Cyanide poisoning and its treatment

Time to Burn? Characteristics of Hydroxocobalamin Administration in an Academic Medical Center

Background/Objective: Hydroxocobalamin is indicated for cyanide poisoning and its package insert states it should be given "without delay". We sought to evaluate time to administration and clinical characteristics when hydroxocobalamin was administered in a quaternary care academic medical center. Methods: All hydroxocobalamin administrations from January 1, 2007 to December 31, 2018 were analyzed. Data points recorded were: carboxyhemoglobin, cyanide and methemoglobin levels, hospital time and course, time and dose of hydroxocobalamin administration, lactate and bicarbonate levels, initial and nadir pH, initial heart rate, and initial and lowest systolic blood pressure. Results: Fifty-six cases were identified. One case was excluded as hydroxocobalamin was administered for nitroprusside toxicity. Among 55 cases analyzed, 93% (n = 51) were adults. Median hospital length of stay was 4.3 days (IQR 2.5 to 12). Burn, inhalation injury, and smoke inhalation were 80% of admitting diagnoses. Median time to hydroxocobalamin administration was 208 minutes (IQR 62.5 to 330). Eleven of 55 cases died. Hydroxocobalamin was given within 60 minutes of arrival in 12 cases, of which 3 died. All adults received 5 g of hydroxocobalamin. Time to hydroxocobalamin administration was longer in death cases [median: 221 minutes (IQR 119 to 594)] vs survivors [median: 184.5 minutes (IQR 62.8 to 315)]. Seventeen cases had cyanide levels drawn, with 9 being measurable, but none were toxic. Conclusions: Significant delay in hydroxocobalamin administration was seen in this study. Cases that resulted in death had significantly longer times to hydroxocobalamin administration. Further studies are warranted to identify reasons for delays in hydroxocobalamin administration.

An α-benzithiazolyl 3-pyrrolyl BODIPY probe for ratiometric selective sensing of cyanide ions and bioimaging studies

A simple chromo-fluorogenic chemodosimeter probe, α-benzithiazolyl 3-pyrrolyl BODIPY, was synthesized by reacting α-formyl 3-pyrrolyl BODIPY with 2-aminothiophenol in DMF at reflux under basic conditions. The probe was structurally characterized by X-ray, HR-MS, and 1D & 2D NMR techniques. The X-ray structure revealed that the appended pyrrole was almost in the plane with a small deviation of 12.15° from the 12-atom mean plane of the BF2-dipyrrin core and the benzithiazolyl moiety was also deviated by 18.74° from the BF2-dipyrrin core. The α-benzithiazolyl 3-pyrrolyl BODIPY exhibits one intense absorption band at 608 nm and a less intense band at 412 nm corresponding to the 3-pyrrolyl BODIPY and benzithiazolyl moiety, respectively. The strongly fluorescent probe shows one intense emission band at 637 nm with a quantum yield of 0.48. The probe acted as an exclusive colorimetric and chemodosimetric sensor for CN- ions over other anions with high sensitivity (LOD = 13 nM) and quick response time (10 s) in an aqueous CH3CN medium. The CN- ion attacks the imine group of the benzithiazolyl moiety of 3via a nucleophilic addition reaction and converts the sp2 to sp3 carbon which disrupts the conjugation between the 3-pyrrolyl BODIPY and benzithiazolyl moieties, which is reflected in the clear colour change from red fluorescence to blue fluorescence as well as significant changes in the spectral and electrochemical properties. The detection of cyanide with the probe for biological applications was also performed with plant tissue. DFT/TD-DFT studies were in agreement with the experimental observations.

Cyanide poisoning after bitter almond ingestion: "A rare case report"

We present a case of a 36-year-old woman with a history of three suicide attempts who had ingested approximately 40 bitter almonds in a suicidal act, leading to her admission to the emergency department of a regional hospital due to complaints of vomiting. Upon arrival, she exhibited confusion, and her vital signs were recorded as follows: pulse rate = 117 beats/min, blood pressure = 160/85 mmHg, oxygen saturation = 95%, respiratory rate = 16, temperature = 37°C. The patient venous blood gas analysis manifested severe metabolic acidosis (pH = 6.92, pO2 = 43 mmHg, HCO3 = 8.6 mmol/L, pCO2 = 42.7 mmHg, base excess = -25.9 mmol/L). Four hours later, she became unconscious and she was intubated. Gastric lavage and a single dose of 60 g of activated charcoal and sodium bicarbonate were administered. In the referral hospital, sodium nitrite was given due to the severity of the poisoning, and norepinephrine infusion was initiated to manage hypotension. Within a day, the patient regained consciousness, underwent extubation, and after 72 h was discharged and subsequently transferred to psychiatric care for further treatment. This case underscores the critical, life-threatening implications of cyanide toxicity following the ingestion of bitter almonds, highlighting the efficacy of supportive measures such as gastric lavage, activated charcoal, and sodium bicarbonate. Furthermore, it emphasizes the successful application of sodium nitrite monotherapy in managing this condition.

Evaluating the health impact of increased linseed consumption in the Danish population

Consumption of linseeds has been suggested to have beneficial effects on human health. However, toxic constituents of linseed may compromise these benefits. We conducted a quantitative risk-benefit assessment to evaluate the overall health impact of increasing linseed intake up to 45 g/day in the Danish population (15-74 years). We quantified the risks associated with increased cadmium exposure and the benefits associated with increased intake of dietary fibre. Increased intakes of alpha-linoleic acid (ALA) were included in a sensitivity analysis. The overall health impact of different linseed intake scenarios was estimated in terms of Disability-Adjusted Life Years (DALYs). We found that the beneficial effects of linseed due to increased intake of dietary fibre outweighed the adverse health effects due to increased cadmium exposure in all scenarios. Up to 670 DALYs/100,000 individuals could be averted per year by increasing linseed consumption in the Danish population. The estimated beneficial health impact increased further when including ALA in the assessment. Different sources of uncertainty might affect the results, and more research is needed on both the health effects associated with intake of linseed and its constituents, and the bioavailability of ALA and cadmium from linseed to further improve the risk-benefit assessment.

Tissue Perfusion and Diffusion and Cellular Respiration: Transport and Utilization of Oxygen

This article provides an overview of the journey of inspired oxygen after its uptake across the alveolar-capillary interface, and the interplay among tissue perfusion, diffusion, and cellular respiration in the transport and utilization of oxygen. The critical interactions between oxygen and its facilitative carriers (hemoglobin in red blood cells and myoglobin in muscle cells), and with other respiratory and vasoactive molecules (carbon dioxide, nitric oxide, and carbon monoxide), are emphasized to illustrate how this versatile system dynamically optimizes regional convective transport and diffusive gas exchange. The rates of reciprocal gas exchange in the lung and the periphery must be well-matched and sufficient for meeting the range of energy demands from rest to maximal stress but not excessive as to become toxic. The mobile red blood cells play a vital role in matching tissue perfusion and gas exchange by dynamically regulating the controlled uptake of oxygen and communicating regional metabolic signals across different organs. Intracellular oxygen diffusion and facilitation via myoglobin into the mitochondria, and utilization via electron transport chain and oxidative phosphorylation, are summarized. Physiological and pathophysiological adaptations are briefly described. Dysfunction of any component across this integrated system affects all other components and elicits corresponding structural and functional adaptation aimed at matching the capacities across the entire system and restoring equilibrium under normal and pathological conditions.

Sodium nitrite poisoning: A series of 20 fatalities in which post-mortem blood nitrite and nitrate concentrations are reported

Sodium nitrite has several industrial applications however its accidental or intentional ingestion has been associated with severe toxicity and death. We present a series of 20 cases over 2 years in which evidence of sodium nitrite ingestion was found at the scene and supported by biochemical analysis of post-mortem blood nitrite and nitrate levels. Routine toxicological screening was performed on post-mortem blood samples received at University Hospitals of Leicester (UHL) NHS Trust, including ethanol analysis by headspace gas chromatography-flame ionisation detection (HS GC-FID), drug screening by high resolution accurate mass-mass spectrometry (HRAM-MS) and confirmatory drug quantitation by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Cases in which the history indicated the possibility of nitrite salts present at the scene, purchase of a suicide kit or a dusky-ash appearance of skin on post-mortem were referred to a specialist laboratory for nitrite and nitrate analysis. Analysis was based upon the gas-phase chemiluminescent reaction between nitric oxide (NO) and ozone; NO levels were determined using an NOA 280A, Sievers NO analyser. Twenty post-mortem cases in which sodium nitrite ingestion was the most probable cause of death were reported between January 2020 and February 2022; mean age was 31 years (range 14-49) with 9/20 (45%) female. 16/20 (80%) of cases had a history of depression and / or mental health issues. In half of the cases, anti-depressant / anti-psychotic drugs were prescribed; these drugs were detected in 8/20 (40%) cases. Ethanol was detected in 4/20 (20%) cases and anti-emetic drugs in 7/20 (35%) cases; anti-emetic drugs may be used to aid retention of sodium nitrite. Illicit drugs (amphetamine, cannabis and cocaine) were present in 3/20 cases (15%). Nitrite was found to be elevated in all but one case (95%), and nitrate was elevated in 17/20 (85%) cases. This paper highlights a surge in numbers of deaths across England and Wales due to sodium nitrite toxicity. Although, nitrite poisoning remains a rare cause of death, it is worthwhile considering its use in individuals with suicidal ideation given its unregulated availability online. The detection and quantitation of nitrite and nitrate requires specialised, highly reliable methodology currently only available in research laboratories. Implication of sodium nitrite ingestion also relies heavily upon circumstantial evidence combined with quantification. The provision of a quantitative nitrite / nitrate analytical service greatly assists in determining the cause of death in these cases.

Identification of Platinum(II) Sulfide Complexes Suitable as Intramuscular Cyanide Countermeasures

The development of rapidly acting cyanide countermeasures using intramuscular injection (IM) represents an unmet medical need to mitigate toxicant exposures in mass casualty settings. Previous work established that cisplatin and other platinum(II) or platinum(IV)-based agents effectively mitigate cyanide toxicity in zebrafish. Cyanide's in vivo reaction with platinum-containing materials was proposed to reduce the risk of acute toxicities. However, cyanide antidote activity depended on a formulation of platinum-chloride salts with dimethyl sulfoxide (DMSO) followed by dilution in phosphate-buffered saline (PBS). A working hypothesis to explain the DMSO requirement is that the formation of platinum-sulfoxide complexes activates the cyanide scavenging properties of platinum. Preparations of isolated NaPtCl₅-DMSO and Na (NH₃)₂PtCl-DMSO complexes in the absence of excess DMSO provided agents with enhanced reactivity toward cyanide in vitro and fully recapitulated in vivo cyanide rescue in zebrafish and mouse models. The enhancement of the cyanide scavenging effects of the DMSO ligand could be attributed to the activation of platinum(IV) and (II) with a sulfur ligand. Unfortunately, the efficacy of DMSO complexes was not robust when administered IM. Alternative Pt(II) materials containing sulfide and amine ligands in bidentate complexes show enhanced reactivity toward cyanide addition. The cyanide addition products yielded tetracyanoplatinate(II), translating to a stoichiometry of 1:4 Pt to each cyanide scavenger. These new agents demonstrate a robust and enhanced potency over the DMSO-containing complexes using IM administration in mouse and rabbit models of cyanide toxicity. Using the zebrafish model with these Pt(II) complexes, no acute cardiotoxicity was detected, and dose levels required to reach lethality exceeded 100 times the effective dose. Data are presented to support a general chemical design approach that can expand a new lead candidate series for developing next-generation cyanide countermeasures.

Main group cyanides: from hydrogen cyanide to cyanido-complexes

Homoleptic cyanide compounds exist of almost all main group elements. While the alkali metals and alkaline earth metals form cyanide salts, the cyanides of the lighter main group elements occur mainly as covalent compounds. This review gives an overview of the status quo of main group element cyanides and cyanido complexes. Information about syntheses are included as well as applications, special substance properties, bond lengths, spectroscopic characteristics and computations. Cyanide chemistry is presented mainly from the field of inorganic chemistry, but aspects of chemical biology and astrophysics are also discussed in relation to cyano compounds.

An Overview of Emerging Cyanide Bioremediation Methods

Cyanide compounds are hazardous compounds which are extremely toxic to living organisms, especially free cyanide in the form of hydrogen cyanide gas (HCN) and cyanide ion (CN−). These cyanide compounds are metabolic inhibitors since they can tightly bind to the metals of metalloenzymes. Anthropogenic sources contribute significantly to CN− contamination in the environment, more specifically to surface and underground waters. The treatment processes, such as chemical and physical treatment processes, have been implemented. However, these processes have drawbacks since they generate additional contaminants which further exacerbates the environmental pollution. The biological treatment techniques are mostly overlooked as an alternative to the conventional physical and chemical methods. However, the recent research has focused substantially on this method, with different reactor configurations that were proposed. However, minimal attention was given to the emerging technologies that sought to accelerate the treatment with a subsequent resource recovery from the process. Hence, this review focuses on the recent emerging tools that can be used to accelerate cyanide biodegradation. These tools include, amongst others, electro-bioremediation, anaerobic biodegradation and the use of microbial fuel cell technology. These processes were demonstrated to have the possibility of producing value-added products, such as biogas, co-factors of neurotransmitters and electricity from the treatment process.

Glyoxylate protects against cyanide toxicity through metabolic modulation

Although cyanide's biological effects are pleiotropic, its most obvious effects are as a metabolic poison. Cyanide potently inhibits cytochrome c oxidase and potentially other metabolic enzymes, thereby unleashing a cascade of metabolic perturbations that are believed to cause lethality. From systematic screens of human metabolites using a zebrafish model of cyanide toxicity, we have identified the TCA-derived small molecule glyoxylate as a potential cyanide countermeasure. Following cyanide exposure, treatment with glyoxylate in both mammalian and non-mammalian animal models confers resistance to cyanide toxicity with greater efficacy and faster kinetics than known cyanide scavengers. Glyoxylate-mediated cyanide resistance is accompanied by rapid pyruvate consumption without an accompanying increase in lactate concentration. Lactate dehydrogenase is required for this effect which distinguishes the mechanism of glyoxylate rescue as distinct from countermeasures based solely on chemical cyanide scavenging. Our metabolic data together support the hypothesis that glyoxylate confers survival at least in part by reversing the cyanide-induced redox imbalances in the cytosol and mitochondria. The data presented herein represent the identification of a potential cyanide countermeasure operating through a novel mechanism of metabolic modulation.

Queering poppers literature: A critical interpretive synthesis of health sciences research on alkyl nitrite use and Canadian policy

BACKGROUND

Poppers (alkyl nitrites) are vasodilators used by many gay, bisexual, and other men who have sex with men (GBMSM) to relieve pain, enhance pleasure, and facilitate penetration during sex. In 2013, the Canadian government cracked down on the sale of poppers products, however prevalence of poppers use among GBMSM in Canada remains high. Poppers have been studied by medical researchers since the 1980s, yet qualitative and community-based research to inform federal policy, remains somewhat less common.

METHODS

We conducted a critical interpretive synthesis (CIS) to better understand poppers health literature using the medical model of health as a point of reference. Analysis was performed using inductive and deductive methods including reflexive note-taking, mind-mapping, and close coding. 153 publications were identified to inform this review of which 5 were chosen for coding based on a purposive sampling framework.

RESULTS

Our findings are unified within a theoretical construct we term responsibility. Responsibility is a construct we use to describe the bias we identified in health sciences literature regarding poppers use that tends to exaggerate the necessity for poppers cessation, and devalue both the benefits of poppers use and the perspectives and experiences of people who use poppers. The emphasis on individual behavior change within the literature appears to be motivated less by objective measures or assessments of health risks and outcomes, and more by harmful stereotypes that position gay men and people who use drugs as inherently irresponsible.

CONCLUSION

We conclude by discussing how these findings have important implications for the review of current policy on poppers sales in Canada which remains influenced by a literature base prejudiced by factors such as homophobia, heteronormativity, and drug stigma, and recommend areas for future work.

Improving oxidative stability of foods with apple-derived polyphenols

Consumers demand healthy and natural food products. Thus, naturally derived antioxidants are emerging as a promising alternative to the use of present ingredients. Apples and apple derivative products (e.g., apple juice, apple cider, apple sauce, and others) are widely consumed throughout the world for a variety of different reasons and supply a large quantity of polyphenolic compounds. The extraction of polyphenolic compounds from apples and their incorporation into processed foods as naturally sourced ingredients could be a preferred alternative to commonly used commercial antioxidants that are used in many foods. In addition, they could have a positive impact on the environment and on the economy due to the utilization of byproducts generated during processing of apples, like apple pomace. In terms of the extraction procedures for the antioxidant compounds found in apples, the most efficient processes are methods that use ultrasound as the extraction tool. With this technique, greater yields are achieved, and less extraction time is required when compared with other, more conventional, extraction methods. However, parameters such as the extraction solvent, temperature during extraction, and extraction time must be suitably optimized in order to obtain the best performance and the highest antioxidant capacity. From an application standpoint, the use of apple-derived polyphenol extracts as a naturally derived food additive has documented applications for bread, meat, fish, cookies, and juices and there is evidence of increased antioxidant capacity, reduced rate of lipid oxidation, and increased storage time without compromising on sensory properties.

Liposome-encapsulated methemoglobin as an antidote against cyanide poisoning

Cyanide induces acute lethal poisoning resulting from inhibition of cytochrome c oxidase located in the complex IV (Complex IV) of mitochondria. However, current therapies for cyanide poisoning using hydroxocobalamin and nitrous acid compounds remain a clinical issue. Here, we show that liposome-encapsulated methemoglobin (metHb@Lipo), nanosized biomimetic red blood cells, replicate the antidotal mechanism of nitrous acid compounds against cyanide poisoning, achieving superior efficacy and fast action with no adverse effects. The structure of metHb@Lipo, which consists of concentrated methemoglobin in its aqueous core and a lipid membrane resembling the red blood cell membrane, provides favorable characteristics as a cyanide antidote, such as binding properties and membrane permeability. Upon cyanide exposure, metHb@Lipo maintained the mitochondrial function in PC12 cells, resulting in a cell viability comparable to treatment with nitrous acid compounds. In a mouse model of cyanide poisoning, metHb@Lipo treatment dramatically improved mortality with a rapid recovery from the symptoms of cyanide poisoning compared to treatment with nitrous acid compounds. Furthermore, metHb@Lipo also possesses satisfactory pharmacokinetic properties without long-term bioaccumulation and toxicity. Our findings showed a novel concept to develop drugs for cyanide poisoning and provide a promising possibility for biomimetic red blood cell preparations for pharmaceutical applications.

African nightshades (Solanum nigrum complex): The potential contribution to human nutrition and livelihoods in sub-Saharan Africa

Achieving zero hunger in sub-Saharan Africa (SSA) without minimizing postharvest losses of agricultural products is impossible. Therefore, a holistic approach is vital to end hunger, simultaneously improving food security, diversity, and livelihoods. This review focuses on the African nightshades (ANS) Solanum spp. contribution to improving food and nutrition security in SSA. Different parts of ANS are utilized as food and medicine; however, pests and diseases hinder ANS utilization. African nightshade is rich in micronutrients such as β-carotene, vitamins C and E, minerals (iron, calcium, and zinc), and dietary fiber. The leaves contain a high amount of nutrients than the berries. Proper utilization of ANS can contribute to ending hidden hunger, mainly in children and pregnant women. Literature shows that ANS contains antinutritional factors such as oxalate, phytate, nitrate, and alkaloids; however, their quantities are low to cause potential health effects. Several improved varieties with high yields, rich in nutrients, and low alkaloids have been developed in SSA. Various processing and preservation techniques such as cooking, drying, and fermentation are feasible techniques for value addition on ANS in SSA; moreover, most societies are yet to adopt them effectively. Furthermore, promoting value addition and commercialization of ANS is of importance and can create more jobs. Therefore, this review provides an overview of ANS production and challenges that hinder their utilization, possible solutions, and future research suggestions. This review concludes that ANS is an essential nutritious leafy vegetable for improving nutrition and livelihoods in SSA.

Plasmapheresis for the management of acute cyanide poisoning: A case report and review of literature

In case of mild to moderate cyanide poisoning, especially when standard antidote kits are not readily available, plasmapheresis can be utilized as an alternative option alongside supportive measures.

Severe lactic acidosis from acute cyanide poisoning after intentional amygdalin ingestion in a teenager

Cyanide poisoning via the oral route is a remarkably rare entity in the United States. Though acute toxicity from this poison may present with classic signs and symptoms (smell of bitter almonds on breath and cherry-red skin), these signs are frequently not clinically observed in the intoxicated patient, making it low on the routine differential diagnosis leading to both diagnostic and therapeutic challenges for the bedside clinician. This is a case of a 17-yearold male with a history of depression who presented to the Emergency Room (ER) with altered mental status, abdominal pain, and emesis. A severely elevated and worrisome lactic acidosis triggered the ER’s septic shock bundle and algorithm, but further investigation ultimately led to the unifying diagnosis of intentional cyanide poisoning.

Basic Biology of Hypoxic Responses Mediated by the Transcription Factor HIFs and its Implication for Medicine

Oxygen (O₂) is essential for human life. Molecular oxygen is vital for the production of adenosine triphosphate (ATP) in human cells. O₂ deficiency leads to a reduction in the energy levels that are required to maintain biological functions. O₂ acts as the final acceptor of electrons during oxidative phosphorylation, a series of ATP synthesis reactions that occur in conjunction with the electron transport system in mitochondria. Persistent O₂ deficiency may cause death due to malfunctioning biological processes. The above account summarizes the classic view of oxygen. However, this classic view has been reviewed over the last two decades. Although O₂ is essential for life, higher organisms such as mammals are unable to biosynthesize molecular O₂ in the body. Because the multiple organs of higher organisms are constantly exposed to the risk of “O₂ deficiency,” living organisms have evolved elaborate strategies to respond to hypoxia. In this review, I will describe the system that governs oxygen homeostasis in the living body from the point-of-view of the transcription factor hypoxia-inducible factor (HIF).

SERS-based nanostrategy for rapid anemia diagnosis

Iron detection is one of the critical markers to diagnose multiple blood-related disorders that correspond to various biological dysfunctions. The currently available anemia detection approach can be used only for pre-treated blood samples that interfere with the actual iron level in blood. Real-time detection approaches with higher sensitivity and specificity are certainly needed to cope with the commercial level clinical analyses. Herein, we presented a novel strategy to determine the blood iron that can be easily practiced at commercial levels. The blend of well-known iron-cyanide chemistry with nanotechnology is advantageous with ultrahigh sensitivity in whole blood analysis without any pre-treatments. This approach is a combined detection system of the conventional assay (UV-visible spectroscopy) with surface-enhanced Raman scattering (SERS). Organic cyanide modified silver nanoparticles (cAgNPs) can selectively respond to Fe3+ ions and Hb protein with a detection limit of 10 fM and 0.46 μg mL-1, respectively, without being affected by matrix interfering species in the complex biological fluid. We confirmed the clinical potential of our new cAgNPs by assessing iron-status in multiple anemia patients and normal controls. Our SERS-based iron quantitation approach is highly affordable for bulk-samples, cheap, quick, flexible, and useful for real-time clinical assays. Such a method for metal-chelation has extendable features of therapeutics molecular tracking within more complex living systems at cellular levels.

Target-triggered hot spot dispersion for cellular biothiol detection via background-free surface-enhanced Raman scattering tags

Abnormal cellular biothiol levels are related to many abnormal physiological processes, including cancer, multidrug resistance and Alzheimer's disease, etc. In this study, the nano-aggregates of the background-free surface-enhanced Raman scattering (SERS) tags were constructed and developed for the intracellular biothiol detection via a target-triggered disaggregation process. The plasmonic nano-tags were prepared by coating gold nanoparticles with a Raman reporter (4-mercaptobenzonitrile, MBN), which exhibits a single strong peak in the cellular Raman silent region (1800-2800 cm^-1) that can eliminate the background interference of cells. Interestingly, this reporter is also the host ligand for guest mercury ions. The coordination of mercury/cyano group induce the formation of the pre-aggregates of nano-tags and the formed nano-aggregates allowing strong SERS signals of reporters. Intracellular biothiols show higher affinity to mercury ions than the SERS tags do, which can break the hot spot geometry and redisperse tags by taking away mercury ions from nano-aggregates, which dramatically decreases the SERS signals of reporters previously laid on gold nanoparticles. The developed SERS "turn off" method was used for biothiol detections in normal, cancer, drug-resistant cells, and biothiol dynamics during chemotherapy. The results demonstrate that the drug-resistant cells (MCF-ADR) lie in a higher biothiol level than cancer cells (MCF-7 and HepG2), and the normal cells (LO2) give a lower biothiol concentration compared with cancer cells. Moreover, most cancer cells are more sensitive to doxorubicin compared with the normal ones. This study provides an important strategy in learning the cellular processes that are highly associated with intracellular biothiol level.

Mg-Al-CO3 layered double hydroxide reinforced polymer inclusion membrane as an extractant phase for thin-film microextraction of cyanide from environmental water samples

In this paper, a flexible and efficient nano-reinforced polymer inclusion membrane (PIM) was fabricated and used for cyanide (CN^-) extraction from water samples. Aliquat 336 (a liquid anion exchanger) was embedded in poly(vinyl chloride) (PVC) support as the extractant. Mg-Al-CO₃ layered double hydroxide (LDH) with high surface area and anion exchange ability was applied to promote the extraction efficiency of PIM. A PIM comprising 56% PVC, 40% Aliquat 336, and 4% Mg-Al-CO₃ LDH showed the best extraction efficiency. A single beam ultraviolet-visible spectrophotometer was used for the detection of cyanide. Surface morphology of the PIM was studied by field emission scanning electron microscopy. The experimental parameters influencing the extraction process were investigated and optimized. The intra- and inter-day relative standard deviations at two different concentrations were in the range of 2.8-7.6%. The dynamic range of the method was in the range of 5-500 μg L^-1, and the detection limit was 1.4 μg L^-1. The LDH reinforced PIM showed proper characteristics for the extraction of cyanide from real water and wastewater samples with recoveries between 82 and 115%.

Iatrogenic pediatric hydroxocobalamin overdose

INTRODUCTION

Hydroxocobalamin, a precursor molecule to vitamin B12, has emerged as the preferred empiric treatment for patients rescued from enclosed-space fires with concern for inhalational injury and potential concomitant cyanide toxicity. Limited data exist on the effects of hydroxocobalamin toxicity, particularly in pediatric patients.

CASE REPORT

We report a case of a healthy three-year old girl who was rescued from an apartment fire and electively intubated by prehospital providers. Due to concern for potential cyanide toxicity, she received 5 g (373 mg/kg) of intravenous hydroxocobalamin, an amount equivalent to one standard adult dose but over five times the appropriate weight-adjusted dose for this 13.4-kilogram child. On hospital arrival, patient was noted to have chromaturia and diffuse erythroderma without cutaneous burns. She was extubated 4 h after prehospital intubation and discharged home the following morning in good condition with persistent erythroderma. Skin color returned to normal within two days.

DISCUSSION

We believe this to be the first reported case of iatrogenic pediatric hydroxocobalamin overdose for the treatment of suspected cyanide toxicity. Erythroderma and chromaturia are expected side effects of hydroxocobalamin, even at therapeutic levels. Along with minor airway burns, the only other finding was a transient and hemodynamically neutral bradycardia, which began shortly after prehospital intubation. As this bradycardia occurred prior to hydroxocobalamin administration, more likely culprits include vagal nerve stimulation from direct laryngoscopy, and sinoatrial muscarinic receptor stimulation caused by repeated doses of succinylcholine. In all, we were unable to appreciate any complications due to excess hydroxocobalamin administration.

An inhalational swine model for the characterization of physiological effects and toxicological profile associated with cyanide poisoning

Cyanides are highly toxic compounds that have been used as weapons of terrorism throughout history. Cyanide (CN) is acutely toxic by all routes of administration; however, inhalation is the main exposure route. To adequately test effective countermeasures against inhalational CN threats, robust and well-characterized animal models are needed. This paper describes the initial development of a hydrogen cyanide (HCN) exposure swine model for documenting the physiological effects and toxicological profile during and after HCN inhalation exposure. Animals were implanted with telemetry transmitters for heart rate (HR), blood pressure, and electrocardiogram monitoring, and vascular access ports for serial blood collections. Nine female swine were exposed to HCN concentrations of 500 ± 6 ppm while breathing parameters were monitored real-time. Inhaled HCN doses ranged from 2.02 to 2.83 mg/kg. Clinical signs included vocalization, agitation, salivation, respiratory distress and apnea. After HCN exposure initiation, systemic arterial pressure fell dramatically with a concomitant increase in HR. Blood samples were collected to determine CN blood levels using LC-MS/MS and blood gas analysis. In summary, the developed HCN inhalation swine model permitted documentation of the physiological effects associated with CN poisoning. This model could be used to evaluate potential CN medical countermeasures in the event of a public health emergency stemming from inhalational CN threats.

A Review on Ingested Cyanide: Risks, Clinical Presentation, Diagnostics, and Treatment Challenges

Cyanide, a metabolic poison, is a rising chemial threat and ingestion is the most common route of exposure. Terrorist organizations have threatened to attack the USA and international food and water supplies. The toxicokinetics and toxicodynamics of oral cyanide are unique, resulting in high-dose exposures, severe symptoms, and slower onset of symptoms. There are no FDA-approved therapies tested for oral cyanide ingestions and no approved intramuscular or oral therapies, which would be valuable in mass casualty settings. The aim of this review is to evaluate the risks of oral cyanide and its unique toxicokinetics, as well as address the lack of available rapid diagnostics and treatments for mass casualty events. We will also review current strategies for developing new therapies. A review of the literature using the PRISMA checklist detected 7284 articles, screened 1091, and included 59 articles or other reports. Articles referenced in this review were specific to risk, clinical presentation, diagnostics, current treatments, and developing therapies. Current diagnostics of cyanide exposure can take hours or days, which can delay treatment. Moreover, current therapies for cyanide poisoning are administered intravenously and are not specifically tested for oral exposures, which can result in higher cyanide doses and unique toxicodynamics. New therapies developed for oral cyanide exposures that are easily delivered, safe, and can be administered quickly by first responders in a mass casualty event are needed. Current research is aimed at identifying an antidote that is safe, effective, easy to administer, and has a rapid onset of action.

Sodium nitrite augments lung S-nitrosylation and reverses chronic hypoxic pulmonary hypertension in juvenile rats

Deficient nitric oxide (NO) signaling plays a critical role in the pathogenesis of chronic neonatal pulmonary hypertension (PHT). Physiological NO signaling is regulated by S-nitrosothiols (SNOs), which act both as a reservoir for NO and as a reversible modulator of protein function. We have previously reported that therapy with inhaled NO (iNO) increased peroxynitrite-mediated nitration in the juvenile rat lung, although having minimal reversing effects on vascular remodeling. We hypothesized that sodium nitrite (NaNO2) would be superior to iNO in enhancing lung SNOs, thereby contributing to reversal of chronic hypoxic PHT. Rat pups were exposed to air or hypoxia (13% O2) from postnatal days 1 to 21. Dose-response prevention studies were conducted from days 1–21 to determine the optimal dose of NaNO2. Animals then received rescue therapy with daily subcutaneous NaNO2 (20 mg/kg), vehicle, or were continuously exposed to iNO (20 ppm) from days 14–21. Chronic PHT secondary to hypoxia was both prevented and reversed by treatment with NaNO2. Rescue NaNO2 increased lung NO and SNO contents to a greater extent than iNO, without causing nitration. Seven lung SNO proteins upregulated by treatment with NaNO2 were identified by multiplex tandem mass tag spectrometry, one of which was leukotriene A4 hydrolase (LTA4H). Rescue therapy with a LTA4H inhibitor, SC57461A (10 mg·kg−1·day−1 sc), partially reversed chronic hypoxic PHT. We conclude that NaNO2 was superior to iNO in increasing tissue NO and SNO generation and reversing chronic PHT, in part via upregulated SNO-LTA4H.

Monitoring Dose Response of Cyanide Antidote Dimethyl Trisulfide in Rabbits Using Diffuse Optical Spectroscopy

INTRODUCTION

Cyanide (CN) poisoning is a serious chemical threat from accidental or intentional exposures. Current CN exposure treatments, including direct binding agents, methemoglobin donors, and sulfur donors, have several limitations. Dimethyl trisulfide (DMTS) is capable of reacting with CN to form the less toxic thiocyanate with high efficiency, even without the sulfurtransferase rhodanese. We investigated a soluble DMTS formulation with the potential to provide a continuous supply of substrate for CN detoxification which could be delivered via intramuscular (IM) injection in a mass casualty situation. We also used non-invasive technology, diffuse optical spectroscopy (DOS), to monitor physiologic changes associated with CN exposure and reversal.

METHODS

Thirty-six New Zealand white rabbits were infused with a lethal dose of sodium cyanide solution (20 mg/60 ml normal saline). Animals were divided into three groups and treated with saline, low dose (20 mg), or high dose (150 mg) of DMTS intramuscularly. DOS continuously assessed changes in tissue hemoglobin concentrations and cytochrome c oxidase redox state status throughout the experiment.

RESULTS

IM injection of DMTS increased the survival in lethal CN poisoning. DOS demonstrated that high-dose DMTS (150 mg) reversed the effects of CN exposure on cytochrome c oxidase, while low dose (20 mg) did not fully reverse effects, even in surviving animals.

CONCLUSIONS

This study demonstrated potential efficacy for the novel approach of supplying substrate for non-rhodanese mediated sulfur transferase pathways for CN detoxification via intramuscular injection in a moderate size animal model and showed that DOS was useful for optimizing the DMTS treatment.

Rationally Designed Circularly Arranged Sextuple Molecule with Dimethoxyphenolic Tentacles for Ample Hunting of Cyanide

Herein, we report the design, synthesis, and cyanide-scavenging behavior of circularly arranged sextuple molecule 4. The six syringaldehyde units carrying equal number of dimethoxyphenolic moieties projecting at the periphery make the molecule highly efficient for cleaning up cyanide from the aqueous solution. The stoichiometric data 1:6 showed that six units of cyanide interact with one unit of compound 4. The association constant of the compound for cyanide was 2.5 × 10⁴ M^-1, and its detection limit for cyanide was 10 nM. The compound was also found to remove cyanide bound to cytochrome c oxidase.

Identification of specific metabolic pathways as druggable targets regulating the sensitivity to cyanide poisoning

Cyanide is a potent toxic agent, and the few available antidotes are not amenable to rapid deployment in mass exposures. As a result, there are ongoing efforts to exploit different animal models to identify novel countermeasures. We have created a pipeline that combines high-throughput screening in zebrafish with subsequent validation in two mammalian small animal models as well as a porcine large animal model. We found that zebrafish embryos in the first 3 days post fertilization (dpf) are highly resistant to cyanide, becoming progressively more sensitive thereafter. Unbiased analysis of gene expression in response to several hours of ultimately lethal doses of cyanide in both 1 and 7 dpf zebrafish revealed modest changes in iron-related proteins associated with the age-dependent cyanide resistance. Metabolomics measurements demonstrated significant age-dependent differences in energy metabolism during cyanide exposure which prompted us to test modulators of the tricarboxylic acid cycle and related metabolic processes as potential antidotes. In cyanide-sensitive 7 dpf larvae, we identified several such compounds that offer significant protection against cyanide toxicity. Modulators of the pyruvate dehydrogenase complex, as well as the small molecule sodium glyoxylate, consistently protected against cyanide toxicity in 7 dpf zebrafish larvae. Together, our results indicate that the resistance of zebrafish embryos to cyanide toxicity during early development is related to an altered regulation of cellular metabolism, which we propose may be exploited as a potential target for the development of novel antidotes against cyanide poisoning.

A countermeasure development pipeline

We have developed an integrated pipeline for countermeasure discovery that, under the auspices of the National Institutes of Health Countermeasures Against Chemical Threats network, is one of the few efforts within academia that by design spans the spectrum from discovery to phase I. The successful implementation of this approach for cyanide would enable efficient proof-of-concept studies that would lay the foundation for a generalizable strategy for parallel mechanistic studies and accelerated countermeasure development in the face of new and emerging chemical threats.

Cyanide bioremediation: the potential of engineered nitrilases

The cyanide-degrading nitrilases are of notable interest for their potential to remediate cyanide contaminated waste streams, especially as generated in the gold mining, pharmaceutical, and electroplating industries. This review provides a brief overview of cyanide remediation in general but with a particular focus on the cyanide-degrading nitrilases. These are of special interest as the hydrolysis reaction does not require secondary substrates or cofactors, making these enzymes particularly good candidates for industrial remediation processes. The genetic approaches that have been used to date for engineering improved enzymes are described; however, recent structural insights provide a promising new approach.

Cyanide Detoxification by the Cobalamin Precursor Cobinamide

Cyanide is a highly toxic agent that inhibits mitochondrial cytochrome-c oxidase, thereby depleting cellular ATP. it contributes to smoke inhalation deaths in fires and could be used as a weapon of mass destruction. Cobalamin (vitamin B12) binds cyanide with a relatively high affinity and is used in Europe to treat smoke inhalation victims. Cobinamide, the penultimate compound in cobalamin biosynthesis, binds cyanide with about 1010 greater affinity than cobalamin, and we found It was several-fold more effective than cobalamin in (i) reversing cyanide inhibition of oxidative phosphorylation in mammalian cells; (ii) rescuing mammalian cells and Drosophila melanogaster from cyanide toxicity; and (iii) reducing cyanide inhibition of Drosophila Malpighian tubule secretion. Cobinamide could be delivered by oral ingestion, inhalation, or injection to Drosophila, and it was as effective when administered up to 5 mins post-cyanide exposure as when given preexposure. We conclude that cobinamide is an effective cyanide detoxifying agent that has potential use as a cyanide antidote, both in smoke inhalation victims and in persons exposed to cyanide used as a weapon of mass destruction.

The Vitamin B12 Analog Cobinamide Is an Effective Antidote for Oral Cyanide Poisoning

INTRODUCTION

Cyanide is a major chemical threat, and cyanide ingestion carries a higher risk for a supra-lethal dose exposure compared to inhalation but provides an opportunity for effective treatment due to a longer treatment window and a gastrointestinal cyanide reservoir that could be neutralized prior to systemic absorption. We hypothesized that orally administered cobinamide may function as a high-binding affinity scavenger and that gastric alkalinization would reduce cyanide absorption and concurrently increase cobinamide binding, further enhancing antidote effectiveness.

METHODS

Thirty New Zealand white rabbits were divided into five groups and were given a lethal dose of oral cyanide poisoning (50 mg). The survival time of animals was monitored with oral cyanide alone, oral cyanide with gastric alkalinization with oral sodium bicarbonate buffer (500 mg), and in combination with either aquohydroxocobinamide or dinitrocobinamide (250 mM). Red blood cell cyanide concentration, plasma cobinamide, and thiocyanate concentrations were measured from blood samples.

RESULTS

In cyanide ingested animals, oral sodium bicarbonate alone significantly prolonged survival time to 20.3 ± 8.6 min compared to 10.5 ± 4.3 min in saline-treated controls, but did not lead to overall survival. Aquohydroxocobinamide and dinitrocobinamide increased survival time to 64 ± 41 (p < 0.05) and 75 ± 16.4 min (p < 0.001), respectively. Compared to aquohydroxocobinamide, dinitrocobinamide showed greater systemic absorption and reduced blood pressure. Dinitrocobinamide also markedly increased the red blood cell cyanide concentration. Under all conditions, the plasma thiocyanate concentration gradually increased with time.

CONCLUSION

This study demonstrates a promising new approach to treat high-dose cyanide ingestion, with gastric alkalinization alone and in combination with oral cobinamide for treating a supra-lethal dose of orally administered cyanide in rabbits.

Development of sulfanegen for mass cyanide casualties

Cyanide is a metabolic poison that inhibits the utilization of oxygen to form ATP. The consequences of acute cyanide exposure are severe; exposure results in loss of consciousness, cardiac and respiratory failure, hypoxic brain injury, and dose-dependent death within minutes to hours. In a mass-casualty scenario, such as an industrial accident or terrorist attack, currently available cyanide antidotes would leave many victims untreated in the short time available for successful administration of a medical countermeasure. This restricted therapeutic window reflects the rate-limiting step of intravenous administration, which requires both time and trained medical personnel. Therefore, there is a need for rapidly acting antidotes that can be quickly administered to large numbers of people. To meet this need, our laboratory is developing sulfanegen, a potential antidote for cyanide poisoning with a novel mechanism based on 3-mercaptopyruvate sulfurtransferase (3-MST) for the detoxification of cyanide. Additionally, sulfanegen can be rapidly administered by intramuscular injection and has shown efficacy in many species of animal models. This article summarizes the journey from concept to clinical leads for this promising cyanide antidote.

Acute Cyanide Poisoning: Hydroxocobalamin and Sodium Thiosulfate Treatments with Two Outcomes following One Exposure Event

Cyanide is rapidly reacting and causes arrest of aerobic metabolism. The symptoms are diffuse and lethal and require high clinical suspicion. Remediation of symptoms and mortality is highly dependent on quick treatment with a cyanide antidote. Presently, there are two widely accepted antidotes: sodium thiosulfate and hydroxocobalamin. These treatments act on different components of cyanide's metabolism. Here, we present two cases resulting from the same source of cyanide poisoning and the use of both antidotes separately used with differing outcomes.

Colorimetric Cyanide Chemosensor Based on 1',3,3',4-Tetrahydrospiro[chromene-2,2'-indole]

A new class of chemosensors based on the 1′,3,3′,4-tetrahydrospiro[chromene-2,2′-indole] ring system, which detects cyanide with high specificity, is described. These chemosensors show a distinct color change when treated with cyanide in acetonitrile solution buffered with sodium phosphate, and this procedure is not affected by the presence of other common anions. The chemisensors exhibit high sensitivity to low concentrations of cyanide, meeting the European Union water quality control criterion of sensitivity below 0.05 mg L⁻¹, and show a very fast response within tens of seconds. The mechanism for detection is rationalized by the nucleophilic substitution of the phenolic oxygen atom at the indoline C-2 atom by the cyanide anion to form a stable indolylnitrile adduct and to generate the colored 4-nitrophenolate chromophore. These chemosensors can be synthesized by a simple procedure from commercially available starting materials.

Nitrocobinamide, a new cyanide antidote that can be administered by intramuscular injection

Currently available cyanide antidotes must be given by intravenous injection over 5-10 min, making them ill-suited for treating many people in the field, as could occur in a major fire, an industrial accident, or a terrorist attack. These scenarios call for a drug that can be given quickly, e.g., by intramuscular injection. We have shown that aquohydroxocobinamide is a potent cyanide antidote in animal models of cyanide poisoning, but it is unstable in solution and poorly absorbed after intramuscular injection. Here we show that adding sodium nitrite to cobinamide yields a stable derivative (referred to as nitrocobinamide) that rescues cyanide-poisoned mice and rabbits when given by intramuscular injection. We also show that the efficacy of nitrocobinamide is markedly enhanced by coadministering sodium thiosulfate (reducing the total injected volume), and we calculate that ∼1.4 mL each of nitrocobinamide and sodium thiosulfate should rescue a human from a lethal cyanide exposure.

Nitrite in organ protection

In the last decade, the nitrate-nitrite-nitric oxide pathway has emerged to therapeutical importance. Modulation of endogenous nitrate and nitrite levels with the subsequent S-nitros(yl)ation of the downstream signalling cascade open the way for novel cytoprotective strategies. In the following, we summarize the actual literature and give a short overview on the potential of nitrite in organ protection.

Excessive nitrite affects zebrafish valvulogenesis through yielding too much NO signaling

Sodium nitrite, a common food additive, exists widely not only in the environment but also in our body. Excessive nitrite causes toxicological effects on human health; however, whether it affects vertebrate heart valve development remains unknown. In vertebrates, developmental defects of cardiac valves usually lead to congenital heart disease. To understand the toxic effects of nitrite on valvulogenesis, we exposed zebrafish embryos with different concentrations of sodium nitrite. Our results showed that sodium nitrite caused developmental defects of zebrafish heart dose dependently. It affected zebrafish heart development starting from 36 hpf (hour post fertilization) when heart initiates looping process. Comprehensive analysis on the embryos at 24 hpf and 48 hpf showed that excessive nitrite did not affect blood circulation, vascular network, myocardium and endocardium development. But development of endocardial cells in atrioventricular canal (AVC) of the embryos at 48 hpf was disrupted by too much nitrite, leading to defective formation of primitive valve leaflets at 76 hpf. Consistently, excessive nitrite diminished expressions of valve progenitor markers including bmp4, has2, vcana and notch1b at 48 hpf. Furthermore, 3', 5'-cyclic guanosine monophosphate (cGMP), downstream of nitric oxide (NO) signaling, was increased its level significantly in the embryos exposed with excessive nitrite and microinjection of soluble guanylate cyclase inhibitor ODQ (1H-[1], [2], [4]Oxadiazolo[4,3-a] quinoxalin-1-one), an antagonist of NO signaling, into nitrite-exposed embryos could partly rescue the cardiac valve malformation. Taken together, our results show that excessive nitrite affects early valve leaflet formation by producing too much NO signaling.

Determination of 3-mercaptopyruvate in rabbit plasma by high performance liquid chromatography tandem mass spectrometry

Accidental or intentional cyanide poisoning is a serious health risk. The current suite of FDA approved antidotes, including hydroxocobalamin, sodium nitrite, and sodium thiosulfate is effective, but each antidote has specific major limitations, such as large effective dosage or delayed onset of action. Therefore, next generation cyanide antidotes are being investigated to mitigate these limitations. One such antidote, 3-mercaptopyruvate (3-MP), detoxifies cyanide by acting as a sulfur donor to convert cyanide into thiocyanate, a relatively nontoxic cyanide metabolite. An analytical method capable of detecting 3-MP in biological fluids is essential for the development of 3-MP as a potential antidote. Therefore, a high performance liquid chromatography tandem mass spectrometry (HPLC-MS-MS) method was established to analyze 3-MP from rabbit plasma. Sample preparation consisted of spiking the plasma with an internal standard ((13)C3-3-MP), precipitation of plasma proteins, and reaction with monobromobimane to inhibit the characteristic dimerization of 3-MP. The method produced a limit of detection of 0.1μM, a linear dynamic range of 0.5-100μM, along with excellent linearity (R(2)≥0.999), accuracy (±9% of the nominal concentration) and precision (<7% relative standard deviation). The optimized HPLC-MS-MS method was capable of detecting 3-MP in rabbits that were administered sulfanegen, a prodrug of 3-MP, following cyanide exposure. Considering the excellent performance of this method, it will be utilized for further investigations of this promising cyanide antidote.

Accelerated stability and bioassay of a new oral α-ketoglutarate formulation for treating cyanide poisoning

CONTEXT

Due to several limitations of existing cyanide antidotes, α-ketoglutarate (α-KG) has been proposed as a promising treatment for cyanide.

OBJECTIVE

This study reports the accelerated stability and bioassay of a new oral α-KG formulation.

MATERIALS AND METHODS

Amber-colored PVDF bottles containing 100 ml of 10% α-KG in 70% sorbitol, preservative (sodium methyl paraben and sodium propyl paraben), sweetener (sodium saccharine), flavor (American ice-cream soda and peppermint) and color (tartrazine), at pH 7.0-8.0 were stored in stability chamber (40 ± 2 °C and 75 ± 5% humidity) for 6 months in a GMP compliant facility. Various physical (pH, color, evaporation, extractable volume and clarity), chemical (identification and quantification of active ingredient) and microbiological (total aerobic count) analyses, together with protection studies were carried periodically in mice. Acute toxicity of the formulation and bioavailability of α-KG were assessed in rats at the beginning of the experiment.

RESULTS

No physical changes and microbiological growth were observed in the formulation. After 6 months, α-KG content in the formulation diminished by ∼24% but its protective efficacy against cyanide remained at 5.9-fold. Protection was further characterized spectrophotometrically by disappearance of α-KG spectrum in the presence of cyanide, confirming cyanohydrin formation. Oral LD50 of α-KG formulation in rats was >7.0 g/kg body weight, and did not produce any acute toxicity of clinical significance. Also, an appreciable amount of α-KG was measured in blood.

CONCLUSION

As per the guidelines of International Conference on Harmonization, the new α-KG formulation exhibited satisfactory stability, bioefficacy and safety as cyanide antidote.