The Use of Activated Charcoal to Treat Intoxications

Effect of Activated Charcoal on Mavacamten Pharmacokinetics in Healthy Participants

OBJECTIVE

To assess the effect of activated charcoal on the single-dose pharmacokinetics of mavacamten when administered 2 h or 6 h after mavacamten dosing.

METHODS

In this open-label, randomized, parallel-group study, healthy adults were randomized into three groups to receive mavacamten 15 mg alone or mavacamten 15 mg plus activated charcoal 50 g administered either 2 h or 6 h after mavacamten dosing. Pharmacokinetic parameters were derived from plasma concentration-time data using noncompartmental methods.

RESULTS

Of the 45 participants randomized, 37 completed the study. When activated charcoal was administered 2 h after mavacamten dosing, mavacamten absorption and exposure were reduced compared with when mavacamten was administered alone: the area under the concentration-time curve from 0 to 72 h (AUC0-72) and area under the concentration-time curve from time 0 extrapolated to infinity (AUCINF) were reduced by 14% and 34%, respectively. The maximum plasma concentration (Cmax) was also slightly lower when activated charcoal was administered 2 h after mavacamten dosing than with mavacamten alone. Pharmacokinetic profiles were similar for mavacamten alone and mavacamten plus activated charcoal administered 6 h after mavacamten dosing.

CONCLUSIONS

Activated charcoal was successful in reducing mavacamten absorption and exposure when administered as soon as possible after identification of a need for adsorption (2 h after mavacamten dosing). No change in exposure was observed when activated charcoal was administered 6 h after mavacamten dosing.

CLINICAL TRIAL REGISTRATION

NCT05320094.

Macrocyclic Neutralizer to Polybrene via Direct Host-Guest Complexation

Hexadimethrine bromide (HB), a synthetic polycationic species, was introduced to clinical practice as a heparin antidote and recently used in gene therapy. However, HB causes various complications such as severe red blood cells (RBCs) aggregation and tissue damage. Herein, we have synthesized a water-soluble quaterphen[3]arene containing multiple sulfonate moieties (SQP3) as a novel macrocyclic neutralizer to reverse HB via direct host-guest complexation. SQP3 exhibited a robust binding affinity toward HB with a considerably high association constant of (4.73 ± 0.61) × 107 M-1. Co-dosed with 1 equiv of SQP3, HB-induced RBCs aggregation and blood coagulation could be effectively reversed. In vitro cellular assay verified that complexation of HB with SQP3 significantly decreased reactive oxygen species production, thereby suppressing cell apoptosis. In vivo neutralization efficacy studies demonstrated that HB/SQP3 was capable of alleviating related organic damage caused by HB and improving the survival rate of HB-treated mice from 20 to 100%.

Methanol Induced Optic Neuropathy: Molecular Mysteries, Public Health Perspective, Clinical Insights and Treatment Strategies

Methanol-induced optic neuropathy (MION) represents a critical public health issue, particularly prevalent in lower socioeconomic populations and regions with restricted alcohol access. MION, characterized by irreversible visual impairment, arises from the toxic metabolization of methanol into formaldehyde and formic acid, leading to mitochondrial oxidative phosphorylation inhibition, oxidative stress, and subsequent neurotoxicity. The pathogenesis involves axonal and glial cell degeneration within the optic nerve and potential retinal damage. Despite advancements in therapeutic interventions, a significant proportion of affected individuals endure persistent visual sequelae. The study comprehensively investigates the pathophysiology of MION, encompassing the absorption and metabolism of methanol, subsequent systemic effects, and ocular impacts. Histopathological changes, including alterations in retinal layers and proteins, Müller cell dysfunction, and visual symptoms, are meticulously examined to provide insights into the disease mechanism. Furthermore, preventive measures and public health perspectives are discussed to highlight the importance of awareness and intervention strategies. Therapeutic approaches, such as decontamination procedures, ethanol and fomepizole administration, hemodialysis, intravenous fluids, electrolyte balance management, nutritional therapy, corticosteroid therapy, and erythropoietin (EPO) treatment, are evaluated for their efficacy in managing MION. This comprehensive review underscores the need for increased awareness, improved diagnostic strategies, and more effective treatments to mitigate the impact of MION on global health.

Overlapping approach Proton Pump Inhibitors/Nux vomica-Heel as new intervention for gastro-esophageal reflux management: Delphi consensus study

BACKGROUND

Gastro-esophageal reflux disease (GERD) may affect the upper digestive tract; up to 20% of population in Western nations are affected by GERD. Antacids, histamine H2-receptor antagonists, and Proton Pump Inhibitors (PPIs) are considered the referring medications for GERD. Nevertheless, PPIs must be managed carefully because their use, especially chronic, could be linked with some adverse effects. An effective and safe alternative pharmacological tool for GERD is needed. After the identification of potentially new medications to flank PPIs, it is mandatory to revise and improve good clinical practices even through a consensus process.

AIM

To optimize diagnosis and treatment guidelines for GERD through a consensus based on Delphi method.

METHODS

The availability of clinical studies describing the action of the multicomponent/multitarget medication Nux vomica-Heel, subject of the consensus, is the basic prerequisite for the consensus itself. A modified Delphi process was used to reach a consensus among a panel of Italian GERD specialists on the overlapping approach PPIs/Nux vomica-Heel as a new intervention model for the management of GERD. The Voting Consensus group was composed of 49 Italian Medical Doctors with different specializations: Gastroenterology, otolaryngology, geriatrics, and general medicine. A scientific committee analyzed the literature, determined areas that required investigation (in agreement with the multiple-choice questionnaire results), and identified two topics of interest: (1) GERD disease; and (2) GERD treatment. Statements for each of these topics were then formulated and validated. The Delphi process involved two rounds of questioning submitted to the panel experts using an online platform.

RESULTS

According to their routinary GERD practice and current clinical evidence, the panel members provided feedback to each questionnaire statement. The experts evaluated 15 statements and reached consensus on all 15. The statements regarding the GERD disease showed high levels of agreement, with consensus ranging from 70% to 92%. The statements regarding the GERD treatment also showed very high levels of agreement, with consensus ranging from 90% to 100%. This Delphi process was able to reach consensus among physicians in relevant aspects of GERD management, such as the adoption of a new approach to treat patients with GERD based on the overlapping between PPIs and Nux vomica-Heel. The consensus was unanimous among the physicians with different specializations, underlying the uniqueness of the agreement reached to identify in the overlapping approach between PPIs and Nux vomica-Heel a new intervention model for GERD management. The results support that an effective approach to deprescribe PPIs through a progressive decalage timetable (reducing PPIs administration to as-needed use), should be considered.

CONCLUSION

Nux vomica-Heel appears to be a valid opportunity for GERD treatment to favor the deprescription of PPIs and to maintain low disease activity together with the symptomatology remission.

Critical care management of acute intoxications, dynamics and changes over time: a cohort study

Acute intoxications and poisonings are a relevant cause for ICU admission of critically ill patients. This study aimed to determine the characteristics of intoxicated patients in a tertiary center medical ICU in Austria over time and to investigate parameters associated with ICU mortality. This study was a retrospective data analysis including adult ICU patients from the years 2007 to 2021. In addition to ICU documentation, pre-hospital, and emergency department documents as well as autopsy reports were utilized. In an exploratory subanalysis, we compared these findings to a historical dataset from our facility from 1992 to 1996. We identified 581 cases admitted to the medical ICU because of acute poisoning (2007-2021), of which 45% were female and 46.6% were mixed intoxications. Suicidal intent was the primary cause of intoxication (48.2%) and ICU length of stay was median 1.2 days. The majority of deceased patients received pre-hospital mechanical CPR. Primary and secondary poison/toxin removal modalities were used in 29.9% and 11.7% of cases, whereas antidotes were administered in 54.4%. Comparing the data with a historical cohort (n = 168), we found a shift in primary detoxification away from gastric lavage and an increase in alternative secondary poison/toxin removal techniques. The ICU mortality was 4.1% and 4.2% in the present and historic cohort, respectively. Pre-existing psychiatric illnesses increased from 49% in the historic to 69% in the present cohort. Psychiatric illness predisposes patients to severe intoxications necessitating ICU care, thus increasing prevention measures seems warranted. Females did present with a different spectrum of intoxications compared to males. ICU mortality remained low over time and most deceased patients had a grim prognosis already on ICU arrival.

Carbon supported ternary layered double hydroxide nanocomposite for Fluoxetine removal and subsequent utilization of spent adsorbent as antidepressant

Fluoxetine (FLX) is one of the most persistent pharmaceuticals found in wastewater due to increased use of antidepressant drugs in recent decades. In this study, a nanocomposite of ternary ZnCoAl layered double hydroxide supported on activated carbon (LAC) was used as an adsorbent for FLX in wastewater effluents. The nanocomposite was characterized using Fourier Transform Infrared Spectroscopy (FTIR), scanning electron microscope (SEM), transmission electron microscope (TEM), X-ray diffraction (XRD), and surface area analysis (BET). The adsorption investigations showed that the maximum removal capacity was achieved at pH 10, with a 0.1 g/L adsorbent dose, 50 mL volume of solution, and at a temperature of 25 °C. The FLX adsorption process followed the Langmuir-Freundlich model with a maximum adsorption capacity of 450.92 mg/g at FLX concentration of 50 µg/mL. Density functional theory (DFT) computations were used to study the adsorption mechanism of FLX and its protonated species. The safety and toxicity of the nanocomposite formed from the adsorption of FLX onto LAC (FLX-LAC) was investigated in male albino rats. Acute toxicity was evaluated using probit analysis after 2, 6, and 24 h to determine LD50 and LD100 values in a rat model. The FLX-LAC (20 mg/kg) significantly increased and lengthened the sleep time of the rats, which is important, especially with commonly used antidepressants, compared to the pure standard FLX (7 mg/kg), regular thiopental sodium medicine (30 mg/kg), and LAC alone (9 mg/kg). This study demonstrated the safety and longer sleeping duration in insomniac patients after single-dose therapy with FLX-LAC. Selective serotonin reuptake inhibitors (SSRIs) like FLX were found to have decreased side effects and were considered the first-line mood disorder therapies.

Medicinal Plant-derived Phytochemicals in Detoxification

The average worldwide human life expectancy is 70 years, with a significantly higher value in Western societies. Many modern diseases are not associated with premature mortality but with a decreased quality of life in aged patients and an excessive accumulation of various toxic compounds in the human body during life. Today, scientists are especially interested in finding compounds that can help increase a healthy lifespan by detoxifying the body. Phytotherapy with specific approaches is used in alternative medicine to remove toxins from the body. Worldwide, research is conducted to identify medicinal plant-derived molecules that, with few or no side effects, may protect the liver and other organs. This review provides updated information about the detoxification process, the traditional and modern use of the most effective medicinal plants, their active metabolites as detoxifying agents, and the mechanisms and pathways involved in the detoxification process. Among medicinal plants with substantial detoxifying properties, a major part belongs to the Asteraceae family (Silybum marianum, Cynara scolymus, Arctium lappa, Helichrysum species, Inula helenium, and Taraxacum officinale). The most widely used hepatoprotective phytocomponent is silymarin, a standardized extract from the Silybum marianum seeds containing a mixture of flavonolignans. Many polysaccharides, polyphenols, and terpenoids have a detoxifying effect. Overall, scientific data on medicinal plants used in phytotherapeutic practice worldwide provides an understanding and awareness of their efficacy in detoxification.

ICP-MS assessment of elemental impurities and metallic contaminants in activated charcoal products

Activated charcoal is an adsorbent material which is consumed as a dietary supplement (100 mg) and as non-specific antidote treatment in acute poisoning at 0.5-1 g kg-1 body weight in infants and 50 g in adults. The ingestion of large quantities of it has aroused our interest in the presence of metals impurities. Therefore, the present study aimed to assess trace elements in activated charcoal products. Multielement analysis were performed using Inductively Coupled Plasma-Mass Spectrometry after digestion. Estimated daily Intake was calculated and compared to references doses for each element. Varying trace elements have been found: chromium (0.3383 ± 0.089 µg g-1), cadmium (0.5991 ± 0.2967 µg g-1), aluminum (0.7033 ± 0.1215 µg g-1), nickel (0.0111 ± 0.003 µg g-1), lead (0.0052 ± 0.0021 µg g-1), zinc (0.0414 ± 0.0076 µg g-1), and manganese (0.0036 ± 0.0006 µg g-1). when 50 g of activated charcoal is consumed by a 70 kg adult, aluminum estimated daily intake is 0.0005 mg/kg bw/day which exceeds the reference dose (0.0004 mg/kg bw/day). In the infants, consumption of 15 g of contaminated activated charcoal exposes to chromium, cadmium and aluminum as their estimated daily intake (0.00034; 0.0006; 0.0007 mg/kg bw/day respectively) exceed their reference doses (0.0003; 0.0005; 0.0004 mg/kg bw/day respectively). These trace elements are not without risk to consumers health. Activated charcoal products could be contaminated with elemental impurities. Pharmaceutical industries should be vigilant to raw materials (plants and wood) used in the preparation, these materials should come from unpolluted areas to avoid contaminations.

A retrospective evaluation of confirmed and suspected poisonings in 166 cats between 2016 and 2020

Background and Aim

Poisonings commonly bring cats and dogs to veterinary emergency facilities. This retrospective study aimed to analyze clinical signs, confirmed or suspected toxicants, treatments, and outcomes of feline poisoning cases presented over 5 years to the emergency service of a small animal referral center.

Materials and Methods

Medical records of 166 cats were evaluated for a history of confirmed or presumed poisoning, suspected toxicant, clinical signs, treatment, and outcome. Poisoning probability was determined using patient history, clinical findings, observation, toxicologic examination, and, in some cases, gastric contents.

Results

Most cats were hospitalized (94.0%) due to poisoning with mostly unknown toxicants (48.2%), rodenticides (21.1%), and various toxic plants (12.0%), followed by antiparasitics (6.0%), chemicals (6.0%), drugs (4.2%), tetrahydrocannabinol (1.2%), or inhaled smoke (1.2%). Patients presented predominantly with neurologic deficits (68.7%), reduced general condition (60.2%), and hypothermia (43.4%). The survival rate was 88.6%. Most cats (93.2%) showed no apparent complications at the time of discharge from the hospital. Toxicant-related complications (48.2%) included thermodysregulation (22.9%), central nervous system signs (18.7%), respiratory issues (7.2%), nephrotoxicity (6.0%), gastrointestinal complications (4.8%), evidence of hepatic failure (4.8%), and hemorrhage (1.8%).

Conclusion

In this study, the causative toxicant remained unidentified in many cases. Known poisonings were mostly caused by rodenticides. Neurological signs were the most common clinical presentation. Survival rates were high and comparable with those reported by others.

Adsorption of Diclofenac and Its UV Phototransformation Products in an Aqueous Solution on PVDF: A Molecular Modeling Study

The presence of pharmaceuticals in drinking water has generated considerable scientific interest in potential improvements to polymeric membranes for water purification at the nanoscale. In this work, we investigate the adsorption of diclofenac and its ultraviolet (UV) phototransformation products on amorphous and crystalline poly(vinylidene difluoride) (PVDF) membrane surfaces at the nanoscale using molecular modeling. We report binding affinities by determining the free energy landscape via the extended adaptive biasing force method. The high binding affinities of the phototransformation products found are consistent with qualitative experimental results. For diclofenac, we found similar or better affinities than those for the phototransformation products, which seems to be in contrast to the experimental findings. This discrepancy can only be explained if the maximum adsorption density of diclofenac is much lower than that of the products. Overall, negligible differences between the adsorption affinities of the crystalline phases are observed, suggesting that no tuning of the PVDF surfaces is necessary to optimize filtration capabilities.

[Intoxications in childhood and adolescence]

Poisoning of children requires quick and rational action. It is crucial to recognize a poisoning, to interpret the symptoms correctly, and to assess the severity of the poisoning as precisely as possible. This is the best way to find the optimal therapy for each patient.Cases of suspected poisoning are common in childhood. The risk of a potential poisoning must be recognized and interpreted correctly. Based on this, symptomatic and specific therapy can be carried out. The poisons information centres have a great experience in the diagnosis and treatment of poisonings and can help the attending physicians to plan the further therapeutic steps.Both the hazard of a toxic substance and a realistic exposure assessment must be considered. This is especially crucial in cases of suspected poisoning of (still) mostly asymptomatic patients. This is the way to prevent overtreatment without overlooking dangerous poisonings.

The Role of Activated Charcoal in Prehospital Care

Background

Administration of a single-dose activated charcoal (SDAC) is an effective method used for gastric decontamination and for other types of poisoning and overdose. This is only true when given within the first hour of poison ingestion as the effectivity of SDAC reduces over time. In addition, generally, not all patients are able to avail treatment within the specified period. Hence, multi-dose activated charcoal is regarded as a solution to a delayed process, although, no proof outweighs the use of SDAC.

Objective

This study aimed to review and assess the adequacy of the past and current use of AC. The author also aimed to offer recommendations believed to be the best method to consider for prehospital care.

Methods

The author conducted 6,337 online literature searches for this review, wherein seven papers met eligibility criteria for inclusion and analysis.

Results

In this review, routine administration of AC in poisoning was found not related to the duration of hospital stay nor any other subsequent outcomes following poison ingestion. Further, this review did not establish that administration of AC could improve patient's clinical outcome. Further research and clinical trials is required to determine the efficacy of this therapy to appropriate patients in the prehospital setting.

Conclusion

Activated charcoal can be used to treat highly acute to life-threatening poisoning if it is administered within the first hour of ingestion. Further studies would be necessary to investigate if this would affect clinical outcome..

Management of Massive Rivaroxaban Overdose With Acetaminophen and Isosorbide Mononitrate Overdose

Direct oral anticoagulants (DOACs) have been used more frequently for the prevention and management of thromboembolic disease in comparison to their predecessors. DOACs provide greater ease of administration, shorter half-lives, less monitoring, and fewer drug-drug interactions. With the rise of DOACs such as rivaroxaban, the opportunity for abuse also increases. Therefore, standardization of care based on rivaroxaban misuse must also be explored, an area in which there is not ample information. We present a case where a patient consumed a stockpile of her home medications in hopes to commit suicide. A 64-year-old female presented to the emergency department due to the ingestion of rivaroxaban 5,000 mg along with ingestion of acetaminophen 30,000 mg and isosorbide mononitrate 1000 mg in the setting of intentional self-harm with multiple declarations of being classified as Do Not Resuscitate. There have been documented cases of rivaroxaban overdose, however, there are no documented cases with levels of ingestion reaching 5,000 mg along with signs of severe bleeding. Our case study reviews the previously documented management of rivaroxaban abuse and the treatment that was given to our patient in the setting of extreme anticoagulant ingestion.

The Relative Risk of Toxico-Clinical Parameters with respect to Poisoning Severity and Outcomes in Patients with Acute Poisoning

Background

Complications or death risk factors is necessary for better monitoring and treatment. The aim of this study was to define the relative risk of toxico-clinical parameters with regard to poisoning severity and outcomes in patients with acute poisoning.

Materials and Methods

This cross-sectional study entailed of patients with acute poisoning admitted to the poisoning emergency center of khorshid hospital, Isfahan, Iran from December 2018 until March 2019. Patients (n = 300) were categorized into four groups (minor, moderate, severe, and fatal poisoning) based on severity. Multivariate logistic regression analysis was employed to calculate the odds ratio (OR) as the estimate of the relative risk of the different variables for the poisoning severity and outcomes prediction.

Results

In the minor group, opioids/opiates, alcohols, and benzodiazepines (14.7%) were the most prevalent poisoning, multidrug (23.3%) was in the moderate and severe groups and finally, pesticides poisoning (23%) was most common in the fatal group. The predictive factors for poisoning severity were pre-hospital antidote administration [OR, (95%CI); P value) [7.08 (1.77-28.34); 0.006]; loss of consciousness [4.38 (1.84-10.42), 0.001]; abnormal ECG [4.56 (1.65-12.56); 0.003]; and time interval of poisoning to admission in the hospital [1.15 (1.02-1.28); 0.01). Patients without complications was observed in 49.7% of subjects. Patients with the loss of consciousness [66.06 (2.41-180.07); 0.01); underlying disease [3.65 (1.09-12.24); 0.03]; abnormal respiration [1.14 (1.02-1.27); 0.02); have had a greater risk of complications and death.

Conclusion

Important factors for poisoning severity and/or outcome were loss of consciousness, pre-hospital antidote administration, abnormal ECG or respiration, underlying disease, and delay to presentation to hospital.

Acute dapsone poisoning with methemoglobinemia: a case report

Methemoglobinemia is a common complication of dapsone poisoning. Its´ treatment usually relies on methylene blue infusion. The aim of this study was to report a case of an acute dapsone poisoning with methemoglobinemia treated only with ascorbic acid and activated charcoal. A 16-year-old female voluntary ingested 3 grams of dapsone in an attempt of suicide and presented with desaturation and tachypnea. Lab findings were compatible with methemoglobinemia. After two days of treatment with ascorbic acid and activated charcoal, we observed the disappearance of desaturation and tachypnea. Methemoglobinemia can be treated with ascorbic acid and activated charcoal in limited resource settings.

Acute poisoning among children and adolescents: a narrative review

Background: Acute poisoning is a frequent emergency and a significant health concern in the pediatric population. The pattern of acute intoxication differs between countries and within each country. Poisoning depends on many factors. It can be divided into two categories (accidental and intentional), and each one has its own characteristics. Aim of the study: This study aimed to analyze and discuss the overall patterns of accidental and intentional poisoning among children and adolescents. Material and methods: A systematic literature search was conducted using Google Scholar, Elsevier, and the PubMed database. The following keywords were used: “acute poisoning”, “pediatric poisoning”, “intentional poisonings”, “unintentional poisonings”, and “suicide attempts”. Results: A total of 38 articles were included in the review. Half had been published in the last five years. The analysis focused on the characteristics of the materials and methods, results, and conclusions sections of each study. Conclusions: Unintentional poisonings dominate among younger children, with a slight male predominance. They usually occur at home and occasionally lead to severe harm or even death. The most common causes of intoxication in this population are medications and household products. The majority of poisonings among adolescents are intentional suicide attempts. Among older children, over-the-counter analgesics are the most common cause of acute poisoning. Accidental poisoning can be avoided by providing preventive educational programs to guardians and replacing potentially toxic household products with safer ones. The prevention of intentional poisoning should be based on a community support system and behavioral programs. Healthcare professionals should be familiar with poisoning and be aware of the different patterns of intoxication according to age and gender.

Recent developments in the use of activated charcoal in medicine

One of the raw forms of graphite is activated charcoal which has an extensive surface area allowing for the adsorption of a wide range of chemicals. It possesses the strongest physical adsorption forces of the available materials, as well as the largest volume of adsorbing porosity. Activated charcoal acts as an adsorbent, collecting and storing substances in the gastrointestinal tract, reducing or blocking absorption in the bloodstream. The ingested toxins interact with charcoal by recycling toxins in the intestinal cavity. In cases where the drug has not been absorbed from the abdominal system, it is recirculated through the liver and intestines or by means of passive diffusion or active secretion. The article aims to review the most recent advances in the use of the activated charcoal, including the dose, how charcoal acts in the body, the mechanism of action, administration, contraindications, as well as the impact of various factors on the adsorption process. In addition, we also discussed numerous medical applications of activated charcoal.

Acidic Activated Charcoal Prevents Obesity and Insulin Resistance in High-Fat Diet-Fed Mice

Obesity is becoming a major public health problem worldwide. Making charcoal from wood (“Sumi-yaki”) has been a traditional activity in the southern part of Nagano Prefecture for centuries, with activated charcoal having reported detoxifying effects. However, it is unclear whether activated charcoal also possesses anti-obesity properties. Additionally, since activated charcoal is usually alkaline and might be affected by gastric juice, we evaluated the effect of acidic activated charcoal on high-fat diet (HFD)-induced obesity. This study demonstrated that co-treatment of acidic activated charcoal with a HFD significantly improved obesity and insulin resistance in mice in a dose-dependent manner. Metabolomic analysis of cecal contents revealed that neutral lipids, cholesterol, and bile acids were excreted at markedly higher levels in feces with charcoal treatment. Moreover, the hepatic expressions of genes encoding cholesterol 7 alpha-hydroxylase and hydroxymethylglutaryl-CoA reductase/synthase 1 were up-regulated by activated charcoal, likely reflecting the enhanced excretions from the intestine and the enterohepatic circulation of cholesterol and bile acids. No damage or abnormalities were detected in the gastrointestinal tract, liver, pancreas, and lung. In conclusion, acidic activated charcoal may be able to attenuate HFD-induced weight gain and insulin resistance without serious adverse effects. These findings indicate a novel function of charcoal to prevent obesity, metabolic syndrome, and related diseases.

Poisoning by Plants

BACKGROUND

Questions on poisoning by plants are a common reason for inquiries to poison information centers (PIC). Over the years 2011-2020, plant poisoning was the subject of 15% of all inquiries to the joint poison information center in Erfurt, Germany (Gemeinsames Giftinformationszentrum Erfurt, GGIZ) that concerned poisoning in children (2.3% in adults). In this patient collective, plant poisoning occupied third place after medical drugs (32%) and chemical substances (24%), and was a more common subject of inquiry than mushroom poisoning (1.5%).

METHODS

This review is based on pertinent publications retrieved by a selective literature search in PubMed/TOXLINE on plant poisoning and on 12 epidemiologically and toxicologically relevant domestic species of poisonous plants in risk categories 2 and 3 (up to 2021).

RESULTS

Medical personnel should have basic toxicological knowledge of the following highly poisonous plants: wolfsbane (aconitum), belladonna, angel's trumpet, cowbane (cicuta virosa), autumn crocus, hemlock, jimson weed, henbane, castor bean (ricinus), false hellebore, foxglove (digitalis), and European yew. The intoxication is evaluated on the basis of a structured history (the "w" questions) and the clinical manifestations (e.g., toxidromes). Special analysis is generally not readily available and often expensive and time-consuming. In case of poisoning, a poison information center should be contacted for plant identification, risk assessment, and treatment recommendations. Specimens of plant components and vomit should be obtained, if possible, for further testing. Measures for the elimination of the poisonous substance may be indicated after a risk-benefit analysis. Specific antidotes are available for only a few types of plant poisoning, e.g., physostigmine for tropane alkaloid poisoning or digitalis antibodies for foxglove poisoning. The treatment is usually symptomatic and only rarely evidence-based. Individualized medical surveillance is recommended after the ingestion of large or unknown quantities of poisonous plant components.

CONCLUSION

The clinician should be able to recognize dangerous domestic species of poisonous plants, take appropriate initial measures, and avoid overdiagnosis and overtreatment. To improve patient care, systematic epidemiological and clinical studies are needed.

A Macroporous Magnesium Oxide-Templated Carbon Adsorbs Shiga Toxins and Type III Secretory Proteins in Enterohemorrhagic Escherichia coli, Which Attenuates Virulence

Enterohemorrhagic Escherichia coli (EHEC) is one of the most common foodborne pathogens. However, no drug that prevents the severe complications caused by this bacterium has been approved yet. This study showed that a macroporous magnesium oxide (MgO)-templated carbon material (MgOC₁₅₀) adsorbs Shiga toxins, and Type III secretory EspA/EspB proteins responsible for EHEC pathogenesis, and decreases the extracellular levels of these proteins. On the other hand, this material did not affect the growth of EHEC. Citrobacter rodentium traditionally used to estimate Type III secretion system-associated virulence in mice is highly virulent. The survival period of infected mice was prolonged when MgOC₁₅₀ was administered. This adsorbent disturbed neither mammalian cells nor normal intestinal bacteria, such as Enterococcus hirae, Lactobacillus acidophilus, and Lactobacillus casei. In contrast, MgOC₁₅₀ adsorbed antimicrobial agents, including β-lactams, quinolones, tetracyclines, and trimethoprim/sulfamethoxazole. However, fosfomycin and amikacin were not adsorbed. Thus, MgOC₁₅₀ can be used with fosfomycin and amikacin to treat infections. MgOC₁₅₀ is used for industrial purposes, such as an electrode catalyst, a bioelectrode, and enzyme immobilization. The study proposed another potential application of MgOC₁₅₀, assisting anti-EHEC chemotherapy.

Beneficial Alteration in Growth Performance, Immune Status, and Intestinal Microbiota by Supplementation of Activated Charcoal-Herb Extractum Complex in Broilers

This study aimed to examine the effects of activated charcoal-herb extractum complex (CHC) on the growth performance of broilers, inflammatory status, microbiota, and their relationships. A total of 864 1-day-old Arbor Acres male broilers (41.83 ± 0.64 g) were distributed to eight dietary treatments with six replicates (18 birds per replicate), which were a corn-soybean meal-based diet (NCON); basal diets supplemented with 250, 500, 750, or 1,000 mg/kg CHC, and three positive controls; basal diets supplemented with 200 mg/kg antibacterial peptide (AMP), 200 mg/kg calsporin (Probio) or 500 mg/kg montmorillonite. The study period was 42 days including the starter (day 0-21) and grower (day 22-42) phases. Compared with the NCON group, CHC supplementation (optimal dose of 500 mg/kg) increased (p < 0.05) growth performance and tended to increase feed conversion rate in broilers. CHC (optimal dose of 500 mg/kg) decreased the level of the interleukin-1β (IL-1β) and interferon-γ (IFN-γ) in serum and improved the levels of immunoglobulins A (IgA) and immunoglobulins A (IgM) in serum, and secretory immunoglobulin A (SIgA) in the mucosa of duodenum and jejunum (p < 0.05). In the ileum, CHC supplementation decreased community abundance represented by lower Sobs, Chao 1, Ace, and Shannon compared with NCON (p < 0.05). At the phylum level, CHC supplementation increased the abundance of Firmicutes, while decreasing the abundance of Bacteroidetes in ileum and cecum (p < 0.05). At the genus level, compared with the NCON group, CHC markedly reduced (p < 0.05) the abundances of pathogenic bacteria Alistipes in the ileum, which were negatively associated with the levels of SIgA and IL-1β in ileum mucosa. In conclusion, CHC had beneficial effects on growth performance, immune status, and intestinal microbiota composition. CHC had dual functions of absorption like clays and antibacterial like antibacterial peptides.

First Descriptive Analysis of the Faecal Microbiota of Wild and Anthropized Barbary Macaques (Macaca sylvanus) in the Region of Bejaia, Northeast Algeria

Simple Summary

The gut microbiota is very important for animal physiology and health. It has been demonstrated that the gut microbiota composition of several primate species is influenced by a variety of anthropogenic factors. However, these aspects are not documented for the gut microbiota of the endangered wild Barbary macaque. This study is the first to characterize the faecal microbiota of the species and investigate the impact on it of tourist food provisioning by comparing two groups of Barbary macaques: a tourist-provisioned group and a wild-feeding group. Our results revealed the presence of 209 bacterial genera from 17 phyla in the faecal microbiota of Barbary macaques. Firmicutes was the most abundant bacterial phylum, followed by Bacteroidetes and Verrucomicrobia. The tourism activity was associated with a significant alteration of this profile, probably due to tourist provisioning issues. Increasing risks of obesity and illness call for special management measures to reduce the provisioning rate in tourist areas.

Abstract

Previous research has revealed the gut microbiota profile of several primate species, as well as the impact of a variety of anthropogenic factors, such as tourist food supply, on these bacterial communities. However, there is no information on the gut microbiota of the endangered wild Barbary macaque (Macaca sylvanus). The present study is the first to characterize the faecal microbiota of this species, as well as to investigate the impact of tourist food provisioning on it. A total of 12 faecal samples were collected in two groups of M. sylvanus in the region of Bejaia in Algeria. The first group—a tourist-provisioned one—was located in the tourist area of the Gouraya National Park and the second group—a wild-feeding one—was located in the proximity of the village of Mezouara in the forest of Akfadou. After DNA extraction, the faecal microbiota composition was analysed using 16S rDNA sequencing. Statistical tests were performed to compare alpha diversity and beta diversity between the two groups. Non-metric multidimensional scaling analysis (NMDS) was applied to visualize biodiversity between groups. Behaviour monitoring was also conducted to assess the time allocated to the consumption of anthropogenic food by the tourist-provisioned group. Our results revealed the presence of 209 bacterial genera from 17 phyla in the faecal microbiota of Barbary macaques. Firmicutes was the most abundant bacterial phylum, followed by Bacteroidetes and Verrucomicrobia. On the other hand, the comparison between the faecal microbiota of the two study groups showed that tourism activity was associated with a significant change on the faecal microbiota of M.sylvanus, probably due to diet alteration (with 60% of feeding time allocated to the consumption of anthropogenic food). The potentially low-fibre diet at the tourist site adversely influenced the proliferation of bacterial genera found in abundance in the wild group such as Ruminococcaceae. Such an alteration of the faecal microbiota can have negative impacts on the health status of these animals by increasing the risk of obesity and illness and calls for special management measures to reduce the provisioning rate in tourist areas.

Severe Colchicine Intoxication: A Case Report and Review of Literature in Adults

Colchicine is used in the treatment of multiple diseases such as gout and auto-immune diseases. Although cases of multiorgan failure have been described in adults with doses usually higher than 0.8 mg/kg, the epidemiology data are scarce and the intoxication mechanisms are not well-known. The authors present the case of a 66-year-old male patient, with a medical history of depression, admitted to the emergency room (ER) due to intentional colchicine ingestion after taking 90 mg (approximately 1.125 mg/kg) 12 hours prior to medical evaluation. Besides some dizziness and sleepiness, he showed no other alteration in the physical examination. After the administration of activated charcoal, he was transferred to the intensive care unit (ICU). The laboratory findings showed mild hepatic dysfunction, acute kidney injury, and metabolic lactic acidosis. Despite treatment, severe clinical worsening with multiorgan failure, including respiratory failure complicated with multiple episodes of cardiac dysrhythmias and finally with persistent cardiac arrest, lead to the patient’s death after 13 hours of admission in the ER. Among drug intoxications, high doses of colchicine ingestion can lead to rapid multiorgan dysfunction, and patients with a severe overdose can experience irreversible multiorgan failure without presenting the typical initial gastrointestinal symptoms. Thus, it is necessary for the physicians to be alert to these situations and to be aware of the epidemiological data and clinical profile of this specific poisoning that should be managed in ICU. The authors perform a review of the cases of colchicine poisoning reported in adults between 2017 and 2019 and the differences in clinical management and outcomes.

Enterosorption in the Treatment of Heavy Metal Poisoning

Enterosorption is a cost-effective and efficient approach to reducing the impact of chronic exposure to heavy metals and radionuclides. As an auxiliary method to medical treatment, it can protect population chronically exposed to the intake of heavy metals or radioactivity due to industrial activities or in the aftermath of technogenic or natural accidents. This paper assesses the current state of the art in the treatment of acute and chronic heavy metal poisoning.

Successful management of massive lamotrigine extended-release intoxication in a dog

A 3-year-old spayed female Siberian Husky presented for evaluation following ingestion of approximately 429 mg/kg of lamotrigine extended-release. She demonstrated severe neurologic and cardiac signs and was treated with lipid emulsion, anticonvulsants, antiarrhythmics and aggressive decontamination and supportive care. She was successfully discharged from the hospital 5 days later.

The Individualized Management Approach for Acute Poisoning

Acute poisoning is a widespread emergency that mandates early management decisions for optimal outcomes. An individualized approach is an ideal way to provide those outcomes. Promoting awareness among healthcare professionals managing acute poisoning about the importance of incorporating the pharmacokinetics and following certain criteria to consider interventions such as activated charcoal, antidote, or specific investigations may improve their risk assessment strategies and management plans. To address the main aspects that should be considered to develop a customized poisoning management plan, we conducted this review based on relevant publications recovered by a careful search in PubMed. Our opinions as experts from the King Saud University (KSU) Drug and Poison Information Center (DPIC) were considered in the review.

Mushroom Poisoning

BACKGROUND

Poisonous mushrooms are eaten by mushroom hunters out of ignorance, after misidentification as edible mushrooms, or as a psychoactive drug. Mushroom poisoning commonly leads to consultation with a poison information center and to hospitalization.

METHODS

This review is based on pertinent publications about the syndromes, toxins, and diagnostic modalities that are presented here, which were retrieved by a selective search in PubMed. It is additionally based on the authors' longstanding experience in the diagnosis and treatment of mushroom intoxication, expert consultation in suspected cases, macroscopic identification of wild mushrooms, and analytic techniques.

RESULTS

A distinction is usually drawn between mushroom poisoning with a short latency of less than six hours, presenting with a gastrointestinal syndrome whose course is usually relatively harmless, and cases with a longer latency of six to 24 hours or more, whose course can be life-threatening (e.g., phalloides, gyromitra, orellanus, and rhabdomyolysis syndrome). The DRG diagnosis data for Germany over the period 2000-2018 include a total of 4412 hospitalizations and 22 deaths due to the toxic effects of mushroom consumption. 90% of the fatalities were due to the death cap mushroom (amatoxins). Gastrointestinal syndromes due to mushroom consumption can be caused not only by poisonous mushrooms, but also by the eating of microbially spoiled, raw, or inadequately cooked mushrooms, or by excessively copious or frequent mushroom consumption.

CONCLUSION

There are few analytic techniques available other than the qualitative demonstration of amatoxins. Thus, the diagnosis is generally made on the basis of the clinical manifestations and their latency, along with meticulous history-taking, assisted by a mushroom expert, about the type(s) of mushroom that were consumed and the manner of their preparation.

Efficacy of Active Charcoal and Mannitol in Patients with Haff Disease Caused by the Consumption of Crayfish (Procambarus clarkii): A Retrospective Cohort Study

This study evaluates the clinical efficacy of activated charcoal combined with mannitol (ACM) for the treatment of Haff disease. This is a retrospective cohort study conducted at the Emergency Department of Affiliated Hospital of Integrated Traditional Chinese and Western Medicine. Consecutive patients who were hospitalized during a two-year time frame (from June 2016 to August 2017) and diagnosed with Haff disease were reviewed. Clinical symptoms, laboratory findings, pain/anxiety scores, and treatment-related adverse events were collected. Sixty-eight Haff disease patients after boiled crayfish consumption were enrolled in this study. Besides standard treatments for Haff disease, 22 patients had an oral administration of activated charcoal and mannitol within 12 hours of hospital admission (ACM group), while the other 46 patients did not receive such treatment (non-ACM group). Baseline characteristics including clinical symptoms, serum enzyme levels, and pain/anxiety scores were comparable between the two groups. Activated charcoal and mannitol treatment led to lower CK-MB and AST levels from 12 hours to 60 hours, lower ALT and LDH levels from 12 hours to 72 hours, and lower CK levels from 24 hours to 72 hours after hospitalization. Patients in the ACM group had significantly shortened duration of hospital stays (7.5 [6.0–8.0] days vs 8.0 [6.8–10.0] days, p = 0.032) and lower anxiety scores 24 hours after hospital admission (40.7 ± 4.9 vs 44.1 ± 6.3, p = 0.032) than in the non-ACM group. No patient experienced treatment-related adverse events. The overall prognosis of both groups is good. Among patients with Haff disease caused by boiled crayfish, activated charcoal combined with mannitol treatment resulted in shorter hospital stays, lower serum CK, CK-MB, AST, ALT, and LDH levels, and lower anxiety scores.