 200 mg vs IR 100 mg, P < 0.001). Median time to lowest GCS: XR 7 h (IQR 4.9-11) versus IR 3.8 h (IQR 2.4-5.7), P < 0.001. Median time to peak pulse: XR 9 h (IQR 3-12) versus IR 2.5 h (IQR 1.5-5), P = 0.01. Median time to recovery from sedation: XR quetiapine 20 h (IQR 12-39) versus 12 h (IQR 5.5-22), P < 0.05. Median duration of intubation: XR 47 h versus 17 h for IR, P = 0.04). CONCLUSION XR quetiapine overdoses without sedating co-ingestants were associated with a doubling of time to peak sedation and pulse, and had longer recovery from sedation. The absence of sedation or tachycardia 12 h post-overdose of XR quetiapine seems a reasonable timeframe to rule out significant poisoning.
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Affiliation(s)
- Lucy Taylor
- Monash Emergency Research Collaborative, Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Andis Graudins
- Monash Emergency Research Collaborative, Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Monash Health Clinical Toxicology Unit, Monash Emergency Medicine Service, Dandenong Hospital, Melbourne, Victoria, Australia
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Diemberger I, Raschi E, Trifirò G. Balancing the Need for Personalization of QT Correction and Generalization of Study Results: Going Beyond Thorough QT Studies. Clin Drug Investig 2018; 37:985-988. [PMID: 28831689 DOI: 10.1007/s40261-017-0563-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico Sant'Orsola-Malpighi, Via Massarenti n. 9, 40138, Bologna, Italy.
| | - Emanuel Raschi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Gianluca Trifirò
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Sicily, Italy
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Montebello ME, Brett J. Misuse and Associated Harms of Quetiapine and Other Atypical Antipsychotics. Curr Top Behav Neurosci 2017; 34:125-139. [PMID: 26695164 DOI: 10.1007/7854_2015_424] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Recent years have seen a significant increase in the reports of atypical antipsychotic diversion, misuse and even dependency syndrome. These reports have arisen amidst a marked increase in prescribing of these agents. Much of this increase in prescribing is because of a preferential use of these medications over typical antipsychotic agents to treat schizophrenia and bipolar disorder due to perceptions of fewer extrapyramidal side effects. However, there has also been a significant increase in the off-label prescribing of these medicines to treat less well evidence-based conditions. Misuse and abuse are perhaps surprising given the putative central role of dopamine in addiction and that these agents are dopamine antagonists. However, there may be other factors such as other pharmacological effects and increasing availability driving this misuse. It is also apparent that certain patient groups appear to be more at risk. Here, we explore the evidence behind the misuse of atypical antipsychotics with a focus of quetiapine. We consider the factors that may be driving this misuse, and then, we also detail some of the adverse effects that may ensue. We end by suggesting interventions at a prescriber and systems level that may be implemented to reduce the risk of atypical antipsychotic misuse.
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Affiliation(s)
- Mark E Montebello
- Drug and Alcohol Service, South Eastern Sydney Local Health District, Surry Hills, Australia.
- National Drug and Alcohol Research Centre, University of New South Wales, Randwick, Australia.
| | - Jonathan Brett
- Drug Health Services, Sydney Local Health District, Camperdown, Australia
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Berling I, Buckley NA, Isbister GK. The antipsychotic story: changes in prescriptions and overdose without better safety. Br J Clin Pharmacol 2016; 82:249-54. [PMID: 26945707 DOI: 10.1111/bcp.12927] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 11/28/2022] Open
Abstract
AIMS Morbidity and mortality from drug overdose has decreased over three decades. This is credited to safer drugs and therefore better outcomes in overdose. We aimed to investigate changing prescriptions of antipsychotic medications and associated changes in antipsychotic overdoses over a 26-year period. METHODS All antipsychotic poisoning presentations to a tertiary referral toxicology unit between 1987 and 2012 were reviewed. Data were collected prospectively on demographics, ingestion information, clinical effects, complications and treatment. Rates of antipsychotic drug use in Australia were obtained from Australian government publications for 1990-2011 and linked to overdose admissions by postcode. RESULTS There were 3180 antipsychotic overdoses: 1235 first generation antipsychotics, 1695 'atypical' second generation antipsychotics and 250 lithium overdoses. Over 26 years, antipsychotic overdoses increased 1.8-fold, with first generation antipsychotics decreasing to one-fifth of their peak (≈80/year to 16) and second generation antipsychotics increasing to double this (≈160/year), olanzapine and quetiapine accounting for 78%. All antipsychotic overdoses had a median length of stay of 18.6 h, 15.7% admitted to intensive care unit, 10.4% ventilated and 0.13% died in hospital, which was the same for first generation compared to second generation antipsychotics. There was a 2.3-fold increase in antipsychotic prescriptions over the same period; first generation antipsychotics declined whereas there was a dramatic rise in second generation antipsychotics, mainly olanzapine, quetiapine and risperidone (79%). CONCLUSION Over 26 years there was an increase in antipsychotic prescribing associated with an increase in antipsychotic overdoses. Although the type of antipsychotics changed, the morbidity and mortality remained the same, so that antipsychotics are an increasing proportion of overdose admissions.
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Affiliation(s)
- Ingrid Berling
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Nicholas A Buckley
- Clinical Pharmacology, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Geoffrey K Isbister
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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Isbister GK. How do we assess whether the QT interval is abnormal: myths, formulae and fixed opinion. Clin Toxicol (Phila) 2015; 53:189-91. [PMID: 25695875 DOI: 10.3109/15563650.2015.1014044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Geoffrey K Isbister
- School of Medicine and Public Health, University of Newcastle , New South Wales , Australia
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15
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Coma After Quetiapine Fumarate Intentional Overdose in a 71-year-old Man: A Case Report. DRUG SAFETY - CASE REPORTS 2015; 2:3. [PMID: 27747715 PMCID: PMC4982457 DOI: 10.1007/s40800-015-0005-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A 71-year-old man developed coma with severe respiratory failure, hypotension, and tachycardia induced by the intentional ingestion of quetiapine fumarate extended release (XR) 20 g. At the time, he had been treated for bipolar depression with venlafaxine 75 mg/day, lamotrigine 100 mg/day, pregabalin 75 mg/day, and quetiapine XR 400 mg/day for approximately 1 year. Comorbidities were hypertension treated with metoprolol, diabetes mellitus type 2 treated with metformin, and benign prostatic hyperplasia treated with silodosin. In the emergency room, about 4 h after ingestion of quetiapine fumarate XR, the presenting symptomatology was characterized by coma (Glasgow Coma Scale score 3), hypotension (blood pressure [BP] 90/60 mmHg), tachycardia (electrocardiogram [ECG] showed sinus tachycardia with heart rate 120 beats per minute and a QTc of 499 ms). A gastric lavage was performed and activated charcoal 50 g and magnesium sulfate 30 g was administered. About 6 h after ingestion, he developed marked desaturation and underwent mechanical ventilation; 13 h after ingestion, a severe hypotensive episode followed (BP 70/40), which was treated with an infusion of ringer lactate 500 cc. On the 3rd day after intentional overdose, an episode of agitation occurred; 4 days after ingestion, the quetiapine plasma level was found to be 42 ng/ml (within therapeutic range). At 5 days after ingestion, the patient developed septicemia caused by staphylococci (probably originating from the central vein catheter), which was treated with antibiotic therapy. On days 10 and 18 after the suicide attempt, two episodes of paroxysmal supraventricular tachycardia (PSVT) occurred and were successfully treated with intravenous adenosine triphosphate. The patient recovered completely without residual symptoms. In line with literature data, in this case report, symptoms of quetiapine overdose were tachycardia, agitation, hypotension, QT interval prolongation, and coma. A causal relationship between PSVT and quetiapine intoxication seems quite unlikely due to the drug level.
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Abstract
Drugs can cause prolongation of the QT interval, alone or in combination, potentially leading to fatal arrhythmias such as torsades de pointes. When prescribing drugs that prolong the QT interval, the balance of benefit versus harm should always be considered. Readouts from automated ECG machines are unreliable. The QT interval should be measured manually. Changes in heart rate influence the absolute QT interval. Heart rate correction formulae are inaccurate, particularly for fast and slow heart rates. The QT nomogram, a plot of QT interval versus heart rate, can be used as a risk assessment tool to detect an abnormal QT interval.
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Affiliation(s)
- Geoffrey K Isbister
- School of Medicine and Public Health, University of Newcastle, New South Wales
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17
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QTc interval prolongation and torsade de pointes associated with second-generation antipsychotics and antidepressants: a comprehensive review. CNS Drugs 2014; 28:887-920. [PMID: 25168784 DOI: 10.1007/s40263-014-0196-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We comprehensively reviewed published literature to determine whether it supported the link between corrected QT (QTc) interval prolongation and torsade de pointes (TdP) for the 11 second-generation antipsychotics and seven second-generation antidepressants commonly implicated in these complications. Using PubMed and EMBASE, we identified four thorough QT studies (one each for iloperidone, ziprasidone, citalopram, and escitalopram), 40 studies specifically designed to assess QTc interval prolongation or TdP, 58 publications based on data from efficacy and safety trials, 18 toxicology studies, and 102 case reports. Thorough QT studies, QTc prolongation-specific studies, and studies based on efficacy and safety trials did not link drug-associated QTc interval prolongation with TdP. They only showed that the drugs reviewed caused varying degrees of QTc interval prolongation, and even that information was not clear and consistent enough to stratify individual drugs for this risk. The few toxicology studies provided valuable information but their findings are pertinent only to situations of drug overdose. Case reports were most informative about the drug-QTc interval prolongation-TdP link. At least one additional well established risk factor for QTc prolongation was present in 92.2 % of case reports. Of the 28 cases of TdP, six (21.4 %) experienced it with QTc interval <500 ms; 75 % of TdP cases occurred at therapeutic doses. There is little evidence that drug-associated QTc interval prolongation by itself is sufficient to predict TdP. Future research needs to improve its precision and broaden its scope to better understand the factors that facilitate or attenuate progression of drug-associated QTc interval prolongation to TdP.
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18
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Downes MA, Calver LA, Isbister GK. Intralipid therapy does not improve level of consciousness in overdoses with sedating drugs: a case series. Emerg Med Australas 2014; 26:286-90. [PMID: 24810248 DOI: 10.1111/1742-6723.12237] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the effect of intralipid emulsion therapy (ILE) in sedating drugs presenting to an urban emergency department. METHODS Following the introduction of a clinical protocol for the use of ILE a retrospective chart review was undertaken, which describes the use of ILE in treating sedating drug overdose in a facility with a tertiary referral level clinical toxicology unit. Demographic data as well as details of drug ingested, physiological parameters and disposition were extracted from the medical record. RESULTS Over a 7 month period nine cases were treated with intralipid, of which two were male and the median age was 33 years (17-52 years). Endotracheal intubation was required in seven cases and of the other two, one required a nasopharyngeal airway for several hours while being observed in a critical care area. One patient was managed in the intensive care unit without intubation. The median duration of ventilation in the seven patients was 31 h (22-82 h), and median length of stay for all nine cases was 63 h (24-133 h). CONCLUSION This study does not support any clinically significant effect of intralipid in sedating drug overdose.
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Affiliation(s)
- Michael A Downes
- Department of Emergency Medicine, Calvary Mater Newcastle, Newcastle, New South Wales, Australia; Faculty of Public Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia; Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
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19
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Isbister GK, Page CB. Drug induced QT prolongation: the measurement and assessment of the QT interval in clinical practice. Br J Clin Pharmacol 2014; 76:48-57. [PMID: 23167578 DOI: 10.1111/bcp.12040] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 11/06/2012] [Indexed: 01/22/2023] Open
Abstract
There has been an increasing focus on drug induced QT prolongation including research on drug development and QT prolongation, following the removal of drugs due to torsades de pointes (TdP). Although this has improved our understanding of drug-induced QT prolongation there has been much less research aimed at helping clinicians assess risk in individual patients with drug induced QT prolongation. This review will focus on assessment of drug-induced QT prolongation in clinical practice using a simple risk assessment approach. Accurate measurement of the QT interval is best done manually, and not using the measurement of standard ECG machines. Correction for heart rate (HR) using correction formulae such as Bazett's is often inaccurate. These formulae underestimate and overestimate the duration of cardiac repolarization at low and high heart rates, respectively. Numerous cut-offs have been suggested as an indicator of an abnormal QT, but are problematic in clinical practice. An alternative approach is the QT nomogram which is a plot of QT vs. HR. The nomogram has an 'at risk' line and QT-HR pairs above this line have been shown in a systematic study to be associated with TdP and the line is more sensitive and specific than Bazett's QTc of 440 ms or 500 ms. Plotting the QT-HR pair for patients on drugs suspected or known to cause QT prolongation allows assessment of the QT interval based on normal population QT variability. This risk assessment then allows the safer commencement of drugs therapeutically or management of drug induced effects in overdose.
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Affiliation(s)
- Geoffrey K Isbister
- Discipline of Clinical Pharmacology, University of Newcastle, Newcastle, NSW 2298, Australia.
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20
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López-Guarnido O, Tabernero MJ, Hernández AF, Rodrigo L, Bermejo AM. Rapid determination of quetiapine in blood by gas chromatography-mass spectrometry. Application to post-mortem cases. J Appl Toxicol 2013; 34:1104-8. [DOI: 10.1002/jat.2944] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 09/09/2013] [Accepted: 09/09/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Olga López-Guarnido
- Department of Legal Medicine and Toxicology; University of Granada School of Medicine; Avda. Madrid, 11 18071 Granada Spain
| | - María Jesús Tabernero
- Institute of Legal Medicine, Forensic Toxicology Service, Faculty of Medicine San Francisco; s/n 15782 Santiago de Compostela Spain
| | - Antonio F. Hernández
- Department of Legal Medicine and Toxicology; University of Granada School of Medicine; Avda. Madrid, 11 18071 Granada Spain
| | - Lourdes Rodrigo
- Department of Legal Medicine and Toxicology; University of Granada School of Medicine; Avda. Madrid, 11 18071 Granada Spain
| | - Ana M. Bermejo
- Institute of Legal Medicine, Forensic Toxicology Service, Faculty of Medicine San Francisco; s/n 15782 Santiago de Compostela Spain
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Hrabetz H, Thiermann H, Felgenhauer N, Zilker T, Haller B, Nährig J, Saugel B, Eyer F. Organophosphate poisoning in the developed world - a single centre experience from here to the millennium. Chem Biol Interact 2013; 206:561-8. [PMID: 23685200 DOI: 10.1016/j.cbi.2013.05.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/06/2013] [Accepted: 05/08/2013] [Indexed: 12/20/2022]
Abstract
Organophosphate (OP) poisoning is still associated with high morbidity and mortality rates, both in resource-poor settings and in well-developed countries. Despite numerous publications dealing with this particular poison, detailed clinical data on more severe overdoses with these agents are relatively sparsely reported. A retrospective study was consequently conducted on 33 patients with OP poisoning admitted to our intensive care unit (ICU) to provide additional data on clinical features. We included moderate to severe poisonings between 2000 and 2012 who required admission to ICU. Patients ingested dimethyl-OPs in 19 cases, diethyl-OPs in 8 cases and otherwise classified OPs in 6 cases. Death (5/33) occurred rather late and only one of these fatalities died during on-going cholinergic crisis. Of the survivors (28/33), 71% recovered fully while 29% showed predominantly neurological disabilities before being transferred to neurologic rehabilitation. Aspiration pneumonia predominated in 27/33 patients and one patient died in refractory acute respiratory distress syndrome (ARDS). The intermediate syndrome occurred twice and cardiopulmonary resuscitation had to be performed in 6/33 patients. Fatalities showed a higher Poison-severity-score, APACHE-II-score and SOFA-score on admission compared with survivors and they showed significantly longer QTc-time in the ECG, lower systolic blood pressure and heart rate, a lower pH and a lower base excess on admission. Patients with diethyl-OPs required intubation significantly earlier and showed lower and more sustained inhibited activity of the plasma-cholinesterase on admission compared with patients ingesting dimethyl-OPs. Treatment with atropine and obidoxime was comparable between these groups and severity of poisoning, outcome, hemodynamics on admission, duration of mechanical ventilation and length of stay in the ICU did not significantly differ between the involved group of dimethyl- and diethyl-OPs. We conclude that the fatality rate in our patient cohort treated in a well-staffed and equipped ICU of a developed country is quite similarly high compared with the rate observed in developing countries. Patients died rather late when severe cholinergic crisis had mostly been overcome and death was therefore related to non-poison specific complications.
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Affiliation(s)
- Heidi Hrabetz
- Department of Clinical Toxicology, II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany
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XXXIII International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 28–31 May 2013, Copenhagen, Denmark. Clin Toxicol (Phila) 2013. [DOI: 10.3109/15563650.2013.785188] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Heilbronn C, Lloyd B, McElwee P, Eade A, Lubman DI. Trends in quetiapine use and non-fatal quetiapine-related ambulance attendances. Drug Alcohol Rev 2013; 32:405-11. [PMID: 23350582 DOI: 10.1111/dar.12028] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 12/31/2012] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND AIMS Concern about the non-medical use of quetiapine and related acute harms is growing. Case series cite quetiapine as a potential drug of misuse, while recent research questions its relative safety in comparison with other atypical antipsychotic preparations. This paper explores population-level patterns of quetiapine-related ambulance attendances over time, identifying associated risk factors and potential subpopulations at-risk of acute harms. DESIGN AND METHODS A retrospective analysis of quetiapine-, olanzapine- and risperidone-related ambulance attendances in metropolitan Melbourne and prescription data in Victoria, Australia. Trends in ambulance attendance and prescription rates, attendance characteristics, and associated risk factors were explored from 2001 to 2010. RESULTS Quetiapine was consistently associated with substantially higher rates of ambulance attendances relative to prescription availability than olanzapine or risperidone. Quetiapine prescribing rates increased at a significantly greater magnitude than olanzapine or risperidone, leading to substantial increases in quetiapine attendances by population. Quetiapine-related attendances were associated with concurrent heroin and opioid replacement therapy toxicity, history of heroin and alcohol misuse, mood disorders, low Glasgow Coma Scale and women. DISCUSSION AND CONCLUSIONS Trends in quetiapine-related ambulance attendances indicate rising community-level harms and greater harm relative to other atypical antipsychotics, while prescription patterns suggest increasing quetiapine availability. The association of quetiapine-related attendances with concurrent heroin and opioid replacement therapy toxicity as well as previous heroin and alcohol misuse suggest illicit and poly-drug users are a subpopulation at greater risk of quetiapine-related harms, consistent with emerging evidence of the use, misuse and diversion of quetiapine.
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Affiliation(s)
- Cherie Heilbronn
- Turning Point Alcohol and Drug Centre, Eastern Health, Melbourne, Australia.
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Levine M, Ruha AM. Overdose of atypical antipsychotics: clinical presentation, mechanisms of toxicity and management. CNS Drugs 2012; 26:601-11. [PMID: 22668123 DOI: 10.2165/11631640-000000000-00000] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Historically, treatment for schizophrenia focused on sedation. The advent of the typical antipsychotics resulted in treatment aimed specifically at the underlying disease, but these agents were associated with numerous adverse effects, and were not particularly effective at treatment of the negative symptoms of schizophrenia. As a result, numerous atypical agents have been developed over the past 2 decades, including several agents within the past 5 years. Overdose of antipsychotics remains quite common in Western society. In 2010, poison control centres in the US received nearly 43,000 calls related to atypical antipsychotics alone. Due to underreporting, the true incidence of overdose with atypical antipsychotics is likely much greater. Following overdose of an atypical antipsychotic, the clinical effects observed, such as CNS depression, tachycardia and orthostasis are largely predictable based on the unique receptor binding profile of the agent. This article, which focuses on the atypical antipsychotics commonly used in the treatment of schizophrenia, discusses the features commonly encountered in overdose. Specifically, agents that result in QT prolongation and the corresponding potential for torsades de pointes, as well as unique features encountered with the various medications are discussed. The diagnosis of this overdose is largely based on history. Routine use of drug screens is unlikely to be beneficial. The primary goal of management is aggressive supportive care. Patients with significant CNS depression with associated loss of airway reflexes and respiratory failure need advanced airway management. Hypotension should be treated first with intravenous fluids, with the use of direct acting vasopressors reserved for persistent hypotension. Benzodiazepines should be used for seizures, with barbiturates used for refractory seizures. Intravenous magnesium can be administered for patients with a corrected QT interval exceeding 500 milliseconds.
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Affiliation(s)
- Michael Levine
- Section of Medical Toxicology, Department of Emergency Medicine, University of Southern California, Los Angeles, CA 90033, USA.
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van Gorp F, Duffull S, Hackett LP, Isbister GK. Population pharmacokinetics and pharmacodynamics of escitalopram in overdose and the effect of activated charcoal. Br J Clin Pharmacol 2012; 73:402-10. [PMID: 21883384 DOI: 10.1111/j.1365-2125.2011.04091.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS To describe the pharmacokinetics and pharmacodynamics (PKPD) of escitalopram in overdose and its effect on QT prolongation, including the effectiveness of single dose activated charcoal (SDAC). METHODS The data set included 78 escitalopram overdose events (median dose, 140mg [10-560mg]). SDAC was administered 1.0 to 2.6 h after 12 overdoses (15%). A fully Bayesian analysis was undertaken in WinBUGS 1.4.3, first for a population pharmacokinetic (PK) analysis followed by a PKPD analysis. The developed PKPD model was used to predict the probability of having an abnormal QT as a surrogate for torsade de pointes. RESULTS A one compartment model with first order input and first-order elimination described the PK data, including uncertainty in dose and a baseline concentration for patients taking escitalopram therapeutically. SDAC reduced the fraction absorbed by 31% and reduced the individual predicted area under the curve adjusted for dose (AUC(i) /dose). The absolute QT interval was related to the observed heart rate with an estimated individual heart rate correction factor (α= 0.35). The heart rate corrected QT interval (QT(c) ) was linearly dependent on predicted escitalopram concentration [slope = 87ms/(mgl(-1) )], using a hypothetical effect-compartment (half-life of effect-delay, 1.0h). Administration of SDAC significantly reduced QT prolongation and was shown to reduce the risk of having an abnormal QT by approximately 35% for escitalopram doses above 200mg. CONCLUSIONS There was a dose-related lengthening of the QT interval that lagged the increase in drug concentration. SDAC resulted in a moderate reduction in fraction of escitalopram absorbed and reduced the risk of the QT interval being abnormal.
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Affiliation(s)
- Freek van Gorp
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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26
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Lannemyr L, Knudsen K. Severe overdose of quetiapine treated successfully with extracorporeal life support. Clin Toxicol (Phila) 2012; 50:258-61. [DOI: 10.3109/15563650.2012.665456] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Eyer F, Pfab R, Felgenhauer N, Strubel T, Saugel B, Zilker T. Clinical and analytical features of severe suicidal quetiapine overdoses – a retrospective cohort study. Clin Toxicol (Phila) 2011; 49:846-53. [DOI: 10.3109/15563650.2011.624100] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Florian Eyer
- Toxicological Department, Klinikum rechts der Isar,
Ismaninger Strasse 22, Munich, Germany
| | - Rudolf Pfab
- Toxicological Department, Klinikum rechts der Isar,
Ismaninger Strasse 22, Munich, Germany
| | - Norbert Felgenhauer
- Toxicological Department, Klinikum rechts der Isar,
Ismaninger Strasse 22, Munich, Germany
| | - Tim Strubel
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar,
Ismaninger Strasse 22, Munich, Germany
| | - Bernd Saugel
- Medical Intensive Care Unit, Klinikum rechts der Isar, II. Medizinische Klinik,
Ismaninger Strasse 22, Munich, Germany
| | - Thomas Zilker
- Toxicological Department, Klinikum rechts der Isar,
Ismaninger Strasse 22, Munich, Germany
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Abstract
PURPOSE OF REVIEW Gastrointestinal decontamination in overdose patients remains a controversial problem in emergency medicine. There has been a significant decrease in the use of single-dose activated charcoal (SDAC) in recent years based on little new evidence and possibly because the overall mortality in overdose patients is low. RECENT FINDINGS Human volunteer studies suggest SDAC is effective and this effect occurs for up to 4 h after ingestion, but the magnitude of the reduction in area under the curve (AUC) decreases over time. Two randomized controlled trials including one recent large study did not find SDAC to be beneficial. Pharmacokinetic and pharmacodynamic studies of specific drugs in overdose suggest that for most drugs SDAC decreases drug exposure, but this does not translate to clinical benefit in all cases. The administration of SDAC is a low-risk intervention. SUMMARY Although SDAC is unlikely to be beneficial in many overdose patients, for some subgroups with severe poisoning, the benefits will outweigh the low risk of administration. The use of SDAC should be based on the potential toxicity of the drug ingested and the potential benefit of SDAC balanced against the willingness of the patient to take SDAC and the low risk of administration.
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Aghaienia N, Brahm NC, Lussier KM, Washington NB. Probable quetiapine-mediated prolongation of the QT interval. J Pharm Pract 2011; 24:506-12. [PMID: 21844216 DOI: 10.1177/0897190011415683] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE QT prolongation can occur with both first- (FGA) and second-generation antipsychotics (SGA). QT prolongation was identified in an adult patient who presented to the emergency room with schizophrenia, fluid and electrolyte imbalances, and pneumonia. Quetiapine, an SGA, was a component of the pharmacotherapy regimen. Based on the Naranjo adverse drug reaction probability scale rating criteria, a probable causal association was made. METHODS PubMed and Ovid were searched using the terms antipsychotic, psychotropic, QT interval, corrected QT interval (QTc) prolongation, and quetiapine. References were examined for additional articles related to antipsychotic drugs and the QT interval. DISCUSSION In this patient, the use of quetiapine was identified as a contributing factor in QT prolongation. Prior QT prolongation was experienced with ziprasidone, another SGA. The antidepressant and dose remained consistent throughout the inpatient course of treatment. Other risk factors in this patient included hypokalemia, dehydration, pneumonia, age, gender, and concurrent usage of an antidepressant. Dual psychiatric diagnoses, preexisting cardiovascular disease, and electrolyte disturbances may increase this risk potential. CONCLUSION Psychiatric patients may be more at risk of cardiovascular complications, such as QT interval prolongation. The pharmacist can help evaluate risk factors and provide input into the care of all patients, particularly those identified as at risk.
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Affiliation(s)
- Nasim Aghaienia
- Department of Pharmacy Practice, Clinical and Administrative Sciences-Tulsa, University of Oklahoma College of Pharmacy, Tulsa, OK 74135, USA
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Capuano A, Ruggiero S, Vestini F, Ianniello B, Rafaniello C, Rossi F, Mucci A. Survival from coma induced by an intentional 36-g overdose of extended-release quetiapine. Drug Chem Toxicol 2011; 34:475-7. [PMID: 21770717 DOI: 10.3109/01480545.2011.564178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Quetiapine is a second-generation antipsychotic drug approved for the treatment of bipolar disorders and schizophrenia. Acute quetiapine overdose is rare, and quetiapine has long been thought to be safer than other antipsychotics. Nevertheless, as reported in the literature, the severity of the effect of quetiapine overdose has not been associated with a high serum concentration of the drug or with the reported ingested dose. In this article, we report a case of survival from coma induced by a massive extended-release (XR) quetiapine ingestion at a dose greater than reported in some previous fatal cases. A 34-year-old woman with chronic schizophrenia ingested 36 g of quetiapine fumarate XR for attempted suicide. She was initially lethargic, but her clinical conditions rapidly deteriorated and she collapsed unconscious. The woman was taken to the nearest hospital, where the medical emergency team found her in deep coma with response only to deep painful stimuli (Glasgow Coma Scale 9). An endotracheal tube was inserted for airway protection, and the patient was transferred to a critical care area for ventilatory support and maintenance of hydration status and electrolytic balance. Spontaneous breathing was restored in approximately 36 hours, and a few days later, she was discharged without reporting clinical complications. This is the first case of coma induced by an intentional 36-g overdose of quetiapine XR. Given the widespread use of quetiapine and the lack of information about its toxicity in overdose, this case report reinforces the importance of closely monitoring patients taking quetiapine and helps to better define the safety of this drug.
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Affiliation(s)
- Annalisa Capuano
- Department of Experimental Medicine, Section of Pharmacology Leonardo Donatelli, Regional Center of Pharmacosurveillance and Pharmacoepidemiology, Faculty of Medicine and Surgery, Second University of Naples, Naples, Italy.
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Isbister GK. Pharmacokinetic–pharmacodynamic modeling in overdose patients – Is it worth the trouble? Clin Toxicol (Phila) 2010; 48:896-7. [DOI: 10.3109/15563650.2010.533680] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA. Randomized Controlled Trial of Intramuscular Droperidol Versus Midazolam for Violence and Acute Behavioral Disturbance: The DORM Study. Ann Emerg Med 2010; 56:392-401.e1. [DOI: 10.1016/j.annemergmed.2010.05.037] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 05/18/2010] [Accepted: 05/26/2010] [Indexed: 11/27/2022]
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Abstract
The role of drug assays for screening, diagnosis, and guiding treatment decisions in overdose patients remains unclear. The use of drug concentration data in clinical toxicology research is more problematic, with studies using drug concentrations to simply confirm ingestion in observational studies or others report drug concentration time profiles with simplified pharmacokinetics. The reasons for the lack of more substantial pharmacokinetic and/or pharmacodynamic analysis in overdose patients include problems with uncertainty in dose, uncertainty in the time of ingestion, and limited sampling in the absorption phase. Many of these can be overcome by using population pharmacokinetic and pharmacokinetic-pharmacodynamic analysis in prospective studies of overdose patients to understand dose-concentration-effect relationships. Uncertainty in dose and dose time can be included using population analysis techniques, which may involve a clinical assessment of the veracity of the patient history. The pharmacokinetic-pharmacodynamic model can then be used as the basis for predicting toxicity and clinical outcomes from historical information such as dose and early clinical effects. Using such an approach means that the use of drug concentration data in research will improve the risk assessment in overdose patients, without requiring these assays to be rapidly available in the acute health setting.
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Abstract
This study aimed to describe the effects of the antipsychotic amisulpride in overdose, including the frequency of QT prolongation and torsades de pointes. Cases of amisulpride overdose (>1 g) were recruited from 2 state poison centers and a tertiary toxicology unit over 5 years. A 1-page clinical research form was used to collect clinical information. Copies of all electrocardiograms were obtained. Electrocardiogram parameters (QRS and QT intervals) were manually measured as previously described, and plots of QT-heart rate (HR) pairs were compared with the QT nomogram. There were 83 patients with amisulpride overdoses with a median age of 29 years (interquartile range [IQR], 23-40 years), and 42 (51%) were female. The median dose ingested was 6 g (IQR, 3-13 g, range, 1.2-120 g). The median HR was 66 beats/min (IQR, 60-81 beats/min). Bradycardia occurred in 20 cases (24%), and hypotension in 19 (23%). From 440 electrocardiograms (average of 5 per case; range, 1-15), an abnormal QT-HR pair occurred in 61 cases (73%). Torsades de pointes developed in 6 cases (7%), with doses of 4, 4.6, 18, 24, 32, and 80 g. The patient taking 32 g died after a cardiac arrest. Widened QRS did not occur except transient rate-dependent bundle-branch block in 3 cases. There were significant associations of bradycardia, hypokalemia, and hypocalcaemia, with QT prolongation and torsades de pointes. Central nervous system effects were uncommon with coma in 7 cases, seizures in 2, and dystonic reactions in 2. Amisulpride overdose commonly causes QT prolongation, bradycardia, and hypotension. Torsades de pointes occurred commonly enough to suggest that amisulpride is highly cardiotoxic in overdose.
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Smithburger PL, Seybert AL, Armahizer MJ, Kane-Gill SL. QT prolongation in the intensive care unit: commonly used medications and the impact of drug–drug interactions. Expert Opin Drug Saf 2010; 9:699-712. [DOI: 10.1517/14740331003739188] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Uncles DR, Willers J, Sable N, Finn SDH. Gift of the glob goes global. Anaesthesia 2010; 65:209-10. [DOI: 10.1111/j.1365-2044.2009.06214.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Isbister GK, Calver L, Van Gorp F, Stokes B, Page CB. Inter-rater reliability of manual QT measurement and prediction of abnormal QT,HR pairs. Clin Toxicol (Phila) 2009; 47:884-8. [DOI: 10.3109/15563650903333820] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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